Female Genital Mutilation: professionals, policy and practice Obi Amadi - Lead Professional Officer 12 September 2015

Efua Dorkenoo OBE An inspirational leader whose integrity and dedication galvanised a movement for women and girls globally to End FGM.

More than 125 million girls and women alive today have suffered some form of female genital mutilation in the 29 countries where the practice is concentrated. 3 million girls in Africa undergo FGM each year. 137,000 affected women and girls, 0 – 50 years resident in E & W

 66,000 women in UK have undergone FGM  22,000 girls at risk of FGM  1.4% of all maternities Increasing numbers of asylum seekers and economic migrants from areas of Africa where FGM is practised.

World Health Organisation (WHO) classification of FGM: Type I: Partial or total removal of the clitoris (clitoridectomy). Type II: Partial or total removal of the clitoris and the labia minora, with or without excision of the labia majora.

Type III: Narrowing of the vaginal orifice with creation of a covering seal by cutting and appositioning the labia minora and/or labia majora with or without excision of the clitoris (infibulation). Type IV: All other harmful procedures to the female genitalia for non- medical purposes, for example: pricking, piercing, incising, scraping and cauterisation.

Immediate Physical Complications Death - no figures available  Due to haemorrhage, neurogenic shock and septicaemia Haemorrhage  Commonest complication 22% Injury to other organs  Urethra, rectum, perineum, vagina Blood borne infections due to dirty/shared instruments eg HIV, Hep B

Long-term Physical Complications Recurrent abscess formation / fistulae / Failure to heal / Cysts Pelvic inflammatory disease / pelvic pain  3x more likely in infibulated women due to ascending infection at the time or accumulation of discharge and menses Infertility - no evidence of magnitude Urinary -  Chronic urinary tract obstruction, infection, Incontinence, retention Psychosexual Complications  Pain, reduced sexual pleasure During Labour  Higher rates of Caesarean Section, PPH, episiotomy, perineal tears & increased perinatal deaths (WHO Multicountry Study, 2006)

Psychological Impact Trauma Flash backs Post Traumatic Stress Disorder Social factors  Vital need for counselling & other psychological support services

Existing Framework Female Circumcision Act (1985) Female Genital Mutilation Act (2003) Multi-agency Practice Guidelines (2011) DH (2013) DHSSPHNI Cabinet Office (2012) Working Together to Safeguard Children (2015) Ministry of Justice (2014)

Child Early Forced Marriage 15 million girls are forced into marriage Over 700 million women alive today were married as children. One in every three girls in the developing world is married by the age of 18 Childbirth complications are the leading cause of death, Denies girls their right to childhood, disrupts their access to education and jeopardizes their health

Child Early Forced Marriage They need special protection to promote their physical, mental, spiritual, moral, and social development Over 700 million women alive today were married as children. Child prostitution, child pornography and trafficking in children Universal Declaration of Human Rights (UN)

Recommendations 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. 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. 8. Empower and support affected girls and young women (both those at risk and survivors): This should be a priority public health consideration; health and education professionals should work together to integrate FGM into prevention messages (especially those focused on avoiding harm, e.g. NSPCC ‘Pants’ Campaign, Personal, Social and Health Education, extracurricular activities for young people). 9. Implement awareness campaign: The government should implement a national public health and legal awareness publicity campaign on FGM, similar to previous domestic abuse and HIV campaigns.

New Emphasis Legislation  Legal changes that will mean parents can be prosecuted if they fail to prevent their daughter being cut.  New legislation to grant victims of FGM lifelong anonymity from the time an allegation is made.  Criminal Justice Act 2015 introduction of FGM protection orders. CEFM orders already in existence. Mandatory reporting  Consulting on how it will be implemented and sanctions for professionals who fail to report.

First Figures (Sept 2014 – March 2015)  3,963 newly identified  60 newly identified <18 years In March (2015) alone:  3,146 active cases  578 newly identified 145 of the 160 eligible acute trusts in England submitted signed-off data.

Steps to Change Awareness raising  Past surveys have shown professionals lack knowledge and awareness about this form of abuse and that it is illegal. It is part of your safeguarding duty and you should be familiar with local policy. Encourage professionals and individuals to engage  There will be a national campaign to raise awareness as all public sector workers need to be aware of the issue and risk of not reporting.  Commitment from board to floor

Encourage local implementation  Practitioners should be following existing guidelines: Multi- agency Practice guidelines  Revisit them and ensure you are familiar with what the expectations are. Support National Campaigns  Be aware of what government and campaigners are saying. Undertaking eLearning training  Does include a basic introduction on what FGM is & its incidence. Shared success stories  Spread good practice in tackling these issues - learn from individuals from affected communities who are now driving through changes

Latest developments NSPCC  Practitioners should be following existing guidelines: Multi- agency Practice guidelines Declaration on UK progress since Girl Summit it-2014 NEW NHS Choices video Trailer released Consultation on statutory multi-agency practice guidance ce-guidance-on-female-genital-mutilation-fgm. ce-guidance-on-female-genital-mutilation-fgm NSPCC Guidance for professionals ns-symptoms-and-effects/

FURTHER INFORMATION Tackling FGM in the UK. Pdf version: Home Affairs Committee: Female Genital Mutilation: the case for a national action plan: htm Multi-Agency Practice guidelines FGM: e/216669/dh_ pdf Communication from the Commission to the European Parliament & The Council: equality/files/gender_based_violence/131125_fgm_communication_en.pdf NSPCC Factsheet: ale-genital-mutilation_wda96841.html

Contact details for specialist FGM support services The Royal College of Obstetricians and Gynaecologist – FGM and its management: Obi Amadi, Lead professional officer - Metropolitan Police Child Abuse Investigation Command / Project Azure – / NSPCC FGM helpline / Black Women’s Health and Family Support / ,

CPHVA and SAPHNA A Practice Guide with Resources for Health Visitors and School Nurses Department of Health England

Mandatory Reporting Section 5B of the FGM Act 2003 (“the 2003 Act”) introduces a mandatory reporting duty which requires regulated health and social care professionals and teachers in England and Wales to report ‘known’ cases of FGM in under 18s to the police. The duty comes into force from October As inserted by section 74 of the Serious Crime Act 2015.

Mandatory reporting “Known” cases where either a girl informs that an act of FGM has been carried out on her, or where the person observes physical signs on a girl to show that an act of FGM has been carried out and the person has no reason to believe that the act was, or was part of, a surgical operation within section 1(2)(a) or (b) of the FGM Act For more information, see sections 2.1a and 2.1b.

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Thank you Any Questions?