g logo nhs blue

Female genital mutilation risk and safeguarding: guidance for professionals

  • As female genital mutilation (FGM) is a form of child abuse, professionals have a statutory obligation under national safeguarding protocols (e.g. Working together to safeguard children 2015) to protect girls and women at risk of FGM. Since October 2015 registered professionals in health, social care, and teaching also have a statutory duty (known as the Mandatory Reporting duty) to report cases of FGM to the police non-emergency number 101 in cases where a girl under 18 either discloses that she has had FGM or the professional observes physical signs of FGM*
  • One specific consideration when putting in place safeguarding measures against FGM is that the potential risk to a girl born in the UK can usually be identified at birth, because through the antenatal care and delivery of the child, NHS professionals can and should have identified that the mother has had FGM. However, FGM can be carried out at any age throughout childhood, meaning that identifying FGM at birth can have the consequence that any safeguarding measures adopted may have to be in place for more than 15 years over the course of the girl’s childhood. This is a significantly different timescale and profile compared with many of the other forms of harm against which the safeguarding framework provides protection. This difference in approach should be recognised when putting in place policies and procedures to protect against FGM
  • Once concerns have been raised about FGM, there should also be a consideration of potential risk to other girls in the family and practicing community. Professionals should be alert to the fact that any one of the girl children amongst these groups could be identified as being at risk of FGM and may need to be safeguarded from harm

Information sharing in relation to FGM

  • All local organisations should make sure their safeguarding policies and procedures take into account three nationally developed arrangements in relation to sharing information:
    • the FGM Mandatory Reporting duty (see Chapter 2) to report when a girl under 18 discloses she has FGM, or when the professional sees this: report is to be made to the police via the 101 non-emergency number
    • the Risk Indicator System (FGM RIS) should be part of wider safeguarding processes. This system displays an indicator on a child's Summary Care Record application (SCRa) following a risk assessment by a healthcare professional (see Chapter 5)
    • SCCI2026: FGM Enhanced Dataset—this information standard details how acute and mental health trusts and GP practices are required to collate and submit information to the Health and Social Care Information Centre (HSCIC), but also sets standards around information sharing about FGM and sharing between different professions and sectors to support safeguarding (see Chapter 2 )
  • The importance of sharing information between practitioners and between agencies in relation to girls potentially at risk of FGM, and in relation to discussions held with family members around safeguarding, must not be under-estimated; this information is vital to all agencies involved, to inform decisions on what the best course of action is to protect anyone at risk ofFGM

Multi-agency approach to safeguarding and when to refer

Children and vulnerable adults

  • If any child (under 18) discloses to a regulated professional that they have had FGM, or if a professional observes that she has had FGM, they must report to the police, using the 101non‑emergency number
  • If a vulnerable adult is identified as having had or being at risk of FGM, this should be responded to within the existing safeguarding processes to protect vulnerable adults
  • If an adult discloses to you that a child has had FGM, this is a report of child abuse. You should follow local safeguarding processes, which would normally mean referring to the police and/or social services. This is because a crime has been committed and a child has suffered physical (and potentially other) abuse
  • After all referrals to either the police or social services, the multi-agency safeguarding response would usually include a referral to a specialist service, to confirm the girl has had FGM. There is a standard published giving detail of what this specialist service must consist*
  • If you suspect a child (or vulnerable adult) may have FGM or is at serious or imminent risk of FGM having considered their family history or other relevant factors, you should act in accordance with your local safeguarding procedures, which would normally be a referral, as is the procedure with all other instances of child abuse. This referral is initially often to the local Children's Services or the Multi-Agency Safeguarding Hub, though other arrangements may be in place locally
  • Additionally, when a patient is identified as being at risk of FGM, this information must be shared with the GP and health visitor (HV) as part of safeguarding actions. In the case of a girl under 18 the FGM RIS on the SCRa should also be set which will alert other healthcare professionals to the risk of FGM
  • If you identify that a child (or vulnerable adult) has a family history or details which mean she may be at risk of FGM, but you do not have information to suggest that the risk is imminent or you would not describe it as serious, you should follow your local safeguarding procedures. Such local procedures would often involve a discussion with your local safeguarding lead, sharing information between professionals, sectors, and agencies appropriately, and considering early intervention options with colleagues from social care

