The World Health Organisation (WHO) divides the FGM procedure into four major types. All types carry a high risk of infection, including HIV transmission, complications and fatality. The procedure is often not carried out in a sterile environment with clean instruments. It is usually perpetrated by the female elders.

Type I

The WHO defines Type I FGM as the partial or total removal of the clitoris (clitoridectomy) and/or the prepuce (clitoral hood) and is regarded as the mildest form of FGM but seems to only be undertaken on a small number of girls and women.

Type II

The WHO's definition of Type II FGM is "partial or total removal of the clitoris and the labia minora, with or without excision of the labia majora".

Type III

The WHO defines Type III FGM as narrowing of the vaginal orifice with creation of a covering seal by cutting and repositioning the labia minora and/or the labia majora, with or without excision of the clitoris leaving an artificial hole the size of a matchstick to allow the flow of urine and menstrual blood (infibulation). It is the most extensive form of FGM.

A reverse infibulation is often performed to allow for sexual intercourse or when undergoing labour. In some communities, the man forces reverse infibulation during the first sexual act to demonstrate his virility.

Women who have been infibulated face a lot of difficulty in delivering children, especially if the infibulation is not undone beforehand, which often results in severe tearing of the infibulated area, or fetal death if the birth canal is not cleared.

The risk of severe physical, and psychological complications is more highly associated with women who have undergone infibulations as opposed to one of the lesser forms of FGM. Although there is little research on the psychological side effects of FGM, many women feel great pressure to conform to the norms set out by their community and suffer from anxiety and depression as a result.

Type IV

There are other forms of FGM, collectively referred to as Type IV. The WHO defines Type IV FGM as "all other harmful procedures to the female genitalia for non-medical purposes, for example, pricking, piercing, incising, scraping and cauterization."

This includes a diverse range of practices, such as pricking the clitoris with needles, burning or scarring the genitals as well as ripping or tearing of the vagina.

Female genital mutilation is a complex issue. Despite the harm it causes, many women from FGM practising communities consider FGM normal to protect their cultural identity.

Although FGM is practised by secular communities, it is most often claimed to be carried out in accordance with religious beliefs.

However, neither the Bible nor the Koran support the practice of FGM.

It is reported to be practised in 28 African countries from the Gambia to Somalia and parts of the Middle and Far East. It has been reported in immigrant African populations in the UK.

In addition to giving religious reasons for subjecting their daughters to FGM, parents say they are acting in a child’s best interests because it:

• Brings status and respect to the girl
• Preserves a girl’s virginity / chastity
• Is a rite of passage
• Gives a girl social acceptance, especially for marriage
• Upholds the family honour
• Helps girls and women to be clean and hygienic

The age at which girls are subjected to female genital mutilation varies greatly, from shortly after birth to any time up to adulthood. The average age is 10 to 12 years.

Short-term health implications can range from severe pain and emotional / psychological trauma to, in some cases, death.

The health problems caused by FGM Type 3 are severe – urinary problems, difficulty with menstruation, pain during sex, lack of pleasurable sensation, psychological problems, infertility, vaginal infections, specific problems during pregnancy and childbirth, including flashbacks.

Women with FGM Type 3 require special care during pregnancy and childbirth.

Indications that FGM may be about to take place include:

• The family comes from a community that is known to practise FGM (in conjunction with any of the following)
• A child may talk about a long holiday to her country of origin or another country where the practice is prevalent, including African countries and the Middle East
• A child may confide to a professional that she is to have a ‘special procedure’ or to attend a special occasion
• A child may request help from a teacher or another adult
• Any female child born to a woman who has been subjected to FGM must be considered to be at risk, as must other female children in the extended family
• A midwife / obstetrician may become aware that FGM has taken place when treating a pregnant woman. This should trigger concern for any female child of the family and result in educational/preventative input via health professionals in liaison with support groups
• Any female child who has a sister who has already have undergone FGM must be considered to be at risk, as must other female children in the extended family.

Indications that FGM may have already taken place include:

• A child may spend long periods of time away from the classroom during the day with bladder or menstrual problems if she has undergone Type 3 FGM
• A prolonged absence from school with noticeable behaviour changes on the girl’s return could be an indication that a girl has recently undergone FGM
• Professionals also need to be vigilant to the emotional and psychological needs of children who may/are suffering the adverse consequence of the practice (e.g. withdrawal, depression etc.)
• A child requiring to be excused from physical exercise lessons without the support of her GP
• A child may ask for help

Any information or concern that a child is at immediate risk of, or has undergone, female genital mutilation should result in a child protection referral to LA children’s social care.

Where a child is thought to be at risk of FGM, practitioners should be alert to the need to act quickly – before the child is abused through the FGM procedure in the UK or taken abroad to undergo the procedure.

On receipt of a referral, a strategy meeting / discussion must be convened within two working days, and should involve representatives from the police, LA children’s social care, education, health and voluntary services. Health providers or voluntary organisations with specific expertise (e.g. FGM, domestic violence and / or sexual abuse) must be invited, and consideration may also be given to inviting a legal advisor.

Every attempt should be made to work with parents on a voluntary basis to prevent the abuse. It is the duty of the investigating team to look at every possible way that parental co-operation can be achieved, including the use of community organisations and / or community leaders to facilitate the work with parents / family. However, the child’s interest is always paramount.

If no agreement is reached, the first priority is protection of the child and the least intrusive legal action should be taken to ensure the child’s safety.

If the strategy meeting / discussion decides that the child is in immediate danger of mutilation and parents cannot satisfactorily guarantee that they will not proceed with it, then an emergency protection order should be sought.