Female Genital Mutilation
Risk and Safeguarding
Guidance for professionals
May 2016

Female Genital Mutilation
Risk and Safeguarding
Guidance for professionals
Prepared by FGM Prevention programme team, Department of Health
Female Genital Mutilation Risk and Safeguarding
Contents
Contents

Female Genital Mutilation Risk and Safeguarding
Chapter 1. Safeguarding against FGM 1
Chapter 1. Safeguarding against FGM
Safeguarding against FGM
FGM is not an issue that can be decided on by personal preference – it is an illegal, extremely
harmful practice and a form of child abuse and violence against women and girls.
Each NHS organisation will have local safeguarding protocols and procedures for helping
children and young people who are at risk of or facing abuse. These should include multiagency policies and procedures, consistent with those developed by their Local Safeguarding
Children Board. If organisations have not already done so, these should be reviewed to
include handling cases where FGM is alleged or known about or where there is a potential
risk of FGM identifed. These policies and procedures should consider the characteristics
around FGM, ensuring that the response to FGM includes the sharing of information with
multi-agency partners throughout the girl’s childhood, and that if, or when, the risk facing the
girl changes (which may mean it escalates or even becomes less immediate), this is identifed
and consideration is given as to whether or not a change in subsequent safeguarding
actions are required. It must always be remembered that fears of being branded ‘racist’ or
‘discriminatory’ must never weaken the protection that professionals are obliged to provide to
protect vulnerable girls and women.
As 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.1
One specifc consideration when putting in place safeguarding measures against FGM is that
the potential risk to a girl born in the UK can usually be identifed at birth, because through the
antenatal care and delivery of the child, NHS professionals can and should have identifed 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 signifcantly different timescale and profle 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.
1 https://www.gov.uk/government/publications/fgm-mandatory-reporting-in-healthcare
2 Female Genital Mutilation Risk and Safeguarding
This guidance has been developed to provide information about the specifc issues frequently
encountered when dealing with FGM. In addition, it provides a framework which organisations
may wish to adopt to support professionals in the ongoing consideration of risks pertaining
to 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 identifed as
being at risk of FGM and may need to be safeguarded from harm.
Information sharing in relation to FGM
Given the need to potentially safeguard over a number of years, it is appropriate to recognise
here that there are a number of different responses to safeguard against FGM, and
appropriate courses of action should be decided on a case by case basis, with expert input
from all agencies involved. Sharing information in line with agreed policies and procedures is
critical to safeguarding effectively. This is often sharing information to support safeguarding
across organisational boundaries.
All local organisations should make sure their safeguarding policies and procedures take into
account three nationally developed arrangements in relation to sharing information:
1. 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;
2. 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);
3. SCCI2026: FGM Enhanced Dataset2 – 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).
Whilst there is little information known about the number of active safeguarding cases in
relation to FGM in England, discussions with key stakeholders support the view that each
safeguarding response should be put in place taking into consideration the individual
circumstances, and that appropriate and high quality responses can widely vary when looking
at what action is taken.
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
of FGM.
2 http://www.hscic.gov.uk/isce/publication/scci2026
Chapter 1. Safeguarding against FGM 3
Multi-agency approach to safeguarding and when to refer
Working across agencies is essential to effective safeguarding efforts. This is referenced
throughout the HM Government Multi-Agency Statutory Guidance on FGM and should be a
central consideration whenever safeguarding girls from FGM.
Given the introduction of mandatory data recording and collection in the NHS (i.e. the
collection and submission of data in respect of the FGM Enhanced Dataset), and the
mandatory reporting duty (requiring reports to be made to the police all cases of FGM
identifed in patients under 18 years of age) there has been some confusion around when
referrals should be made to Children’s Social Services, and the national policy on this.
The sections below give some guidance regarding this.
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
101 non-emergency number.
If a vulnerable adult is identifed 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 confrm the girl has had
FGM. There is a standard published giving detail of what this specialist service must consist.3
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 identifed as being at risk of FGM, this information must be
shared with the GP and health visitor 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.
