Mother Under Pressure to Submit Daughter to Fgm — Free SCA Practice Case
Mother under pressure to submit daughter to FGM
Station Timer
Golden Minute
Initial Introduction
•Introduce yourself
•Ask an open question — "How can I help you today?"
•Listen — don't interrupt
•Catch early cues
Data Gathering
History, ICE & Diagnosis
Clinical Management
Diagnosis, Plan & Decisions
Safety Net
Follow-up & Close
Five cases are free: a live 12-minute consultation with an AI patient each, marked, and no card.
Materials for Candidate
Please review before starting the consultation
Full Name
Faduma Hassan
Age
32 years
Consultation Type
TelephoneAge
32
Situation
Video or Telephone Consultation.
Reason for Encounter
"Patient complaining of burning when passing urine for 3 days. Requesting antibiotics."
Medical Records
- ●PMH: Recurrent UTIs. Type 3 FGM (Infibulation) documented during her pregnancy 6 years ago.
- ●Medications: None regular.
- ●Allergies: NKDA.
- ●Social: Lives with husband and 6-year-old daughter, Aisha. Originally from Somalia, moved to the UK 10 years ago.
Patient Script
For the friend playing the patient role
Character Overview: You are Faduma. You booked this appointment because of a painful water infection, but your real agony is emotional. You are exhausted, tearful, and terrified. Your mother-in-law is visiting from Somalia next month and has declared it is time for your 6-year-old daughter, Aisha, to be "cut." You suffered horrific trauma from your own FGM and desperately want to protect Aisha, but you feel powerless against your husband and his family's cultural expectations. You are looking for the doctor to give you a "medical excuse" or use their authority to stop it.
Opening Sentence: "Hello Doctor. I need some antibiotics again, it's burning when I pee and takes a long time to come out. But... I'm also just so stressed. I haven't been sleeping. I have a terrible problem at home and I don't know who to talk to."
History if Asked (Data Gathering Phase)
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The Physical Symptoms (UTI secondary to FGM):
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"It stings a lot. I have to push to empty my bladder because the opening is so small."
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The Psychosocial Crisis (The "At Risk" Child):
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If the doctor explores the stress: "My mother-in-law is flying over from Somalia in a few weeks. She says Aisha is 6 now, and it is time for her to be 'purified'. To be cut."
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"I told my husband I don't want it. It ruined my life. Every time I go to the toilet or have intimacy, it is pain. But he says we cannot disrespect his mother. She might even try to take Aisha back to Somalia for a 'holiday' to get it done."
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Aisha's Current Status:
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"Aisha is fine right now. She hasn't been touched. But they are making plans."
ICE — Ideas, Concerns, Expectations
Actor guidance: Faduma does not volunteer these unprompted. These responses surface only if the candidate directly explores her perspective.
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Ideas: "I know the burning is because of the cutting they did to me — they sewed me up so tight that everything down there is difficult. The infections keep coming back because I can't empty properly. I've had this before, I know it's a water infection."
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Concerns: "Honestly, the infection I can cope with. What I can't cope with is the thought of them doing to Aisha what they did to me. I can't sleep thinking about it. I'm terrified that if my mother-in-law takes her to Somalia, I won't be able to stop it. And I'm scared that if I involve the authorities here, I'll lose my family."
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Expectations: "I was hoping you could write me a letter — something official, from a doctor — saying it's medically dangerous. Something I can show my husband and his mother to make them stop. I also need something for the burning, but Aisha is what I really came about."
If Asked — Medical History and Medications
Actor guidance: Faduma confirms the following if the candidate asks directly about her medical history or medications.
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Recurrent UTIs: "Yes, I've had infections like this a few times over the years. Maybe three or four times since I came to the UK. The doctors always give me antibiotics and it clears up, but then it comes back again after a few months. I think it's because of the way I was cut — the opening is so narrow that I can never fully empty my bladder."
