4 10 240 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Robert Darby Subject The topic of the resource Circumcision history Description An account of the resource Archive of the work published by Robert Darby Creator An entity primarily responsible for making the resource Robert Darby Source A related resource from which the described resource is derived circinfo.org historyofcircumcsion.org Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Text Any textual data included in the document <div class="intro" id="intro"> <h3>Circumcision booklet slammed by sexual health expert</h3> <h4>"A serious disservice to parents"</h4> <h4>BOOK REVIEW</h4> Brian Morris, In favour of circumcision. University of New South Wales Press, 1999 (Paperback, 104 pp, $16.95) Reviewed by Basil Donovan Director, Sydney Sexual Health Centre Professor Morris is a man on a mission to rid the world of the male foreskin. His book is targeted squarely at new parents, but he states that "doctors, nurses, midwives and other health professionals will also benefit". While the author says that the information in the book is intended "to give a balanced overview of the medical and other literature on the topic", even the most naÃ¯ve reader can see that, like all of its predecessors (both for and against circumcision), it is a very unbalanced book. The author is an eminent molecular geneticist, but not a clinician, though a layperson could be forgiven for failing to discern the latter fact from the author's biographical details. He gives himself away with his first clinical anecdote, received via email correspondence to the author's pro-circumcision website: <div>A concerned father: "We have a boy of two years and four months with balanitis and retraction problems (not confirmed). Right now it is 3 am, and my son is crying as he has done since yesterday. We are waiting until we can take him to his paediatrician. ... I feel bad at not having my baby circumcised when newborn. ... What can be done to relieve the pain until the doctor sees him? (Today is a holiday in my country.)"</div> A clinician would have advised this distressed father that we don't forcibly retract two-year-old foreskins. The lay readers of this book should also have been told this, but they were not. Moreover, balanitis is rarely so painful â€“ this child should be directed to an emergency department to have more sinister pathology excluded. Indeed, a number of the author's email correspondents seemed to have more serious problems above the belt than below it. But the author is not easily distracted from his mission. Immediately after his brisk preface about the value of the scientific method, he preys on parental fears with his (unreferenced) claims that the presence of a foreskin "serves as an impediment to sexual intercourse" and that "circumcision facilitates procreation". Perhaps he hopes that members of the target audience with shorter attention spans who fail to read any further will at least have been imprinted with these little gems. Job done. I will spare you the details, but thereafter the author discusses at length issues such as urinary tract infections in babies, zipper injuries, HIV and STD transmission, circumcision procedures ("pain is something that is experienced from time to time by babies"), phimosis leading to urinary retention and (ultimately) stroke and heart attack, penile cancer, prostate cancer, cervical cancer, aesthetics, sexual function, and even the difficulty hospital orderlies have inserting a urinary catheter into uncircumcised men. The list goes on, and the agenda remains clear. Needless to say, no mention is made of the total absence of randomised trials â€“ after all, if so many parents are equivocal about circumcision that there is a market for books like this, recruitment for such trials would seem quite achievable. The ubiquitous issue of socio-economic confounders (the presence [or absence] of a foreskin is typically an economic, ethnic or religious marker) is brushed aside, less drastic surgical interventions for men with phimosis are conveniently never mentioned, and the morbidity statistics are presented in their grimmest possible light. The author seems unaware that most balanitis is caused by Candida [a kind of fungus, commonly present on the skin], with only minor roles played by Streptococci and anaerobes, so the treatment of balanitis contributes nothing to global antibiotic resistance. Opponents of circumcision are variously dismissed in the book as being anti-Semitic, under the influence of hippies, convicted felons, on the lunatic fringe, members of a politically correct lobby to feminise men, or (at best) selective in the surveying of the evidence. Hmm ... Given this climate, it is no wonder that the medical colleges choose to sit on the fence. It appears that beauty is in the eye of the holder as well as of the beholder. In one of the book's numerous low points, the author reminds us that the character Elaine in the comedy series Seinfeld exclaimed that an uncircumcised penis "looks like an alien". The scientist, not content with anecdote, has stooped to the level of outright fiction. The slender data presented that supports an aesthetic preference for circumcised penises came from cultures where most men are circumcised. One can only speculate what the preference would have been if similar studies were presented from cultures where most men were uncircumcised â€“ or perhaps even from cultures where they are subincised. [a] Not surprisingly, the book concludes with a list of "points for and against" circumcision which provides 11 points in favour and one point against (that circumcision is a minor surgical procedure that carries with it small surgical risks). Readers of this journal may be particularly interested in the sixth summary point: <div>Lack of circumcision is the biggest risk factor for heterosexually-acquired HIV infection in men. By itself, the risk is eight times higher, but is even higher if lesions from other STDs are present. In an uncircumcised man the risk per exposure has been estimated as 1 in 300.</div> Let's address the second sentence first, remembering that the author has already told us to deplore those who are selective in their use of the evidence. Of the many studies that have looked at circumcision status and HIV risk, only one been approached an eight-fold risk for the uncircumcised, and they were members of an ethnic minority in Kenya. The bulk of the studies clustered around a relative risk of 1.37. Typically, the uncircumcised men were from ethnic minorities, and thus the association with HIV infection had a good chance of being confounded [b]. Indeed, when having a foreskin signalled membership of the ethnic majority, its presence ceased to be a risk factor for HIV infection. [1] It is possible that the author of this meta-analysis may also have had an element of selectiveness in his use of the literature, but at least he subjected himself to the peer-review process. The ball's in your court, Professor Morris. But what about the first sentence? What message does it send to the father of the baby boy whose physical integrity is under consideration? Let's hope the father has the wisdom to substitute either the word "condom" or the word "restraint" â€“ depending on your philosophy â€“ for the word circumcision. I would consider this sentence alone to be so dangerous that it provides sufficient grounds for the publishers to withdraw the book. I have no strong feelings about the medical indications for male circumcision either way. It is a culturally entrenched practice with mainly murky evidence to inform the debate. This sort of document adds to the murk and amounts to a serious disservice to parents. Basil Donovan is Director of the Sydney Sexual Health Centre and Clinical Professor in the School of Public Health and Community Medicine, University of Sydney. Reference 1. Van Howe RS. <a href="http://www.cirp.org/library/disease/HIV/vanhowe4/" rel="noopener" target="_blank">Circumcision and HIV infection: A review of the literature and meta-analysis</a>. International Journal of STDs and AIDS, Vol. 10, 1999, pp. 8-16 Source: Venereology, Vol. 12, 1999, pp. 68-9 <h4>Response by Brian Morris</h4> In his review of my book Dr Donovan would seem intent on misrepresenting the evidence I present in favour of circumcision. While I appreciate that the howls from both sides in this debate have caused the colleges, as he