3 www.gov.uk/government/publications/fgm-mandatory-reporting-in-healthcare
4 Female Genital Mutilation Risk and Safeguarding
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 frst 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.
As already highlighted, there has been little research in outcomes of safeguarding against
FGM within the UK or similar health systems. However, there are multiple accounts that
women who have ongoing physical and/or psychological problems, and who recognise that
these are a result of FGM, are less likely to support or carry out FGM on their own children.
This is also reported in women who are involved or highly supportive of FGM advocacy work
and eradication programmes. However, any woman may still be under pressure from her
husband, partner or other family members to allow or arrange for her daughter to be cut.
Wider family engagement and discussions with both parents and potentially wider family
members may be appropriate.
Chapter 2. Existing Guidance and legislative framework 5
Chapter 2. Existing Guidance and
legislative framework
The status of this document
This document provides practice guidance and is designed to provide an example which can
be used to implement day-to-day frontline processes; it is not a substitute for existing multiagency practice guidelines or statutory guidance.
Multi-agency Statutory Guidance on Female Genital Mutilation
In 2016, the government launched statutory multi-agency guidance on FGM.4 The guidance
aims to provide information on FGM, to provide strategic guidance on FGM and to provide
advice and support to front-line professionals.
No single agency can adequately meet the multiple needs of someone affected by FGM. This
guidance encourages agencies to cooperate and work together to protect and support those
at risk of, or who have undergone, FGM.
The guidance provides information on:
• Identifying when a girl (including an unborn girl) or young woman may be at risk of FGM
and responding appropriately to protect them.
• Identifying when a girl or young woman has had FGM and responding appropriately to
support them, and
• Measures that can be implemented to prevent and ultimately help end the practice of
FGM.
The guidelines make clear that FGM is child abuse and a form of violence against women
and girls, and therefore should be dealt with as part of existing child and adult safeguarding/
protection structures, policies and procedures.
Working together to safeguard children
The Department for Education published statutory guidance in 2013 (updated in March 2015)
titled Working together to safeguard children.5
4 www.gov.uk/government/publications/multi-agency-statutory-guidance-on-female-genital-mutilation
5 www.workingtogetheronline.co.uk
6 Female Genital Mutilation Risk and Safeguarding
This guidance covers:
• the legislative requirements and expectations on individual local authority and school
services to safeguard and promote the welfare of children; and
• a clear framework for Local Safeguarding Children Boards (LSCBs) to monitor the
effectiveness of local services.
The guidance replaces Working Together to Safeguard Children (2010); The Framework for the
Assessment of Children in Need and their Families (2000); and statutory guidance on making
arrangements to safeguard and promote the welfare of children under section 11 of the
Children Act 2004 (2007). Links to relevant supplementary guidance that professionals should
consider alongside this guidance can be found at Appendix C.
This statutory guidance should be read and followed by a range of professionals including
those working in health services. Whilst the guidance does not make specifc provision for
safeguarding activities relating to FGM, it sets out requirements around information sharing
which are needed to effectively safeguard against FGM and all forms of child abuse.
Female Genital Mutilation Act 2003 and amendments brought through
the Serious Crime Act 2015
In England, Wales and Northern Ireland, FGM is illegal under the Female Genital Mutilation Act
20036 (this offence captures mutilation of a female’s labia majora, labia minora or clitoris), and
in Scotland it is illegal under the Prohibition of Female Genital Mutilation (Scotland) Act 2005.
Under the 2003 Act, a person is guilty of an offence if they excise, infbulate or otherwise
mutilate the whole or any part of a girl’s or woman’s labia majora, labia minora or clitoris,
except for necessary operations performed by a registered medical practitioner on physical
and mental health grounds; or an operation performed by a registered medical practitioner
or midwife (or a person undergoing training with a view to becoming a medical practitioner or
midwife) on a woman who is in labour or has just given birth, for purposes connected with the
labour or birth (these exceptions are set out in section 1(2) and (3) of the Act).
The Serious Crime Act 2015 strengthened the legislative framework around tackling FGM.
