Standard Operating Procedure for Recording and Reporting Female Genital Mutilation (FGM)

1. Staff Summary & Introduction
2. Purpose & Effect
3. Key Definitions
4. Process Flow Charts & Supporting Information
5. Key Staff and Committees/Groups
6. Equality Analysis
7. Consultation and Review Process
8. Standards/Key Performance Indicators
9. Process for Monitoring Compliance and Effectiveness
10. Plan for Communication and Dissemination of Procedure
11. References/ Associated Documentation

• Appendix B - Pregnant Women (Or Has Recently Given Birth)
• Appendix C - Non-Pregnant Adult Woman (Over 18)
• Appendix D - Blossom Clinic Leaflet
• Appendix E - Leeds Workflow for Female Genital Mutilation
• Appendix F - Child/Young Adult (Under 18 Years Old)
• Appendix G - Mandatory Reporting to Police

1. Staff Summary & Introduction

This Standard Operating Procedure (SOP) is for all clinicians and CSU’S across Leeds Teaching Hospitals NHS Trust (LTHT) and includes guidance where Safeguarding Children or Adult procedures are indicated. The purpose of this SOP is to:

1. Standardise procedures for recording and sharing information in relation to Female Genital Mutilation (FGM) to safeguard women and female children.
2. Ensure LTHT policy is in line with the latest intercollegiate and government guidance.
3. Strengthen information sharing pathways internally and externally to safeguard women and female children from harm.

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2. Purpose & Effect

This guidance is for frontline professionals and their managers in Leeds Teaching Hospitals NHS Trust to:

• Record and report FGM cases identified through self-disclosure or clinical assessment.
• Identify when a woman or female child may be at risk of being subjected to FGM and responding appropriately to protect her;
• Identify when a woman or female child has been subjected to FGM and respond appropriately to support the woman or female child; and
• Implement measures to prevent and ultimately eliminate the practice of FGM.

This procedure should be read in conjunction with Leeds Safeguarding Children Partnership (LSCP) procedures, LTHT Adults Safeguarding Policy, the FGM in Pregnancy, Childbirth and Postnatal Period policy and the LTHT Children’s Safeguarding Policy.

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3. Key Definitions

Health workers are in a unique position to identify those who have undergone Female Genital Mutilation (FGM) and those at risk of having FGM.

The Department of Health is leading a programme of work to improve responses to FGM. This includes a mandatory requirement for health organisations to capture and report information about FGM. The FGM Enhanced Dataset (coordinated by NHS Digital) requires organisations to record and collect information about the prevalence of FGM within the female population that has contact with health services. This includes if a woman or female child is receiving treatment for any condition; it is not limited to reporting those receiving treatment for FGM-related conditions. In some departments or services it will be routine practice to enquire whether a woman has had FGM for example maternity or gynaecology services.

It has been estimated in a 2015 UK government report that approximately 60,000 girls aged 0-14 were born in England and Wales to mothers who had undergone FGM and approximately 103,000 women aged 15-49 and approximately 24,000 women aged 50 and over who have migrated to England and Wales are living with the consequences of FGM^[1]. In addition, approximately 10,000 girls aged under 15 who have migrated to England and Wales are likely to have undergone FGM¹. NHS Digital² report there were 1,530 individual women and girls who had a NHS attendance where FGM was identified in the period July 2021 to September 2021. However, the true extent is unknown, due to the hidden nature of the crime.

FGM is a deeply embedded social norm, practised by families for a variety of complex reasons. It is often thought to be essential for a girl to become a proper woman and to be marriageable - the practice is not required by any religion¹.  It is usually carried out on female children before they reach puberty, but in some cases it is performed on new-born infants or on women before marriage or pregnancy. It is often asserted by the belief that it is beneficial for the female child or woman, but FGM is an extremely harmful practice which violates basic human rights. The most significant risk factor for females is coming from a community where FGM is known to be practised and/or where a mother, sister or other female family member has been subjected to FGM. Practitioners should be aware of this and provide families with advice and information, which makes it clear that FGM is illegal in the UK. Female children are often taken back to their countries of origin so FGM can be carried out during the summer holidays, allowing them time to ‘heal’ before returning to school. There is also evidence that some female children have FGM performed in the UK and to date there has been one conviction in the UK³.

Practitioners should be aware that FGM is a form of ‘hidden serious harm’ which includes practices of child sexual exploitation, trafficking, forced marriage and honour based violence and the ‘voice’ and safety of the child or adult should remain paramount when undertaking any assessments.