says, to maintain a stance of sitting on the fence, it seems clear that, contrary to his statement in the last paragraph of his review, that Dr Donovan does have "strong feelings about the medical indications for male circumcision". This is most evident in the single reference he choose to cite (by Van Howe) [1] to refute my review of the large number of studies that have been performed that show higher HIV incidence in uncircumcised men, even after adjusting for potential confounding factors. Dr Donovan surely must be aware that the same journal as Van Howe published his "meta-analysis" an article appeared resoundingly debunking the latter as "highly unsound methodology" leading to erroneous conclusions. [2] When an accepted approach was used an odds ratio of 3.0 (95 per cent CI 2.6-3.4) was obtained, so that "the evidence that lack of male circumcision increases the risk for HIV infection appears compelling, contrary to the contention of Van Howe's paper". Thus Dr Donovan's "the ball is in your court, Professor Morris" comment has been very well dealt with by Moses et al already. Dr Donovan takes my statement out of context, and contrary to what he says, I do advocate use of condoms (although perhaps he might like to comment on the relative ease of fitting one of these to a circumcised as opposed to an uncircumcised penis!?) [c] Basil knows me well enough to appreciate that I am an easy gong kind of person, not "a man with a mission". After all, my book started with a joke (which was modified by the publisher from little Johnny telling how he learnt at school that day that Sir Francis Drake had circumcised the world with a 60 foot cutter). As well as several chapters that summarise all of the medical research data published in peer reviewed international journals, the book also attempts to deal with more general aspects. Thus to broaden the scope of the book I also included a chapter on reproducing the personal accounts from men. These include the diversity of views "out there" concerning the circumcision issue. The fact that these were clearly not my words gets misconstrued in Dr Donovan's book review. I might add that most of the people with psychological problems who emailed me were clearly members or supporters of anti-circumcision groups. To all who emailed me seeking help I always emailed back telling them to see a medical practitioner as soon as possible, so I don't understand why Dr Donovan makes an issue about how he would have responded to "A concerned father" in an email account he reproduces from my book. I have been very grateful to Dr Donovan for his help to me in the supply of samples for my research years ago on validating molecular methods for HPV detection in cervical screening. While we may share a chat over a beer and I may laugh at his ringbarking comments, if he rolls a cigarette I might have to leave the room. Yes, medical researchers and clinicians are united in their thinking about many issues, but there are some matters where consensus has never, and may never be, reached. If my book clears the air a bit then I would be happy. Indeed, the intention of my book, as should be apparent to the reader, and as stated, is to inform â€“ especially on this issue, which has been the subject of an enormous amount of misinformation, hysteria and distortion by anti-circumcision campaigners. I feel it is my duty as an academic to present an up-to-date review and believe it does help push aside the murk, thereby helping parents and health professionals. The reader is free to consult the 170 references I cite for a fuller account. I point out that after properly studying the issues it is up to the reader to come to their own decision. I too would welcome further studies and would gladly present these in the similar balanced manner as I have done in my book. The Australian College of Paediatrics similarly reviewed the evidence and dropped its opposition to circumcision several years ago. [d] In the interests of sexual health, perhaps Dr Donovan should acknowledge that consensus of studies now affirm that there is a case in favour of circumcision. References 1. Van Howe RS. <a href="http://www.cirp.org/library/disease/HIV/vanhowe4/" rel="noopener" target="_blank">Circumcision and HIV infection: A review of the literature and meta-analysis</a>. International Journal of STDs and AIDS, Vol. 10, 1999, pp. 8-16 2. Moses S. Nagelkerkle NJD. Blanchard JF. Analysis of scientific literature on male circumcision and risk of HIV infection. International Journal of STDs and AIDS, Vol. 10, 1999, pp. 626-8 Source: Venereology, Vol. 12, 1999, p. 154 <h4>Response by Basil Donovan</h4> Perhaps it's timely to out my own views on the relationship between the foreskin and sexual health. Professor Morris may be surprised to learn that I had long suspected that the presence of an intact foreskin might increase the risk of men acquiring certain STDs. I base this starting point on an analogy with the well-documented greater efficiency of transmission of many STDs from men to women rather than from women to men. The sub-preputial space on an uncircumcised man would seem to me to present a larger and more hospitable target foreskin some pathogens, as does the vagina. Indeed, I find that I am able to help many uncircumcised men with chronic balanitis by drawing that analogy and getting them to wash out that space no more than once a day, plus minimising exposure to substances that are not friendly to the vagina, such as soap and antiseptics. [e] Armed with this hunch, rather than set up a website I chose to do some research. Australia is a good place to do such research because there is a roughly even population split for the intervention (circumcision) and in most cases it is not a maker of ethnicity, wealth, education or religion. Unexpectedly, our research findings were uniformly negative. [1] Circumcision did not protect against STDs in our clinic population, though we did not look at HIV because it is rare in heterosexual men in Sydney. We were careful to point out that the spectrum of STDs and access to facilities for genital hygiene â€“ that's code for running water â€“ differed between Sydney and most parts of Africa. This was even implied by the title of the article. Nevertheless, this honest bit of research, honestly reported, earned us the dubious title of "anti-circumcision campaigners". You may have noticed that that this area of human inquiry is riddled with name calling and other attempts at discrediting the messenger. I remain of the reversible opinion that, in certain settings, being uncircumcised is a risk factor for some STDs. But, to me, the question isn't whether or not; the key questions are "how much?" and "where?". No, Professor Morris, it is not legitimate to extrapolate blandly from east Africa to urban Australia. Nor can data on the relative safety of the surgical process derived from hospitals in industrialised countries be applied to situations where surgical skills and levels of infection control cannot be guaranteed. Could it be that in the countries where circumcision is safest it is least indicated? Answers to these questions are needed before the intervention can even be seriously considered. Questions that would then arise would include the acceptability and feasibility of mass circumcision. The ensuing public outcry would overwhelm and affect other important issues, such as vaccination. Equally importantly, limited resources would be diverted from more wide-ranging interventions, such as improving access to clean water, which could partly obviate the need for circumcision anyway. If I campaign against anything, I campaign against extremism and over-simplification of the issues. I selected the review by Van Howe [2] because Morris had chosen directly to attack him in his book. Among Morris's criticisms was that Van Howe's website was biased and that he avoided the peer review process. At least Van Howe can no longer be accused of the latter. Moses et al's letter [3] in response to Van Howe estimated an odds ratio of 3, derived from prospective studies in Africa. This falls far short of the 8-fold protection against HIV claimed by Morris in his book intended for Australian parents. I'm pleased to hear that Morris has become a condom advocate, because he wasn't in his book. Since he has not retracted his claim that circumcision is the most effective HIV prevention strategy available to most men, by inference ahead