Mandatory reporting duty
One of the new measures introduced through Section 5B of the 2003 Act requires regulated
health and social care professionals and teachers in England and Wales to report ‘known’
cases of FGM in under 18s which they identify in the course of their professional work to the
police (the mandatory reporting duty). However, healthcare professionals are not expected
to investigate or make decisions upon whether a case of FGM was a crime or not, under the
legislation. All cases should be dealt with under existing safeguarding frameworks, which for
children under 18 who have undergone FGM would mean a referral to Children’s Social Care
and the police.
Health professionals and organisations can access a range of support materials, including
2-page process guide. These can be found at www.gov.uk/dh/fgm.
6 www.legislation.gov.uk/ukpga/2003/31/contents
Chapter 2. Existing Guidance and legislative framework 7
Other measures
Other measures were introduced through the Serious Crime Act 2015. This now includes:
• An offence of failing to protect a girl from the risk of FGM;
• Extra-territorial jurisdiction over offences of FGM committed abroad by UK nationals
and those habitually (as well as permanently) resident in the UK;
• Lifelong anonymity for victims of FGM;
• FGM Protection Orders which can be used to protect girls at risk.
For further information on these measures, see the FGM statutory guidance.7
7 www.gov.uk/government/publications/multi-agency-statutory-guidance-on-female-genital-mutilation
Female Genital Mutilation Risk and Safeguarding
Chapter 3. Methodology 9
Chapter 3. Methodology
Existing risk assessment frameworks/tools
During October and November 2014, the FGM Prevention programme team identifed and
collected a number of existing FGM risk assessment frameworks in use across NHS services.
The content of these ranged signifcantly.
The team reviewed the documents and compiled a single draft framework which aimed to
capture all potential risk from the frameworks reviewed, removing duplicated risk factors
and challenging whether each individual element could provide information pertinent to the
ongoing assessment of risk/potential risk.
Patient pathway analysis
The team identifed standard care pathways where risk or potential risk of FGM was likely to
be or could be identifed. The assumption was that clinicians were aware of the risk factors
and signs of which to be aware, and therefore were able to identify the opportunities to
consider risk of FGM.
In addition, the team approached this from a different direction by considering the full range of
risk factors which could lead to an FGM concern, or at least the need for further discussions
to take place.
It was identifed that whilst there are many contact points with women and girls where
potential FGM risk could be identifed; the concept of a discussion around safeguarding
could and should remain broadly constant. The questions and risk factors considered in each
discussion would not relate primarily to the type of care contact in which the discussion was
taking place, but to the patient, whether she is an adult or child, and whether she is pregnant.
Considering this work in conjunction with reviewing the existing risk assessment frameworks,
the model from Oxford LSCB had also identifed that their tool primarily worked on this basis.
This tool was therefore then reviewed, cross-referencing other documents, and developed into
a draft document.
10 Female Genital Mutilation Risk and Safeguarding
Workshop review
A number of workshop review sessions and individual consultation meetings were held with
stakeholders from across the professions, including acute, community and mental health
settings and with both extensive and more limited experience with FGM to date.
The stakeholders involved in these consultations are credited in Annex 2.
The document was reviewed, debated and circulated for comment, and amendments made
accordingly.
Pilot
Considering the limited timescales available to the FGM Prevention programme and the
challenge that any outcomes from effective safeguarding will take many years to evidence,
it was decided to publish guidance ahead of full piloting of the document. This guidance
was originally published in March 2015 ahead of full piloting of the document in order to
provide organisations and professionals with clear help in managing FGM in the context of
safeguarding.
Since then the guidance has been taken up by a number of organisations and reviewed as
part of the many workshops and events that have been taking place in the context of FGM
prevention work. Organisations which have been “early adopters” of the FGM RIS system
have also been using this guidance to determine whether a RIS indicator should be set in
respect of particular children. Feedback has been used both to make minor updates during
the year and also to produce this new version which has also been updated to include the
mandatory reporting duty, the FGM RIS, and an editable version of the risk assessment form.
As with all guidance, organisations will need to consider an appropriate implementation
schedule themselves, with options to review, adapt, initially pilot, assess outcomes, further
review, and introduce to standard local protocols and policies.
