The landmark case of R v Noor (2024), which resulted in a conviction under the Female Genital Mutilation Act 2003, marks a critical juncture in the legal landscape of female genital mutilation prosecution in the UK. This was the first time that a conviction for assisting female genital mutilation outside the UK has taken place; the first conviction was the case of R v N (2019) (Courts and Tribunals Judiciary, 2019). This case underscores the vital role of midwives in identifying, reporting and providing care for victims of female genital mutilation, as well as their potential involvement in legal processes. It also highlights the complexities of female genital mutilation as a socio-cultural, legal and medical issue, emphasising the importance of midwifery practice in safeguarding women and girls. This case serves as a call to action for midwives to enhance their awareness, education and collaborative efforts with legal authorities to protect vulnerable individuals from female genital mutilation.
Despite increasing cross-sector calls for the eradication of female genital mutilation, women and girls across the globe remain at risk, with the World Health Organization (WHO, 2024) estimating that over 200 million women and girls alive today have been subjected to female genital mutilation. In the UK, it was estimated that 137 000 women and girls had undergone female genital mutilation with a further 60 000 at continued risk (UK Government, 2021). NHS Digital (2023) reported that between July and September 2023, 1785 women and girls had an attendance where female genital mutilation was identified.
Addressing female genital mutilation
The WHO (2024) classifies female genital mutilation into four types. Type 1 is the partial or total removal of the clitoral glans (the external and visible part of the clitoris, which is a sensitive part of the female genitals), and/or the prepuce/clitoral hood (the fold of skin surrounding the clitoral glans). Type 2 is the partial or total removal of the clitoral glans and the labia minora (the inner folds of the vulva), with or without removal of the labia majora (the outer folds of skin of the vulva). Type 3, also known as infibulation, is the narrowing of the vaginal opening through the creation of a covering seal. The seal is formed by cutting and repositioning the labia minora, or labia majora, sometimes through stitching, with or without removal of the clitoral prepuce/clitoral hood and glans. Type 4 includes all other harmful procedures to the female genitalia for non-medical purposes eg, pricking, piercing, incising, scraping and cauterising the genital area.
Internationally, the response to female genital mutilation has been part of a broader movement against gender-based violence. Various instruments, such as the Istanbul Convention (Council of Europe, 2011), explicitly address female genital mutilation as a form of violence against women. The United Nations (2015; 2020; 2024) has also issued resolutions calling for the prohibition of female genital mutilation, and it is addressed under goal 5 of the sustainable development goals, which aims to achieve gender equality and empower all women and girls.
The WHO also plays a crucial role in setting international health policy and has been instrumental in the global effort to eradicate female genital mutilation. WHO (2016) guidelines on female genital mutilation are comprehensive, covering not only the need to eliminate the practice but also the care required for those who have undergone female genital mutilation. The WHO (2016) strongly advocates for the elimination of female genital mutilation, emphasising its lack of health benefits and the harm it causes. It also provides guidelines for healthcare providers on how to manage and care for women living with female genital mutilation, including psychological, sexual and reproductive health services (WHO, 2016).
Legal backdrop
Domestically, the Female Genital Mutilation Act 2003 is a crucial piece of legislation aimed at preventing the practice of female genital mutilation in line with the UK's Convention obligations. The Act made it illegal to perform female genital mutilation in the UK (section 1) or assist a girl to mutilate her own genitalia (section 2). Notably, the Act also made it an offence for UK nationals or permanent residents to perform or assist in the performance of female genital mutilation abroad, even in countries where the practice is legal (section 3). It is also an offence to fail to protect a girl from female genital mutilation (section 3A). Section 3, in particular, was a significant expansion of the law's territorial scope, aimed at preventing ‘female genital mutilation tourism’, otherwise referred to as transnational female genital mutilation (Office of the United Nations High Commissioner for Human Rights, 2024).
Introduced in the UK under section 70 of the Serious Crime Act 2015, which amended the Female Genital Mutilation Act 2003 via Schedule 2, female genital mutilation protection orders are specific legal measures in the Family Courts, which are designed to protect individuals from being subjected to female genital mutilation (UK Government, 2016). These orders can be applied for by the individual at risk, a relevant third party or any other person with the permission of the court. The conditions imposed by a female genital mutilation protection order can be wide-ranging, designed to safeguard the individual according to their circumstances. This may include measures to stop someone from being taken abroad for female genital mutilation.