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Type 3 FGM (Infibulation): "It was done to me when I was about 7 — back in Somalia. They sewed me up almost completely. When I had Aisha, the midwife had to cut me open to deliver her, and then I was stitched again afterwards. I have a very small opening now. Everything is difficult — going to the toilet, intimacy, everything."
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Medications: "I'm not on any regular medication. I just take the antibiotics when I get these infections. I don't take anything else."
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Allergies: "No, no allergies to any medicines that I know of."
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Pregnancy / obstetric history (if asked): "I had Aisha six years ago. The birth was very difficult because of the FGM — they had to cut me open. I haven't been pregnant since. We would like more children but intimacy is so painful that it doesn't happen often."
Social History and Lifestyle Impact
Actor guidance: Faduma shares this naturally in conversation if the candidate asks about her daily life, work, or how the symptoms affect her.
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Occupation / daily life: "I don't work at the moment. I look after Aisha and I do some volunteering at a Somali community centre — helping other women with English and filling in forms. My husband works long hours as a security guard so I'm on my own with Aisha most of the day."
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Lifestyle impact of the UTI / FGM: "The burning makes everything harder. When the infection is bad, I'm going to the toilet every twenty minutes but barely anything comes out, and it stings every time. I can't take Aisha to the park or go to the community centre because I need to be near a toilet. Last time it got really bad I just stayed in bed and my neighbour had to take Aisha to school for me. It's embarrassing — I'm only 32 and sometimes I feel like an old woman."
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Emotional and social isolation: "I don't really have anyone to talk to about this. The women in my community — some of them think FGM is normal. My own mother had it done to her and she had it done to me. I can't talk to my husband because he takes his mother's side. I feel very alone with all of this."
If Asked — Associated Symptoms
Actor guidance: Faduma answers the following only if the candidate asks directly. She does not volunteer these symptoms.
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If asked about fever or feeling hot and cold: "No, I don't think I have a temperature. I feel tired but not feverish."
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If asked about back pain or loin pain: "No, I don't have any pain in my back or sides — just the burning at the front when I pass water."
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If asked about blood in the urine: "No, I haven't noticed any blood. It's just the stinging and the slow stream."
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If asked about vaginal discharge: "No, nothing unusual. Just the burning when I pee."
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If asked about abdominal pain or pelvic pain: "I get a bit of aching low down in my tummy, like a heaviness, but nothing sharp. It's been like that for a while — I think it's because of the way I was sewn up."
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If asked about nausea or vomiting: "No, nothing like that."
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If asked about frequency and urgency: "Yes, I'm going all the time at the moment — every twenty minutes sometimes. And when I need to go, I really need to go, but then I have to sit there and push and barely anything comes out."
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If asked about pain during intercourse (dyspareunia): "Yes, it's always painful. It has been ever since the cutting. That's part of why I'm so desperate to protect Aisha — I don't want her life to be like mine."
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If asked about could she be pregnant: "No, I don't think so. We haven't been intimate for a few weeks because I've been so stressed and in pain."
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If asked about previous urine tests or investigations: "They've dipped my urine before and given me antibiotics. I don't think I've ever had a scan or anything like that. No one has really looked into why it keeps happening — they just give me tablets."
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If asked about symptoms of diabetes (thirst, weight loss): "No, nothing like that. I'm not thirsty all the time and my weight has been the same."
Responses to Management (The Negotiation Phase)
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If the Doctor mentions referring to Social Services/Safeguarding:
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Reaction: Terrified and defensive. "Social services? No! Will they take my baby away? Will my husband be arrested? Please, I just wanted you to write a letter saying it's bad for her health!"
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If the Doctor explains the UK Law (FGM Act):
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Reaction: Searching for a lifeline. "So you are saying it is a serious crime here? Even if they take her abroad? Can you give me a leaflet or something official? Maybe if I show my husband that we will go to prison, he will stand up to his mother."
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If the Doctor focuses ONLY on the UTI and ignores the stress:
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Reaction: Desperate. "Doctor, please, the infection is nothing. Did you hear what I said about my daughter? They are going to cut her!"