Adults

  • There is no requirement for automatic referral of adult women with FGM to adult social services or the police. Healthcare professionals should be aware that any disclosure may be the first time that a woman has ever discussed her FGM with anyone. Referral to the police must not be introduced as an automatic response when identifying adult women with FGM, and each case must continue to be individually assessed. The healthcare professional should seek to support women by offering referral to community groups who can provide support, and for possible clinical intervention or other services as appropriate, for example through an NHS FGM clinic. The wishes of the woman must be respected at all times

Adult children

  • If a woman discloses she has adult daughter(s) over 18 who have already undergone FGM, even if the daughter does not want to take her case to the police, it is likely to be important to establish when and where this took place. This should lead to enquiries about other daughters, cousins, or girls in the wider family context. If a decision has been taken within the family not to carry out FGM on a UK-born female child, this can allow for a useful conversation to ascertain whether this was as a result of a change in attitude, a fear of prosecution, or due to a lack of opportunity or other motivations. This is a complex area and many women have greater influence in decision making with regards to FGM when they are outside their country of origin, and may therefore elect to discontinue FGM practice. Again, all information should be recorded and shared with the appropriate multi-agency partners

Continuing discussions

  • Risk can only be considered at a particular moment in time. Healthcare professionals should take the opportunity to continue their discussions around FGM throughout the standard delivery of healthcare. If for example a HV or GP has been passed information from a midwife about potential risk of FGM, at the next appointment with the woman/child, the HV/GP should look to discuss this, and may use the appropriate part of this guidance to help structure those conversations

Service support—interpreters

  • Care must be taken to ensure that an interpreter is available, as this will be required in many appointments relating to FGM
  • The interpreter should be an authorised accredited interpreter and should not be a family member, not be known to the individual, and not be an individual with influence in the individual's community

Observing the partner or family member, if either are present, during the consultation

  • If a woman or child is accompanied by a partner or parent/relative/guardian respectively, the health and social care professional must be vigilant and aware of the signs of coercion and control as detailed by the Crown Prosecution Service (CPS) www.cps.gov.uk/publications/equality/domestic_violence.html in the Serious Crime Act 2015. Identifying these characteristics will assist the professional during the risk assessment in parts 1, 2, and 3

Information sharing processes

  • Any concerns, whether identified through using this guidance or through discussion with the patient and family, should be recorded within the patient’s records by the healthcare professional who has obtained the information
  • Information relating to safeguarding concerns should routinely be shared with other key professionals within the child’s life. In practice this means that concerns identified should be shared with the patient’s GP and her HV or school nurse (SN), depending on the age of the child who is potentially at risk of FGM
Guide to information sharing responsibilities
Maternity services
  • All existing maternity discharge information sent to GPs and HVs must also include all relevant FGM information, where appropriate, when FGM or family history of FGM has been identified; prior to, during, or after the birth of a baby
  • Upon issue of the Red Book, it is the responsibility of the midwife to populate the following section, "Are there any other particular illnesses or conditions in the mother’s or father's family that you feel are important?" to reflect that FGM has been identified in the mother
  • As part of the prenatal assessment appointment, every woman must be asked if they have undergone FGM
  • Their healthcare record must then be updated with confirmation of the question being asked and the response
Health visitors
  • It is the responsibility of the HV to update the following section within the Red Book: "Are there any other particular illnesses or conditions in the mother's or father's family that you feel are important?" when applicable to do so with new FGM information
  • Where a HV identifies that there is or are sisters of a girl with FGM, it is the responsibility of the HV to inform the GP
General practitioners
  • It is the responsibility of the GP to update the following section within the Red Book, "Are there any other particular illnesses or conditions in the mother's or father's family that you feel are important?" when applicable to do so with new FGM information
  • On receipt at the GP Practice of the maternity discharge information, where FGM information has been included, the new-born baby's healthcare record must be updated with that FGM information
  • On receipt at the GP Practice of the maternity discharge information, where FGM information has been included, the mother's healthcare record must be updated with the FGM information, identified prior to, during, or after the birth of a baby
  • On receipt at the GP Practice of any clinical notes or discharge summary information where FGM has been included, then that information must be included within the young girl or woman's healthcare record
  • Where FGM is identified within a General Practice, all referrals made by the GP must include the FGM information when referring the patient to services where FGM may be relevant
  • On receipt of a notification from a HV or SN that a girl under their care has a sister or sisters that are also under the same GP's care, then the sister/s healthcare records must be updated to include family history of FGM
Acute Trusts/ Mental health Trusts
  • When it has been identified in an Acute or Mental health Trust, that a young girl or woman has had FGM undertaken, information must be included within any clinical notes or discharge summary information sent to the patient's GP. This will be in addition to any other clinical findings as part of the provision of care
  • When it has been identified in an Acute or Mental health Trust, that a young girl has had FGM undertaken, in addition to the GP being informed of the FGM information in any clinical notes or discharge summary, this should also be sent to:
    • the girl's HV if the girl is under 5
    • the girl's SN if the girl is over 5
School Nurses
  • Where a SN identifies that there is or are sisters of a girl with FGM it is the responsibility of the SN to inform the GP
HV=health visitor; FGM=female genital mutilation; GP=General Practitioner; SN=School nurse.