Female genital mutilation protection orders can be applied for by the person at risk, or someone else (for example, from a local authority). Victims of female genital mutilation may also apply for a protection order so that they cannot be prevented from returning to the UK. Once an application has been made, the court will hold a private hearing, at which evidence may need to be given. Both temporary and permanent orders may be made. If a protection order has been breached, then the applicant should contact the police or apply for a warrant of arrest with the court. On further application, protection orders can be extended, varied or discharged at any time. (UK Government, 2017).
Despite the existence of robust legal mechanisms, their application has remained a cause of controversy, with only one successful prosecution prior to R v Noor. This sits at odds with the 900 newly recorded individuals (note: this means that the cases appeared for the first time in the dataset, but this does not indicate how recently they experienced female genital mutilation or whether it was their first attendance for it) identified as having undergone female genital mutilation by NHS services between July and September 2023 (NHS Digital, 2023). This suggests that the Female Mutilation Act 2003 is ineffectual in preventing female genital mutilation in women and girls.
Signs and symptoms of female genital mutilation
Recognising the signs and symptoms of female genital mutilation is crucial for midwives to provide appropriate care and support to affected women and girls. Below are some of the main signs and symptoms that midwives can look for in suspected female genital mutilation cases (Royal College of Obstetricians and Gynaecologists (RCOG), 2015; National Society for the Prevention of Cruelty to Children, 2024).
Physical signs include visible scarring or alterations in the genital area, closure or narrowing of the vaginal opening, and urination difficulties, such as a slow stream or pain. Obstetric/gynaecological symptoms include painful menstruation, irregular periods or difficulty with menstrual flow, pain during intercourse, vaginal infections or chronic discharge, and complications during childbirth, including prolonged labour or the need for caesarean section. Psychological signs may manifest in symptoms of post-traumatic stress disorder, including flashbacks or anxiety, depression, mood swings or feelings of shame and guilt. Finally, social and behavioural indicators may include reluctance for a physical examination or discussion of sexual health, and coming from a community where female genital mutilation is practiced.
During pregnancy and childbirth, a woman may have special care needs or require deinfibulation and may be at risk of obstetric complications. Midwives should approach suspected female genital mutilation cases with sensitivity, ensuring a safe and non-judgmental environment for the woman to discuss her health and concerns.
Case overview
The case of R v Noor (2024) marks the first successful prosecution under section 3 of the Female Genital Mutilation Act 2003, representing a significant legal and societal condemnation of female genital mutilation. Mrs Noor was convicted on 26 November 2023 and sentenced on 16 February 2024 in the Old Bailey (the Central Criminal Court). The offence was committed against a vulnerable 3-year-old child (who has been anonymised as Jade). Jade was under the care of the defendant, Amina Noor, who took the child to Kenya from the UK for the procedure. The offence fell under Type 1 of the WHO (2024) classification (the total or partial removal of the clitoris); however, it was the defence's argument that Type 4 had been committed through piercing or the drawing of blood from the clitoris. Mr Justice Bryan, the judge throughout the case, held that despite the Female Genital Mutilation Act 2003 not explicitly referring to which of the WHO (2024) classifications were specifically included as an offense, it was the intention of Parliament that all four types should be included (Courts and Tribunals Judiciary, 2024).
Noor is of Somali descent, having moved to Kenya as a refugee at a young age because of conflict at the time. The evidence put before the jury was that Somalia has one of the highest rates of female genital mutilation globally, approximately 98–99% (UK Government, 2021; Courts and Tribunals Judiciary, 2024). It was an agreed fact that in Somali, ‘Gudniin’ is a general term for female genital mutilation, while ‘Sunnah Gudniin’, sometimes abbreviated to ‘Sunnah’ is specifically type 1 mutilation. Mr Justice Bryan found that while the words have different meanings, they can be used interchangeably when talking about type 1 female genital mutilation (Courts and Tribunals Judiciary, 2024).
The sentencing remarks delve into the horrific nature of female genital mutilation, emphasising its permanent and life-altering consequences for victims, including for Noor herself. It underscores the cultural and familial pressures that can perpetuate such practices, but firmly establishes that such pressures and ignorance of the law do not excuse the crime. The Court took a strong stance on the importance of eradicating female genital mutilation, highlighting the need for open discourse to deter these practices, and the courage of victims like Jade in coming forward (Courts and Tribunals Judiciary, 2024).
Mr Justice Bryan considered the seriousness of the offence, the defendant's personal circumstances, including her own experience with female genital mutilation, and the broader context of the practice's prevalence in certain cultures (Courts and Tribunals Judiciary, 2024). Despite acknowledging Noor's background, including her refugee status and lack of previous convictions, the judge emphasised the grave breach of trust and the deliberate infliction of irreversible harm on the victim (Courts and Tribunals Judiciary, 2024).