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If the Doctor offers referral to a specialist FGM clinic for Faduma:
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Reaction: Hopeful but hesitant. "A clinic? Can they open me up a bit so passing water isn't so hard? I would like that, but Aisha is my priority right now."
Mark Scheme
Domain 1: Data Gathering and Diagnosis
Domain 2: Clinical Management and Medical Complexity
Domain 3: Relating to Others
Clinical Learning Points
FGM: Classification, Clinical Presentation, and Complications
- ●Type 3 FGM (Infibulation) is the most severe form: near-complete narrowing of the vaginal introitus with a covering seal. It accounts for approximately 10% of FGM globally but is prevalent in Somalia, where prevalence exceeds 90%.
- ●Infibulation creates a significantly reduced urinary meatus, causing incomplete bladder emptying and urinary stasis — the principal mechanism driving Faduma's recurrent lower UTIs.
- ●Recognised FGM-related complications include: recurrent UTIs, chronic pelvic pain, dysmenorrhoea, haematocolpos, dyspareunia, apareunia, and severe obstetric complications requiring deinfibulation in labour.
- ●Obstetric history is a key prompt to review FGM documentation: women with Type 3 FGM commonly require deinfibulation at delivery, with re-infibulation (re-stitching) — itself illegal in the UK — sometimes performed post-partum. Always check what was done at the time of delivery.
Recurrent UTI: Investigation and Management in the Context of FGM
- ●Recurrent UTI is defined as ≥2 episodes in 6 months or ≥3 episodes in 12 months (NICE CKS). Faduma's pattern meets this threshold and must not be managed with repeated empirical antibiotic courses without investigation.
- ●Send a midstream urine (MSU) for culture and sensitivity before or alongside empirical treatment. This guides targeted therapy, confirms the causative organism, and establishes a formal microbiological record — essential for patients with structurally-driven recurrence.
- ●First-line empirical treatment for uncomplicated lower UTI in women (NICE CKS / UKHSA guidelines): nitrofurantoin 100 mg modified-release twice daily for 3 days (if eGFR ≥45 ml/min). If nitrofurantoin is contraindicated or eGFR is borderline, use trimethoprim 200 mg twice daily for 7 days (check local resistance patterns first).
- ●Recurrence prevention measures — adequate hydration, post-coital voiding, avoiding prolonged bladder holding — have modest evidence but are worth discussing. In Faduma's case, however, these measures will not resolve the underlying structural problem: only specialist intervention can do that.
- ●Exclude upper UTI (pyelonephritis) at every recurrent presentation: fever, rigors, loin pain, nausea, or vomiting indicate upper tract involvement and require a longer antibiotic course (cefalexin or co-amoxiclav for 7–14 days) and urgent review.
Specialist FGM Clinic Referral — Deinfibulation
- ●All women with FGM-related complications should be offered referral to a specialist NHS FGM clinic. These clinics provide: gynaecological and urological assessment, psychological support, and surgical deinfibulation.
- ●Deinfibulation (surgical opening of the infibulation scar) is a relatively minor procedure performed under local or general anaesthetic. It relieves urinary obstruction, reduces recurrent UTI frequency, and significantly improves dyspareunia and quality of life.
- ●This referral is appropriate for Faduma regardless of the safeguarding situation and should be framed as care she deserves for her own health — not as an add-on to the child protection discussion.
- ●Re-infibulation after childbirth or any other procedure is illegal in the UK under the FGM Act 2003 and must never be performed.
UK Legal Framework: FGM Act 2003
- ●FGM is a criminal offence in England, Wales, and Northern Ireland under the Female Genital Mutilation Act 2003 (amended 2015). It is illegal to:
- ●Perform FGM in the UK on any person.
- ●Assist a girl to carry out FGM on herself.
- ●Take or assist in taking a UK national or permanent resident abroad for FGM (extraterritorial provision — this explicitly covers Aisha's situation).
- ●Fail to protect a girl from risk of FGM (parents and those with parental responsibility can be prosecuted).
