Responding to female genital mutilation: multi-agency guidance

7. Responding to women who have experienced FGM

All agencies

There is no requirement to automatically refer adult women (i.e. over age of 18) with FGM to adult social services or the police.

If a woman discloses FGM, it may be the first time she has discussed it with anyone. Practitioners must not automatically refer her to the police as their first response. They should conduct an initial risk assessment, including whether there are others in the family who are at risk of, or affected by, FGM.

If a woman is pregnant and/or has daughters, practitioners must consider their welfare as well as that of other girls in the extended family, since they may be at risk. Action should be taken in accordance with the guidance in section 6.

A woman may disclose that she has adult daughter(s) over 18 who have already undergone FGM. Even if the daughter(s) do not want to involve the police, it is important to establish when and where the FGM was performed, and whether there are other girls in the wider family.

If a family has decided against FGM on a UK-born girl, practitioners should try to find out whether this is because of a change in attitude, fear of prosecution, lack of opportunity or some other reason. Women tend to be more influential in preventing FGM when they are away from their country of origin. It may be that they would benefit from ongoing support to prevent any future attempts to carry out FGM on their daughters.

Given the long-term impact of FGM, professionals should ensure that women affected get proper support to meet their health and wellbeing needs. Professionals must respect the wishes of women.

Support might include:

• Referral/signposting to health services such as psychological/psychosexual; sexual health; physical health such as gynaecology.
• Referral to specialist services for peer or community support.
• Discussing options to report FGM as victim of a crime.
• Giving information about FGM and the law in Scotland.

If a woman is of childbearing age, she may need support at a later date to protect her children.

NHS response: healthcare staff

Given the adverse mental, physical and sexual health consequences of FGM, the NHS is vital in helping women and girls into services. Women may present in settings such as obstetric and midwifery services, cervical smear screening, sexual and reproductive health clinics, travel clinics, paediatrics, urology, gynaecology, mental health services, A&E, dermatology, out-of-hours primary care services, Scottish Ambulance Service and GP practices.

Treatment depends on the symptoms, type of FGM, and whether or not the woman is pregnant. FGM is often identified during antenatal care or delivery. Women with gynaecological symptoms such as pelvic or genital pain, incontinence and menstrual dysfunction may need referral to gynaecological services such as general gynaecology and urogynaecology or be managed in a single service that may provide all care needed.

Healthcare staff should provide or help women into services such as:

• Psychosexual services.
• Mental health services.
• Maternity services.
• Gynaecology services including general gynaecology and urogynaecology.
• Advocacy/patient support.
• Child protection services.
• De-infibulation as in-patient and out-patient.
• Local community FGM support services.

Healthcare staff should:

• Understand that a woman may not be aware she has had FGM (particularly if it was performed when she was very young).
• Be realistic about options available to women.
• Check what services can do for a woman before referring her.

Staff must never perform FGM or re-infibulate a woman.

Staff should follow professional guidance as well as consult their senior colleague and/or follow child protection procedures or adult support and protection procedures as appropriate.

See Royal College of Obstetricians and Gynaecologists guidelines:
https://www.rcog.org.uk/en/guidelines-research-services/guidelines/gtg53/

Clinical response

Healthcare staff should use an assessment checklist to ensure consistency and that critical aspects are covered (see Appendix 4).

Staff should document referrals to specialist care in clinical records and inform the GP practice of any interventions, transfer of care, outpatient follow up and discharge. To enable the coders to code FGM in a hospital setting, FGM should be recorded in the discharge summary or any communication to the GP (for example from an out-patient attendance) even if the attendance was not related to FGM at that visit. ( http://www.sehd.scot.nhs.uk/cmo/CMO(2014)19.pdf)

The key elements of the clinical response are:

• Medical examinations.
  • As most girls and women will require a genital assessment, a chaperone is needed. Staff should explain the reason for the examination; who will do it; why there is a chaperone; and anything else that will help to reassure the woman. They should do this in a sensitive manner, before the woman undresses (ref to GMC chaperone guidance:
    www.gmc-uk.org/guidance/ethical_guidance/21168.asp).
  • Staff should avoid unnecessary and repeated examinations.
• De-infibulation.
  • All health boards must offer a de-infibulation service, whether provided by the board or by referral elsewhere. The referral pathway for de-infibulation should be clear. De-infibulation may not be appropriate in all cases. Staff should discuss options for surgical intervention with the woman. This should include telling her about the benefits and risks.
  • Most de-infibulations should be performed under local anaesthetic in an outpatient setting. Some women with extensive genital scarring or who are very distressed during examination need de-infibulation under a general or spinal anaesthetic. This will usually require a day case hospital admission. See service specification:
    http://www.sehd.scot.nhs.uk/cmo/CMO(2016)05.pdf
• Mental health.
  • Staff should refer women and girls with mental health difficulties including anxiety, depression, PTSD and complex PTSD to the appropriate trauma-informed or trauma specialist mental health service.
• Documentation.
  • All consultations must include discussion about the legal status of FGM. Staff must document this discussion in the notes in the agreed template.