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NEWS ROUNDUP: Debashis Singh BMA says non-therapeutic circumcision needs consent of both parents BMJ 2003; 326: 782e [Full text]

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BMA circumcision guidance has significant omissions

George Hill   (13 April 2003)

The law and ethics of male circumcision

Aziz Sheikh, Shuja Shafi, and Abdul Rashid Gatrad   (2 May 2003)

Medical doctors must respect the human rights of their patients

George Hill   (22 May 2003)

Circumcision: Why Informed Consent of Parents is so important

Michael Glass   (23 May 2003)

"Two wrongs don't a right make" (so to speak)

John Antonopoulos   (24 May 2003)

Circumcision. Information Parents Need.

Michael Glass   (29 May 2003)

BMA circumcision guidance has significant omissions 13 April 2003
George Hill, Executive Secretary Doctors Opposing Circumcision, Suite 42, 2442 NW Market St, Seattle, Washington 98107, USA Send response to journal: Re: BMA circumcision guidance has significant omissions	EDITOR--The new British Medical Association (BMA) guidance on circumcision 1 replaces a sadly outmoded 1996 guidance. It provides new and welcome information that doctors need to comply with court decisions regarding child circumcision,2 the Human Rights Act 1998,3 and new consent regulations promulgated by the General Medical Council.4       The guidance is not perfect, however. The BMA disingenuously claims that it does not know if male neonatal circumcision (excision of healthy functional erogenous tissue from a non-consenting minor) is a violation of human rights.1 The Norwegian Council for Medical Ethics, however, suffers from no such disability and has forthrightly advised that the circumcision of male children is an offence against the child’s human rights, and, therefore, an unethical medical practice.5 The BMA guidance also fails to adequately address concerns that circumcision of children under 16 years of age may be an offence under the Children and Young Person’s Act 1933.6       The guidance fails, moreover, to give proper weight to the risks incurred with child circumcision, even when performed in a hospital setting.7 Although rare in hospital, children who are circumcised are exposed to risk of infection, loss of blood, penile mutilation, or penile necrosis. There is even risk of death.8 Given the lack of medical value, the exposure of children to such unnecessary risk shows poor medical judgment and is unethical.       Nature put the prepuce there for a purpose. The BMA guidance fails to give adequate weight to new findings regarding the physiological value and utility of the prepuce in protection against disease, and in sexual intercourse.9 10 Moreover, circumcision recently has been shown to contribute to erectile dysfunction,11 12 but no mention is made of these findings.       The BMA has failed to adequately recognize that the child and his parents are separate persons - each with his own set of rights. The child will not necessarily adopt his parents’ religious views, so he should be protected from non-therapeutic circumcision until he is of age to decide for himself.       The BMA guidance on circumcision is a welcome and needed step forward, but more work remains to be done to fully protect the bodily and genital integrity of male children. Very truly yours, George Hill Executive Secretary Doctors Opposing Circumcision Suite 42 2442 NW Market Street Seattle, Washington 98107 USA Web: http://www.doctorsopposingcircumcision.org/  References: Committee on Medical Ethics. The law & ethics of male circumcision - guidance for doctors. London: British Medical Association, 2003. Re J [2000] 1 FCR 307. Human Rights Act 1998, HMSO, London. General Medical Council. Seeking patients' consent: the ethical considerations. London: General Medical Council, 1998. Gulbrandsen P. Rituell omskjæring av gutter. [Ritual circumcision of boys.] Tidsskr Nor Lægeforen [Journal of the Norwegian Medical Association] 2001;121(25):2994. Edge PW. Male circumcision after the human rights act 1998. J Civil Liberties 2000;5:320-337. Williams N, Kapila L. Complications of Circumcision. Brit J Surg 1993; 80: 1231-6. Jason Proctor. Totally unexpected' death of baby probed. The Province, Vancouver, British Columbia, Thursday, 29 August 2002. Fleiss P, Hodges F, Van Howe RS. Immunological functions of the human prepuce. Sex Trans Inf 1998;74:364-367. Cold CJ, Taylor JR. The prepuce. BJU Int 1999;83 Suppl. 1:34-44. Coursey JW, Morey AF, McAninch JW, et al. Erectile function after anterior urethroplasty. J Urol 2001;166(6):2273-6. Fink KS, Carson CC, DeVellis RF. Adult Circumcision Outcomes Study: Effect on Erectile Function, Penile Sensitivity, Sexual Activity and Satisfaction. J Urol 2002;167(5):2113-2116. Competing interests:   None declared
The law and ethics of male circumcision 2 May 2003