- ●The extraterritorial provision is the key legal tool in Aisha's case: the planned trip to Somalia to undergo FGM is a criminal offence under UK law even though it would occur outside the UK.
Mandatory Reporting Duty vs Safeguarding Referral — A Critical Distinction
- ●Mandatory Reporting Duty (introduced by the Serious Crime Act 2015): regulated healthcare professionals (including GPs) must report to the police (101) if they identify — in the course of their professional duties — that a girl under 18 has already had FGM, or a girl under 18 discloses to them that she has had FGM. This is a duty to report to police, not to social care.
- ●This duty does not apply to Aisha, who has not yet been harmed. For a child at risk but unharmed, standard child safeguarding procedures apply.
- ●Safeguarding referral (to Children's Social Care / MASH): this is the correct pathway for Aisha. It is a legal duty under Section 47 of the Children Act 1989 when a GP has reasonable cause to suspect a child is at risk of significant harm. FGM is explicitly recognised as significant harm.
- ●The referral must be made today — this is an imminent, named threat with a specific timeline. Do not defer pending further information.
FGM Protection Orders (FGMPOs)
- ●An FGM Protection Order is a civil legal order available under the FGM Act 2003 (Schedule 2). It can be applied for by the police, local authority, or the victim herself.
- ●FGMPOs can contain any conditions the court considers appropriate, including: surrender of the child's passport, prohibition on removing the child from the UK, and restrictions on contact with named individuals.
- ●In Aisha's case, a FGMPO is the most important immediate legal protection — it directly addresses the risk of her being taken to Somalia. Social Services or the police (not the GP) apply for the order, but the GP should explain its existence and purpose to Faduma.
- ●Candidates should know: the GP does not apply for the FGMPO — this is the role of social care or police following the safeguarding referral.
Safety-Netting
- ●For the UTI: Advise Faduma to return or seek urgent review if she develops fever, loin pain, rigors, vomiting, or if symptoms do not improve within 48 hours of starting antibiotics. These features indicate possible pyelonephritis requiring different management.
- ●For the safeguarding situation: Provide Faduma with clear, specific guidance on what to do if the situation escalates before the referral is processed:
- ●If she believes Aisha is in immediate danger: call 999.
- ●If she needs urgent advice or support: NSPCC FGM Helpline: 0800 028 3550 (free, 24/7).
- ●She can also return to the GP practice at any time — she does not need a scheduled appointment if she is concerned Aisha is about to be removed.
- ●Arrange a follow-up appointment within 1–2 weeks to review UTI treatment response, MSU results, and the progress of the safeguarding referral.
Common Candidate Mistakes in This Case
- ●Writing a medical letter as a standalone response: Faduma requests a letter saying FGM is medically dangerous. While empathic acknowledgement of this request is important, agreeing to a letter as the primary intervention gives false reassurance. A GP letter has no legal authority to prevent FGM or international travel. The correct response is to redirect to the mechanisms that do have legal authority: the safeguarding referral and FGMPO.
- ●Conflating mandatory reporting with safeguarding: Calling 101 to report Aisha's situation is incorrect — the mandatory reporting duty applies only where FGM has already occurred. The correct pathway here is a MASH referral. This distinction is commonly confused and frequently tested.
- ●Neglecting the UTI: The safeguarding dimension is clinically dominant, but Faduma has a symptomatic lower UTI that requires treatment today. Candidates who become so focused on safeguarding that they forget to prescribe antibiotics or send a culture fail to manage the full consultation.
- ●Not sending an MSU: Prescribing empirical antibiotics without a culture in a patient with recurrent UTIs is poor practice. The MSU identifies the causative organism, detects antibiotic resistance, and is essential for longer-term management planning.
- ●Failing to address Faduma's own FGM complications: The referral to a specialist FGM clinic for Faduma is a distinct and important management step. Candidates who focus only on Aisha and fail to offer Faduma any pathway for her own care miss a significant positive indicator.
Mapped to the RCGP curriculum topic: Gynaecology and Breast.
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