Care pathway provision

  • All organisations should ensure that they have identified appropriate arrangements with regard to both providing care and support to patients with FGM, and to meeting the associated safeguarding requirements
  • Many organisations may in particular need to consider how to support a patient under 18 who has undergone FGM. If a child or young adult (under 18 years) is discovered to have had FGM then a report to the police non-emergency number 101 should be made as per the Mandatory Reporting duty. A referral to social care should also be considered and she is highly likely to also require a specialist paediatric appointment to ascertain any physical or mental health needs. Part of this is likely to include identifying what type of FGM she has had and the assessment will need to be appropriate to her age

Professional sensitivity in delivery care

  • Healthcare professionals need to be sensitive to the fact that women and families may have been under intense cultural/social pressure from within their country of origin to practise FGM
  • Professionals need to consider how to discuss FGM without being judgemental and whilst being sensitive

NSPCC Helpline

  • Organisations should also ensure that professionals are aware of the NSPCC FGM helpline, 0800 028 3550

FGM safeguarding risk assessment guidance

Introductory questions

  • Do you, your partner, or your parents come from a community where cutting or circumcision is practised? (See local terms)
  • Have you been cut? It may be appropriate to use other terms or phrases.

If you answer YES to either one of these questions please complete one of the risk templates

Part 1: For an adult woman (18 years or over)

  • Woman who is pregnant or has recently given birth—ask the introductory questions
    • if the answer is yes to either question, use part 1(a) to support your discussions
  • Non-pregnant woman where you suspect FGM for example if a woman presents with physical symptoms or emotional behaviour that triggers a concern (e.g. frequent urinary tract infections, severe menstrual pain, infertility, symptoms of post-traumatic stress disorder such as depression, anxiety, flashbacks or reluctance to have genital examination etc., see consequences of FGM); or if FGM is discovered through the standard delivery of healthcare (e.g. when placing a urinary catheter, carrying out a smear test etc), ask the introductory questions
    • if the answer is yes to either question, use part 1(b) to support your discussions

Part 2: For a Child (under 18 years)

  • Ask the introductory questions (see above) to either the child directly or the parent or legal guardian depending upon the situation
    • if the answer to either question is yes or you suspect that the child might be at risk of FGM, use part 2 to support your discussions

Part 3: For a Child (under 18 years)