The case also revealed the complex interplay between cultural practices, individual responsibility and legal standards. While recognising the defendant's cultural background and personal challenges, the court maintained a strong stance against female genital mutilation, reflecting its commitment to protecting children's rights and bodily integrity in the UK's multicultural society (Courts and Tribunals Judiciary, 2024).
There are no sentencing guidelines for female genital mutilation offences. This is only the second successful prosecution of female genital mutilation in the UK, the first being the case of R v N (2019), which carried a sentence of 11 years (but was conducted in the UK and had materially different facts). In the case of R v Noor, the court also considered Noor's personal background, including her own experience with female genital mutilation, her family circumstances and the delay in bringing charges. Ultimately, Noor was sentenced to 7 years in prison, reflecting her personal mitigations, the gravity of the offense, her role in facilitating female genital mutilation, and the broader objectives of sentencing, such as punishment, deterrence and the protection of public interest against such practices.
Implications for midwifery
The case of R v Noor highlights several key implications for midwives and midwifery practice. Home et al (2020) have previously discussed and advocated for key implementations in this area, as outlined below.
Legal and professional implications
As part of their professional practice, midwives are mandated to report known cases of female genital mutilation in under 18-year-olds to the police. This legal requirement emphasises the role of midwives not only as caregivers but also as protectors and advocates for the welfare of children and vulnerable groups. This follows the Nursing and Midwifery Council (2015) code of practice, particularly sections 3, 4, 16, 17 and 23.
The need for midwives to be adequately trained and aware of the issues surrounding female genital mutilation and protection orders is paramount. This includes understanding the legal mechanisms for protecting girls and women, recognising the signs and knowing the appropriate steps to take when female genital mutilation is suspected or disclosed.
Ethical considerations
Beyond legal obligations, midwives have an ethical duty to protect their patients from harm. This includes navigating complex cultural sensitivities while advocating for the health and rights of women and girls. The case of R v Noor underscores the importance of recognising female genital mutilation as a violation of human rights and the ethical responsibility of healthcare professionals to prevent and report such practices.
Midwives must balance the ethical principle of patient confidentiality with the need to protect vulnerable individuals from harm, as prescribed by the Nursing and Midwifery Council (2015) code of practice. In cases where female genital mutilation is suspected or confirmed, the duty to report and protect the child may override the usual considerations of confidentiality.
Practice implications
Midwives should be equipped to create an environment where women and girls feel safe to disclose signs and symptoms, experiences and/or fears related to female genital mutilation. This involves being culturally sensitive, non-judgmental and supportive, ensuring that patients understand their rights and the protections available to them, including female genital mutilation protection orders. This should be done through flagging and signposting but not by providing legal advice itself.
Implementation of female genital mutilation protection orders and safeguarding of women and girls from female genital mutilation require a multidisciplinary approach. Midwives need to work closely with legal, social and child protection services to ensure that appropriate measures are taken to protect at-risk individuals. Female genital mutilation specialist services play a critical role in the care and support of women affected by female genital mutilation (RCOG, 2015). Each acute trust or health board is required to have a designated consultant and midwife responsible for the care of women with female genital mutilation (RCOG, 2015). Additionally, all gynaecologists, obstetricians and midwives must undergo mandatory training on female genital mutilation and its management, including learning deinfibulation. This training includes completing a programme of female genital mutilation e-modules developed by Health Education England (RCOG, 2015).
These specialist multidisciplinary services, led by a consultant obstetrician and/or gynaecologist, must be accessible through self-referral. They offer a range of services including information and advice about female genital mutilation, child safeguarding risk assessment, gynaecological assessment, deinfibulation and access to other relevant services. Healthcare professionals must ensure that consultations and examinations for women affected by female genital mutilation are conducted in a safe and private environment. Their approach should be sensitive and non-judgemental, and professional interpreters should be used when necessary, avoiding the use of family members as interpreters.
The evolving legal landscape around female genital mutilation and female genital mutilation protection orders necessitates continuous learning and professional development for midwives. Staying informed about current laws, guidelines and best practices related to female genital mutilation is essential for providing competent and holistic care.
The importance of protection orders
The case of R v Noor serves as a stark reminder of the legal and ethical obligations of healthcare professionals, including midwives, to actively participate in the detection, reporting and prevention of female genital mutilation. This is despite protection orders not being available to Jade at the time of the offence, as there was no legislative mechanism to do so. However, this case does underscore the importance of more recent legal frameworks, such as the Female Genital Mutilation Act 2003 and subsequent Serious Crime Act 2015, which not only criminalise the act of female genital mutilation but also provide mechanisms for protection against it.
