3.3 FGM Mandatory Reporting, Clinical Classification & Trauma-Informed Practice

FGM Mandatory Reporting, Clinical Classification & Trauma-Informed Practice

Female Genital Mutilation (FGM) comprises all procedures involving partial or total removal of the external female genitalia, or other injury to the female genital organs for non-medical reasons. FGM is recognized internationally and within the United Kingdom as a severe violation of the human rights of girls and women, a form of gender-based violence, and an egregious manifestation of child abuse. It carries no health benefits and inflicts immediate and lifelong physical, sexual, and psychological trauma.

Midwives in the UK play a critical dual role: delivering culturally sensitive, trauma-informed clinical care to pregnant women living with FGM, while upholding strict statutory safeguarding duties and the personal mandatory reporting obligation to protect girls from mutilation.

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UK Legal Architecture Governing FGM

The statutory framework governing FGM in England and Wales is anchored in comprehensive criminal legislation that carries extraterritorial reach.

The Female Genital Mutilation Act 2003

The Female Genital Mutilation Act 2003 replaced the earlier Prohibition of Female Circumcision Act 1985, significantly strengthening criminal prohibitions:

• Primary Offences: It is a criminal offence for any person to perform FGM in the UK, to assist a girl to perform FGM on herself, or to assist from within the UK a non-UK person to carry out FGM abroad.
• Extraterritorial Jurisdiction: The Act makes it illegal for UK nationals or permanent UK residents to carry out FGM abroad, or to arrange for a girl to be taken abroad for FGM (so-called "vacation cutting"), even in countries where the practice is legal.
• Criminal Penalties: Conviction under the Act carries a maximum sentence of up to 14 years' imprisonment, a fine, or both.

The Serious Crime Act 2015 Amendments

The Serious Crime Act 2015 introduced sweeping enhancements to the 2003 Act:

1. FGM Protection Orders (FGMPOs): Civil court orders designed to safeguard girls suspected of being at risk of FGM (e.g. mandating the surrender of passports, prohibiting travel to high-prevalence countries, and restraining perpetrators).
2. Offence of Failure to Protect: Establishes criminal liability for parents or legal guardians who fail to protect a girl under 16 years of age from FGM, carrying up to 7 years' imprisonment.
3. Lifelong Anonymity for Victims: Guarantees statutory lifelong anonymity to anyone alleging they have been subjected to FGM.
4. Section 5B Mandatory Reporting Duty: A direct, personal statutory duty for healthcare professionals to report known cases of FGM in minors directly to the police.

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World Health Organization (WHO) Clinical Classification

Midwives must accurately diagnose and document the specific anatomical subtype of FGM in accordance with the World Health Organization (WHO) classification:

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Obstetric & Perinatal Complications of FGM

FGM significantly increases the risk of severe morbidity and mortality for both mother and fetus during childbirth:

Antenatal Complications

• Recurrent urinary tract infections (UTIs) and chronic pyelonephritis caused by urinary stasis behind infibulation seals.
• Dysmenorrhoea, hematocolpos, chronic pelvic inflammatory disease (PID), and secondary subfertility.
• Profound psychological trauma: Post-Traumatic Stress Disorder (PTSD), severe generalized anxiety, depression, and severe needle/examination phobias.
• Extreme anxiety regarding pelvic examinations, often leading to avoided or late antenatal bookings.

Intrapartum Complications

• Inability to Assess Labour Progress: In Type 3 FGM, introital stenosis prevents manual vaginal examination to determine cervical dilatation or fetal station.
• Inability to Monitor Fetal Wellbeing: Inability to apply a fetal scalp electrode (FSE) or obtain fetal scalp blood samples (FBS) when non-reassuring cardiotocography (CTG) patterns arise.
• Obstructed Labour: Rigid, inelastic scar tissue prevents normal crowning of the presenting fetal head, causing a prolonged, arrested second stage of labour.
• Catastrophic Perineal Trauma: Extensive third- and fourth-degree perineal tears (obstetric anal sphincter injuries [OASIS]), anterior perineal tears involving the urethra and clitoral bed, and extensive labial tissue avulsion.
• Postpartum Haemorrhage (PPH): Profuse bleeding from vascularized scar tissue, lacerations of the clitoral bed, and secondary uterine atony following prolonged obstructed labour.
• Perinatal Hypoxia & Asphyxia: Prolonged second stage and obstructed delivery substantially increase rates of fetal distress, meconium aspiration, low 5-minute Apgar scores, and stillbirth.

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De-infibulation: Timing, Surgical Technique & Legal Boundaries

De-infibulation (frequently termed reversal or anterior episiotomy) is the surgical division of the scar tissue sealing the vaginal introitus in Type 3 FGM to expose the urethral opening and vaginal canal.