of condoms, I have to persist in condemning the book as dangerous. In response to his question about circumcision status and success with using condoms, I only have preliminary data to report. In one study [4] we found no tendency for uncircumcised men to indicate physical discomfort with condoms when compared with circumcised men. In another study [5], condoms slipped off circumcised penises more often. I call these findings preliminary because they await confirmation, and the second finding was unexpected. But these studies were omitted â€“ along with many others â€“ when Morris attempted to "summarise all [emphasis mine] of the medical research data published in peer reviewed international journals" in his book. Though, in Morris's defence, he did cite Reference 1. Similarly, his selection of clinical anecdotes could hardly claim to represent the "diversity of views out there", when not a single happily intact male got a voice. But never mind, Van Howe and his ilk are on the case. It's a pity that two wrongs don't make a right. Morris and I seem to be like spirits in urging further higher quality research on this topic. Heat of debate is no substitute for sound data in its proper context. References 1. Donovan B, Bassett I., Bodsworth NJ. <a href="http://www.cirp.org/library/disease/STD/donovan1/" rel="noopener" target="_blank">Male circumcision and common sexually transmissible diseases in a developed nation setting</a>. Genitourinary Medicine, Vol. 70, 1994, pp. 317-20 2. Van Howe RS. Circumcision and HIV infection: A review of the literature and meta-analysis. International Journal of STDs and AIDS, Vol. 10, 1999, pp. 8-16 3. Moses S. Nagelkerkle NJD. Blanchard JF. Analysis of scientific literature on male circumcision and risk of HIV infection. International Journal of STDs and AIDS, Vol. 10, 1999, pp. 626-8 4. Richters J., Gerofi J., Donovan B. Are condoms the right size(s)? A method for measurement of the erect penis. Venereology, Vol. 8, 1995, pp. 77-81 5. Richters J., Gerofi J., Donovan B. Why do condoms break or slip off in use? International Journal of STDs and AIDS, Vol. 6, 1995, pp. 11-18 Source: Venereology, Vol. 12, 1999, p. 155 <h3>Editorial notes</h3> a. The practice of slitting the underside of the penis (originally with a sharp stone), so as to open the urethra, as performed as an initiation rite among a few Aboriginal peoples in the central Australian desert. There is an interesting (if gruesome) paper on this by Jon Willis, covering the effect of the penis surgery undergone by Pitjantjatjara men in the course of their tribal initiations. This involves circumcision followed later by subincision, and then regular reopening of the wounds in all-male bonding rites, where blood must flow. The author shows that the combination of these surgeries cripples the penis so effectively that the men have very little interest in or capacity for sex, and suggests that the only place where it would feel remotely comfortable if touched is inside a very soft and well-lubricated vagina; anywhere else, touch on the penis would be too painful. Jon Willis, "Heteronormativity and the deflection of male same-sex attraction among the Pitjantjatjara people of Australia's Western Desert", Culture Health and Sexuality, Vol. 5, 2003, pp. 137â€“151 b. That is, holding the foreskin responsible for differences in sexual behaviour or contacts produced by the person's membership of a particular ethnic, religious or other social group, where that adherence determines the kinds of sexual behaviour engaged in or the range of his sexual contacts. The <a href="http://www.cirp.org/library/disease/HIV/cochrane2003/" rel="noopener" target="_blank">authoritative Cochrane Review</a>, concluding that circumcision could not be recommended as an effective AIDS strategy in Africa, noted that confounding was a serious problem with nearly all the studies which claimed to find an association between lack of circumcision and greater susceptibility to HIV infection. c. One wonders as to the extent and sources of Professor Morris's experience on this point. d. Blatant misrepresentation, contradicting Morris's earlier comment that the colleges were sitting on the fence. Although the paediatricians' 1996 statement was weaker than that of 1983, it maintained their opposition to routine circumcision, a stance that was more strongly affirmed in 2002. <a href="http://www.circinfo.org/previous_statements.html" rel="noopener" target="_blank">Previous policy statements</a> <a href="http://www.cirp.org/library/statements/" rel="noopener" target="_blank">Statements by other medical authorities</a> e. "Balanitis" (any inflammation of the glans) is more likely to be caused by excessive washing and irritation from soap than by its natural covering. <a href="http://www.cirp.org/library/disease/balanitis/" rel="noopener" target="_blank">Further information</a> Not to be confused with the more serious (but very rare) lichen sclerosis, or <a href="http://www.cirp.org/library/treatment/BXO/" rel="noopener" target="_blank">Balanitis xerotica obliterans (BXO)</a> </div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Brian Morris reviewed darby Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Robert Darby Subject The topic of the resource Circumcision history Description An account of the resource Archive of the work published by Robert Darby Creator An entity primarily responsible for making the resource Robert Darby Source A related resource from which the described resource is derived circinfo.org historyofcircumcsion.org Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Text Any textual data included in the document <div class="intro" id="intro"> <h1>The foreskin: Guide for carers and owners</h1> The following guide to foreskin management, including treatment options for foreskin problems, was prepared by the British Association of Paediatric Urologists. Although it is aimed at medical professionals, it includes much sensible advice that will be of interest and value to parents and foreskin owners. <h2>MANAGEMENT of FORESKIN CONDITIONS</h2> Statement from the British Association of Paediatric Urologists on behalf of the British Association of Paediatric Surgeons and the Association of Paediatric Anaesthetists. <h2>Table of contents</h2> Executive Summary Recommendations 1. Natural History of the foreskin 2. Common conditions and diseases associated with the presence of a foreskin 3. Treatment of conditions of the foreskin 4. Circumcision (a) British Medical Association (BMA) Guidelines (b) Anaesthesia and analgesia for circumcision (c) Complications of circumcision (d) Governance issues References Addenda (a) Comments by Doctors Opposing Circumcision (b) Comment from NORM-UK (c) Comments from a Muslim male religious circumcision practitioner (d) Response from the Association of Reform & Liberal Mohelim Working Party members and contact address <h2> <a id="exec" name="exec"></a>EXECUTIVE SUMMARY</h2> <h3>Strategic context</h3> The management of foreskin conditions varies amongst medical practitioners from observation to circumcision. Therapeutic circumcision is performed in the U.K for specific indications. There is as yet no policy for non-therapeutic or religious/cultural circumcision in the U.K., although a position statement was issued by the British Association of Paediatric Surgeons (BAPS) in 2001 [34]. <h3>Background</h3> 1. The natural history of the foreskin Almost all boys have a non-retractile foreskin at birth [1]. The inner foreskin is attached to the glans. Foreskin adhesions break down and form smegma pearls, white cysts under the foreskin, which are then extruded. The foreskin does not retract before the age of 2 years, after which it “pouts like a flower” -- physiological phimosis. The process of retractility is spontaneous and does not require manipulation. The majority of boys will have a retractile foreskin by 10 years of age and 95% by 16-17 years of age [2-4]. 