Ethics

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Health risks and benefits of non-therapeutic male circumcision

 

Is non-therapeutic male circumcision (NTMC) of overall benefit or harm to a child’s health?

There is significant disagreement about whether circumcision is overall a beneficial, neutral or harmful procedure, and different medical organisations have adopted different views (see the background on NTMC). At present, the medical literature on the health, including sexual health, implications of circumcision can be contradictory, and often subject to claims of bias in research. 

An evaluation of the research by the BMA’s specialists in science and public health has shown, for example, good evidence from international studies that male circumcision can reduce the chances of acquiring HIV infection in some circumstances, although caution must be taken about how this can be extrapolated to the UK; evidence in respect of other STIs (sexually transmitted infections) is more mixed. As well as some, generally relatively low, risks of complication during the circumcision operation itself, there is some weaker evidence that circumcision may give rise to sexual problems. 

The BMA considers that the evidence concerning health benefit from NTMC is insufficient for this alone to be a justification for boys undergoing circumcision. In addition, some of the anticipated health benefits of male circumcision can be realised by other means – for example, condom use.

Whether NTMC is neutral, or of overall harm to a child’s health, will be based on an individual assessment of a child’s circumstances based on the latest clinical evidence, taking into account the inherent risk in any procedure (see section below) and any underlying health issues the child may have. This health assessment will then need to be measured against broader interests (see our guidance on best interests).

As part of the review of the BMA’s guidance on NTMC, the BMA was sent many clinical articles on male circumcision. It should be noted that although representing doctors, the BMA is not a clinical organisation. We would welcome a more comprehensive review of the literature on this issue from an impartial clinical organisation.  

 

What are the risks of the procedure?

There are clearly risks inherent in any surgical procedure: for example, pain, bleeding, surgical mishap and complications of anaesthesia. With NTMC there are associated medical and psychological risks, although it is generally considered a low-risk procedure. Usually risks of surgery are offset by the medical benefits that ensue – where there are no clear medical benefits, some other justification is needed for exposing children to this risk.  

The procedure may be higher risk in children with certain underlying health conditions. It may be appropriate to screen patients for conditions that would substantially increase the risks of circumcision – for example haemophilia – and seek advice from a relevant specialist. The procedure will also be higher risk when carried out by individuals lacking the competence to adequately assess the child prior to, during and after the procedure. 

All appropriate steps must be taken to minimise these risks.

Fitness to practise case – importance of assessing the health of the child prior to NTMC

In 2016, a doctor had conditions placed on his registration at a medical practitioners tribunal. The doctor performed NTMC on a child who was subsequently diagnosed with a fistula. The patient’s parents began legal proceedings for clinical negligence, which were settled by the payment of damages, with no admission of liability. Nevertheless, in the fitness to practise proceedings, the doctor was found to have failed to have:

  • Fully examined and/or assessed the patient
  • Made an adequate record of the treatment he provided
  • Informed the patient’s GP of the procedure

GMC reference 5205264

  

What should I tell parents or patients?

Doctors should ensure that any parents seeking circumcision for their son in the belief that it confers health benefits, are informed of the lack of consensus amongst the profession over such benefits, and how great any potential benefits and harms are.  

Doctors performing circumcision must ensure that those giving consent are aware of the issues, including the risks associated with any surgical procedure. 

GMC (General Medical Council) guidance – discussing benefits, risks and side effects

'18. If patients (or those with parental responsibility for them) ask for a procedure, such as circumcision of male children, for mainly religious or cultural reasons, you should discuss with them the benefits, risks and side effects of the procedure. You should usually provide procedures [where you have the knowledge, skills and experience to do so safely] that patients request and that you assess to be of overall benefit to the patient. If the patient is a child, you should usually provide a procedure or treatment that you assess to be in their best interests. In all circumstances, you will also need the patient’s or parental consent.'

GMC, Personal beliefs and medical practice


Next page - Determining best interests

 

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