Practitioners, particularly those working in health services with young people should also consider potential indictors that FGM may be going to take place, or has already taken place;

• Preparations for the female child to take a long holiday - arranging vacations or planning an absence from school;
• A change in the female child behaviour after a prolonged absence from school, including; being withdrawn; crying or being away from class for long periods;
• The female child has bladder or menstrual problems, and/ or may have difficulty walking, sitting or standing.

Prevalence of FGM

FGM affects female adults and children worldwide and is a major human rights issue. UNICEF (2021)⁴ report that more than 200 million females alive today in 31 countries in Africa, the Middle East and Asia have undergone FGM. Four million more are at risk each year⁴.

The practice of FGM is highly concentrated in a broad band of countries that spans from the Atlantic coast to the horn of Africa, parts of the Middle East including Iraq and Yemen. It is also important to note that countries such as Colombia, India, Saudi Arabia the UAE, Oman and Malaysia also have wide variations in prevalence and practice. FGM can also be found in small pockets of Europe, Australia and North America where there is a large migrant population. Over 50% of cases worldwide now occur in Egypt, Ethiopia and Indonesia⁴.

[1] HM Government - Multi-agency statutory guidance on Female Genital Mutilation (publishing.service.gov.uk)

2 Female Genital Mutilation - NHS Digital

3 Mother of three-year-old is first person convicted of FGM in UK | Female genital mutilation (FGM) | The Guardian

4 Female genital mutilation | UNICEF

The maps below illustrate the global prevalence of FGM (2016):

Definitions:

The practice of FGM is illegal in England, Wales and Scotland and should be considered as a public health, human rights and an adult and children’s safeguarding issue.

FGM is legally prohibited in England, Wales and Northern Ireland by The Female Genital Mutilation Act 2003⁷. This Act came into force on 3rd March 2004; it repeals the Female Circumcision Act 1985⁸ and states;

• A person is guilty of an offence if s/he excises, infibulates or otherwise mutilates the whole or any part of a girl's labia majora, labia minora or clitoris.
• It is also an offence for a UK national or permanent UK resident to aid, abet, counsel or procure this procedure for another person.

Therefore it is not only practitioners of FGM who are liable to punishment, but parents who seek this procedure for their children or indeed any person who advises or assists another to have FGM performed. This carries a maximum sentence of 14 years imprisonment.

This act also applies if FGM occurs outside the UK, even in countries where this practice is legal, for children or young people taken abroad to have this performed.

It is essential that all health care professionals are aware of this legislation and how it affects our practice. We must inform practicing communities of its protective and punitive functions. Some families for example don’t know that by choosing FGM, they’re committing an offence. Other families want to protect their children from FGM but don’t know this law exists to help them.

The Serious Crime Act (2015) brought into force mandatory reporting duty to the police for practitioners in regulated professions (health, teaching, social work) regarding female children under 18. NHS England have provided additional guidance for health professionals.⁹  If an offence of FGM is committed against a child under the age of 18, each person who is ‘responsible’ for the child at the time the FGM occurred, will be liable for prosecution. The ‘responsible’ person will have parental responsibility for the child and/or frequent contact.The Serious Crime Act (2015) also enables the high court or family courts to make a FGM Protection Order for individuals who are victims or at risk of FGM (similar to forced marriage protection orders). Victims, those at risk, or relevant third parties (including local authorities) can apply for an FGM Protection order which set restrictions to protect an individual.

5 Female genital mutilation (who.int)

6 Questions | West Yorkshire Police

7 https://www.legislation.gov.uk/ukpga/2003/31/contents

8 https://www.legislation.gov.uk/ukpga/1985/38/contents

9 https://www.legislation.gov.uk/ukpga/2015/9/contents/enacted

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4. Process Flow Charts & Supporting Information

All females presenting at LTHT with FGM must be considered potential victims of crime in line with the intercollegiate recommendations¹⁰

All pregnant women with FGM presenting at LTHT must be referred to the FGM Maternity clinic, where a thorough risk assessment will be undertaken. Any pregnant women under 18, as well as being referred to FGM maternity clinic, will need to follow the children’s process and where appropriate, a referral will be made to Children Social Work Services (CSWS), support services, and the Police. Please also refer to Women’s CSU maternity procedure FGM in pregnancy, childbirth and postnatal period and the associated maternity SOP.