2. Common foreskin conditions and diseases associated with presence of a foreskin A. Common foreskin conditions: Definitions (a) Balanoposthitis: inflammation of the glans and foreskin [5, 6]. (b) Balanitis: inflammation of the glans that often spreads along the shaft and may occur in the circumcised population [7]. (c) Posthitis: inflammation restricted to the foreskin itself. (d) Balanitis Xerotica Obliterans (BXO): a lesion akin to lichen sclerosus et atrophicus, is the cause of true scarring of the foreskin -- pathological phimosis -- the shutter type foreskin with no pouting of the inner foreskin on gentle retraction [8]. It is rare before the age of 5 years [9] and presents with discomfort on voiding and white firm scarring of the foreskin tip. The aetiology is unknown but may be of viral origin. This condition may also affect the glans and urethra. (e) Paraphimosis: results when the narrow tip of the foreskin is retracted behind the glans at the coronal sulcus causing oedema of the glans and foreskin and inability to manipulate the foreskin back over the glans. (f) Hooded foreskin: is an abnormal dorsal hemiforeskin (the penis is anatomically described in the erect position) which is deficient ventrally and is usually associated with hypospadias. B. Diseases associated with presence of a foreskin There is no current evidence to support an increased risk of penile cancer [10-14], human immunodeficiency virus infection [15] or cervical cancer [16, 17] in uncircumcised males. Circumcision to prevent urinary tract infection (UTI) is unproven except in boys with abnormal renal tracts [18]. 3. Treatment of conditions of the foreskin (a) Inflammatory conditions: Balanoposthitis, Balanitis, Posthitis: Simple bathing, topical steroids and antibiotics. (b) Non retractile healthy foreskin (physiological phimosis): No intervention, topical steroids, preputioplasty infrequently [19-25]. (c) BXO: Circumcision. There are no randomised trials that can ascertain the efficacy of other techniques and their long term outcome [26-30]. (d) Paraphimosis: Reduction with or without anaesthetic [31, 32]. (e) Hooded foreskin: Without hypospadias: no treatment, modified circumcision, foreskin reconstruction. With hypospadias: no treatment, circumcision or foreskin reconstruction with hypospadias repair. 4. Circumcision Background Male circumcision is the most common surgical procedure in the world. It may be performed for clinical reasons or to comply with religious/cultural practice -- "non-therapeutic circumcision". Non therapeutic circumcisions are not uniformly available on the NHS (where they are performed by medical practitioners and nurse practitioners ) and are also performed in the community by general practitioners and non clinicians. 4 (a) British Medical Association guidelines Reproduced in part from the BMA document: The law and ethics of male circumcision, London, 2006 [35]. (i) Ethics and the Law Male circumcision is generally assumed to be lawful provided that: <ul> <li>it is performed competently;</li> <li>it is believed to be in the child's best interests;</li> <li>there is valid consent.</li> </ul> (ii) Consent and refusal <ul> <li>Competent children may decide for themselves.</li> <li>The wishes that children express must be taken into account.</li> <li>If parents disagree, non-therapeutic circumcision must not be carried out without the leave of a court.</li> <li>Consent should be confirmed in writing.</li> </ul> (iii) Best interests <ul> <li>Doctors must act in the best interests of the patient.</li> <li>The views that children express are important in determining what is in their best interests.</li> <li>Parental preference must be weighed in terms of the child's interests.</li> <li>The child's lifestyle and likely upbringing are relevant factors to take into account.</li> <li>Parents must explain and justify requests for circumcision, in terms of the child's interests.</li> </ul> (iv) Health issues Parents seeking circumcision for their son for reasons of hygiene or health benefits must be fully informed of the lack of consensus amongst the profession over such benefits. The BMA considers there is insufficient evidence concerning health benefit from non-therapeutic circumcision. (v) Standards The General Medical Council advises that doctors must have the necessary skills and experience both to perform the operation and use appropriate measures, including anaesthesia, to minimise pain and discomfort. There is no legal requirement for non-therapeutic circumcisions to be undertaken by registered health professionals. (vi) Facilities Doctors must ensure that the premises in which they are carrying out circumcision are suitable for the purpose. In particular, if general anaesthesia is used, full resuscitation facilities must be available. (vii) Charging patients Although non-therapeutic circumcision is not a service which is provided free of charge, some doctors and hospitals have been willing to provide non-therapeutic circumcision without charge rather than risk the procedure being carried out in unhygienic conditions. In such cases doctors must still be able to justify any decision to circumcise a child based on the considerations above. (viii) Conscientious objection Health care professionals are under no obligation to comply with a request to circumcise a child. Where the procedure is not therapeutic but a matter of patient or parental choice, there is no ethical obligation to refer on. 4 (b) Anaesthesia and Analgesia for circumcision (i) Anaesthesia There is an increased risk from general anaesthesia in the neonatal period [36, 37]. According to the Royal College of Anaesthetists handbook, any general anaesthetic should be administered by an appropriately trained anaesthetist with ongoing relevant paediatric experience (38). (ii) Analgesia It is essential that adequate analgesia be provided when undertaking male circumcision. Dorsal nerve block and ring block are equally effective [45, 70]. Adequate time needs to elapse after the block before surgery is started. Eutectic mixture of local anaesthetics (EMLA), contraindicated on open wounds and mucous membranes, should be allowed 1 hour to take effect [40].This can be tested by picking up the foreskin in forceps before commencing the procedure. Non-pharmacological methods (non-nutritive suckling, rocking, massaging, cuddling) or systemic analgesia with paracetamol are inadequate in isolation for analgesia [49-59]. Caudal analgesia is effective in anaesthetised boys but has not been studied in neonatal awake circumcisions [62, 64]. 4 (c) Complications of circumcision Bleeding (1.5%), local sepsis (8.5%), oozing (36%), discomfort > 7 days (26%), meatal scabbing or stenosis, removal of too much or too little skin, urethral injury ,amputation of the glans and inclusion cyst are recorded complications [81-85]. There is conflicting evidence with respect to penile sensation, sexual function and satisfaction in adult men following circumcision [86-89]. 4 (d). Governance Issues Clinical Governance applies to all professionals i.e. clinicians including medical and nurse practitioners [90]. Non clinical practitioners performing circumcisions in the community may apply similar governance principles. <h2> <a id="recommendations" name="recommendations"></a>RECOMMENDATIONS</h2> <h3>A. Treatment of conditions of the foreskin</h3> 1. Inflammatory conditions: Balanoposthitis, Balanitis, Posthitis Simple bathing, topical steroids and antibiotics. 2. Non retractile healthy foreskin ( physiological phimosis ) No intervention, topical steroids, preputioplasty -- infrequently. 3. BXO Circumcision: There are no randomised trials that can ascertain the efficacy of other techniques and their long term outcome. 4. Paraphimosis Reduction with or without anaesthetic. 5. Hooded foreskin Without hypospadias: no treatment, modified circumcision, foreskin reconstruction. With hypospadias: no treatment, circumcision or foreskin reconstruction with hypospadias repair. <h3>B. Circumcision</h3> 1. Indications for circumcision 2. The operator 3. Standards of care 1. Indications for circumcision (a) Absolute (i) Penile malignancy (ii) Traumatic foreskin injury where it cannot be salvaged. (b) Medical (i) Balanitis Xerotica Obliterans. (ii) Severe recurrent attacks of balanoposthitis. (iii) Recurrent febrile UTIs with an abnormal urinary tract. (c) Non-therapeutic ritual circumcision 2. The operator (a) The person performing the procedure should be experienced and competent to do so. Written consent should be obtained from both parents. (b) The operator should be able to identify co-morbidity and deal with it appropriately. (c) The operator should have a full understanding of the risks and complications of the procedure and their management. (d) The operator should be familiar with various modes of analgesia for the procedure. (e) The operator should keep thorough records and regularly audit his/her practice. 