Chapter 4. How to use this document 11
Chapter 4. How to use this document
Local adaptation
The guidance includes a risk assessment framework tool which helps a professional to know
the type of risk to look for, and the specifc factors which are most likely to affect families with
girls who are at risk of FGM.
The tool is not exhaustive, however, it may be that working within a particular community,
there is a specifc risk factor. For example, it is known that in certain communities FGM is
closely associated with when a girl reaches a particular age. If a Trust/organisation is working
in an area where detailed risk factors such as this are known, the tool should be adapted to
incorporate this knowledge. However, care must be taken not to narrow the considerations
to too small a feld. Firstly, whilst it may be known what the population with the highest FGM
prevalence and/or with the highest number of patients within an area is, it is always possible
that patients from other communities will also present. If adapting the tool, always ensure that
this does not result in a narrowing that causes other patients who may need safeguarding to
be excluded.
Links with local safeguarding procedures and multi-disciplinary teams
The guidance must be reviewed and local processes updated to take into account how this
can be used in conjunction with the existing local safeguarding framework. Organisations
must also ensure processes take into account the mandatory reporting duty.
Frequent references are made within the guidance to the local safeguarding lead/framework.
When adapted to suit a local setting, it should be considered whether these references can
include specifc details of the local arrangements in place.
There are also regions in England where a policy to refer a child to either an FGM service
or to Children’s Social Care at birth is in place. This guidance is not intended to replace or
alter local processes and arrangements, but is a base-line tool which can be used in all
circumstances. If a threshold has been agreed between multi-disciplinary teams or at the
Local Safeguarding Children’s Board (LSCB), this will remain in place. Some LSCBs or areas
may decide to review this guidance and consider whether they wish to make any changes in
light of this, but it is not a mandated provision.
An important element in all the risk templates in Annex 1 is the consideration of whether
the patient (woman, child, pregnant woman) and/or her family are already known to social
services, and whether there are any existing safeguarding arrangements in place, prior to
12 Female Genital Mutilation Risk and Safeguarding
the identifcation of potential risk of FGM. In all situations, professionals should ensure they
consider whether there are already wider/active safeguarding issues associated with that
family being managed, and whether the social worker managing the case is aware that
concerns relating to FGM have newly been identifed. Any information identifed must be
shared.
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 health visitor or GP has been passed information from
a midwife about potential risk of FGM, at the next appointment with the woman/child, the
health visitor (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) http://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.
Training for healthcare professionals
Introducing a safeguarding process using this guidance will not replace the need to train
healthcare professionals.
NHS organisations and health and social care professionals can access an FGM e-learning
programme on the e-learning for healthcare website, www.e-lfh.org.uk, consisting of six
sessions providing training on all aspects of FGM and standard care provision principles.
NHS organisations should consider the training need within their organisation, and implement
a training plan accordingly. If adopted, the training should ensure that professionals are able to
confdently use this guidance.
Chapter 4. How to use this document 13
Information sharing processes
In April 2015, the Information Standards Board published SCCI2026 Female Genital
Mutilation Enhanced Dataset Information Standard8 and supporting documentation. This
standard requires all NHS organisations (including all mental health trusts and GP practices)
to record information about FGM within the patient population in healthcare records and
confrms the local data sharing practices which must be adopted. This data must be reported
to the Health and Social Care Information Centre on a monthly basis. SCCI2016 supersedes
the FGM Prevalence Dataset (ISB 1610) which had been in use since April 2014. The
associated Requirements Specifcation contains detailed guidance on recording and sharing
information (and the table below is based on that guidance although does not provide the
same level of detail).9
Comprehensive information sharing practices must be introduced in order to develop a
resulting effective and long term approach to safeguarding against FGM.
Any concerns, whether identifed 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 identifed 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.
Table 1 – guide to information sharing responsibilities

8 http://www.hscic.gov.uk/isce/publication/scci2026
9 http://www.hscic.gov.uk/media/16781/2026122014spec/pdf/2026122014spec.pdf
14 Female Genital Mutilation Risk and Safeguarding

Health passport – Statement opposing female genital mutilation
The Government publishes a ‘Statement Opposing Female Genital Mutilation’ leaflet,
commonly referred to as the “Health Passport”. This pocket-sized document sets out the
law and the potential criminal penalties that can be used against those allowing FGM to take
place. It is designed to be discreetly carried in a purse, wallet or passport.