  • Ask the introductory questions (see above) to either the child directly or the parent or legal guardian depending upon the situation
    • if the answer to either question is yes or you suspect that the child has had FGM (see consequences of FGM), use part3 to support your discussions
  • In all circumstances:
    • the woman and family must be informed of the law in the UK and the health consequences of practising FGM
    • ensure all discussions are approached with due sensitivity and are non-judgemental
    • any action must meet all statutory and professionals responsibilities in relation to safeguarding, the Mandatory Reporting duty, and meet local processes and arrangements
    • using this guidance does not replace the need for professional judgement in relation to the circumstances presented
    • document all actions in the woman's/child's healthcare records
  • If when asking questions based on this guide, any answer gives you cause for concern, you should continue the discussion in this area, and consider asking other related questions to further explore this concern. Please remember either the assessment or the information obtained must be recorded within the patient’s healthcare record. The templates also require that you record when and by whom it and at what point in the patient’s pathway this has been completed
  • Having used the guide, you will need to decide:
    • do I need to make a referral through my local safeguarding processes, and is that an urgent or standard referral?
    • do I need to seek help from my local safeguarding lead or other professional support before making my decision? Note, you may wish to consult with a colleague at a Multi-Agency Safeguarding Hub, Children’s Social Services or the local Police Force for additional support
    • if I do not believe the risk has altered since my last contact with the family, or if the risk is not at the point where I need to refer to an external body, then you must ensure you record and share information about your decision accordingly
  • An urgent referral should be made, out of normal hours if necessary, if a child or young adult shows signs of very recently having undergone FGM. This may allow for the police to collect physical evidence
  • An urgent referral should also be made if the healthcare professional believes that there are plans perhaps to travel abroad which present a risk that a child is imminently likely to undergo FGM if allowed to leave your care

Action for Part 1(a) and (b) and Part 2

Ask more questions—if one indicator leads to a potential area of concern, continue the discussion in this area.

Consider risk—if one or more indicators are identified, you need to consider what action to take. If unsure whether the level of risk requires referral at this point, discuss with your named/ designated safeguarding lead.

Significant or immediate risk—if you identify one or more serious or immediate risks, or the other risks are, by your judgement, sufficient to be considered serious, you should look to refer to Social Services/Child Abuse Investigation Team/Police/Multi-Agency Safeguarding Hub, in accordance with your local safeguarding procedures.

If the risk of harm is imminent, emergency measures may be required and any action taken must reflect the required urgency.

In all cases:

  • share information of any identified risk with the patient'sGP
  • document in notes
  • discuss the health complications of FGM and the law in the UK.

Action for Part 3

Ask more questions—if one indicator leads to a potential area of concern, continue the discussion in this area.

Please remember: any child under 18 who has undergone FGM must be referred to police under the Mandatory Reporting duty using the 101 non‑emergency number.

If you suspect but do not know that a girl has undergone FGM based on risk factors presenting, you should look to refer to Social Services/Child Abuse Investigation Team/Police/Multi-Agency Safeguarding Hub, in accordance with your local safeguarding procedures.

In all cases:

  • share information of any identified risk with the patient'sGP
  • document in notes
  • discuss the health complications of FGM and the law in the UK.

Part 1 (a): pregnant women (or has recently given birth)

  • This is to help you make a decision as to whether the unborn child (or other female children in the family) are at risk of FGM or whether the woman herself is at risk of further harm in relation to her FGM
IndicatorYesNoDetails
Consider risk   
Woman comes from a community known to practice FGM      
Woman has undergone FGM herself      
Husband/partner comes from a community known to practice FGM      
A female family elder is involved/will be involved in care of children/unborn child or is influential in the family      
Woman/family has limited integration in UK community      
Woman and/or husband/partner have limited/no understanding of harm of FGM or UK law      
Woman's nieces, siblings, and/or in-laws have undergone FGM      
Woman has failed to attend follow-up appointment with an FGM clinic/FGM-related appointment      
Woman's husband/partner/other family member are very dominant in the family and have not been present during consultations with the woman      
Woman is reluctant to undergo genital examination      
Significant or immediate risk   
Woman already has daughters who have undergone FGM      
Woman or woman's partner/family requesting reinfibulation following childbirth      
Woman is considered to be a vulnerable adult and therefore issues of mental capacity and consent should be considered if she is found to have FGM      
Woman says that FGM is integral to cultural or religious identity      
Family are already known to social care services—if known, and you have identified FGM within a family, you must share this information with social services      

Please remember: any child under 18 who has undergone FGM must be referred to police under the Mandatory Reporting duty using the 101 non-emergency number.