3. Standards of Care (a) The operation should be undertaken in an environment capable of fulfilling guidelines for surgical procedures in children. (b) Adequate analgesia is essential. This involves systemic (oral) paracetamol and an adequate local anaesthetic. Sufficient time for the local infiltration to provide analgesia is crucial and this should be tested prior to conducting the circumcision. (c) There should be close links with the community, GP and hospital services for ongoing care and ease of referral if complications arise. (d) Regular audit of practice at individual level, trust level and in the community is essential. <h2> <a id="natural" name="natural"></a>1. The NATURAL HISTORY of the FORESKIN</h2> The fate of the foreskin has been well documented after the initial description by Gairdner in 1949 [1]. There is developmental variability in the appearance of the normal foreskin throughout childhood and puberty. The inner foreskin is attached to the glans. Foreskin adhesions break down and form smegma pearls -- white cysts under the foreskin -- which are then extruded. The foreskin does not retract before the age of 2 years. The process of retractility is spontaneous and does not require manipulation. The majority of boys will have a retractile foreskin by 10 years of age and 95% by 16-17 years of age [2-4]. Since 1996, there has been a decline in the number of children aged 0-14 treated by general surgeons with more children being seen by paediatric surgeons and paediatric urologists. Figures from the Department of Health demonstrate a reduction in paediatric surgical procedures from 30,000 per annum to nearer 20,000 per annum over a period of 10 years (Prof. D.F.M. Thomas, unpublished data). This may partly be secondary to a decrease in the number of circumcisions due to the recognition that physiological phimosis -- a healthy non-retractile foreskin which pouts like a flower on gentle retraction is normal. <h2> <a id="common" name="common"></a>2. COMMON FORESKIN CONDITIONS and DISEASES ASSOCIATED with the PRESENCE of a FORESKIN</h2> <h3>Common foreskin conditions</h3> Balanoposthitis (Balanos Greek for acorn, posthos, Greek for foreskin) is the term used for inflammation of both the glans and foreskin. It may present with dramatic swelling and erythema of the distal penis and foreskin associated with discharge, bleeding from the prepuce, dysuria, and occasionally urinary retention. It occurs in about 4% of uncircumcised boys between 2-5 years of age [5]. The aetiology is unclear although infection, contact allergy and contact irritation have been described [6]. Although balanoposthitis may be recurrent, the episodes decrease in frequency in older boys and reflect foreskin maturation. Balanitis refers to inflammation of the glans that often spreads along the shaft and may occur in the circumcised population [7]. Posthitis refers to inflammation restricted to the foreskin itself. Balanitis Xerotica Obliterans (BXO), a lesion akin to lichen sclerosus et atrophicus is the cause of true scarring of the foreskin i.e. pathological phimosis and the shutter type foreskin [8] -- no pouting of the inner foreskin on gentle retraction. It is rare before the age of 5 years [9] and presents with discomfort on voiding and a white firm scarring of the foreskin tip. The aetiology is unknown but may be of viral origin. This condition may also affect the glans and urethra. Whereas there is a strong association between BXO in adults and penile carcinoma, there is no such evidence to link it as a precancerous condition in children because the majority of children with BXO have historically undergone a circumcision. Paraphimosis results when the narrow tip of the foreskin is retracted behind the glans at the coronal sulcus causing oedema of the glans and foreskin and inability to manipulate the foreskin back over the glans. A hooded foreskin is an abnormal dorsal hemiforeskin (the penis is anatomically described in the erect position ) which is deficient ventrally and may or may not be associated with hypospadias. <h3>Diseases associated with presence of a foreskin</h3> Penile cancer Cancer of the penis is extremely rare and was previously not documented in circumcised men. Several recently reported cases question the protective effect of circumcision on the development of penile cancer as an adult [10-13]. Poor personal hygiene, smoking and exposure to wart virus (human papilloma virus) increase the risk of developing penile cancer at least as much as being uncircumcised [12-13]. Circumcised men are more at risk from penile warts than uncircumcised men [14], and the risk of developing penile cancer is now almost equal in the two groups. Routine circumcision in children cannot be recommended to prevent penile cancer. Human immunodeficiency virus (HIV) infection The results from existing observational studies showed a strong epidemiological association between male circumcision and prevention of HIV. These observational studies however were done in specific high risk groups. Randomised controlled trials are currently under way and the results are awaited. A Cochrane review [15] found insufficient evidence to support an interventional effect of male circumcision on HIV acquisition in heterosexual men. [CIA note: Since this document was prepared the World Health Organisation has recommended that in African countries with a high prevalence of HIV and a high rate of female-to-male infection, circumcision be offered as an option to sexually active adult males. Contrary to the propaganda of circumcision promoters, it has not recommended circumcision of children or proposed that adult circumcision programs be introduced in developed nations. For a full discussion of why the African data and WHO policies are not applicable to countries such as Australia, <a href="https://www.circinfo.org/hiv.html">see the HIV page on this site</a>.] Cervical cancer Several studies have shown an association between an increased incidence of human papilloma virus infection in heterosexual uncircumcised men with high risk activity (multiple sexual partners, avoidance of condoms) and cervical cancer [16-17]. These studies are retrospective observational studies from different geographical areas with a variable incidence of cervical cancer. The current evidence is inadequate to recommend routine male circumcision as a preventive measure against cervical cancer. Urinary tract infection (UTI) Recent meta analysis [18] data on 402,908 children were identified from 12 studies (one randomized controlled trial, four cohort studies, and seven case-control studies). Circumcision was associated with a significantly reduced risk of UTI for all three types of study design. This study concluded that circumcision reduces the risk of UTI. Given a risk in normal boys of about 1%, the number-needed-to treat to prevent one UTI is 111. In boys with recurrent UTI or high grade vesicoureteric reflux, the risk of UTI recurrence is 10% and 30% and the numbers-needed-to-treat are 11 and 4, respectively. <h2> <a id="treatment" name="treatment"></a>3. TREATMENT of CONDITIONS of the FORESKIN</h2> Inflammatory conditions: Balanitis, Balanoposthitis, Posthitis Simple bathing, topical steroids and antibiotics. Circumcision may very rarely be considered if recurrent severe episodes of inflammation occur. Physiological phimosis No intervention is necessary. Topical steroid application to the preputial ring to treat ?phimosis? has reported success rates between 33% and 95% in various series [19-24] but frequently authors fail to define the difference between a healthy non retractile foreskin and true BXO. A preputioplasty technique has been described with good results [25] for the non-retractile foreskin though the authors gave no significant reason for intervention. Pathological phimosis (BXO) Intralesional steroid injection [26], long term antibiotics [27], carbon dioxide laser therapy [28], a radial preputioplasty alone [29] or with intralesional injection of steroid [30] have all been described. There are no randomised trials to ascertain the efficacy and the long term outcome of these techniques. Most paediatric urologists circumcise the foreskin for BXO. Once the range of treatment options are presented, the surgeon should express his or her own preference. If a surgeon is faced with a parent who refuses a conventional circumcision for BXO, but wishes for an alternative option, the surgeon