It can be used by families who have immigrated to the UK and do not want their children to
be subjected to FGM, but still feel compelled by cultural and social norms when visiting family
abroad. It has been supported and signed by Ministers from the Home Offce, Department of
Health, Ministry of Justice, Department for Education and the Director of Public Prosecutions
(DPP). In Holland a similar document is used, where it has supported families and has sent a
strong signal that FGM is unacceptable.
Chapter 4. How to use this document 15
Organisations should consider routinely offering this leaflet to patients when discussing FGM.
Copies can be obtained from the Department of Health orderline https://www.orderline.
dh.gov.uk or else an online PDF version is available on the NHS Choices website.10
Care Pathway provision
All organisations should ensure that they have identifed 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
Health care 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. Organisations may wish to consider using the NHS Choices video resource
Women talking about their personal experiences of FGM or the Health Education England
‘Communication Skills for FGM Consultations’ e-learning session to help staff gain confdence
when talking about FGM with patients.
NSPCC Helpline
Organisations should also ensure that professionals are aware of the NSPCC FGM helpline,
0800 028 3550. This helpline can support both professionals or family members concerned
that a child is at risk of, or has had, FGM.
10 www.nhs.uk/Conditions/female-genital-mutilation/Pages/Introduction.aspx
Female Genital Mutilation Risk and Safeguarding
Chapter 5. Future work 17
Chapter 5. Future work
FGM Risk Indication System
During autumn 2015 three trusts and six GP practices began work on piloting a system that
allows a clinician to record on a child’s healthcare record that she is potentially at risk of FGM
at some point in her childhood/lifetime (the “early adopters”). This indicator will be accessible
to all healthcare professionals throughout childhood, highlighting that they need to consider
the potential risk of FGM as and when they provide care, as well as whether they need to take
any action in this regard. The system will be available via the NHS Summary Care Record
application (SCRa).
Successful implementation will be dependent upon the clinician understanding that there
is a potential risk of FGM, and on their continuing awareness and consideration of this
through the early years of a girl’s life. For the system to succeed, a critical factor will be the
use of a tool such as the FGM Safeguarding Risk Assessment (see Annex 1). Therefore, it
is recommended that organisations look to adopt this guidance which will act as preparation
for this new change.
Further information will be released in due course.
Female Genital Mutilation Risk and Safeguarding
Annex 1. Female Genital Mutilation (FGM) Safeguarding Risk Assessment Guidance 19
Annex 1. Female Genital Mutilation (FGM)
Safeguarding Risk Assessment Guidance
Introduction
The aim is to help make an initial assessment of risk, and then support the on-going
assessment of women and children who come from FGM practising communities (using
parts 1 to 3). For a list of communities where FGM is prevalent please see part 6.
INTRODUCTORY QUESTIONS:–
(1) Do you, your partner or your parents come from a community where cutting or
circumcision is practised? (See part 6 for map; see part 7 for local terms).
(2) Have you been cut? It may be appropriate to use other terms or phrases.
If you answer YES to questions (1) or (2) please complete one of the risk
templates.
PART ONE:– For an adult woman (18 years or over)
(a) 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.
(b) 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 PTSD such as depression, anxiety, flashbacks or reluctance to have genital
examination etc., see part 5); 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
introduction questions.
If the answer is YES to either question, use part 1(b) to support your discussions.
PART TWO:– 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.
20 Female Genital Mutilation Risk and Safeguarding
PART THREE:– 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 part 5), use part 3 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 health care records.
Guidance
The framework is designed to support healthcare professionals to identify and consider risks
relating to female genital mutilation, and to support the discussion with the patient and family
members.
It should be used it to help assess whether the patient you are treating is either at risk of harm
in relation to FGM or has had FGM, and whether your patient has children who are potentially
at risk of FGM, or if there are other children in the family/close friends who might be at risk.
