42.6 Male Circumcision

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Contents

• Introduction(Jump to)
• Circumcision for Therapeutic / Medical Purposes(Jump to)
• Legal Position(Jump to)
• Principles of Good Practice(Jump to)
• Doctors’ Response(Jump to)
• Recognition of Harm(Jump to)
• Multi-agency Response(Jump to)
• Role of community / Religious Leaders(Jump to)

Introduction

Non-therapeutic male circumcision (NTMC) is the removal of part or all of the foreskin (prepuce) that covers the penile glans. If it is undertaken for any reason other than current physical clinical need, it is termed non-therapeutic (or sometimes ‘ritual’) circumcision.

The procedure is usually requested for social, cultural, or religious reasons (e.g., families who practice Judaism or Islam). Some parents request circumcision for assumed medical benefits.

There is no requirement in law for professionals undertaking male circumcision to be medically trained or to have proven expertise. Traditionally, religious leaders or respected elders may conduct this practice.

Circumcision for Therapeutic / Medical Purposes

The British Association of Paediatric Surgeons advises that there is rarely a clinical indication for circumcision. Doctors should be aware of this and reassure parents accordingly.

Where parents request circumcision for their son for assumed medical reasons, it is recommended that circumcision should be performed by or under the supervision of doctors trained in premises authorised and suitable for surgical procedures.

Doctors/health professionals should ensure that any parents seeking circumcision for their child, in the belief that it confers health benefits, are fully informed that there is a lack of professional consensus as to current evidence demonstrating any benefits. The risks/benefits to the child must be fully explained to the parents and the child, if Gillick- Fraser competent.

The medical harms or benefits have not been unequivocally proven except to the extent that there are clear risks of harm if the procedure is done inexpertly.

Legal Position

Professionals may assume that the procedure is lawful provided that:

• (In instances where the person is too young to give consent) there is valid consent by each person with parental responsibility for the child.  Where there is a conflict between the parents that cannot be resolved, it would be a matter for the Courts to resolve, it would not be appropriate for the Local Authority to exercise their section 33 Children Act 1989 powers to either consent or veto, in circumstances where they have an Interim Care Order or Care Order.
• The procedure is performed by a competent person, in a clinically suitable environment, reducing risks of infection, cross-infection and contamination to the child;
• It is believed to be in the child's best interests  (and religious and cultural considerations can and should be taken into account alongside medical ones in weighing this up)
• and
• the child, if old enough, is Gilick Competent.

If doctors or other professionals are in any doubt about the legality of their actions, they should seek legal advice.

Principles of Good Practice

The child's welfare should be paramount, and all professionals must act in the child's best interests. Children who can express views about circumcision should always be involved in the decision-making process:

• Even where they do not decide for themselves, the views that children express are important in determining what is in their best interests;
• Parental preference alone does not constitute sufficient grounds for performing a surgical procedure on a child unable to express his own view. Parental preference must be weighed in terms of the child's interests;

The High Court, in the case cited earlier, confirmed that the child's religion, lifestyle and likely upbringing are relevant factors to take into account. Each individual case needs to be considered on its own merits. There may be particular health risks to the child of undertaking the procedure, which would need to be considered.

An assessment of best interests concerning non-therapeutic circumcision should include consideration of:

• The risk of harm or likelihood of harm the child may suffer;
• The child's own ascertainable wishes, feelings and values;

• The child's ability to understand what is proposed and weigh up the alternatives;
• The child's potential to participate in the decision, if provided with additional support or explanations;
• The child's physical and emotional needs;
• The views of parents and family;
• The implications for the child and family of performing, and not performing, the procedure;
• Relevant information about the child and family's religious or cultural background.

Consent for circumcision is valid only where the people (or person) giving consent have parental responsibility and the authority to do so and understand the implications (including that it is a non-reversible procedure) and the risks the procedure carries.  Where they do not show an understanding of such implications, professionals can and should provide them with assistance in reaching such an understanding. Where people with parental responsibility for a child disagree about whether he should be circumcised, the child should not be circumcised without the leave of a Court.

Doctors’ Response

Doctors are under no obligation to comply with a request to circumcise a child, and circumcision is not a service that is provided free of charge. Nevertheless, some doctors and hospitals are willing to provide circumcision without charge rather than risk the procedure being carried out in unhygienic conditions.

Poorly performed circumcisions have legal implications for the doctor responsible. In responding to requests to perform male circumcision, doctors should follow the guidance issued by the:

• General Medical Council: Guidance for doctors;
• British Medical Association: in respect of responding to requests to perform male circumcision;
• https://www.bma.org.uk/media/1847/bma-non-therapeutic-male-circumcision-of-children-guidance-2019.pdf
• Statement from the British Association of Paediatric Urologists on behalf of the British Association of Paediatric Surgeons and The Association of Paediatric Anaesthetists on the management of foreskin condition and circumcision in male children.

Recognition of Harm

As the President of the Family Division has ruled, male circumcision does involve harm to a young person, but it would not be Significant Harm for the purposes of the Children Act 1989.  Whilst this may seem to be a semantic distinction, it means that in the usual course of events, a proposed male circumcision would not be a child protection issue in and of itself, although there may be aggravating factors that could make it so.

There might be circumstances, such as clear medical evidence, that the procedure for this particular child would pose health risks or danger over and above the usual issues inherent in the procedure, or how the procedure is planned poses a significant risk of harm to the young person, or is being imposed on the young person against their will. Circumcision may constitute significant harm  (for the purposes of the Children Act 1989) to a child if the procedure was undertaken in such a way that they:

• Acquire an infection as a result of neglect;
• Sustain physical functional or cosmetic damage;
• Suffer emotional, physical or sexual harm from how the procedure was carried out;
• Suffer emotional harm from not having been sufficiently informed and consulted or not having their wishes taken into account.

In such circumstances, professionals should consider the case carefully and consider necessary referrals and seek appropriate legal advice as to whether the circumstances are such that the Court can and should be asked to intervene to either halt the planned procedure or conduct it in another way.

Harm may stem from the fact that clinical practice was incompetent (including lack of anaesthesia) and/or that clinical equipment and facilities are inadequate, not hygienic etc.

The professionals most likely to become aware that a child is at risk of, or has already suffered, harm from circumcision are health professionals (GPs, health visitors, A&E staff or school nurses) and childminding, daycare and teaching staff.

Multi-agency Response

If a professional in any agency becomes aware, through something a child discloses or another means that the child has been or may be harmed through male circumcision, a referral must be made to Children's Services in line with local procedures. Children's Services should assess the risk of harm to other male children in the same family, including unborn children.

Role of community / Religious Leaders

Community and religious leaders should take the lead in the absence of approved professionals and develop safeguards in practice. This could include setting standards around hygiene, advocating and promoting the practice in a medically controlled environment and outlining best practice if complications arise during the procedures.