is at liberty to decline to treat. The surgeon then has a duty to offer a second opinion, although there is no obligation to find a colleague who is likely to advocate the alternative option. Paraphimosis Gentle compression with a saline soaked swab [31] followed by reduction of the prepuce over the glans is usually successful. Alternatives include multiple punctures in the oedematous foreskin [32] or injection of hyaluronidase [31] prior to compression reduction. General anaesthesia may be required. Paraphimosis is not an indication for circumcision as after reduction, the foreskin continues to develop normally. Hooded foreskin A hooded foreskin without hypospadias is a cosmetic abnormality. Any therapeutic intervention should be undertaken after full discussion with both parents and may be a modified circumcision or foreskin reconstruction. Hooded foreskin with hypospadias needs treatment with correction of the hypospadias. <h2> <a id="circum" name="circum"></a>4. CIRCUMCISION</h2> Circumcision is a surgical procedure that involves partial or complete removal of the foreskin (prepuce) of the penis. Circumcision may be performed for therapeutic or non therapeutic reasons and both are accepted practices within the U.K. provided certain standards are met [33, 91]. There is as yet no policy for non-therapeutic or religious circumcision in the U.K., although a position statement was published by BAPS in 2001 [34]. <h3> <a id="bma" name="bma"></a>4 (a) British Medical Association (BMA) Guidelines 2003</h3> The BMA have set out guidelines with respect to both therapeutic and non therapeutic circumcision [35]. These guidelines discuss the issues mentioned below. <ul> <li>Ethics and the law</li> <li>Consent and refusal</li> <li>Best interests</li> <li>Health issues</li> <li>Standards</li> <li>Facilities</li> <li>Charging patients</li> <li>Conscientious objection</li> </ul> A full discussion of the guidelines is beyond the scope of this document. The 2003 guidelines (The law and ethics of male circumcision - Guidance for doctors) can be obtained from the BMA website. [CIA NOTE: This statement was <a href="http://www.bma.org.uk/ethics/consent_and_capacity/malecircumcision2006.jsp">updated in November 2007</a>.] With respect to consent the working party point out that having both parents consent for a therapeutic circumcision is not necessary. The legal purpose of consent is to provide the clinician with a defence against negligence and battery, so a single consent is valid. In non-therapeutic circumcision, the purpose of the second consent is to protect the second parent from having a procedure performed on their son of which they disapprove. At present case law is clear: <a href="http://www.cirp.org/library/legal/Re_J/">Re J (Child's religious upbringing and circumcision)</a> COURT OF APPEAL (CIVIL DIVISION) 25 November 1999. Permission from both parents is required for non-therapeutic circumcision. Currently, the only way for the clinician to show that they have conformed to this is to get both parents to sign the consent form. However, legal advice has suggested that this position is open to challenge. In discussion with the wider membership of BAPU there was widespread support for the requirement for both parents' signatures, but this was not unanimous. Paediatric patient information documents for circumcision (ref. PSO2) are available from EIDO Healthcare at www.eidohealthcare.com. <h3> <a id="anaesthesia" name="anaesthesia"></a>4 (b) Anaesthesia and analgesia for circumcision</h3> (i) Anaesthesia Modern general anaesthesia is extremely safe. However the risk of general anaesthesia will never be zero and is increased in infants. In two large series [36-37] the risk of complications was significantly higher in infants than in children. Adequate analgesia must always be provided whether a general anaesthetic is being administered or not. There is an increased risk from general anaesthesia in the neonatal period. According to the Royal College of Anaesthetists handbook [38], any general anaesthetic should be administered by an appropriately trained anaesthetist with ongoing relevant paediatric experience. (ii) Analgesia INTRODUCTION Adequate analgesia for male circumcision is required and is the subject of two Cochrane reviews [39-40]. In non-anaesthetised neonates who underwent circumcision a rise in adrenal corticoids [41-42], skin flushing, vomiting and cyanosis43, increases in crying [41-44], apnoea and choking [45] and a pneumothorax [46] have all been described. Increases in heart rate and respiratory rate with decreases in oxygen saturation [47] have been recorded with inadequate analgesia. Infants who undergo circumcision show exaggerated pain behaviour to their routine immunisations during the ensuing six months when compared to uncircumcised control infants [48] suggesting that they develop a "pain memory" from an early age. INTERVENTIONS Non-pharmacological In neonates, rocking, massage, tucking and cuddling reduce pain responses to invasive procedures [49-51]. Music and heartbeat sounds have been shown to modulate pain perception [52]. None of these seem adequate as stand alone methods of providing analgesia for neonatal circumcision and cannot be endorsed as such. These and similar methods may well have a role to play as adjunctive therapies. Non-nutritive suckling There are several trials comparing sugar solutions to water and or no treatment in neonatal circumcisions without general anaesthesia [53-59]. Since a large range of concentrations (24-50%) and volumes (1.5 to 10 ml) were used across these studies it is hard to draw any firm conclusions. Heterogeneous outcome measures were used but, cry times and heart rate changes were not significantly different in the treatment groups when compared to the controls in the context of circumcision. This is not to say that non-nutritive suckling does not have a role to play as an adjunctive therapy. Systemic analgesia Paracetamol has been compared to placebo in two trials [60-61]. Macke [61] found a benefit from Paracetamol compared to placebo but Howard [61] found no difference between placebo and paracetamol as judged by a 20-point comfort score. Parenteral opioids have been compared to caudal anaesthetics in older children having general anaesthetics for circumcision. Intramuscular codeine62, fentanyl and paracetamol [63], intramuscular morphine [64], intravenous diamorphine65 and intramuscular buprenorphine [66] have all been compared with caudal analgesia. In summary, parenteral opioids lead to a greater need for rescue analgesia than caudals and result in a higher incidence of nausea and vomiting. Post-procedural analgesia should always be provided. The paracetamol dose should not exceed 60mg/kg/24 hours for neonates and 90mg/kg/24 hours for older children. Dorsal Penile Nerve Block (DPNB) The results of DPNB when used against active treatment controls are shown in the table below. Penile block is recommended as an effective means of providing analgesia. It should be noted that performance of this block requires training, and that it is generally best performed in the anaesthetized infant. TABLE: Comparison of active treatments versus DPNB in neonatal circumcision [Not shown here: <a href="http://baps.org.uk/page14/page14.html">Available in PDF at BAPS website</a>.] Bicarbonate solution Although there are theoretical advantages to adding bicarbonate to the local anaesthetic solution in any block in terms of decreasing the pain on injection and increasing the speed of onset of the block Stang et al [56] showed no advantage in doing this as judged by any of the outcome measures of heart rate, cry time, behavioural distress score or serum cortisol levels. Ring Block There are two trials comparing ring block to no treatment [45, 71] the latter showing significantly lower heart rates in the treatment group and the former showing no difference in respiratory rate and oxygen saturation. When compared to EMLA there was no advantage versus ring block as judged by heart rate and cry time [45]. A test of the adequacy of the block such as gently picking up the foreskin with forceps should always be undertaken prior to surgery and the operator should be satisfied that there is no pain response to this test. Caudal Epidural Block There is a reduced requirement for early post-operative rescue analgesia and less post-operative nausea and vomiting if a caudal is used. Urinary retention and leg