01OverviewDefinition, clinical context and the essential points that orientate the chapter.
FGM is defined by the World Health Organization as procedures involving partial or total removal of external female genitalia, or other injury to female genital organs, for non-medical reasons. It is not required by any religion and occurs in diverse countries and communities. Clinical care should avoid racial profiling: ask because history, symptoms, pregnancy or safeguarding context makes it relevant, not because of appearance or a surname. Some patients prefer terms such as cutting or circumcision; mirror their language while documenting anatomy accurately.
Classification describes anatomy, not severity of experience. Type I involves partial or total removal of the clitoral glans and/or prepuce. Type II involves removal of the clitoral glans and labia minora, with or without labia majora. Type III, infibulation, narrows the vaginal opening by cutting and apposing labial tissue, with or without clitoral removal. Type IV includes other non-medical injury such as pricking, piercing, incising, scraping or cauterisation. Examination may not fit neatly into one type and should never become a test of credibility.
Ask sensitively about urinary stream, recurrent infection, menstruation, pelvic pain, sexual pain, vaginal penetration, pregnancy and birth experiences, previous deinfibulation and psychological effects. Explain each reason and permit refusal. If examination is clinically needed, obtain specific consent, offer a trained chaperone and trauma-informed choices, and stop on request or distress. A child should not undergo an examination merely to establish whether FGM occurred; obtain specialist paediatric and safeguarding advice and avoid multiple examinations.
The England-and-Wales mandatory-reporting duty has a narrow trigger. Regulated health and social care professionals and teachers must make a personal report to police when, in professional work, a girl under 18 tells them directly that FGM has been carried out or they visually identify physical signs that appear to show FGM. Use police 101 as soon as possible, ordinarily by the close of the next working day; government procedural guidance allows no more than one month in exceptional cases. If immediate danger exists, use 999.
The specific duty does not apply when the affected person is 18 or older, when another person reports it, or when a girl is only suspected to be at risk. That boundary does not mean ‘do nothing’. Apply ordinary child protection, adult safeguarding and information-sharing duties, seek the safeguarding lead’s advice and consider police or children’s social care. Alongside any mandatory report, arrange local referral, clinical treatment and assessment of siblings or other girls. Scotland and Northern Ireland use their own legislation and procedures; follow the applicable local pathway.
Clinical management is symptom-led and multidisciplinary. Acute complications include haemorrhage, infection, severe pain and urinary retention. Longer-term consequences include slow urinary flow, recurrent infection, scarring, inclusion cysts, dysmenorrhoea, difficulty with vaginal examination, dyspareunia, sexual dysfunction, infertility associations, obstetric injury and psychological trauma. Offer specialist FGM clinic, gynaecology, urology, sexual health, pelvic-floor, psychosexual and mental-health support according to the person’s goals. Do not imply that every affected person has symptoms or needs surgery.
Deinfibulation divides scar tissue from type III FGM to open the vaginal introitus. It may improve urinary, menstrual, sexual, examination or childbirth access and can be offered before pregnancy, antenatally or during labour depending on circumstances. Discuss analgesia or anaesthesia, expected anatomical change, sexual concerns and the possibility of family pressure. RCOG states that reinfibulation must not be undertaken; explain this antenatally and make the plan accessible to the birth team.
Safeguarding plans must be individual. Ask about daughters, sisters, other children, travel, family expectations, who holds passports and whether discussion itself could cause danger. Affected adults are not automatically perpetrators; engage them as partners in protecting children without blame. FGM protection orders and specialist legal or police advice may be appropriate for imminent risk. Document exact disclosure, age, anatomical finding if observed during legitimate care, who was present, report reference, local referrals and safe communication restrictions.
Key points
- FGM means partial or total removal of external female genitalia or other injury to female genital organs for non-medical reasons; it has no health benefit and is illegal in the UK.
- WHO type I affects the clitoral glans or prepuce, type II also removes labial tissue, type III narrows the vaginal opening by infibulation, and type IV covers other non-medical injury such as pricking or cutting.
- Use the person’s preferred language, explain why you are asking and avoid assuming nationality, ethnicity, religion or symptoms establish FGM.
- Do not perform a genital examination solely to check whether a child has FGM; examine only for a genuine clinical or safeguarding purpose with specialist planning, valid consent or lawful best-interests authority.
- In England and Wales, a regulated professional must personally report to police when a girl under 18 directly discloses FGM or FGM is visually identified during professional work.
- The mandatory duty does not cover an adult disclosure, suspicion of future risk, or a third-party report; those situations still use local child or adult safeguarding processes and proportionate information sharing.
- Make a mandatory report to police using 101 as soon as possible, ordinarily by the end of the next working day; exceptional delay should never exceed the statutory procedural limit.
- After a mandatory police report, continue clinical care, local children’s social-care referral, assessment of siblings or other girls, and immediate 999 action when danger is current.
- Refer affected adults to an NHS specialist FGM service for symptom assessment, deinfibulation options, psychosexual care, maternity planning and safeguarding support with informed involvement.
- Discuss deinfibulation before pregnancy, antenatally or intrapartum according to need and preference; explain clearly that reinfibulation after birth is illegal and clinically harmful.