16-17 year old pregnant women Any young female presenting in maternity services between the ages of 16-17, if able to consent should be examined by the FGM midwifery team but should still follow the under 18 pathway in this policy.

Please see Appendix B part A for an example of the risk assessment for clinicians to undertake to mitigate any risks to any other females. Please ensure any assessments, advice and patient wishes are documented on PPM+ or the relevant clinical notes and details shared with the GP.

All female infants born to a mother with FGM are examined by a paediatrician on the post-natal ward and document examination of female genitalia in the patient records. The female new born and mother are reviewed postnatally in the maternity FGM clinic and this is where the FGM-IS is completed as mentioned below. If a mother with a female infant is not reviewed antenatally and postnatally they should be referred to the 0-19 service (on 01138434527 or emailed on lcht.019centralemail@nhs.net) for follow up. Please also refer to Women’s CSU maternity procedure FGM in pregnancy, childbirth and postnatal period as above. 

Any non-pregnant adult women over 18 who have FGM identified through clinical assessment or self-disclosure at LTHT will also need a risk assessment undertaking.  There is a statutory duty to enquire if there are any other females or children that could be at risk in the family and take steps to protect them. Appendix C part B shows some guidance on questions to ask adult females and if relevant any actions that may need taking including documenting that they know it is illegal in the UK. Please ensure any assessments, advice and patient wishes are documented on PPM+ or the clinical notes and details shared with the relevant GP. Patients may suffer from the psychological effects of FGM and therefore can be offered the Blossom clinic leaflet Appendix D for after care support as required or refer to the LTHT Gynaecology FGM Lead with their consent if they are suffering from any gynaecological issues as a result of the FGM.

The LTHT Safeguarding Adults team can be contacted for advice as needed (Ext 0113 2066964). For any ‘clinical’ advice the Blossom Clinic can be contacted on 0113 2718277 and the LTHT Gynaecology FGM Lead for women over 18 years of age via Switchboard.

Also please consider discussion with the Learning Disability & Autism or the MCA/MHA teams for further advice and support in these areas.

Safeguarding Children

Staff need to be familiar with Leeds Safeguarding Children Partnership Procedures in relation to FGM.¹¹ The LSCP flow chart and FGM assessment to identify where a child may be at risk of significant harm is available in Appendix E and F.

The LTHT Safeguarding Children & Midwifery team (Ext 23937) will provide support, advice and guidance where there are concerns about FGM in a female child under 18 and should always be informed about all cases where risks are identified and a referral is required to Children Social Work Services. For further ‘clinical’ advice please contact the Named Doctor for Safeguarding Children related to any child under 18 years of age.

All female children (under 18 regardless of being pregnant or not) presenting, self-disclosing FGM or considered at risk of FGM must be formally referred to CSWS and the police as per the procedure below:

1. Discuss with Leeds Children Social Work Services verbally on 0113 3760336 or 0113 5350600 out of hours.
2. Complete a ‘Record of Contact’ form as per the link; . Email to ChildScreening@leeds.gov.uk and send a copy to the Trust Children’s and Midwifery Safeguarding Team at leedsth-tr.SafeguardingChildren@nhs.net.
3. The reporter must ensure that the information is shared with the paediatric clinical lead/ Named Doctor for Safeguarding Children and the LTHT Safeguarding Children & Midwifery via the email leedsth-tr.SafeguardingChildren@nhs.net or Ext 0113 3923937.
4. If an FGM Child Protection Examination is required, this must be requested by Children Social Work Services and is currently undertaken by Leeds Community Health (LCH) paediatricians (0113 8432001) *for children residing in Leeds only.
5. All direct disclosures by or observations of under 18s with FGM must be referred to the Police via 101 and completion and submission of West Yorkshire Police reporting proforma: See Appendix G. (Please check if this has already been done during the strategy meeting discussion).  
6. Any completed risk assessments and the outcome of any strategy meetings should be shared with the LTHT Children’s and Midwifery Safeguarding team.
7. The child’s GP and the 0-19 team (0113 8434527 / 8435683 or email hvspa.safeguarding@nhs.net) should be informed by the reporter.
8. Where a clinician identifies a female relative (e.g. sister) of a child with FGM, it is the responsibility of the clinician to inform the woman or female child’s GP and/paediatric clinical lead.
9. Please also refer to the Safeguarding Children Policy;  

Reporting FGM Process

There are two types of reporting required by the NHS. The first is mandatory and the second is required recording.