Aziz Sheikh, NHS/PPP Mational Primary Care Post Doctoral Fellow St George's Hospital Medical School, London SW17 0RE, Shuja Shafi, and Abdul Rashid Gatrad Send response to journal: Re: The law and ethics of male circumcision	EDITOR The British Medical Association's recently published guidance on the law and ethics of male circumcision quite rightly emphasises that "…the welfare of infant and child patients is paramount" and British Muslims will of course share this view.[1][2] Whilst broadly welcoming these guidelines, we do however have a number of concerns regarding the processes employed in formulating this document and in relation to some of the key recommendations made. Firstly, it is essential that in pluralist democratic societies such as ours in Britain every attempt be made to solicit and duly consider the views of minority ethnic and faith communities. This is of course particularly relevant when considering the merits of practises that are commonplace in such communities. This simple common-sense principle was recognised by the General Medical Council when it formulated its guidance notes on male circumcision, the process involving "…consultation amongst religious groups, civil rights and children's' rights groups and the medical profession".[3] It is therefore regrettable that when drawing up their recent guidance for clinicians, the British Medical Association failed to consult with representatives of Britain's 1.6 million Muslims. Secondly, the document contains no explicit critique of the evidence for the benefits and/or harm of ritual circumcision and, more importantly, the extent to which this evidence relates to Jewish and Muslim males. We are not aware of any published reports of long-term cohort studies of circumcised British Jewish and Muslim infants. Thirdly, the suggestion that both parents be routinely obliged to provide written consent for circumcision is we believe inappropriate. Whilst we understand and accept that this might be necessary in certain very specific cases of parental disagreement,[4] such scenarios are not at all typical of most Muslim (and we suspect Jewish) households where the event is often marked and indeed celebrated as a religious rite of passage. As far as we are aware, there is no comparable requirement for obtaining written consent of both parents in relation to any other medical or non-medical procedures such as surgery, immunisations or body piercing. Lastly, there is no meaningful discussion on the possibility of routinely offering the procedure on the National Health Service, despite there being evidence that minority ethnic and faith communities might welcome such provisions.[5] We believe that the interests of families wishing to have their male children circumcised are best served by offering circumcisions on the National Health Service, these being performed within the framework of existing General Medical Council guidelines. Professor AR Gatrad Consultant Paediatrician, Manor Hospital, Walsall Dr Shuja Shafi Consultant Microbiologist, North West London Hospitals NHS Trust, Harrow Dr Aziz Sheikh NHS/PPP National Primary Care Post Doctoral Fellow, St George's Hospital Medical School, London References 1. British Medical Association. The law and ethics of male circumcision. Guidance for doctors. London: BMA, 2003. 2. Gatrad AR, Sheikh A. Birth customs: meaning and significance. In: Sheikh A, Gatrad AR (eds.). Caring for Muslim patients. Oxford: Radcliffe, 2000: 57-71. 3. General Medical Council. Guidance for doctors who are asked to circumcise male children. London: GMC, 1997. 4. Wall J. Re J - Muslim upbringing and circumcision. Specific Issue Orders. Family Division. Jordan Publishing, May 1999. 5. Bhopal R, Madhok R, Hameed A. Religious circumcision on the NHS: opinions of Pakistani people in Middlesborough, England. J Epidemiol Commun Hlth 1998;62:758-759. Competing interests:   AS chairs the Research & Documentation Committee of the Muslim Council of Britain and ARG is an advisor to this committee. SS chairs the Health & Medical Committee of The Muslim Council of Britain. These are all honorary appointments.
Medical doctors must respect the human rights of their patients 22 May 2003
George Hill, Executive Secretary Doctors Opposing Circumcision, Suite 42, 2442 NW Market Street, Seattle, Washington 98107, USA Send response to journal: Re: Medical doctors must respect the human rights of their patients	EDITOR--Gatrad et al. are unhappy because the Medical Ethics Committee of the British Medical Association suggests the written consent of both parents for a child circumcision.1 This requirement was not invented by the Medical Ethics Committee. It is a requirement laid down in a court of law as a protection for the child2 and is not under the control of the British Medical Association. The Medical Ethics Committee would be remiss in its duty if it did not inform doctors of this legal requirement. The requirement