02AetiologyUnderlying causes, associations and risk factors, with why each one matters.
Socially enforced practice
FGM may be maintained through expectations about marriageability, sexuality, family honour, cleanliness or identity rather than any medical need or health benefit.
Intergenerational pressure
Parents may face pressure from relatives or community networks and may have experienced FGM themselves, creating both safeguarding risk and opportunities for prevention support.
Migration and travel context
Risk can change around overseas travel, ceremonies, visiting relatives or contact with a practitioner, but country of origin alone cannot establish individual danger.
03PathophysiologyThe causal sequence from the underlying abnormality to symptoms and harm.
- 1Tissue injury and scarring
Cutting damages highly innervated vascular tissue; haemorrhage and infection may be acute, while fibrosis, neuroma and altered anatomy can cause persistent symptoms.
- 2Narrowed outlet
Infibulation restricts the vaginal opening, which can slow urine and menstrual flow, impair examination and penetration, and obstruct aspects of childbirth.
- 3Obstetric tissue constraint
Inelastic scar tissue can limit expansion during birth and contribute to laceration, haemorrhage or instrumental intervention unless anatomy is assessed and managed appropriately.
- 4Trauma-related neurobiology
Painful loss of bodily control can produce persistent hyperarousal, intrusive memories, avoidance or dissociation that may reactivate during examination, sex, pregnancy or birth.
04Clinical features and red flagsSymptoms, examination findings, patterns of presentation and time-critical warnings.
Absent or altered clitoral or labial tissue and scar patterns may fit type I or II, but normal variation, injury and surgery require careful specialist interpretation.
Apposed labial scar tissue narrows the introitus, sometimes leaving a small opening for urine and menstrual flow and limiting examination or birth.
A girl under 18 personally states that FGM occurred; in England and Wales this triggers the regulated professional’s personal police report as well as safeguarding action.
Travel plans, family pressure, a known affected sibling, ceremonial language or withdrawal from care can indicate a girl is at risk before any physical sign exists.
Slow urinary stream, recurrent infection, painful menstruation, penetration difficulty, dyspareunia, scarring or obstetric difficulty may reflect FGM complications and guide specialist referral.
Fear, intrusive memories, dissociation, avoidance or distress during reproductive care may be related to FGM and requires choice, pacing and psychological support.
05InvestigationsWhat to request, why it matters and how to interpret it.
Read from the initial assessment onwards. Tests may run in parallel in urgent care; first-line, preferred, confirmatory, definitive and gold-standard labels appear only when the chapter explicitly states them.
- 01
Sensitive clinical and safeguarding historyFirst step - Why
- Identify symptoms, procedure history, pregnancy implications and girls who may be at risk.
- Interpretation and limitations
- Use private professional interpretation and the patient’s words. Disclosure can be sufficient for safeguarding; do not demand examination as proof.
- 02
Consented specialist genital examination - Why
- Assess clinically relevant anatomy, scarring, infection, cysts or suitability for deinfibulation.
- Interpretation and limitations
- Perform only when indicated and with trauma-informed consent or lawful paediatric planning. Record descriptive anatomy and avoid repeated examinations or speculative typing.
- 03
Urinary and infection assessment - Why
- Investigate retention, slow flow, recurrent urinary symptoms, discharge or acute wound infection.
- Interpretation and limitations
- Select urinalysis, culture, bladder scan or microbiology from symptoms. Infection requires treatment, while structural obstruction may need specialist deinfibulation assessment.
- 04
Pregnancy and obstetric assessment - Why
- Plan examinations, deinfibulation and birth in an affected pregnant patient.
- Interpretation and limitations
- Identify type III anatomy early, document timing options and communicate the agreed plan; ordinary antenatal risks still require full assessment.
- 05
Psychological and sexual wellbeing assessment - Why
- Identify trauma symptoms, depression, anxiety, sexual pain and priorities for support.
- Interpretation and limitations
- Use validated tools when helpful but avoid making disclosure contingent on a score. Offer specialist therapy or psychosexual care with consent.
- 06
Mandatory-duty trigger check - Why
- Distinguish the specific police-reporting duty from broader safeguarding concerns.
- Interpretation and limitations
- Record age, whether disclosure was direct or the sign was visually identified during work, professional role, UK nation and report timing; seek advice without delaying a clear duty.
06Differential diagnosisRealistic alternatives and the features that help distinguish them.
Normal anatomical variation
Labial size, asymmetry and clitoral hood appearance vary widely; uncertainty should prompt experienced assessment rather than a speculative FGM label.
Obstetric or accidental injury
Birth tears, trauma and wound repair can alter genital anatomy; history and scar distribution help distinguish these from a non-medical cutting procedure.
Medically indicated surgery
Cancer surgery, treatment of disease and some reconstructive procedures have a therapeutic purpose and are excluded from the non-medical FGM definition.
Inflammatory scarring disease
Lichen sclerosus, severe infection and other dermatoses may cause fusion or architectural loss and need dermatological or vulval assessment.
07ManagementImmediate care, first-line treatment, alternatives and escalation.
