Responding to female genital mutilation: multi-agency guidance

5. Responding to girls at risk of, or who have already undergone, FGM: all agencies

‘Protecting girls at risk of harm through FGM poses specific challenges because the families may give no other cause for concern. There may be an intergenerational element, or husband and wife may have differing views about daughters. The wish to carry out FGM is also not confined to individuals within particular levels of education or social class. The pressure to undertake this procedure may be embedded in family structures. At all times, however, it is important to think the unthinkable, and act with respectful uncertainty.’

(Department of Health, 2003)

Identifying risk

The National Child Protection Guidance for Scotland (2014) defines risk and significant harm:

‘Risk is the likelihood or probability of a particular outcome given the presence of factors in a child or young person’s life…Risks may be deemed acceptable; they may also be reduced by parents/carers or through the early intervention of universal services. At other times, a number of services may need to respond together as part of a co-ordinated intervention. Only where risks cause, or are likely to cause, significant harm to a child would a response under child protection be required. Where a child has already been exposed to actual harm, assessment will mean looking at the extent to which they are at risk of repeated harm and the potential effects of continued exposure over time.’

It can be difficult to identify girls at risk of FGM because, by tradition, different communities perform it at different ages. A girl/woman could be at risk in infancy, early childhood, adolescence, at marriage or first pregnancy. So, while practitioners might identify potential risk to a girl at birth, it may not become an imminent risk until she is (much) older.

Despite the difficulties, practitioners need to take action to protect girls or women at risk, consistent with their statutory duties.

Because of the variation in FGM practice, professionals need to share information about what they know or suspect so that action can be taken if, or when, the girl is at risk. Agencies may need to instigate child protection measures at birth and leave these in place for up to 18 years.

Practitioners should also ensure that families know that FGM is illegal, and that authorities are actively tackling the issue. This knowledge alone may deter families from having FGM performed on their children, and save girls and women from harm.

Women who experienced physical and/or psychological problems as a result of FGM, and who recognise the association, are less likely to support or carry out FGM on their own children and more likely to support or actively work to end FGM. However, any woman may be pressured by her husband, partner or other family members to allow or arrange for her daughter to undergo FGM. Fathers have legal responsibilities as well as rights and professionals should discuss FGM (the law and health issues) with the girl’s father and, if appropriate, other members of the family as well as the mother. If there are identified risks, any approach to the family should be considered as part of an interagency referral discussion ( IRD).

Potential risk factors for FGM

There are various factors which indicate that a girl may be at risk of FGM for example:

• The family is from a community in which FGM is practised.
• The girl’s mother has experienced FGM.
• The girl has a female sibling/cousin who has experienced FGM.
• Family elders are very influential.
• The family is not well integrated within the UK.

Practitioners need to consider these factors within the girl’s overall situation, rather than assuming individual factors to be an indicator of imminent risk. For example, some women who have experienced FGM are opposed to their daughters undergoing it.

Indicators that a girl may be at imminent risk

Indicators that a girl may be at imminent risk of FGM include:

• Parents say that they or a relative intends to take the girl out of the country for a prolonged period.
• Girl says she is going on a long holiday to her country of origin, or another country where FGM is common.
• Girl tells a professional that she is to have a ‘special procedure’ or is to attend a special occasion to ’become a woman’.
• A professional hears FGM coming up in conversation, for example a girl might be talking to her friends about it.
• A girl might ask a teacher or another adult for help.

Indicators that FGM has already been performed

Indicators that FGM has been performed include:

• Girl has difficulty walking, sitting or standing and seems uncomfortable.
• Girl in school leaves the classroom for extended periods because of bladder or menstrual problems; she spends longer in bathroom because of difficulties urinating.
• Girl is absent from school; absences may be prolonged and/or repeated.
• Girl is withdrawn, depressed, shows significant behaviour change and other signs of emotional and psychological distress.
• Girl confides in a professional or asks for help but is not explicit about the problem.
• Girl needs excused from physical education or sport.
• Girl talks about pain or discomfort between her legs.
• Girl is reluctant to undergo medical examination.

Risk assessment

The purpose of risk assessment is to establish the level of risk to a girl/woman in order to inform action taken and/or inform child protection or adult support and protection proceedings. The main points to consider are:

• What risk factors are identified?
• What are the mother’s/family’s views on FGM?
• Protective (may be opposed to FGM and determined girl will not have it).

or

• Non-protective (may not realise health, legal, child protection issues and believe girl should have FGM).
• Undetermined.
• Is there an impending trip to the country of origin? (This significantly increases imminence of risk.)

If there is concern about FGM, practitioners should also consider potential risk to other girls in the wider family/community who may also be a ‘child in need of protection’. As FGM can be deeply embedded in family and/or community belief systems, these girls may also be at significant risk of harm.

Because risk can change according to the age of the girl and other circumstances, practitioners who have an ongoing relationship with the girl and/or her family need to be alert to indicators.

The level or extent of risk may change over time. Practitioners should be alert to changes in circumstances which might elevate risk and the need to undertake the risk assessment.

The Department of Health in England has developed a risk assessment framework with factors to consider. This has been amended slightly to reflect the Scottish context and is in Appendix 4.