for the signature of both parents protects doctors from being caught between warring parents and it protects children from unnecessary non-therapeutic circumcision when parents disagree. Gatrad and colleagues also dislike the requirement for written consent.1 However, written consent is necessary to protect the doctor. A male circumcision, like other surgical procedures, would be assault on a patient without a valid written informed consent, which protects a doctor from lawsuit in most cases. The Medical Ethics Committee has acted properly in advising a written consent as a record of the consent should litigation occur.3 Persons who are injured while a minor have a right to institute litigation to recover damages when they reach the age of majority. Doctors must retain the written consent in their files as protection against a possible lawsuit decades after the surgical operation on the infant. Even a signed written consent, however, may offer little protection.4,5 Parental decisions must be made in a child’s best interest,5,6 so the existence of parental power to consent to an unnecessary non-therapeutic assault on a child, which results in the permanent excision of healthy functional erogenous tissue remains questionable. The lawfulness of the circumcision of male children under the Human Rights Act 1998 has not been resolved.7 Gatrad and associates claim to endorse the view of the Medical Ethics Committee that "…the welfare of infant and child patients is paramount," but then they improperly elevate the “interest of families” above the best interest of the child-patient, because they want the National Health Service to cover the cost of religious circumcisions.1 The Medical Ethics Committee acted properly by excluding this topic from their discussion of the ethics and law of male circumcision.3 This proposal would divert taxpayer funded medical resources to serve the personal religious views of the parents. Moreover, the NHS is a public body that must comply with human rights law, so it must honour the human rights of patients.8 The circumcision of male children violates the four principles of medical ethics – beneficence, non-maleficence, autonomy, and justice.9 Moreover, studies demonstrate that male circumcision impairs or degrades the function of the penis in several ways.4,5,9 Degrading treatment is an offence against Article Three of the European Convention on Human Rights.10 Children born into Muslim or Jewish homes have the same human rights as children born into other homes. Medical doctors must respect the human rights of their patients.3 Doctors who refuse to perform non-therapeutic circumcision of male children are on solid ground. George Hill Executive Secretary Doctors Opposing Circumcision Suite 42 2442 NW Market Street Seattle, Washington 98107 USA Web: http://www.doctorsopposingcircumcision.org/ References: Gatrad AR, Shafi S, Sheikh A. The law and ethics of male circumcision. BMJ 2003; rapid response: 2 May. Re J [2000] 1 FCR 307. Medical Ethics Committee. The law and ethics of male circumcision: Guidance for doctors. London: BMA, 2003. Gregory J Boyle, J Steven Svoboda, Christopher P Price, J Neville Turner. Circumcision of Healthy Boys: Criminal Assault? 7 J Law Med 301 (2000). J. Steven Svoboda, Robert S. Van Howe, James G. Dwyer, Informed Consent for Neonatal Circumcision: An Ethical and Legal Conundrum. 17 J Contemporary Health Law Policy 61 (2000). American Academy of Pediatrics Committee on Bioethics. Informed consent, parental permission, and assent in pediatric practice. Pediatrics 1995;95(2):314-317. Peter W Edge. Male circumcision after the human rights act 1998. 5 J Civil Liberties 320 (2000). Hewsen B. Why the human rights act matters to doctors. BMJ 2000;321:780-781. Hill G. Can anyone authorize the non-therapeutic permanent alteration of a child’s body? Am J Bioeth 2003;3(2): in press. Council of Europe. Convention for the Protection of Human Rights and Fundamental Freedoms. Rome, 4.XI.1950. Competing interests:   None declared
Circumcision: Why Informed Consent of Parents is so important 23 May 2003
Michael Glass, school teacher Sydney Distance Education High School Send response to journal: Re: Circumcision: Why Informed Consent of Parents is so important	Circumcision raises difficult moral and legal issues for society. The two responses of George Hill and of Sheikh, Shafi and Gatrad show what difficulties there are. I hope the following points will be of interest to readers. First, while male circumcision is an age-old rite in both the Islamic and Jewish communities, it does not have unanimous support in either community (1, 2). Elsewhere, there is evidence that attitudes are hardening against this practice (3). Both Muslims and Jews realize that they are a small minority in English-speaking countries. They are rightly concerned that their rights, rites and practices should be respected, and that