Protection orders are a pivotal development in the legal protection available to potential victims of female genital mutilation. These orders can be tailored to the specific needs of the individual at risk, imposing conditions that directly address potential threats. For instance, they can prevent the removal of the individual from the UK, where they might be taken abroad to undergo female genital mutilation. This preventive measure is particularly significant in cases similar to R v Noor, where the risk of female genital mutilation might extend beyond the UK's borders.
The effectiveness of protection orders in safeguarding individuals from female genital mutilation hinges on the vigilance and proactive engagement of healthcare professionals, notably midwives, who are often the first point of contact for women and girls at risk. Midwives are uniquely positioned to identify signs of female genital mutilation or the risk thereof, given their close involvement with women's health and their access to sensitive information that may indicate a threat of female genital mutilation. Their role extends beyond the identification and reporting of female genital mutilation cases; they must also be knowledgeable about the legal protections available to their patients, including protection orders, and guide them through the process of obtaining such orders when necessary.
Moreover, the case of R v Noor, and the discussion of female genital mutilation protection orders by academics, such as Home et al (2020), highlight the necessity for continuous education and training for midwives and other healthcare professionals. This education should not only cover the identification of female genital mutilation and its health implications, but also provide healthcare professionals with a comprehensive understanding of the legal measures designed to combat this practice. Midwives must be equipped with knowledge of the appropriate safeguarding pathways (as must all clinicians in their appropriate disciplines), and be able to liaise with legal authorities and provide support to their patients in seeking female genital mutilation protection orders.
Female genital mutilation commissioner
Home et al (2020) and Malik et al (2018) argued for the establishment of a female genital mutilation commissioner based on analysis of the legal framework surrounding female genital mutilation protection orders in the UK. There is a notable discrepancy between the number of protection order applications and known recorded cases of female genital mutilation, suggesting a gap in protection measures and the effectiveness of existing legal frameworks.
Despite the introduction of female genital mutilation protection orders, there is a lack of concrete evidence demonstrating their effectiveness in safeguarding women and girls from female genital mutilation. This uncertainty underlines the need for critical exploration and evaluation of female genital mutilation protection orders as a protective measure.
There are several barriers to the effective implementation of female genital mutilation protection orders, including potential issues around awareness, reporting and the legal process itself. The discussion suggests the need for solutions to overcome these barriers to ensure that female genital mutilation protection orders can serve their intended protective role. The authors argue that the appointment of a female genital mutilation commissioner could facilitate a more coordinated and effective approach to combating female genital mutilation. This role could oversee the collection and analysis of data, evaluate the effectiveness of female genital mutilation protection orders and address implementation barriers. A commissioner could also play a crucial role in raising public awareness and fostering collaboration among stakeholders.
Conclusions
R v Noor represents a watershed moment in the fight against female genital mutilation in the UK, setting a precedent for the prosecution of female genital mutilation cases and underscoring the critical role of healthcare professionals, especially midwives, in this battle. This landmark case highlights the intersection of healthcare, law and ethics, emphasising the need for a collaborative and informed approach to protect women and girls from this harmful practice.
For midwives, the implications of this case are manifold, requiring a deep understanding of the legal landscape, cultural sensitivity and an unwavering commitment to the welfare of their patients. The case of R v Noor not only brings to light the legal responsibilities that midwives have in reporting and preventing female genital mutilation but also emphasises their role as educators, advocates and supporters of women and girls at risk of or affected by female genital mutilation.
The introduction of female genital mutilation protection orders and the successful prosecutions under the Female Genital Mutilation Act serve as crucial tools in the legal arsenal against female genital mutilation. However, their effectiveness is contingent upon the proactive engagement of healthcare professionals in identifying risks, reporting incidents and supporting victims through the legal process.
Moving forward, it is imperative that midwives and other healthcare providers continue to receive comprehensive education and training on female genital mutilation, its legal implications and the resources available to protect and support victims. Strengthening partnerships with legal and social services is essential to create a robust support system for vulnerable women and girls. Moreover, fostering an environment where patients feel safe to disclose their experiences and fears is crucial for the early detection and prevention of female genital mutilation.
The case of R v Noor is a call to action for midwives and healthcare professionals to bolster their efforts in the fight against female genital mutilation. It serves as a reminder of the power of legal and healthcare collaboration in safeguarding the rights and wellbeing of women and girls. This should be maintained and monitored by a female genital mutilation commissioner. As we move forward, it is crucial that the lessons learned from this case inform practice, policy and education, ensuring that female genital mutilation is eradicated not only in the UK but around the world.