Part 1 (b): non-pregnant adult woman (over 18)

  • This is to help decide whether any female children are at risk of FGM, whether there are other children in the family for whom a risk assessment may be required, or whether the woman herself is at risk of further harm in relation to her FGM
IndicatorYesNoDetails
Consider risk   
Woman already has daughters who have undergone FGM—who are over 18 years of age      
Husband/partner comes from a community known to practice FGM      
A female family elder (maternal or paternal) is influential in family or is involved in care of children      
Woman and family has limited integration in UK community      
Woman's husband/partner/other family member may be very dominant in the family and have not been present during consultations with the woman      
Woman/family have limited/no understanding of harm of FGM or UK law      
Woman’s nieces (by sibling or in-laws) have undergone FGM      
Woman has failed to attend follow-up appointment with an FGM clinic/FGM-related appointment      
Family are already known to social services—if known, and you have identified FGM within a family, you must share this information with social services      
Significant or immediate risk   
Woman/family believe FGM is integral to cultural or religious identity      
Woman already has daughters who have undergone FGM      
Woman is considered to be a vulnerable adult and therefore issues of mental capacity and consent should be triggered if she is found to have FGM      

Please remember: any child under 18 who has undergone FGM must be referred to police under the Mandatory Reporting duty using the 101 non-emergency number.

Part 2: child/young adult (under 18 years old)

  • This is to help when considering whether a child is at risk of FGM, or whether there are other children in the family for whom a risk assessment may be required
IndicatorYesNoDetails
Consider risk   
Child's mother has undergone FGM      
Other female family members have had FGM      
Father comes from a community known to practice FGM      
A female family elder is very influential within the family and is/will be involved in the care of the girl      
Mother/family have limited contact with people outside of her family      
Parents have poor access to information about FGM and do not know about the harmful effects of FGM or UK law      
Parents say that they or a relative will be taking the girl abroad for a prolonged period—this may not only be to a country with high prevalence, but this would more likely lead to a concern      
Girl has spoken about a long holiday to her country of origin/another country where the practice is prevalent      
Girl has attended a travel clinic or equivalent for vaccinations/anti-malarials      
FGM is referred to in conversation by the child, family, or close friends of the child (see traditional and local terms)—the context of the discussion will be important      
Sections missing from the Red book. Consider if the child has received immunisations, do they attend clinics etc      
Girl withdrawn from personal health and social education lessons or from learning about FGM—School Nurse should have conversation with child      
Girls presents symptoms that could be related to FGM—continue with questions in part 3      
Family not engaging with professionals (health, school, or other)      
Any other safeguarding alert already associated with the family      
Significant or immediate risk   
A child or sibling asks for help      
A parent or family member expresses concern that FGM may be carried out on the child      
Girl has confided in another that she is to have a 'special procedure' or to attend a 'special occasion'. Girl has talked about going away 'to become a woman' or 'to become like my mum and sister'      
Girl has a sister or other female child relative who has already undergone FGM      
Family/child are already known to social services—if known, and you have identified FGM within a family, you must share this information with social services      

Please remember: any child under 18 who has undergone FGM must be referred to police under the Mandatory Reporting duty using the 101 non-emergency number.

Part 3: child/young adult (under 18 years old)

  • This is to help when considering whether a child has had FGM
IndicatorYesNoDetails
Consider risk   
Girl is reluctant to undergo any medical examination      
Girl has difficulty walking, sitting, or standing or looks uncomfortable      
Girl finds it hard to sit still for long periods of time, which was not a problem previously      
Girl presents to GP or A&E with frequent urine, menstrual, or stomach problems      
Increased emotional and psychological needs, e.g., withdrawal, depression, or significant change in behaviour      
Girl avoiding physical exercise or requiring to be excused from physical education lessons without a GP's letter      
Girl has spoken about having been on a long holiday to her country of origin/another country where the practice is prevalent      
Girl spends a long time in the bathroom/toilet/long periods of time away from the classroom      
Girl talks about pain or discomfort between her legs      
Significant or immediate risk   
Girl asks for help      
Girl confides in a professional that FGM has taken place      
Mother/family member discloses that female child has had FGM      
Family/child are already known to social services—if known, and you have identified FGM within a family, you must share this information with social services      

Please remember: any child under 18 who has undergone FGM must be referred to police under the Mandatory Reporting duty using the 101 non-emergency number.

