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FGM: A local responsibility

Updated guidance encourages primary care nurses to identify those at risk, writes Seeta Bhardwa.

The RCN released updated FGM guidance to coincide with the UN's International Day of Zero Tolerance for FGM on 6 February.

The guidance, Female genital mutilation, an RCN resource for nursing and midwifery practice, has specific sections dedicated to community and practice nurses, as well as health visitors, midwives and school nurses.

It contains sections on legal advice, warning signs, the types of FGM and resources for further reading.

The DH separately announced that it will invest £1.6 million for the forthcoming financial year to facilitate the next phase of FGM prevention.

The DH is also introducing changes this year to the way healthcare professionals are required to document patient risk on health records. Guidance on how this will be implemented will be released in September by the DH.


Carmel Bagness, professional lead for midwifery and women's health at the RCN, said that nurses are often unaware of their responsibilities around FGM. 'We have tried to create a generic reference document that all nurses can refer to for guidance. There are specific sections for the different groups of nurses, including primary care nurses,' she says.

The guidance is clear that community and practice nurses who have regular access to women in the community or home setting are in a position to note information that could indicate girls being at risk, including behavioural changes.

Practice nurses who administer travel vaccinations or nurses working in travel clinics should remain aware of women who may be returning to countries where FGM is prevalent. Practice nurses might observe warning signs such as women attending regular GP appointments but avoiding smear tests, which could be an indication that they have undergone FGM, says Ms Bagness.

A practice nurse at the launch of the guidance agreed that this wasn't just an issue for nurses and midwives in the acute sector. 'It is important for all practice nurses when they are carrying out smear tests to ask the women if they are feeling uncomfortable. All nurses can play their part in helping to identify those at risk.'

Health visitors, school and community children's nurses (CCNs) are also given ways to recognise and support girls and families. School nurses and CCNs are often in a position of trust and girls might confide in them, indicating that the child is at risk.

School nurses and CCNs can be aware of behavioural change in young girls such as prolonged visits to the toilet may indicate that a girl or young woman is experiencing difficulty urinating following the procedure.

The RCN guidance lists a number of questions that clinicians can ask when considering a risk assessment, such as where does the woman/girl come from originally, and does she have any female relatives who have undergone FGM.

To increase the awareness of FGM and encourage more nurses to learn about it, HEE created a set of e-learning modules for healthcare professionals in November 2014. The first one has already been released and the full programme will be released by March this year. FGM is not always included on pre-registration university courses nursing courses. However, some nurses at the launch of the guidance suggested that training should be carried out post-registration.


The data on FGM incidence in the UK is not very clear, due to the nature of the practice and the lack of reporting.

Around a third of the referrals that the Metropolitan police received in the past year has come from healthcare professionals. 'A nurse might call us up and tell us any concerns that they might have around a family or a particular child,' says Jason Ashwood, detective superindent at the Metropolitan Police. 'We will then work with children's social care services to assess the situation and then we work with the family.'

He acknowledges that healthcare professionals are often concerned about what the police will do when concerns are reported. 'We do take a sensitive approach to such cases. We would only make an arrest or remove the child from the parent's care after deciding with social care that this was the most appropriate course of action.'

Comfort Momoh, FGM/public health specialist at Guy's and St Thomas's Foundation Trust, believes that the language around reporting should change for this reason. 'I prefer to call it recording, rather than reporting.'

To ensure that healthcare professionals report any concerns, the HSCIC released data on FGM in hospitals from October 2014, where hospitals are encouraged to record the number of FGM cases seen each month. This will be extended to GP practices and mental health trusts from October 2015 to create a broader picture of FGM incidence.

Vanessa Lodge, director of nursing in North Central and East London at NHS England, says that these figures will then inform commissioners of the need for dedicated FGM services in their area. Ms Lodge said: 'Practice nurses have a big part to play in identifying those at risk of FGM. Practice nurses can work with commissioners to identify the need for FGM services in their local areas. We are actually currently working on quality standards around setting up FGM clinics stating how many minutes each consultation should take, the skill mix required of doctors and nurses, the minimum training they would need and things like that, to make it a lot easier for nurses in the community to have a framework to set up specialist clinics.'

Ms Lodge also says that it is important that healthcare professionals are aware of what is legal and what is not, in relation to FGM. This was highlighted by the recent court case centred on a doctor from Whittington Hospital in London who repaired a women's FGM following childbirth.

The updated RCN guidance has a section outlining the Acts of Parliament that are relevant to FGM, the Prohibition of Female Circumcision Act (1985) and the Female Genital Mutilation Act (2003) (Box 1). The 2003 Act came into force to address concerns about girls being taken out of the country for FGM. The Act covers cases in which UK nationals were taken out of the country for FGM, increased the penalty from five to 14 years imprisonment and made it illegal to re-infibulate a woman following the birth of her baby.

In July 2014, the Home Affairs Committee published its report on FGM calling for a national action plan and highlighted a number of issues. These included the need to revise multi-agency guidelines on FGM to include mandatory questioning and that the failure to report child abuse should become a criminal offence. In October 2014, the Ministry of Justice announced that it would amend the Serious Crime Bill which is still going through parliament. This may have an impact on healthcare professionals as it questions duties for protection.

Psychological support

Something raised at the launch that isn't always considered in relation to FGM was mental health. Ms Momoh said that for things such as post-traumatic stress disorder there was not proper support. 'It is still early days in recognising the mental health side of the service provision for FGM.'

She says that there still isn't specific psycho-sexual care for those who have undergone FGM and it is important to start developing these services.

FGM is a complex issue. Primary care nurses must be aware of the lasting psychological impact it can have, as well as pressure from the cultural attitudes embedded in families.

The updated guidance will be reviewed in a year and the introduction of e-learning modules are just the beginning. But for FGM to be eradicated within a generation, as was proposed at the Girl Summit last year, healthcare professionals need to have the right tools and skills to confidently ask the difficult questions. 'Nurses and midwives must maintain professional curiosity around FGM. Continue to ask questions and learn as much as you can about the culture and the practice,' says Ms Bagness. 'We should look at the woman as whole rather than just as someone who has undergone FGM.'


1. Female Genital Mutilation, An RCN resource for nursing and midwifery practice. RCN. 2015.