weakness are known complications of caudal block. All studies [62, 64] comparing caudal block against other modes of analgesia for circumcision were in anaesthetized children. Topical Analgesia EMLA cream Six studies compare EMLA (Eutectic Mixture of Local Anaesthetic) to placebo as cited in the Cochrane review by Brady-Fryer and colleagues [40]. EMLA significantly reduced pain behaviour scores in most studies. Heart rate was significantly reduced in the EMLA groups whereas respiratory rate and blood pressure were not. There is risk of methaemoglobinaemia with the use of prilocaine (a constituent of EMLA) especially in neonates. Indeed the BNF for children 2005 does not recommend its use in neonates. It has been safely used for heel lancing in neonates on neonatal units. EMLA should not be used on open wounds or mucous membranes. EMLA cream should be allowed adequate time to take effect and one hour is regarded as the minimum. Amethocaine (tetracaine 4%) gel Like EMLA the BNF for children 2005 does not recommend the use of amethocaine gel in neonates although it is commonly used in this population. Repeated applications should be avoided. Amethocaine only takes 30 minutes to become clinically effective and is thus twice as fast in onset as EMLA [72]. A common practice is to apply topical local anaesthetic such as amethocaine gel half an hour before performing a deeper block such as DNPB or ring block thus helping to minimise the pain of injection of the deeper block. Lidocaine Three trials compare topical lidocaine to placebo [73-75]. Cry time is significantly reduced by lidocaine. Oxygen saturations tend to be higher in the treatment groups but not statistically so. SUMMARY It is essential to provide adequate analgesia when undertaking male circumcision. Dorsal nerve block and ring block are easy to perform and are effective. Adequate time needs to elapse after the block before surgery is started. Non-pharmacological methods and optimum treatment with systemic analgesics should also be employed. <h3> <a id="complications" name="complications"></a>4 (c) Complications of circumcision</h3> Numerous techniques have been described for circumcision. This is achieved either by the freehand or sleeve technique [76], using a clamp [77, 78] or a plastibell device [79]. Circumcisions performed in hospitals have a statistically lower complication rate than those in the community [80-82]. These include bleeding, local sepsis, meatal scabbing or stenosis, removal of too much skin or too little skin, urethral injury ,amputation of the glans and inclusion cyst. Engorgement of the glans as a result of failure of the plastibell ring to fall off is well recognized [83] and necessitates removal of the ring. An inappropriate circumcision in the presence of a penile abnormality such as a hypospadias can lead to long term morbidity. Griffiths et al [84] in a prospective survey of hospital circumcision recorded the following complications: oozing in 36%, discomfort >7 days 26%, infection needing antibiotics 8.5% and haemorrhage in 1.5%. Kaplan [85] noted the effect of the exposed glans to wet diapers causing meatitis and meatal ulcers. There is conflicting evidence with respect to penile sensation, sexual function and satisfaction in adult men following circumcision [86-89]. <h3> <a id="governance" name="governance"></a>4 (d) Governance issues</h3> In 1999 the Department of Health set out a white paper defining clinical governance in the NHS [90].This is maintained by regular audit, evidence based practice, Continuing Professional Development (CPD) and Research, risk management and clinical effectiveness. All medically qualified practitioners fall under this umbrella and are answerable to their peers. The role of nurse practitioners in performing circumcision depends on their contractual position and consultant supervision. It is anticipated that liability would be shared between the employing trust and the operator, and only with the supervisor if it is "just and reasonable" that they should share liability. Non medical personnel performing circumcisions in the community must obtain valid consent and have appropriate experience. There is a need for personal audit in these circumstances. <a id="refs" name="refs"></a><a href="https://www.circinfo.org/baps_refs.html">References</a><a href="https://www.circinfo.org/baps_refs.html">: On separate page</a> <h2> <a id="addenda" name="addenda"></a>ADDENDA</h2> <h3>Addendum A: Comment by Doctors Opposing Circumcision</h3> This statement, Management of Foreskin Conditions, is a progressive move to reform the treatment of foreskin conditions. The statement favours conservative treatment over radical circumcision and should do much to promote genital integrity. We urge its speedy adoption. Our comments are small ones. Lawfulness. The lawfulness of non-therapeutic male circumcision is questionable under British law. Law professors Fox and Thomson recently argued that non-therapeutic male circumcision is unlawful under the Offences Against the Person Act 1861 after the House of Lords decision of R v Brown (1993). Fox and Thomson argue that consent cannot excuse the practice of non-therapeutic circumcision because no one can consent to a criminal act [1]. No court has ruled on this matter so this question remains unsettled. Complications. Death is a possible outcome of male circumcision [2]. Natural history and development of retractile foreskin. This section provides newer and more accurate data. These data should greatly reduce the incidence of erroneous diagnosis of pathological phimosis in boys and adolescents. Diagnosis and Treatment of Inflammation (Balanitis, Posthitis, and Balanoposthitis). We would like to see greater emphasis placed on the importance of careful diagnosis, since these conditions have varied etiology, which require varied treatment [3]. Careful diagnosis is necessary to find the cause and select the appropriate treatment. The British Guidelines provide excellent information [4]. Diagnosis may include a patient history, physical examination, swab and culture, and biopsy [3, 4]. The presence of infection with Candida Albicans should cause suspicion of diabetes mellitus. Recurrent mycotic infection may indicate a compromised immune system and dictate further investigation [5]. References 1. Fox M, Thomson M. <a href="http://www.cirp.org/library/legal/UKlaw/fox-thomson2005/">A covenant with the status quo? Male circumcision and the new BMA guidance to doctors</a>. J Med Ethics 2005;31:463-9. 2. Williams N, Kapila L. <a href="http://www.cirp.org/library/complications/williams-kapila/">Complications of circumcision</a>. Brit J Surg 1993;80:1231-6. 3. Edwards S. <a href="http://www.ncbi.nlm.nih.gov/pmc/issues/120947/">Balanitis and balanoposthitis: a review</a>. Genitourin Med 1996;72(3):155-9. 4. Edwards S. (for the Clinical Effectiveness Group) National guideline on the management of balanitis. Association for Genitourinary Medicine (U.K.) and the Medical Society for the Study of Venereal Diseases (U.K.). (2001) [CIA Note: Balanitis is a generic term covering a wide range of conditions that may affect the glans of the penis and the foreskin. Posthitis merely means an "itis" of the "posthe", or in English an inflammation of the foreskin. The various conditions called balanitis may be caused by any one or more of a dozen different agents, which may be bacterial, viral, fungal, or the result of injury. For full details on the identification and treatment of such inflammations, see the <a href="http://www.bashh.org/guidelines">guidelines issued by the British Association for Sexual Health and HIV</a>. BAHSH points out that balanitis is one of the most common conditions encountered at sexual health clinics, and that it is nearly always easy to treat. The guidelines do not recommend circumcision as either a treatment or preventive for these mild and easily-curable problems.] 