Types of FGM

FGM is classified into four major types. The WHO definitions of the following are:

  • Type 1: Clitoridectomy—partial or total removal of the clitoris (a small, sensitive, and erectile part of the female genitals) and, in very rare cases, only the prepuce (the fold of skin surrounding the clitoris)
  • Type 2: Excision—partial or total removal of the clitoris and the labia minora, with or without excision of the labia majora (the labia are "the lips” that surround the vagina)
  • Type 3: Infibulation—narrowing of the vaginal opening through the creation of a covering seal. The seal is formed by cutting and repositioning the inner, or outer, labia, with or without removal of the clitoris
  • Type 4: Other—all other harmful procedures to the female genitalia for non-medical purposes, e.g., pricking, piercing, incising, scraping, and cauterizing the genital area

Consequences of FGM

  • The short-term consequences following a girl undergoing FGM can include:
    • severe pain
    • emotional and psychological shock (exacerbated by having to reconcile being subjected to the trauma by loving parents, extended family, and friends)
    • haemorrhage
    • wound infections, including tetanus and blood-borne viruses (including HIV and Hepatitis B and C)
    • urinary retention
    • injury to adjacent tissues
    • fracture or dislocation as a result of restraint
    • damage to other organs
    • death
  • The long-term health implications of FGM can include:
    • chronic vaginal and pelvic infections
    • difficulties with menstruation
    • difficulties in passing urine and chronic urine infections
    • renal impairment and possible renal failure
    • damage to the reproductive system, including infertility
    • infibulation cysts, neuromas, and keloid scar formation
    • obstetric fistula
    • complications in pregnancy and delay in the second stage of childbirth
    • pain during sex and lack of pleasurable sensation
    • psychological damage, including a number of mental health and psychosexual problems such as low libido, depression, anxiety, and sexual dysfunction; flashbacks during pregnancy and childbirth; substance misuse and/or self-harm
    • increased risk of HIV and other sexually transmitted infections
    • death of mother and child during childbirth

Traditional and local terms for FGM

CountryTerm used for FGMLanguageMeaning
EGYPT Thara Arabic Deriving from the Arabic word 'tahar' meaning to clean/purify
  Khitan Arabic Circumcision—used for both FGM and male circumcision
  Khifad Arabic Deriving from the Arabic word 'khafad' meaning to lower (rarely used in everyday language)
ETHIOPIA Megrez Amharic Circumcision/cutting
  Absum Harrari Name giving ritual
ERITREA Mekhnishab Tigregna Circumcision/cutting
KENYA Kutairi Swahili Circumcision—used for both FGM and male circumcision
  Kutairi was ichana Swahili Circumcision of girls
NIGERIA Ibi/Ugwu Igbo The act of cutting—used for both FGM and male circumcision
  Sunna Mandingo Believed to be a religious tradition/obligation by some Muslims
SIERRA LEONE Sunna Soussou Believed to be a religious tradition/obligation by some Muslims
  Bondo Temenee/Mandingo/Limba Integral part of an initiation rite into adulthood
  Bondo/Sonde Mendee Integral part of an initiation rite into adulthood
SOMALIA Gudiniin Somali Circumcision—used for both FGM and male circumcision
  Halalays Somali Deriving from the Arabic word 'halal' ie. 'sanctioned'—implies purity. Used by Northern and Arabic speaking Somalis
  Qodiin Somali Stitching/tightening/sewing refers to infibulation
SUDAN Khifad Arabic Deriving from the Arabic word 'khafad' meaning to lower (rarely used in everyday language)
  Tahoor Arabic Deriving from the Arabic word 'tahar' meaning to purify
CHAD – the Ngama Bagne   Used by the Sara Madjingaye
Sara subgroup Gadja   Adapted from 'ganza' used in the Central African Republic
GUINEA-BISSAU Fanadu di Mindjer Kriolu 'Circumcision of girls'
GAMBIA Niaka Mandinka Literally to 'cut/weed clean'
  Kuyango Mandinka Meaning 'the affair' but also the name for the shed built for initiates
  Musolula Karoola Mandinka Meaning 'the women's side'/'that which concerns women'

*www.gov.uk/government/publications/fgm-mandatory-reporting-in-healthcare

www.hscic.gov.uk/isce/publication/scci2026

www.who.int/mediacentre/factsheets/fs241/en/

full guideline available from…
www.gov.uk/government/uploads/system/uploads/attachment_data/file/525390/FGM_safeguarding_report_A.pdf

Department of Health. Female genital mutilation risk and safeguarding; guidance for professionals. London: Department of Health.
First included: June 2016.