they do not suffer unfair discrimination. The general society is also rightly concerned that minority views are respected and that its ideals of individual and child rights are accepted and understood. It is obvious that the right of a child to bodily integrity clashes with the assertion that parents or faith communities have a right to circumcise minors. At the moment the law appears to accept that parents have the right to choose circumcision for their boys, even though all genital modification of girls is forbidden. However, there is a caveat: the parents must agree. The BMA has said that the written consent of both parents must be obtained. Sheikh, Shafi and Gatrad have objected to this suggestion, making the following observation: "Whilst we understand and accept that this might be necessary in certain very specific cases of parental disagreement, such scenarios are not at all typical of most Muslim (and we suspect Jewish) households where the event is often marked and indeed celebrated as a religious rite of passage." Requiring the written consent of both parents should pose no great hardship to parents who agree to circumcise. It will assure both the medical attendants and the wider society that both parents did consent, as the law commands. If this requirement reveals that either or both parents do not consent to the circumcision, the law has already determined that the child must not be circumcised. Thus the proposal for the written consent of both parents safeguards the interests of both those parents who agree on circumcision and it upholds the law in the case of a dispute. However, such a process would be of little point unless all parents are fully informed about the procedure. Every parent should know that circumcision removes sexually sensitive skin from the penis. Every parent should know that there are less invasive methods of treating the conditions such as phimosis or infection, and these methods should be the first resort of treatment, not circumcision. I believe that doctors have a moral obligation to give full information about circumcision and its consequences. Nothing less than informed consent should be acceptable. Notes: (1) For opinions against circumcision from an Islamic perspective see and . Islamic objections to circumcision are grounded in the fact that the Koran is silent on the question of male and female circumcision, and the traditions concerning this rite are at variance. See http://www.quran.org/CIRCUMCISION.HTM (2) For examples of opinions against circumcision from a Jewish perspective see http://www.cirp.org/pages/cultural/karsenty/ and http://members.aol.com/paradise79/QuestioningMilah .html (3) For example, a Rabbi who accepts circumcision argues that increasing criticism of circumcision should be treated with respect. http://www.rabbishmuel.com/thoughtsonsoc/circumci sion.doc Competing interests:   I write as a parent who had to make a decision about circumcision with incomplete information from doctors.
"Two wrongs don't a right make" (so to speak) 24 May 2003
John Antonopoulos, President Circumcision Information Resource Centre, Les Atriums, C.P. 32065, Montreal, Quebec, Canada H2L 4Y5 Send response to journal: Re: "Two wrongs don't a right make" (so to speak)	Editor: Michael Glass's position (expressed in "Re: Circumcision: Why Informed Consent of Parents is so important") is that provided - and only provided - both parents are furnished with complete information and both agree, proceeding with non-therapeutic child circumcision is ethically and legally acceptable. Yet Mr. Glass also recognizes (and may I add, states most effectively) the fundamental problem with parental consent in the connection of non-therapeutic child circumcision: "It is obvious that the right of a child to bodily integrity clashes with the assertion that parents or faith communities have a right to circumcise minors." Despite his recognition of this clash, Mr. Glass would still (would ultimately) be prepared to weigh in on the side of the parents' wishes, and/or their sense of religious obligation, and to tolerate interference with the child's fundamental right to bodily integrity. But does it make it any less of a violation of the child's right that both parents should (be required to) consent to circumcision, than that only one should? Can the child's right to bodily integrity simply, or even ultimately, be ignored? Knowing the drill, I appeal to readers to resist the temptation to fall back on the all-too-common ear-piercing analogy; for the latter imposition upon a child, objectionable as it may be, does not go as far as to involve, as by contrast the American Academy of Pediatrics makes plain about circumcision [1], the "amputation" of any body part, a functional, highly specialized and erogenous one to boot. It is now clearly confirmed on both sides of the Atlantic as a cardinal principle of paediatric medical ethics that, when a child is presented for treatment, the doctor's duties, responsibilities, and obligations are to the child-patient and not to the parents.