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 MultiAgency 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.
Annex 1. Female Genital Mutilation (FGM) Safeguarding Risk Assessment Guidance 21
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.
In urgent cases, Children’s Social Services and the Police will consider what action to
take. One option is to take out an FGM Protection Order (Schedule 2 of the Female Genital
Mutilation Act 2003). A (family) court can order prohibitions, requirements and restrictions
which could, for example, include surrendering of passports. Also, if required, an Emergency
Protection Order is an order made under Section 44 of the Children Act 1989 enabling a
child to be removed to a place of safety where there is evidence that the child is in “imminent
danger”.
In most cases the situation where a child or young adult under 18 years of age is discovered
to have had FGM will be a historic case. This must be reported under the mandatory
reporting duty using the non-emergency police number 101. A crime reference number
should be obtained and this should normally take place the next working day. In exceptional
circumstances and in consultation with your local safeguarding lead, however, the report can
be made within one month of disclosure or visual confrmation of FGM.
22 Female Genital Mutilation Risk and Safeguarding
Part One (a): PREGNANT WOMEN Date: _______________ Completed by: _______________
(OR HAS RECENTLY GIVEN BIRTH) Assessment: Initial/On-going
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.

ACTION
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 identifed, 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.
Signifcant or Immediate risk – if
you identify one or more serious or
immediate risks, or the other risks are,
by your judgement, suffcient to be
considered serious, you should look
to refer to Social Services/CAIT team/
Police/MASH, 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
identifed risk with the
patient’s GP
• Document in notes
• Discuss the health
complications of FGM and the
law in the UK
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.
Annex 1. Female Genital Mutilation (FGM) Safeguarding Risk Assessment Guidance 23
Part One (b): NON-PREGNANT ADULT WOMAN Date: _______________ Completed by: _______________
(over 18) Assessment: Initial/On-going
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.

ACTION
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 identifed, 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.
Signifcant or Immediate risk – if
you identify one or more serious or
immediate risk, or the other risks are,
by your judgement, suffcient to be
considered serious, you should look
to refer to Social Services/CAIT team/
Police/MASH, 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
identifed risk with the
patient’s GP
• Document in notes
• Discuss the health
complications of FGM and the
law in the UK
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.
24 Female Genital Mutilation Risk and Safeguarding
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
Date: _______________ Completed by: _______________
Assessment: Initial/On-going

ACTION
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 identifed, 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.
Signifcant or Immediate risk – if
you identify one or more serious or
immediate risk, or the other risks are,
by your judgement, suffcient to be
considered serious, you should look
to refer to Social Services /CAIT team/
Police /MASH, 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
identifed risk with the
patient’s GP
• Document in notes
• Discuss the health
complications of FGM and the
law in the UK
Annex 1. Female Genital Mutilation (FGM) Safeguarding Risk Assessment Guidance 25

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.
ACTION
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 identifed, 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.
Signifcant or Immediate risk – if
you identify one or more serious or
immediate risk, or the other risks are,
by your judgement, suffcient to be
considered serious, you should look
to refer to Social Services /CAIT team/
Police /MASH, 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
identifed risk with the
patient’s GP
• Document in notes
• Discuss the health
complications of FGM and the
law in the UK
26 Female Genital Mutilation Risk and Safeguarding
Part 3: CHILD/YOUNG ADULT (under 18 years old)
This is to help when considering whether a child HAS HAD FGM.
Date: _______________ Completed by: _______________
Assessment: Initial/On-going

ACTION
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 nonemergency 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
/ CAIT Team / police / MASH,
in accordance with your local
safeguarding procedures.
In all cases:–
• Share information of any
identifed risk with the
patient’s GP
• Document in notes
• Discuss the health
complications of FGM and the
law in the UK
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.
Annex 1. Female Genital Mutilation (FGM) Safeguarding Risk Assessment Guidance 27
Part 4: Types of Female Genital Mutilation
Female genital mutilation is classifed into four major types. The WHO defnitions11 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: Infbulation: 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.
