Religious Surgery on Children (including circumcision)

 

The Secular Medical Forum believes that genital surgery (such as male circumcision) should only ever be performed on children where there are compelling medical indications.

Circumstraint device
The below article was originally published in the June 2012 Quarterly Newsletter of the British Association for Community Child Health. It is reproduced here with their permission.

 

Male circumcision and child safeguarding

 

Ritual circumcision or non-therapeutic excision of the foreskin (NTEF) is increasingly under the spotlight. We explore some of the reasons why the medical profession, the public, and even some religious organisations are increasingly turning away from this traditional religious operation, and why it should now be considered a child safeguarding issue.

 

The gender dichotomy

How many doctors would perform surgery on a child’s genitals without any medical reason? You might think it unlawful, and for girls, it is: in 1985 the UK Government enacted the Prohibition of Female Circumcision Act. In 2003 it was updated and renamed the Female Genital Mutilation (FGM) Act. The Act prohibits non-therapeutic surgery on the genitals of female – but not male – children. Why the discrimination?

FGM is sometimes so severe that it affects bodily functions. But even minor ‘symbolic nicks’ would still (rightly) be illegal, because UK law establishes the principle that a girl’s genitals should not be tampered with for any non-medical reason. Section 1(5) of the FGM legislation states: ‘it is irrelevant whether or not a person believed the operation to be necessary in the child’s best interests as a matter of custom or ritual.’ In contrast, this is the main reason given for NTEF of boys born to Jewish or Muslim parents.

In some NHS Trusts, NTEF is even taxpayer-funded.1 Furthermore, it is lawful for persons with no medical degree to perform it. In New York, two baby boys recently died from herpetic infections following the religious practice of sucking the cut penis.2-3 In the UK, NTEF by non-medical practitioners is also unregulated; consequently it is not possible to determine the UK prevalence of this practice.

Governmental organisations are understandably reluctant to offend religious sensibilities, but protecting children from medically unnecessary surgery is a more important consideration. Even tattooing a child is illegal4 (except for medical reasons), leading to the legally risible situation where you would be prosecuted for placing a small tattoo on a child’s foreskin, but if instead you cut off the entire structure, you are acting within the law.

 

A real risk of harm

The foreskin is a normal body part with physical, sexual and immunological functions. Surgically removing it from non-consenting children has been associated with various physical and psychological difficulties; these are likely to be greatly under-reported because people who have experienced sexual harm are often reluctant to reveal it as societal dismissal or stigmatisation may compound the harm.

However, clinical and epidemiological research is increasing our understanding in this area. After studying fine-touch pressure thresholds in adults, Sorrells et al concluded in 2007 that ‘circumcision ablates the most sensitive parts of the penis.’5 In 2011, Danish researchers concluded that circumcision was associated with ‘frequent’ sexual and orgasm difficulties for men and for their female partners.6 And while these ‘routine’ circumcisions are responsible for the loss of normal foreskin functions, some operations can lead to frank medical complications including bleeding, infection,7 sepsis,8 meatitis, lymphoedema, urinary retention,9 meatal stenosis,10-11 meningitis from infected wounds,12 and death.13 More recently, a review of almost 9,000 children found that late complications from male circumcision were ‘common’.14

The sense of loss from childhood NTEF has led some men to try to ‘restore’ their foreskin. Several organisations now exist15 to provide support to thousands of men who consider themselves harmed, and to try to minimise further harm by education.

 

The health benefit fallacies

Throughout history, male circumcision has been advocated as a cure for a variety of ailments. Recently it has been suggested16 that adult circumcision may reduce the incidence of HIV transmission in Africa. There is neither evidence nor rationale for extrapolating these contested findings17 to pre-pubertal boys; nor would existing prevalence data support such a move. No national medical, paediatric, surgical or urological society in the world recommends routine circumcision of all boys as a health intervention. Clearly, if the benefits of the operation outweighed the risks, NHS doctors would be recommending it for every child – regardless of the parents’ religion – and they do not.

 

Growing medical consensus

Medical organisations are starting to state firmly that our ethical principles of non-therapeutic childhood surgery must no longer include an exception for NTEF. In May 2010, the Royal Dutch Medical Association (KNMG) released a policy statement as follows:18

The official viewpoint of KNMG and other related medical/scientific organisations is that non-therapeutic circumcision of male minors is a violation of children’s rights to autonomy and physical integrity. Contrary to popular belief, circumcision can cause complications – bleeding, infection, urethral stricture and panic attacks are particularly common. KNMG is therefore urging a strong policy of deterrence. KNMG is calling upon doctors to actively and insistently inform parents who are considering the procedure of the absence of medical benefits and the danger of complications.

A similar position has been taken in Sweden.19 Unfortunately, not all medical associations have felt able to condemn the procedure in this way; for example, the General Medical Council has ‘no position’ on male circumcision. This may be due to a fear of being mistaken as anti-religious. But religious communities themselves are starting to see the sense in either waiting until the child is old enough to choose, or developing less invasive ceremonies as an alternative. These progressive religious groups20 are questioning the relevance of infant circumcision in their modern religious practice, and their members and readers are posting videos and blogs online, detailing positive experiences of leaving their child intact. Additionally, the last two Social Attitudes Surveys showed that 45% of UK adults feel they have ‘no religion’, so we cannot assume that a child will grow up to accept their parents’ religious beliefs, or agree with permanent changes made to their most intimate body parts before they could give their consent.