Responding to risk

The level of involvement with the girl and her family depends on the role and responsibilities of the practitioner or agency. The specific responsibilities of statutory and third sector agencies are set out in section 6. These take account of the different settings in which professionals might encounter a girl or woman affected by FGM.

Most practitioners have never knowingly encountered a girl/woman who has undergone FGM. This might change as awareness of FGM increases. So, more experienced social workers and/or public protection police officers or certain health professionals may be best placed to discuss FGM with girls/women and families.

Although many individual practitioners may not be responsible for investigating FGM, they should consider FGM in their assessments and know who to refer any concerns to. If a professional identifies an FGM risk factor, they need to assess the risk, act on the risk assessment and document this.

Any one single factor of potential risk will require the practitioner to initiate a discussion with the woman or parents.

Girls who have undergone FGM

If a practitioner suspects, believes or knows that FGM has been performed on a girl, they should take immediate action to ensure the girl gets medical and other care, and instigate child protection procedures.

Imminent or serious risk of FGM

If a practitioner has information or is concerned that a girl is at imminent or serious risk of FGM they should make a child protection referral. Emergency measures may be required to ensure swift action if a girl is at immediate risk or is being taken abroad to have FGM performed.

Adult support and protection procedures should be instigated in cases of vulnerable women who are at serious risk of FGM.

Potential risk of FGM

If a girl/woman is identified as potentially being at risk of FGM but the current situation does not indicate that the risk is imminent or significant, an IRD should take place to ensure that the information is shared appropriately with all relevant agencies. This should ensure that they understand her circumstances, and have an agreed plan for identifying and responding to any future risk.

Practitioners should involve relevant senior colleagues. They may also need to seek the advice and guidance of their professional representative/regulatory organisations.

See Appendix 5 for multi-agency child protection decision-making and action flowcharts.

Information sharing

‘Any reasonable professional concern that a child may be at risk of harm will always over-ride a professional or agency requirement to keep information confidential.’

(s.587, National Guidance for Child Protection in Scotland, 2014)

Practitioners should know the law, policy and practice for sharing personal and/or sensitive information; the limits of confidentiality and consent; and that they can share personal and/or sensitive information.

If practitioners are concerned about a child or young person’s safety or wellbeing, nothing prevents them from sharing information.

If there is a risk to a child or young person’s safety or wellbeing, which may lead to harm, confidential information can be shared under the Data Protection Act 1998.

Not all information is confidential. Confidentiality is not an absolute right.

Any sharing of information should be relevant, necessary, appropriate and proportionate and go no further than the minimum necessary to achieve the public interest objective of protecting a child or young person’s safety and wellbeing.

As the level of risk can vary across different age groups, depending on the cultural background of the family, professionals should decide their response on a case-by-case basis, with other agencies involved.

Information sharing with relevant colleagues is vital for informing decisions on the best course of action to protect a girl or woman at risk of FGM. Given the links with other forms of violence against women, however, it is crucial that the safety of women and children is assessed before engaging in discussions with other family members.

Inter-agency discussions

Each area has arrangements for inter-agency discussions at the point of child protection referral in accordance with its own child protection procedures or guidance. In this guidance, these discussions are referred to as the inter-agency referral discussion ( IRD). In line with the National Guidance for Child Protection in Scotland (2014), information should be shared, and joint assessment and planning undertaken by relevant police, health and social work staff.

Taking action

Local child protection procedures should indicate the threshold of risk for FGM. Agencies need to work together to protect girls from FGM. This should be a central element of the response. The diagram below shows the three levels of response ^[31] :

Any child considered at risk of FGM should have a Child’s Plan.

Whilst there is little information about the number of ongoing child protection cases relating to FGM in Scotland, the above diagram shows response types. Sharing information between practitioners and agencies about girls potentially at risk of FGM and about discussions with family members over child protection is vital for all agencies involved. It will inform decisions about the best course of action to protect anyone at risk of FGM.

Good Practice - Example

Woman A had twin daughters at a nursery in Edinburgh. She told the nursery staff she was planning to go back to Sudan for an extended visit for a year. She discussed her visit with a social worker and the nursery. Together they discussed the risks of FGM to her daughters and when she said she was against it, they asked her how she planned to protect her daughters and talked this through with her. Social workers gave her a number and said, if you have any problems in your country you can call the number in the UK and they will call the embassy in Sudan and pick up your family and take them back straight away.

They recommended that she did not go for such a long visit this time. She went to Sudan as planned but only stayed for 2 months. She was scared about going and scared about coming back, she was scared that her mother and granny would do something to her kids saying ‘you know in my country if I have a girl and I go outside with my husband, my mum will take my girl and she can do anything because she has looked after them. Because of your religion you have to respect your mum, you can’t be rude to her. You just cant’.

When she arrived back in Sudan she told her granny and mum ‘you are not allowed to do anything to my daughter because there are a lot of laws in Scotland, maybe they are going to put me in detention’. She told the peer researcher ‘I don’t want to do this to my daughters, it was done to me and it was very bad for me. But I am sick of the health visitor talking to me about it’. However she feels that the visit went well, she was able to protect her daughters and she has returned for a subsequent visit.

(My Voice)