Male Circumcision

Male circumcision is the surgical removal of the foreskin of the penis. The procedure is usually requested for social, cultural or religious reasons (e.g. by families who practice Judaism or Islam). There are parents who 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.

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 children's surgery in premises suitable for surgical procedures.

Doctors/health professionals should ensure that any parents seeking circumcision for their son 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 to the young man himself, if 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.

The Hertfordshire Clinical Commissioning Group has provided the following guidance:

Circumcision should only be funded by the NHS for medical reasons, and not for religious or social reasons.

The indicators for which circumcision will be funded are:

1. Pathological phimosis, with permanent scarring of the preputial orifice;
2. Severe recurrent balanitis/balanoposthitis;
3. Exceptionally, recurrent febrile urinary tract infections in children with abnormal urinary tracts.

There may be other functional indications, these need to be approved on a case by case basis through local IFR departments.

Conservative management is preferable for all other common conditions of the foreskin, including physiological phimosis, paraphimosis, balanitis, posthitis and hooded foreskin.

Male circumcision that is performed for any reason other than physical clinical need is termed non-therapeutic circumcision.

The legal position on male circumcision is untested and therefore remains unclear. Nevertheless, professionals may assume that the procedure is lawful provided that:

• It is performed competently, in a suitable environment, reducing risks of infection, cross infection and contamination;
• It is believed to be in the child's best interests;
• There is valid Consent from those with parental responsibility and the child, if old enough, is Fraser Competent.

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

The welfare of the child should be paramount, and all professionals must act in the child's best interests. Children who are able to 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;
• When the courts have confirmed that the child's lifestyle and likely upbringing are relevant factors to take into account. Each individual case needs to be considered on its own merits.

An assessment of best interests in relation to non-therapeutic circumcision should include consideration of:

• 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 risk of harm or suffering for the child;
• 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 the authority to do so and understand the implications (including that it is non-reversible procedure) and risks. 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 the court.

Doctors are under no obligation to comply with a request to circumcise a child and circumcision is not a service which 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 any guidance issued by the:

• General Medical Council
• British Medical Association in respect of responding to requests to perform male circumcision
• Royal College of Surgeons

Circumcision may constitute Significant Harm to a child if the procedure was undertaken in such a way that he:

• Acquires an infection as a result of neglect;
• Sustains physical functional or cosmetic damage;
• Suffers emotional, physical or sexual harm from the way in which the procedure was carried out;
• Suffers emotional harm from not having been sufficiently informed and consulted, or not having his wishes taken into account

Significant Harm is defined as a situation where a child is likely to suffer a degree of physical, sexual and/or emotional harm (through abuse or Neglect) which is so harmful there needs to be compulsory intervention by child protection agencies in the life of the child and their family.

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 boy is at risk of, or has already suffered, harm from circumcision are health professionals (GP's, health visitors, A&E staff or school nurses) and childminding, day care and teaching staff.

lf 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 under the Contacts and Referrals Procedure. Children's Services should assess the risk of harm to other male children in the same family, including unborn children.

Community and religious leaders should take a 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.