Ethics

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Background to non-therapeutic male circumcision

 

What is NTMC (non-therapeutic male circumcision)?

Male circumcision is the removal of part or all of the foreskin 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. 

 

What is the structure and function of the foreskin?

The foreskin is often described simply as a loose fold of skin in medical textbooks, with an inner surface containing modified sebaceous glands that secrete smegma.  

The London School of Hygiene and Tropical Medicine, World Health Organisation (WHO) and Joint United Nations Programme on HIV/AIDS (UNAIDS) joint publication on male circumcision goes further, noting that:

‘There is debate about the role of the foreskin, with possible functions including keeping the glans moist, protecting the developing penis in utero, or enhancing sexual pleasure due to the presence of nerve receptors. The foreskin is part of our phylogenetic heritage; non-human primates, including our closest living relatives, chimpanzees, have prepuces that partially or completely cover the glans penis.’

 

Why is it performed?

Some people ask for NTMC for their children or themselves as they believe it is a defining feature of their identity and/or faith. For example, it is traditionally recommended in the Jewish and Muslim religions that followers observe the practice, and so it is common in those religious groups.

Others ask for NTMC to incorporate a child into a practising community, and some want their sons to be like their fathers. For example, NTMC is routinely carried out on newborn males in a number of countries, including the USA.

It should not be assumed, however, that because a child is born into a practising community, the parents will automatically seek NTMC and are supportive of the practice.

 

How prevalent is NTMC?

The routine circumcision of male infants and children has been practised across the globe for centuries. The practice is deeply embedded in the family life of some populations. The WHO estimates that 30% of males aged 15 years old and over are circumcised worldwide.

The prevalence of NTMC in the UK is unknown. Hospital Episode Statistics (HES) showed in 2016-17 that just under 10,000 males under the age of 18 underwent circumcision on the NHS in England. It is not known however, how many of these operations, if any, were for non-therapeutic reasons as opposed to being carried out to rectify a medical condition. 

In addition, the rate of circumcisions carried out privately or by religious practitioners is not recorded, although indicatively, the WHO notes that 99% of Jewish males in the UK are estimated to have undergone NTMC and it is likely that there is similar prevalence for Muslim males. The 2011 Census for England and Wales found 2.7 million people identifying themselves as Muslim (4.8% of the population) and 263,000 identifying themselves as Jewish (0.5% of the population). 

 

Who carries out NTMC?

Male infant circumcision does not require a medical professional and, indeed, is often done by special practitioners within religious groups who are not medically qualified. We urge parents who are considering having their child circumcised, to ensure that the practitioner who carries out the circumcision has undergone relevant training and has proven experience and competence in the practice. As with other areas of clinical practice, doctors may have professional obligations to notify authorities if they become aware of medical or non-medical practitioners falling below the expected standards of care when performing NTMC.

Doctors do carry out NTMC, sometimes but rarely on the NHS (see our guidance on providing NTMC), but also privately or primarily as a religious practitioner. All doctors who perform NTMC, wherever and in whatever capacity, are obliged to adhere to professional standards, including having the necessary skills and experience to perform the procedure; and to be registered in England with the Care Quality Commission (CQC), in Wales with Healthcare Inspectorate Wales (HIW) and in Scotland with Healthcare Improvement Scotland (HIS). (In Northern Ireland, there is no requirement to be registered with The Regulation and Quality Improvement Authority (RQIA) to carry out circumcision.)

The BMA is aware of reports of individual doctors who perform NTMC being harassed for their involvement in the provision of NTMC. The BMA respects the right to peaceful protest and to democratic processes to challenge accepted norms. However, the BMA abhors the harassment of individual doctors through intimidating and threatening behaviour on the basis of their involvement in the provision of NTMC.

 

 

Why is it controversial?

In recent years, some overseas medical organisations have published new or updated statements on NTMC, which illustrate the diversity of opinion on the issue:

  • The Danish Medical Association (Lægeforeningen) 2016 statement outlines its view that NTMC is ethically unacceptable if the procedure is performed without the informed consent of the person undergoing it. It takes the view that NTMC should only be done with the informed consent of the person himself. The Association does not believe there is evidence that there is a health benefit in NTMC. It notes that the process towards the elimination of NTMC is complex, and should be conducted in dialogue with the populations for whom boys’ circumcision has a religious or cultural significance. 
  • The American Academy of Pediatrics (AAP) 2012 statement notes that the current evidence suggests that the health benefits of NTMC outweigh the risks. (This analysis of the benefits and risks has been heavily criticised by some.) The AAP argues that this justifies the procedure for families who choose it but not the routine circumcision of all male newborns. NTMC is commonplace in the US, with approximately 80% of the male population being circumcised. The statement goes on to say it is for parents to decide what is in the best interests of their son: ‘they will need to weigh medical information in the context of their own religious, ethical, and cultural beliefs and practices. The medical benefits alone may not outweigh these other considerations for individual families.’
  • The Royal Dutch Medical Association’s (KNMG) 2010 statement outlines its view that NTMC ‘conflicts with the child’s right to autonomy and physical integrity’. It seeks ultimately ‘to minimise non-therapeutic circumcision of male minors’. Amongst other things, it calls on (referring) doctors to explicitly inform parents/carers of the risk of complications and the lack of convincing medical benefits of NTMC. The KNMG statement goes on to express fears that a legal prohibition would result in the intervention being performed by non-medically qualified individuals, in circumstances in which the quality of the intervention could not be sufficiently guaranteed. This could lead to more serious complications than is currently the case. 
 

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