Female Genital Mutilation ( FGM ) - Standard Operating Procedure for recording and reporting

Publication: 26/05/2016  --
Last review: 04/09/2019  
Next review: 31/08/2021  
Standard Operating Procedure
CURRENT 
ID: 4658 
Supported by: Trust Wide Safeguarding Steering Groups
Approved By: Chief Nurse / Deputy CEO 
Copyright© Leeds Teaching Hospitals NHS Trust 2019  

 

This Standard Operating Procedure is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

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

  1. Purpose
  2. Scope
  3. Background
  4. Definitions/Abbreviation
  5. Legislation and policy
  6. Procedure to be followed
  7. Roles and responsibilities
  8. Links to other documents
  9. Monitoring arrangements
  10. Appendix 1 - Leeds workflow for Female Genital Mutilation
  11. Appendix 2 - Female Genital Mutilation - Mandatory Reporting to Police. Pro-Forma for Use by Health, Teaching and Social Care Professionals
  12. Appendix 3 - FGM Blossom Gynaecology Clinic
    FGM Blossom Gynaecology Clinic - Appendix E - Proforma for deinfibulation
    FGM Blossom Gynaecology Clinic - Appendix F - Template for collection of FGM prevalance data

1. Purpose

This guidance is for all clinicians and CSU’S across Leeds Teaching Hospitals NHS Trust and includes guidance where Safeguarding Children procedures are indicated. The purpose of this SOP is to:

  1. Standardise procedures for recording and sharing information in relation to FGM to safeguard women and 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 children from harm.

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2. Scope

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.
  • Identifying when a woman or girl may be at risk of being subjected to FGM and responding appropriately to protect the her;
  • Identifying when a girl or woman has been subjected to FGM and respond appropriately to support the woman or 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 procedures, Adults Safeguarding Policy and the FGM in Pregnancy, Childbirth and Postnatal Period and the Children’s Safeguarding Policy.

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3. Background

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 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 girl 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 to enquire whether a woman has had FGM.

It has been estimated that over 20,000 girls under the age of 15 are at risk of female genital mutilation (FGM) in the UK each year and 66,000 women in the UK are living with the consequences of FGM. However, the true extent is unknown, due to the ‘hidden’ nature of the crime.

FGM is deeply embedded in some communities and is performed for cultural, religious and social reasons within families and communities. It is usually carried out on girls 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 girl or woman, but FGM is an extremely harmful practice which violates basic human rights. The most significant risk factor for girls and women 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. Girls 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 girls have FGM performed in the UK.

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 should remain paramount when undertaking any assessments.

Practitioners, particularly those working  in health services should be aware of and consider potential indictors that FGM may be going to take place, or has already taken place;

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

Prevalence of FGM

FGM affects girls and women worldwide and is a major human rights issue. A report published by UNICEF in 2016 shows that more than 200,000,000 girls and women alive today in 30 countries in Africa, the Middle East and Asia have undergone FGM. Thirty million more are at risk over the next ten years.

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. The practice is almost universal up to 90%   Somalia, Guinea and Djibouti, although in Cameroon and Uganda only affects only 1% of girls and women. (UNICEF 2016)

The maps below illustrate the global prevalence of FGM:

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4. Definitions/abbreviation

FGM is defined as “All procedures which involve partial or total removal of the female external genitalia, or any other injury to the female genital organs, for non-therapeutic reasons.”

TYPES OF FGM

World Health Organisation definitions below should be used to identify the type of FGM

Type 1: Partial or total removal of the clitoris and/or the prepuce (clitoridectomy).

Type 2: Partial or total removal of the clitoris and the labia minora, with or without excision of the labia majora (excision).

Type 3: Narrowing of the vaginal orifice with creation of a covering seal by cutting and appositioning the labia minora and/or the labia majora, with or without excision of the clitoris (infibulation).

Type 4: All other harmful procedures to the female genitalia for non-medical purposes, for example: pricking, piercing, incising, scraping and cauterization.

Deinfibulation: The surgical procedure to open up the vagina of woman who have experienced FGM Type 3

Reinfibulation: The re suturing of FGM type 3, usually after childbirth.

FGM is known by a number of names, including female genital cutting or circumcision. The term female circumcision is unfortunate because it is anatomically incorrect and gives a misleading analogy to male circumcision. The names ‘FGM’ or ‘cut’ are increasingly used at the community level, although they are still not always understood by individuals in practicing communities, largely because they are English terms.

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5. Legislation and policy

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 2003. This Act came into force on 3rd March 2004; it repeals the Female Circumcision Act 1985 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.