01Affected adultTreat symptoms, support autonomy and assess children at riskFirst stepAn adult discloses FGM or anatomy is identified during consented clinical care.+
- 1Ask what terminology and help the patient prefers, assess acute and chronic complications, pregnancy context, psychological wellbeing and immediate safety.
- 2Explain confidentiality, offer specialist FGM and relevant gynaecology, psychosexual or maternity services, and discuss deinfibulation without pressure when type III causes difficulty.
- 3Assess daughters, siblings and other girls proportionately and use local safeguarding referral where risk exists; do not make a mandatory police report solely because the affected person is an adult.
02Mandatory reportPersonally notify police and continue safeguardingIn England or Wales, a girl under 18 directly discloses completed FGM or a regulated professional visually identifies it during normal duties.+
- 1Confirm the trigger and immediate safety, tell the girl and family about reporting where this is appropriate and safe, and seek senior safeguarding support without transferring personal responsibility.
- 2Make the police 101 report as soon as possible, normally by the end of the next working day, documenting the reference and any exceptional reason for delay.
- 3Complete local child safeguarding and healthcare referrals, assess other girls and use 999 for immediate danger because the police report alone does not create a care plan.
03Girl at riskProtect before harm occursThere are risk indicators but no direct disclosure or visual identification of completed FGM.+
- 1See the child and relevant caregiver safely, obtain specialist safeguarding advice and assess travel, family pressure, affected relatives and other children.
- 2Refer through local children’s social care and police pathways according to risk and consider an FGM protection order with specialist legal support.
- 3Do not arrange a genital examination merely to satisfy suspicion; maintain safe follow-up around travel and changes in family circumstances.
04Pregnancy and birthAgree deinfibulation timing and prevent reinfibulationA pregnant patient has type III FGM or scarring that may affect assessment or birth.+
- 1Refer early to an experienced obstetric or FGM service, assess anatomy with consent and explain antenatal, first-stage or delivery deinfibulation options.
- 2Record the patient’s informed plan, anaesthetic needs and communication preferences so unscheduled care and labour teams can act consistently.
- 3Explain that reinfibulation will not be performed, provide postpartum wound and psychological care, and review safeguarding for any daughters.
08ComplicationsImportant consequences, why they occur and why they matter clinically.
Acute physical harm
Major bleeding, shock, infection, urinary retention, pain and injury to adjacent tissues can occur immediately and may become life-threatening without treatment.
Urogenital and sexual effects
Scarring can contribute to recurrent urinary symptoms, painful menstruation, cysts, dyspareunia, penetration difficulty and altered sexual function, although experiences vary.
Pregnancy and birth morbidity
Restricted anatomy and scar tissue can complicate vaginal assessment, catheterisation and birth and may increase tearing, haemorrhage and neonatal compromise.
Psychological injury
Post-traumatic stress, anxiety, depression, shame, sleep disturbance and distress during healthcare may persist or emerge around relationships, pregnancy or disclosure.
Safeguarding recurrence
Sisters, daughters and other girls can face similar pressure, while unsafe professional disclosure may expose the affected person to family or community retaliation.
09Monitoring and follow-upTreatment response, safety checks and longer-term review.
- Track acute infection, urinary obstruction, pain, wound healing and specialist referral outcomes, escalating deterioration rather than waiting for a routine FGM-clinic appointment.
- In pregnancy, confirm that the deinfibulation and birth plan is visible to the relevant team and revisit it if symptoms, place of birth or patient preference changes.
- For every child concern, document local safeguarding action, police report reference where the mandatory duty applies, other girls assessed and named follow-up ownership.
- Review psychological distress, sexual pain and the patient’s chosen support over time; absence of interest in surgery does not close other care options.
- Maintain safe communication and professional interpretation, particularly when family pressure, travel or portal access could expose the patient or a protected child.
10Special situationsVariants, exceptions and circumstances that change the usual approach.
Mandatory does not mean universal
The England-and-Wales personal police duty has precise age and evidence triggers; adults and risk-only cases still need thoughtful safeguarding through other routes.
No examination for proof
A child disclosure should be believed and referred; repeated or non-indicated genital examination can compound trauma and rarely improves immediate protection.
Type does not predict experience
Anatomical classification helps plan care but cannot measure pain, sexual impact, trauma or the person’s priorities.
Deinfibulation is a choice
Explain potential urinary, sexual, examination and birth benefits while allowing the affected person to decide timing outside an emergency.
Protection can include family
An adult survivor may be a powerful partner in preventing FGM for daughters and relatives; risk assessment should not presume perpetration from survivor status.
11Common pitfallsFrequent interpretation and management errors.
- 01
Reporting every adult FGM disclosure to police as though the under-18 mandatory duty applied.
- 02
Failing to refer a girl at future risk because she has not disclosed completed FGM.
- 03
Delegating a clear personal mandatory report to the safeguarding lead and assuming responsibility has transferred.
- 04
Examining a child solely to confirm suspicion or repeating genital examination across several services.
- 05
Promising reinfibulation after birth or treating it as a culturally required part of wound repair.
- 06
Assuming ethnicity proves FGM or that an affected adult necessarily wants deinfibulation.