Timing of De-infibulation

According to Royal College of Obstetricians and Gynaecologists (RCOG) guidelines:

1. Elective Antenatal De-infibulation (Preferred Standard):
   • Ideally performed before pregnancy; where adequate vaginal assessment in labour is unlikely to be possible, RCOG GTG53 recommends antenatal de-infibulation, usually in the second trimester, typically at around 20 weeks' gestation.
   • Usually performed under local anaesthetic, often in a specialist FGM clinic or a delivery suite room, by an appropriately trained midwife or obstetrician.
   • Clinical Rationale: Undertaking de-infibulation antenatally allows the surgical margins to heal completely before delivery, facilitates essential mid-trimester transvaginal scans and speculum examinations, alleviates anxiety, and eliminates the need for emergency intrapartum surgical incisions.
2. Intrapartum De-infibulation:
   • Some women prefer de-infibulation during labour, which is usual practice in some countries where FGM is prevalent.
   • If vaginal examination, intrapartum procedures or catheterisation are not possible, de-infibulation is recommended in the first stage of labour, and an epidural is offered.
   • If vaginal access is adequate, de-infibulation can be performed at delivery under local anaesthetic (lidocaine without adrenaline), using scissors just before crowning of the fetal head. The need for episiotomy is then assessed.
   • If a caesarean birth is needed, perioperative de-infibulation after the birth can be discussed.
   • The midwife or obstetrician inserts two fingers beneath the scar tissue to protect the presenting fetal part and bladder, incises the scar strictly along the midline anteriorly to expose the urethral meatus, and over-sews the cut edges with absorbable sutures to secure haemostasis. A mediolateral episiotomy may be performed concurrently to protect the posterior perineum.

Absolute Legal Prohibition: Re-infibulation

Midwives must never re-infibulate under any circumstances, even if directly requested by the woman, her partner, or her family. Acceding to a request for re-infibulation constitutes committing an act of FGM, carrying criminal prosecution and up to 14 years' imprisonment. Midwives must compassionately explain this legal prohibition during antenatal consultations to manage expectations well before labour.

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The Statutory Mandatory Reporting Duty (Section 5B)

Under Section 5B of the Female Genital Mutilation Act 2003 (as inserted by Section 74 of the Serious Crime Act 2015), a specific, personal statutory duty is placed on registered healthcare professionals, teachers, and social care workers in England and Wales.

Scope and Trigger Criteria

The mandatory reporting duty applies strictly and exclusively when a healthcare professional, in the course of their professional duties:

1. Visually Observes physical signs appearing to show that an act of FGM has been carried out on a girl under the age of 18; OR
2. Is Verbally Informed Directly by a Girl Under the Age of 18 that she has undergone FGM.

Reporting Procedure & Timeline

• Personal Duty: The duty is strictly personal. The midwife who visually identifies or receives the disclosure must make the report themselves. It cannot be delegated to a lead midwife, matron, consultant, or safeguarding lead.
• Direct Police Notification: The report must be made directly to the police by calling the 101 non-emergency telephone service (or in person).
• Mandatory Timeframe: The report to 101 should be made as soon as possible, and normally within one month of the visual identification or verbal disclosure.
• Acute Immediate Threat: If the minor is at immediate, acute physical risk, the emergency 999 service must be contacted immediately.

Vital Distinctions: When Mandatory Reporting Does NOT Apply

Understanding what does not trigger the Section 5B police mandatory duty is one of the most frequently tested areas on the NMC CBT:

1. Adult Women (Aged 18 and Over):
   • The mandatory police reporting duty DOES NOT apply to adult women aged 18 or older.
   • If a midwife examines a 22-year-old woman and discovers Type 2 FGM, the midwife must NOT call the 101 police mandatory reporting line.
   • Instead, the case is recorded on the national NHS FGM Enhanced Dataset (a statutory digital record of FGM in the NHS), managed clinically, and assessed for safeguarding risks regarding female dependents.
2. Suspected FGM or Girls "At Risk" (No Visual Evidence or Verbal Disclosure):
   • If a midwife suspects a child under 18 might have FGM, or is at risk of being subjected to FGM in the future, the 101 mandatory reporting duty DOES NOT apply.
   • Cases of suspicion or future risk must instead be referred immediately to Children's Social Care (MASH) following standard child protection procedures.

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Safeguarding Procedures for the Unborn Female Infant

Whenever a pregnant woman is identified as having FGM (of any WHO type), a formal FGM Risk Assessment must be conducted to safeguard any existing daughters and the unborn female child.

Midwives must utilize the national Department of Health FGM Risk Assessment tool to evaluate:

• The woman's and partner's views regarding FGM (e.g. whether they believe it is a cultural or religious obligation).
• The country of origin and prevalence of FGM within the family's community.
• Whether older female siblings have been subjected to FGM.
• Family plans to travel abroad with female children during infancy or school holidays.

If the risk assessment identifies that an unborn baby or older sibling is at risk of FGM:

1. A pre-birth safeguarding referral is submitted to the Multi-Agency Safeguarding Hub (MASH).
2. The Named Midwife and Health Visitor are notified to ensure enhanced postnatal surveillance.
3. In England, an FGM Information Sharing (FGM-IS) indicator is added to the baby girl's NHS record, alerting GPs and health visitors to a family history of FGM.
4. If family travel to a high-prevalence country is imminent or intended, Children's Social Care or the police apply for a civil FGM Protection Order (FGMPO) to seize passports and enforce travel bans.

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Trauma-Informed Practice & Culturally Competent Communication

Caring for women with FGM requires exceptional sensitivity, compassion, and professional dignity.

• Non-Judgmental Terminology: Healthcare professionals must avoid pejorative, accusatory, or sensationalist words (such as "barbaric", "mutilated", or "uncivilized") during consultations. Midwives should use professional anatomical terms or mirror the non-stigmatizing terms used by the woman (e.g. "circumcision", "sunna", or community-specific terms like "Gudniin" in Somali or "Tahoor" in Arabic), while accurately documenting the clinical WHO classification in medical records.
• Trauma-Informed Environment: Midwives must recognize that genital examinations can trigger acute flashbacks of childhood abuse. Always explain what the examination involves, obtain explicit consent, ensure complete physical privacy, offer a chaperone, and permit the woman to pause or terminate the examination at any point.