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 circumcision, they’re committing an offence. Other families want to protect their girls 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 girls under 18. NHS England have provided additional guidance for health professionals available at https://www.gov.uk/government/publications/fgm-mandatory-reporting-in-healthcare/how-to-report-female-genital-mutilation-guidance-for-health-professionals If an offence of FGM is committed against a girl under the age of 18, each person who is ‘responsible’ for the girl at the time the FGM occurred, will be liable for prosecution. The ‘responsible’ person will have parental responsibility for the girl 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.

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6. Procedure to be followed

All Females presenting at LTHT with FGM must be considered potential victims of crime in line with the intercollegiate recommendations.

All non-pregnant adult women over 18 with FGM, identified through clinical assessment or self-disclosure must be referred to the Gynaecology FGM Lead. Please also refer to the Safeguarding Adults Policy. detail.aspx?ID=1206

All pregnant women over 18 presenting at LTHT must be referred to the FGM clinic, where a thorough risk assessment will be undertaken. Where appropriate, a referral will be made to Children Social Work Services (CSWS), support services, and if required, the Police.

All girls (under 18 regardless of being pregnant or not) presenting, self-disclosing FGM or considered at risk of FGM must be formally referred

  1. CSWS and the ‘Record of Contact’ form completed as per the link; http://lthweb.leedsth.nhs.uk/sites/safeguarding/children/request-for-services/request-for-services
  2. Trust Safeguarding Children and Midwifery Team informed and a copy of the above referral sent to leedsth-tr.SafeguardingChildren@nhs.net
  3. The paediatric clinical lead/ Named Doctor for Safeguarding Children must also be informed by the reporter.
  4. 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 2
  5. Please also refer to the Safeguarding Children Policy.
    detail.aspx?ID=587

The Trust Safeguarding Children team will provide support regarding this process. See LSCP Flow chart Appendix1. *FGM Child Protection Examinations are currently undertaken by Leeds Community Health paediatricians (0113 8432001) for girls residing in Leeds only.

Recording FGM Information

The FGM information captured is needed to help provide a consistent approach to sharing FGM information locally and includes the following;

  1.  All clinicians are required to record in medical notes/health records when FGM is identified using the FGM clinical codes. This includes whether this is identified by physical examination or reported/disclosed without physical examination. The type of FGM should also be recorded following clinical examination. Please note clinical examinations should only need to be undertaken as part of a usual, routine or requested provision of care – there is no expectation for all clinicians to undertake a clinical examination in order to record the type of FGM. The importance of using the correct terminology when recording FGM enables the FGM Dataset to be populated accurately. For further clinical advice please contact Gynaecology FGM Lead for women over 18 years of age and the Named Doctor for Children related to girls under 18 years of age.
  2. All Maternity discharges shared with the GP and Health Visitor must contain the type of FGM identified, the date and actions/outcome of the FGM assessment undertaken. This includes where no safeguarding risks have been identified and includes females who are not resident in Leeds but access services at Leeds Teaching Hospitals. Please refer to Women’s CSU maternity procedure FGM in pregnancy, childbirth and postnatal period.
  3. All female babies born to a mother with FGM must have the relevant FGM information recorded in the baby’s health record and PCHR Red Book to help identify the potential risk of FGM facing the girl. Refer to Women’s CSU maternity procedure FGM in pregnancy, childbirth and postnatal period
  4. Where a clinician identifies a female family relative (sister) of a girl with FGM, it is the responsibility of the clinician to inform the woman or girls GP and clinical lead.
  5. When FGM is identified both health promotion and information regarding FGM legislation MUST also be provided and this should be fully documented.
  6. When a female under the age of 18 has had FGM identified her GP and Clinical Paediatric lead should be informed and this should be clearly documented in the clinical notes and/or in the discharge summary. This should also be formally reported to Children Social Work Services, the Trust Safeguarding Children and Midwifery team, Police, the Health Visitor (for under 5’s) or the girl’s School Nurse (if over 5).

Reporting FGM Information

FGM data is to be collected on a monthly basis by the agreed service lead using the Trust FGM data collection template and submitted to the Trust Informatics department. The following information is provided to the Trsut Informatice Team:

The following information should be recorded on the FGM Data Collection template:
NHS number – this will identify whether this is a new case *
Date of birth of patient – this will identify whether this is an adult or child *
Postcode of usual address *
Forename and surname *
Country of Birth
Region of Country of Birth
GP registration code *
Care contact date *
Referring organisation type
Site/Code of Treatment *
Treatment function *
Pregnancy Status *
FGM Identification *
FGM Family history
Number of daughters under 18 *
Advised on health implications of FGM * Confirmation, that the woman has been advised on the health implications of FGM
Advised on legal implications of FGM *Confirmation that the woman has been advised that FGM is illegal
Daughters born at this attendance *
Country of birth baby’s father
Country of origin of baby’s father
FGM type * only when a physical examination (as part of routine, usual or requested provision of care for a woman) is undertaken and when FGM has been identified, the FGM Type MUST be recorded. It is NOT required that every clinician has to perform a physical examination solely in order to populate the FGM Enhanced dataset.
If a physical examination is not undertaken but disclosure is made this should be recorded as self- reported

