Female Genital Mutilation Update November 2015 Carmel Bagness RCN Professional Lead Midwifery & Women’s Health

Female Genital Mutilation WHO (2000) defines FGM as ‘procedures involving partial or total removal of the external female genitalia or other injury to the female genital organs whether for cultural, religious or other non-therapeutic reasons’. 130 million worldwide (WHO 2012) 137,000 women and girls living in the UK who have been affected by FGM Macfarlene (2015)

FGM is practised in about 28 African countries, the Middle East and South East Asia. Women and girls who have undergone FGM are also found in Europe, Canada, USA and Australia because of the increasing movement of communities and individuals between countries (WHO, 2000). Movements of people seeking refuge and asylum from the Horn of Africa has led to the situation now being taken more seriously in the UK than once was the case. The situation worldwide: ✦ 100 million to 140 million girls and women have undergone some form of FGM, the majority from Africa (WHO, 2000) ✦ an estimated 2 million or more undergo some form of FGM every year worldwide, and 6,000 are at risk every day (WHO,1997) ✦ many girls and women die from the short-term effects of FGM, such as haemorrhage, shock or infection ✦ many more suffer lifelong disability and may die from the long-term effects such as recurrent urinary or vaginal infections. Pain during intercourse and infertility are common consequences of FGM ✦ FGM increases the risk of women dying during childbirth and makes it more likely that the baby will be born dead. This increased risk can be as a result of severe bleeding and obstructed labour in places where safe and appropriate maternal health services are inadequate or inaccessible. In Somalia, where between 90% to 98% of women are infibulated, one in every 100 women giving birth dies as a result of this procedure.

UK Law Acts of Parliament have made it a criminal offence for anyone to perform, aid, abet, or counsel to procure FGM in the United Kingdom. It is also illegal to take a child out of the country to perform FGM. Prohibition of Female Circumcision Act 1985 Female Genital Mutilation Act 2003. The 2003 Act applies to England Wales and Northern Ireland. Scotland has passed the Prohibition of Female Genital Mutilation (Scotland) Act 2005. Serious Crime Act 2015

Tackling FGM in the UK 1. Treat it as Child Abuse 2. Document and collect information 3. Share that information systematically 4. Empower frontline professionals 5. Identify girls at risk and refer them as part of child safeguarding obligation 1. Treat it as Child Abuse: FGM is a severe form of violence against women and girls. It is child abuse and must be integrated into all UK child safeguarding procedures in a systematic way. 2. Document and collect information: The NHS should document and collect information on FGM and its associated complications in a consistent and rigorous way. 3. Share that information systematically: The NHS should develop protocols for sharing information about girls at risk of – or girls who have already undergone – FGM with other health and social care agencies, the Department for Education and the police. 4. Empower frontline professionals: Develop the competence, knowledge and awareness of frontline health professionals to ensure prevention and protection of girls at risk of FGM. Also ensure that health professionals know how to provide quality care for girls and women who suffer complications of FGM.

Tackling FGM in the UK 6. Report cases of FGM 7. Hold frontline professionals accountable 8. Empower and support affected girls and young women (both those at risk and survivors) 9. Implement awareness campaign http://www.rcn.org.uk/__data/assets/pdf_file/0004/547996/Tackling_FGM_in_the_UK_Intercollegiate_recommendations_for_identifying,_recording_and_reporting.pdf 5. Identify girls at risk and refer them as part of child safeguarding obligation: Health professionals should identify girls at risk of FGM as early as possible. All suspected cases should be referred as part of existing child safeguarding obligations. Sustained information and support should be given to families to protect girls at risk. 6. Report cases of FGM: All girls and women presenting with FGM within the NHS must be considered as potential victims of crime, and should be referred to the police and support services. 7. Hold frontline professionals accountable: The NHS and local authorities should systematically measure the performance of frontline health professionals against agreed standards for addressing FGM and publish outcomes to monitor the progress of implementing these recommendations.

What is happening in England? Ministry of Justice / Home Office Department of International Development /Foreign & Commonwealth Office Department of Education Department of Health Guidance for teachers including nursery schools International Campaign : £35 million programme to support an Africa led movement to end FGM – supporting 17 countries Law enforcement, including prosecutions UK Borders Agency National FGM Programme NHS England: Operational strategy for implementation across Health & Social Care Health Education England – multi professional e learning modules Public Health England – Safeguarding

and the rest of the UK………… Wales Scotland Northern Ireland Women and girls, fathers, partners families communities and support groups Media & Public Awareness Royal Colleges and Professional Organisations Doctors, nurses, midwives, police, teachers, social workers Nurses & Midwives understanding FGM and the safeguarding procedures to support best practice

Messages : Health & Social Care Professional Curiosity Understanding the local community Safeguarding Procedures Mandatory Reporting Data Collection and Use Protection of women and girls Service Provision – Physical & Psychological, Psycho sexual Care

Applies to England and Wales only Serious Crime Act (2015) – Changes to FGM Act 2003 Clause 68: Anonymity for victims Clause 69: Offence for failing to protect Clause 70: Protection orders Clause 74: Mandatory Duty Serious Crime Act 2015 introduced a new duty for regulated health, social care and teaching professionals to report cases of FGM when identified in a girl under 18 or disclosed by her to a professional and to the police. Applies to England and Wales only

Female Genital Mutilation (FGM) is child abuse and illegal Female Genital Mutilation (FGM) is child abuse and illegal. Regulated health and social care professionals and teachers are required now to report cases of FGM in girls under 18s which they identify in the course of their professional work to the police. This is a personal duty; it cannot be transferred to anyone else.

What do I need to do? Discuss with local safeguarding lead to identify if there are other safeguarding action required, and how these will be taken forward Telephone ‘101’, the non-emergency crime number Make a record of your actions, and write down the Police reference number Make sure that you / someone with access to all the information is available to discuss further with the police lead investigator

Which cases does this cover? Within scope of DUTY Within scope of existing safeguarding processes Girls under 18 who disclose they have FGM Using all accepted terminology Cut Circumcised Sunna Other words – link to the list When you see physical signs appearing to show she has had FGM You have no reason to believe it was for the girl’s physical or mental health or for purposes connected with labour or birth Remember this includes genital piercings and tattoos for non-medical reasons Adult woman (18 and over) has had FGM Parent/guardian discloses that child has had FGM You believe a girl is at risk of FGM You think a girl might have had FGM but she has not disclosed, and you have not seen any signs/symptoms

What if I don’t make the report? Failure to comply may be considered through existing Fitness to Practise proceedings with your regulator Regulators will, as with all other matters, consider professionals ability currently to practise safely and take into account the circumstances of the case. The safety of the girl or other individuals at risk of harm is paramount.

Mandatory Reporting duty within Safeguarding context FGM happened Suspected Risk / sibling / other types of harm / other considerations FGM MR Duty EVERYTHING IS PART OF… Safeguarding children and vulnerable adults from harm

Enhanced Data Set Safeguarding of girls and women To improve Awareness To enhance Provision of service To improve management of FGM

Enhanced Data Set mandatory data collection General Practitioners, Mental Health Trusts and Acute Trusts (mandatory since 1 July 2015). Sexual health and GUM (Genito-Urinary Medicine) clinics are required to have regard to the FGM Enhanced dataset standard from October 2015. The data collected is sent to the Health and Social Care Information Centre (HSCIC), where it is anonymised, analysed and published in aggregate form.

Your role…………… Curiosity and Awareness Encourage individuals to engage Understand local implementation Support National Campaigns Collaboration and Multi agency working Professional responsibility and duty to care and protect.