1. Mandatory Reporting

LTHT patients who are under 18

The NHS have a responsibility to report FGM that has already occurred in females under the age of 18. This is known as the FGM Mandatory Reporting Duty and is a legal duty provided for in section 5A of the FGM Act 2003⁷ (as amended by the Serious Crime Act 2015⁹). It requires regulated health and social care professionals and teachers to report to the police cases of FGM in girls under 18 if, in the course of their professional duties, they see signs or symptoms indicating that a girl has undergone FGM or if she tells the professional that she has undergone it. Complying with the duty does not breach any confidentiality requirement or other restriction on disclosure which might otherwise apply.

At LTHT, children under the age of 18 who are noted to have undergone FGM are referred to LCH community teams for assessment and follow up. Therefore it is the responsibility of LCH to report this via the Mandatory reporting process. LTHT staff would only need to refer the female child to LCH as per normal process.

LTHT patients who are 16-17 years old and who are pregnant

There are some anomalies such as 16-17 year old females who may be attending our maternity services when they are pregnant. In this instance it would be appropriate for the specialist FGM midwives to examine the young person and therefore have the necessary information to record the mandatory data. This will be done via the midwifery electronic patient record (K2) in a monthly report led by LTHT Informatics reporting team.

LTHT patients under 16 years old who are pregnant

On the occasion that there is a under 16 year old who is pregnant and also a victim of FGM then they would need a referral to LCH as per the normal process for children and therefore LCH will report the mandatory data. Please also consider discussion with the MCA/MHA team in relation to capacity queries.

2. Required Recording for FGM-Enhanced Dataset

Over 18

NHS Digital collects data about women and girls who have undergone FGM and who are being cared for by the NHS in England. This is the FGM Enhanced Dataset. The purpose of this data collection is to build a national picture of prevalence, and to support work in the NHS to prevent and treat FGM. The data is collected whenever a woman is identified in a healthcare setting in England as having undergone FGM and the FGM could have happened at any point in the past. This means that the Enhanced Dataset will record cases which are not eligible for mandatory reporting (for example, where FGM is identified in a patient who is over 18). The FGM Enhanced Dataset requires organisations to record, collect and return detailed information about FGM within the patient population, as treated by the NHS in England. At LTHT this information is reported monthly by the FGM Lead Consultant who reports on NHS digital directly and Adult Safeguarding team to the LTHT Informatics reporting team. For more information on this please see attached link Clinical Audit Platform - NHS Digital

Under 18

The FGM-IS  (Information Sharing)  system¹² is a national digital system which shares information within the healthcare record of a female under 18 - if she has a family history of FGM - between authorised healthcare professionals and administrative staff across England. FGM-IS supports effective early intervention and on-going safeguarding of girls who are potentially at risk of FGM. It includes information such as family history and risk indicators including those under the care of midwifery who give birth to female babies. The data is removed once the child reaches their 18th birthday and the risk is minimised. At LTHT this information is currently recorded monthly by the FGM Midwives for 16-17 year olds. Any under 16’s will be reported by LCH. 

Identified named contacts within service/divisions are to ensure data is collected and submitted. Advice and support will be offered from the Trust Safeguarding team on: 0113 3923937 Children’s & Midwifery/0113 2066964 Adults.

Training

In all Trust Safeguarding mandatory training FGM is included there however additional training is available on the national training platform and this is available for all NHS employees via the link: http://www.e-lfh.org.uk/programmes/female-genital-mutilation/

10 Safeguarding Children and Young People: Roles and Competencies for Healthcare Staff | Royal College of Nursing (rcn.org.uk)

11 https://westyorkscb.proceduresonline.com/p_fem_gen_mut.html

7 https://www.legislation.gov.uk/ukpga/2003/31/contents

9 https://www.legislation.gov.uk/ukpga/2015/9/contents/enacted

12 Female Genital Mutilation - Information Sharing - NHS Digital

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5. Key Staff and Committees/Groups

Trust Board

The Trust Board has a responsibility to ensure that there is a procedure in place and complied with to protect women and female children who have undergone FGM or at risk of FGM (HM Government, 2015¹).

Chief Executive

The Chief Executive devolves the responsibility for compliance and monitoring to the Chief Nurse/Chief Operating Officer, ensuring that the Trust meets its statutory and non-statutory obligations in respect of maintaining required standards in relation to FGM.