11 http://www.who.int/mediacentre/factsheets/fs241/en/
28 Female Genital Mutilation Risk and Safeguarding
Part 5: Consequences of FGM
Many men and women in practising communities can be unaware of the relationship between
FGM and its harmful health and welfare consequences as set out below, in particular the
longer-term complications affecting sexual intercourse and childbirth.
1. Short-term implications for a girl’s health and welfare
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.
2. Long-term implications for a girl’s or woman’s health and welfare
The longer-term implications for women who have had FGM Types 1 and 2 are likely to be
related to the trauma of the actual procedure, while health problems caused by FGM Type 3
are more severe and long-lasting. However, all types of FGM are extremely harmful and cause
severe damage to health and wellbeing. World Health Organization research has shown that
women who have undergone FGM of all types, but particularly Type 3, are more likely to have
complications during childbirth.
The long-term health implications of FGM can include:
• Chronic vaginal and pelvic infections
• Diffculties with menstruation
• Diffculties in passing urine and chronic urine infections
• Renal impairment and possible renal failure
• Damage to the reproductive system, including infertility
• Infbulation cysts, neuromas and keloid scar formation
• Obstetric fstula
• 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.
Part 6: Countries that practice FGM
Iraq
8 FGM has also been documented in
Egypt communities including:
87
Senegal Mauritania Mali • Iraq
25 69 89 Niger Sudan
Chad Yemen
Gambia
75
2
44
87
19 • Israel
GuineaBissau Nigeria
45 25 Central Ethiopia 74 Somalia 98 • Oman
Guinea Sierra Cameroon African Republic
97 Leone 1 24 Less than 10%
90 Uganda Djibouti 10% – 25% • the United Arab Emirates
1 Kenya 93 26% – 50%

38 Republic United 21 Eritrea 83 51% – 80% Above 80% Countries with no comparable data • the Occupied Palestinian Territories
4 of Tanzania in UNICEF global databases
15
• India
• Indonesia
Percentage of girls aged 0 to 11 years who have undergone FGM/C
• Malaysia
Indonesia • Pakistan
49
Percentage of girls and women aged 15 to 49 years who have undergone FGM/C
Note: In Liberia, girls and women who have heard of the Sande society were asked whether they were members; this provides indirect information on FGM/C since it
is performed during initiation into the society. Data for Indonesia refer to girls aged 0 to 11 years since prevalence data on FGM/C among girls and women aged 15 to
49 years is not available.
Source: UNICEF global databases, 2016, based on DHS, MICS and other nationally representative surveys, 2004-2015.
http://data.unicef.org/child-protection/fgmc.html#sthash.iIhVu5Mr.dpuf
NB: In February 2016 UNICEF published a report updating their information on the global prevalence of FGM including new data on Indonesia revealing that 49% of
girls there have undergone FGM (and half of those procedures were carried out by a medical professional).
Annex 1. Female Genital Mutilation (FGM) Safeguarding Risk Assessment Guidance 29
30 Female Genital Mutilation Risk and Safeguarding
Part 7: Traditional and local terms for FGM

Annex 2. Contributors 31
Annex 2. Contributors
Existing risk assessment/screening tool reviewed:
• Oxfordshire Safeguarding Children Board FGM Screening Tool
• Imperial College Healthcare NHS Trust risk assessment documents
• Royal Free Questionnaire and Screening Doc
• FGM screening questions – North Middlesex University Hospital NHS Trust
• Wandsworth FGM risk identifcation leaflet
• Lambeth SCG FGM Procedures
In consultation with (and thanks to):
Cressida Zielinski; Gayle Hann; Alison Renouf; Gourita Gibbs; Janet Fyle; Gerald Chan;
Hannah Costelloe; Sarah Baker; Mark Norris; Nigel Mathers, Rachel Mawby; Deborah
Hodes, Neil Remsbery, Tracey Harrington, Richard Steele, Sharon Raymond, Neera Dholakia
Members of FGM NHS England (London) Steering Group, Members of FGM Prevention
Working Group.
© Crown copyright 2016
2905363 May 2016
Produced by Williams Lea for the Department of Health