 

Safeguarding children: a need for honesty and openness

The UN Convention on the rights of the child (UNCRC)21 recommends respect for the right of the child to freedom of thought, conscience and religion, and advises that traditional practices prejudicial to the health of children should be abolished.

Safeguarding is defined as: ‘All agencies working with children, young people and their families taking all reasonable measures to ensure that the risks of harm to children’s welfare are minimised’.22 Good practice when treating people without the capacity to give consent is to consider whether lack of capacity is temporary or permanent, and to take the ‘least restrictive option, including the option not to treat.’23 We see no reason why children should be excluded from these guiding GMC principles. We disagree with all non-therapeutic surgical procedures on non-consenting children: boys deserve this protection as much as girls.We recommend that the surgical assignation of a child’s genitals with the religious preferences of their parents should be seen in a safeguarding context.

Parents who are considering circumcising their child should be advised of the risks of the procedure – including the rare and severe risks – as for any other operation.  It may be appropriate to make them aware of organisations promoting alternatives.20 For many parents, finding others of the same religion with intact sons will itself be a revelation, and their own sons may then face reduced risk. Effective safeguarding does not exempt special groups from challenge; effective safeguarding educates parents and protects children.

 

Dr Antony Lempert

Dr Anish Shah

 

References

1. Circumcision on the NHS, a report by Nina Teggarty. More 4 News, broadcast 5 August 2008. Clip available at http://www.londoncircumcision.org.uk/circumcision-on-the-NHS.htm  Accessed 26 March 2012.

2. Baby Dies of Herpes in Ritual Circumcision By Orthodox Jews. ABC News. Available at: http://abcnews.go.com/Health/baby-dies-herpes-virus-ritual-circumcision-nyc-orthodox/story?id=15888618. Accessed 16 March 2012.

3. ‘An open letter to the Jewish Community from the New York City Health Commissioner’ Thomas Frieden December 13 2005 Available at http://www.nyc.gov/html/doh/downloads/pdf/std/std-bris-commishletter.pdf accessed 19 March 2012.

4. Tattooing of Minors Act 1969.

5. Sorrells ML, Snyder JL, Reiss MD et al. Fine-touch pressure thresholds in the adult penis. BJU Int 2007; 99(4): 864-869.

6. Frisch M, Lindholm M, Gronbaek M. Male circumcision and sexual function in men and women: a survey-based, cross-sectional study in Denmark. Int J Epidemiol 2011; 40(5): 1367-1381.

7. Williams N, Kapila L. Complications of circumcision. Br J Surg 1993; 80(10): 1231-1236.

8. Woodside JR. Circumcision disasters. Pediatrics 1980; 65(5): 1053-1054.

9. Berman W. Letter: Urinary retention due to ritual circumcision. Pediatrics 1975; 56(4): 621.

10. Persad R, Sharma S, McTavish J, Imber C, Mouriquand PD. Clinical presentation and pathophysiology of meatal stenosis following circumcision. Br J Urol 1995; 75(1): 91-93.

11. Cold CJ, Taylor JR. The prepuce. BJU Int 1999; 83 Suppl 1: 34-44.

12. Scurlock JM, Pemberton PJ. Neonatal meningitis and circumcision. Med J Aust 1977; 1(10): 332-334.

13. Cleary TG, Kohl S. Overwhelming infection with group B beta-hemolytic Streptococcus associated with circumcision. Pediatrics 1979; 64(3): 301-303.

14. Pieretti RV, Goldstein AM, Pieretti-Vanmarcke R. Late complications of newborn circumcision: a common and avoidable problem. Pediatr Surg Int 2010; 26(5): 515-518.

15. NORM (http://www.norm.org); NORM-UK (http://www.norm-uk.co.uk); NOCIRC (http://www.nocirc.org); Men Do Complain (http://www.mendocomplain.com); Intact America (http://www.intactamerica.org).

16. Siegfried N, Muller M, Deeks JJ, Volmink J. Male circumcision for prevention of heterosexual acquisition of HIV in men. Cochrane Database Syst Rev 2009(2): CD003362.

17. Green LW, Travis JW, McAllister RG, Peterson KW, Vardanyan AN, Craig A. Male circumcision and HIV prevention insufficient evidence and neglected external validity. Am J Prev Med 2010; 39(5): 479-482.

18. Non-Therapeutic Circumcision of Male Minors. KNMG, 2010. http://knmg.artsennet.nl/Publicaties/KNMGpublicatie/Nontherapeutic-circumcision-of-male-minors-2010.htm Accessed online 26 March 2012.

19. Circumcision of young boys for religious and non-medical reasons ought to be banned in Sweden, urged the Swedish Paediatric Society (Svenska barnläkarföreningen, BLF). 19 February 2012. http://www.thelocal.se/39200/20120219/ Accessed 26 March 2012.

20. Jews Against Circumcision (http://www.jewsagainstcircumcision.org); Jewish Circumcision Resource Centre (http://jewishcircumcision.org); Quranic Path (http://www.quranicpath.com).

21. UNCRC. Available at: http://www2.ohchr.org/english/law/crc.htm accessed 19 March 2012. See Articles 14(1), 19(1) and 24(3).

22. Definition of Safeguarding, Charity Commission. version March 2009. http://www.charitycommission.gov.uk/charity_requirements_guidance/charity_governance/managing_risk/protection.aspx#2 Accessed 19 March 2012.

23. Consent guidance: Making decisions when a patient lacks capacity. General Medical Council. http://www.gmc-uk.org/guidance/ethical_guidance/consent_guidance_making_decisions_patient_lacks_capacity.asp  Accessed 26 March 2012.

 

 

 

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