Chief Nurse

The Chief Nurse/Chief Operating Officer is the Executive lead for safeguarding and is responsible for ensuring that Trust staff uphold the principles of FGM guidance; and the Trust’s Adult and Children Safeguarding Policies are effectively managed and implemented.

Nurse Director (Corporate) Deputy Chief Nurse

The Chief Nurse/Chief Operating Officer is responsible for:

The implementation and operation of the FGM procedure;

• Ensuring staff know how to report and record FGM cases.
• Ensure staff understand their roles in safeguarding children in respect of FGM
• Supporting the delivery of FGM training;
• Reporting overall compliance to the Trust Board as required at a strategic level;
• Building and strengthening local partnership and inter-agency working to prevent incidences of FGM.
• Representing the Trust at local FGM strategic forums.

Director of Informatics

The Director of Informatics is responsible for:

• Effective management and processes in place required to ensure national compliance with NHS digital national FGM mandatory and required reporting  dataset;
• Having systems in place to record FGM data on to the national prevalence dataset.

Head of Safeguarding (Adult and Children)

The Head of Safeguarding is the designated Trust lead for FGM and is responsible for

• Ensuring the principles and risks of FGM are reflected in Trust safeguarding policy;
• Incorporating FGM into safeguarding training;
• Contributing to Leeds Safeguarding Children and Adult Board multi-agency FGM.

FGM Clinical Leads

The Trust FGM Clinical Leads are responsible for:

• Providing clinical advice and guidance to practitioners in cases of FGM;
• Supporting and providing clinical advice to women and female children with FGM.
• Act as key contacts for clinical education and expertise in FGM.

Safeguarding Team

The Trust Safeguarding Team are responsible for:

• Supporting and providing advice to staff on the FGM procedure and its implications/direct link to the wider ‘safeguarding children and adult procedures and  requirements;
• Provide and support the delivery of FGM training throughout the Trust;
• Act as key contacts for advice on the management of cases of FGM;
• Liaising with West Yorkshire Police on specific cases of FGM in under 18 year old female children.

Clinical Service Units (CSUs) - Clinical Director, Heads of Nursing

The CSU Clinical Directors and Heads of Nursing are responsible for:

• Supporting the implementation of the FGM procedure within their areas of responsibility ensuring staff within the CSUs are aware of and implement the FGM procedure requirements;
• Facilitating reporting and recording of FGM;
• Ensuring that staff receive mandatory safeguarding training;
• Ensuring that reported FGM cases are recorded on national enhanced dataset;
• Ensuring all cases of FGM in female children under 18 years of age have safeguarding children policies and procedures followed.

Department Managers

Department Managers are responsible for:

• Ensuring that the requirements of the FGM procedure are effectively managed within their Department and that their staff are aware of, and implement requirements;
• Ensuring that staff record FGM cases on national enhanced dataset systems.
• Arranging for staff to undertake FGM training as required;
• Advising staff on the processes to record and report FGM, facilitate escalation of FGM safeguarding concerns and liaise with Trust Safeguarding teams.

All Staff and Volunteers

All staff and volunteers are responsible for:

• Reporting all FGM related concerns to their Manager, Safeguarding Lead, Social work services and the police as required.
• Undertaking FGM training as required;
• Understand when to raise a safeguarding children or adult concern in respect of FGM.

Contribute to discussions following an incident in order for any lessons to be learnt and/or improvements to be made.

1 HM Government - Multi-agency statutory guidance on Female Genital Mutilation (publishing.service.gov.uk)

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6. Equality Analysis

Patients  who were assigned female at birth (AFAB) and have had FGM performed on them and whom are now presenting as a male or trans can be offered the same services for support. In these cases it would be appropriate to clarify at which stage they are in their transitioning to clarify which service would be able to best support their needs.

This Procedure has been assessed for its impact upon equality. The Leeds Teaching Hospitals NHS Trust is committed to ensuring that the way that we provide services and the way we recruit and treat staff reflects individual needs, promotes equality and does not discriminate unfairly against any particular individual or group.

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7. Consultation and Review Process

This policy has been presented at both the Safeguarding Children’s Trust wide Steering Group meeting and Safeguarding Adults Trust wide Steering Group with representatives from the Trust (including medical teams and nursing staff) and CCG present. The community blossom clinic were also consulted.

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8. Standards/Key Performance Indicators

This Standard Operating Procedure will be monitored through the return of monthly data from services and departments across the Trust.

Audit activity will be identified by Trust Safeguarding Committee in relation to recording in health records.

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