[2,3] Doctors must give the patient the treatment he needs, "not what someone else expresses."[2] It is clear that "parental preference alone is not sufficient justification for performing a surgical procedure on a child."[3] John Antonopoulos President, Circumcision Information Resource Centre Montreal, Quebec, Canada [1] American Academy of Pediatrics Task Force on Circumcision. Circumcision Policy Statement, Pediatrics 1999;103(3):686-93.  [see section "Methods of Circumcision."] See also annotated presentation, by the Circumcision Information and Resource Pages (not to be confused with our organization), of the AAP position statement, with links to supporting on-line documents. [2] American Academy of Pediatrics Committee on Bioethics. Informed consent, parental permission, and assent in pediatric practice. Pediatrics 1995;95(2):314-317. [3]  Medical Ethics committee. The law & ethics of male circumcision - guidance for doctors. London: British Medical Association, 2003. Competing interests:   None declared
Circumcision. Information Parents Need. 29 May 2003
Michael Glass, school teacher Sydney Distance Education High School Send response to journal: Re: Circumcision. Information Parents Need.	John Antonopoulos <http://bmj.com/cgi/eletters/326/7393/782/e> takes me to task for coming down on the side of parents who agree to circumcise and so against the right of a child to bodily integrity. That was not my intention. Rather, it was to ensure that the law as it stands today was fulfilled in both its letter and its spirit. Everyone knows that two important communities of faith demand that their boys be circumcised. Some fear that if circumcision is limited too much, people will take the matter into their own hands, and circumcise their own children (1). It is at this point, too many people throw up their hands and treat the situation as impossible to resolve. I believe that this is mistaken. Much more can be done to reduce the number of juvenile circumcisions even without a legal prohibition. Great Britain has already taken the first two steps by removing the government subsidies and by the medical societies coming out against routine neonatal circumcision. As a result, most juvenile circumcisions have already ceased in the UK. Nevertheless, while the medical establishment only says is that circumcision is not recommended, some will continue to promote the practice. It is therefore important that medical authorities publicise the information that circumcision removes sexually sensitive tissue from the penis (2, 3, 4), that most problems that arise with foreskins can be treated by less drastic methods than surgery (5) and that the medical authorities support the rights of medical workers who have a conscientious objection to the circumcision of minors (6). When this message gets through to the general public, the circumcision rate will fall even more. All it takes to stop the circumcision of a child in the UK is for just one of his parents to refuse to assent to the surgery. I believe that if the general public knew that circumcision removes sexually sensitive tissue and that foreskin problems could be treated without surgery, the number of circumcisions would fall even further. As for those who still believe in circumcision, it is up to them to make their own arrangements, within the law. If that law is broken, then perhaps the penalty should be the same as what applies to female genital mutilation. (1) Basil Elnazir, 'The lesser of two evils' in Archives of Disease in Childhood, 11 February 2002 <http://adc.bmjjournals.com/cgi/eletters/archdischild;86 /2/76#254> (2) J.R. Taylor, A.P. Lockwood and A.J. Taylor, 'The prepuce: Specialized mucosa of the penis and its loss to circumcision' British Journal of Urology, Volume 77, 291-295, February 1996. <http://www.cirp.org/library/anatomy/taylor/> (3) K. S. Fink, C. C. Carson, R. T S. DeVellis, 'Adult Circumcision Outcomes Study: Effect on Erectile Function, Penile Sensitivity, Sexual Activity and Satisfaction', Journal of Urology, Volume 167, Number 5: Pages 2113-2116, May 2002. <http://www.cirp.org/library/sex_function/fink1/> (4) C.J. Cold & J. R. Taylor, 'The prepuce', British Journal of Urology (1999), 83, Suppl. 1, 34-44 <http://www.cirp.org/library/anatomy/cold-taylor/> (5) The Law & Ethics of Male Circumcision: Guidance for Doctors, Circumcision for Medical Purposes <http://www.bma.org.uk/ap.nsf/Content/malecircumcisi on2003#Circumcisionformedicalpurposes> (6) The Law & Ethics of Male Circumcision: Guidance for Doctors, <http://www.bma.org.uk/ap.nsf/Content/malecircumcisi on2003#Conscientiousobjection> Competing interests:   I write as a parent who had to make a decision about circumcision with incomplete information from doctors.