If FGM cannot be clearly identified, then the clinician MUST record;

  • FGM Type Unknown

When FGM Type 4 is identified this SHOULD be qualified with the following FGM Type 4 qualifiers;

  • Pricking
  • Piercing
  • Cauterisation
  • Incising
  • Scraping

FGM Type 4 qualifier * If Type 4 is identified, but it is not possible to clearly identify the specific FGM Type 4, then FGM Type 4 MUST still be recorded without a qualifying code

De-infibulation undertaken * Confirmation that a de-infibulation procedure took place to facilitate the delivery of a birth where applicable.

Age when FGM undertaken • Age at which the woman had FGM if specified or confirmation of the following;

  • Under 1
  • Between 1 and under 5
  • Between 5 and under 10
  • Between 10 and under 15
  • Between 15 and under 18
  • Over 18
  • Didn’t say or 0113
  • Unknown
  • Country where FGM undertaken

Please note * denotes mandatory field.

Trust FGM Data Reporting Process

Contact with any health professional provides the opportunity for screening, identification or disclosure of FGM.

Were clinical staff identify concerns about FGM there is a requirement to record and report FGM and include FGM as part of a wider assessment.

When FGM Is identified this will require further consideration of health needs and safeguarding adult and children procedures.

Service /departments are required to collect monthly data using Trust FGM dataset of all FGM cases.

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 39 23937 / 0113 2066964

Service/departments are to submit the data to the Trust Informatics Team.

The Safeguarding Children Team review data to identify any actions where there are indicated risks identified that require a child protection referral.

Safeguarding Children

If it is thought that an adult has undergone FGM it is important to consider the implications for all females in the family. Staff need to be familiar with Leeds Safeguarding Children Partnership Procedures in relation to FGM:
http://westyorkscb.proceduresonline.com/chapters/p_fem_gen_mut.html

A flow chart and FGM assessment is available to identify where a child or young person may be at risk of significant harm (Appendix 1, LSCP Flowchart) but is also available on the LSCP website:

The Safeguarding Children team are able to offer advice and guidance where there are concerns about FGM.

The Safeguarding Children team should be informed about all cases of FGM where risks are identified and a referral is made to Children Social Work Services. The completed risk assessment and the outcome of any strategy meetings should be shared with the Safeguarding team.

Regulated health professionals are required to report cases of FGM in children aged under 18’s to the police using the local police reporting form as per appendix 2.

Training.

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

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7. Roles and responsibilities

Trust Board
The Trust Board has a responsibility to ensure that there is a procedure in place and complied with to protect women and girls who have undergone FGM or at risk of FGM (HM Government, 2015).

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 as 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 HSCIC national FGM prevalence 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 girls 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 girls.

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 under 18 year old girls that safeguarding children procedures are 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 attend 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 team.

All Staff and volunteers
All staff and volunteers are responsible for:

  • Reporting all FGM related concerns to their Manager, Safeguarding Lead and the police as required.
  • Attending FGM training as required;
  • Understand when to raise safeguarding children 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.

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8. Links to other documents

http://westyorkscb.proceduresonline.com/chapters/p_fem_gen_mut.html

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9. Monitoring arrangements

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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Appendix 1 - Leeds Workflow for FGM

Provenance

Record: 4658
Objective:
Clinical condition:

Female Genital Mutilation (FGM)

Target patient group:
Target professional group(s): Secondary Care Doctors
Secondary Care Nurses
Midwives
Adapted from:

Evidence base

Rerferences

  1. Prohibition of Female Circumcision Act. 1985 United Kingdom available at www.statutelaw.gov.uk
  2. Female Genital Mutilation Act 2003. Available at www.hmso.gov.uk
  3. https://www.gov.uk/government/publications/female-genital-mutilation-guidelines
  4. https://www.gov.uk/government/publications/female-genital-mutilation-resource-pack/female-genital-mutilation-resource-pack
  5. https://www.rcog.org.uk/globalassets/documents/guidelines/gtg-53-fgm.pdf
  6. http://westyorkscb.proceduresonline.com/chapters/p_fem_gen_mut.html#law

Approved By

Chief Nurse / Deputy CEO

Document history

LHP version 1.0

Related information

Not supplied

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