5. Mayser P. Mycotic infections of the penis. Andrologia 1999;31 Suppl 1:13-6. <a href="http://www.doctorsopposingcircumcision.org/" rel="noopener" target="_blank">Doctors Opposing Circumcision</a> Suite 42, 2442 NW Market Street Seattle, Washington 98107-4137 USA <h3>Addendum B: Comment from Norm-UK</h3> On the whole NORM-UK do not consider that this is a balanced view of the management of foreskin conditions, since they are looking at circumcision rather than the management of foreskin conditions. It is pleasing to see that conservative management is stressed in the cases of balanitis/balanoposthitis, non-retractile foreskin and paraphimosis. With regard to circumcision, a realistic view of complication rates is mentioned. We also welcome your sensible, up to date view of the natural history of the foreskin. It is also pleasing that the authors of report are not impressed by supposed prevention of penile cancer by circumcision. It is interesting, however, that they note increased risk of penile warts in circumcised men as compared with intact. With regard to BXO, we would urge you to state that this is lichen sclerosus, rather than merely being akin to lichen sclerosus. We also believe that there is RCT evidence to support the efficacy of topical steroids for the treatment of lichen sclerosus. Lindhagen presented a prospective, randomised, double-blind study, although it is admittedly unclear as to whether those who were effectively treated actually had lichen sclerosus [1]. Kiss and colleagues also presented a randomised, placebo controlled double blind study to show the effective treatment of "BXO" histopathology by mometasone furoate [2]. At the very least this would seem to merit a recommendation for further research. It is also pleasing that they are not impressed by claims that circumcision prevents cervical cancer in female partners. Unfortunately in this connection they have not questioned the ethics of performing surgery on a healthy child with a view to preventing disease in a third party at some distant time in the future on the assumption that the individual will go on to have a partner of the opposite sex. Setting aside that this is outside the scope of managing actual disease of the foreskin, it is surely an example of where a choice for circumcision could be made by a consenting adult rather than being imposed on an un-consenting child? In the case of prevention of UTIs the fact that it is necessary to operate on 111 infants to prevent one case of UTI is pretty clear evidence that circumcision should not be undertaken for this reason, particularly in view of the complication rates, which they report. However, they have not pressed that conclusion clearly enough. It is also noteworthy that the one RCT to examine circumcision for the prevention of UTI in boys found that circumcision was not effective at reducing recurrences of UTI [3]. While this was a study solely of boys having anti-reflux surgery for VUR, this is to the best of our knowledge the only published RCT to consider circumcision for prevention of UTI. It seems disingenuous to recommend circumcision in boys with VUR when the only RCT to have considered the matter shows that it does not work. References 1. Lindhagen T. Topical clobetasol propionate compared with placebo in the treatment of the unretractable foreskin. Eur J Surg. 1996; 162:969. 2. Kiss A, Csontai A, Pirot L, Nyirady P,Merksz M, Kiraly L. The response of balanitis xerotica obliterans to local steroid application compared with placebo in children. J Urol. 2001; 165(1):219-20. 3. Kwak C, Oh SJ, Lee A, Choi H. Effect of circumcision on urinary tract infection after successful antireflux surgery. BJU Int. 2004; 94(4):627-629 We note that in their discussion of the management of Hooded Foreskin, a congenital defect of cosmetic but not functional significance, the authors do not propose a course of management of waiting for the patient to be mature enough to express an opinion as to whether he wants surgical correction or not, which might be a suitable plan in some cases. We consider this to be an illustration of the wider question as to why male circumcision should be construed as a matter of personal (parental) choice as opposed a choice to be made by the individual affected when he is of sufficient age and maturity to make the choice for himself. We urge you to bear this in mind when you go on to consider religious circumcision. Dr J Warren Chairman <a href="http://www.norm-uk.org/" rel="noopener" target="_blank">Norm UK</a> <h3>ADDENDUM C: Comments from a Muslim male religious circumcision practitioner</h3> In my capacity as a General Practitioner who also serves my community with such a service, my comments will only concern "non-therapeutic ritual/religious" circumcision. I would like to make mention, again, that I do NOT ascribe to the view that a child should be circumcised simply to "look like his dad" -- the main reason for circumcision in the United States and elsewhere! I think this is a deplorable state of affairs! I have had to turn many parents away who come to me to have it done "because his dad is circumcised"! Circumcision been an irreversible procedure with attendant surgical/anaesthetic risks. Specifically I would like to raise certain pertinent points under the headings Non Therapeutic "Ritual" circumcision and Standards of Care of the associations draft statement. "The operator should have a full understanding of the risks and complications of the procedure and their management." I assume this means the operator must be aware of the different management decision making processes when he/she encounters complications, as opposed to actually been able, skilled, and qualified to deal/handle any complications that may arise. Whereas some us may at the very least be "trained to" o perform circumcisions, most us are necessarily not trained to handle the more than simple, albeit uncommon, complications of circumcisions e.g., significant bleeder, significant infection, concealed penis, denuded penis, meatal stenosis, revision of circumcisions, urethrocutaneous fistula, etc. There was a G.M.C. case recently where it was felt that it was inappropropriate and beyond the professionalism of the G.P. to manage a post-operative bleeder. The child should have been referred to hospital instead. This is in keeping with the very useful and almost pragmatic B.A.P.S guidelines and G.M.C guidelines on offering "appropriate after care" A lot of us who seek support or training have been either turned down (no PCT funding etc) or have had very "unsupportive" letters back. There is a lot of noise about protecting children and the welfare of children being paramount, but in reality, training/support is never forthcoming for those G.P.s who want to offer a circumcision service for the children amongst the 3,000,000 Muslims who live in the UK. Even if help is offered, the conditions under which one will be trained would be that of a motionless, unconscious child with a low blood pressure: i.e. general anaesthetic. One should not underestimate the singular advantage this gives the operator. Community practitioners are faced with the singular hurdle of operating on a person with local anaesthesia with all its limitations, including a moving, slippery target. A lot of Paediatric surgeons/urologists have stated how difficult it is to operate on a moving target, and that they view with disbelief and awe how we manage to perform circumcision under L.A. (personal e-mail communications with >10 paediatric surgeons, including a professor of paediatric surgery). It would therefore not be unreasonable to form an opinion that community practitioners would legitimately have intra-/post operative outcomes not as favorable as those performed in hospitals. Who then decides what an acceptable outcome in the community setting is? Throw in certain confounding variables: assent NOT consent, unlicensed usage of local anaethesia, operators not been surgeons NOR trained properly, a contentious surgical technique, suboptimal anaesthetic conditions e.g. the child been awake! In medical malpractice litigation the standard of care is that degree of care which a reasonably prudent person in similar circumstances would be expected to exercise [1-2]. In view of the recent statement on Medical Expert Witness from the Academy of Medical Royal Colleges, it would be very difficult for a hospital paediatric surgeon to claim to pronounce on a case carried out by a community practitioner [3]. There being a difference between, reasonable, acceptable practice and the Gold standard, as explained by Bolam and Bolitho. In terms of drawing up guidelines around religious circumcision it is unclear what benefit can be derived from such publications when such a position does not reflect the diversity of opinion and practice in the profession itself [4]. "The operation should be undertaken in an environment capable of fulfilling guidelines for surgical procedures in children". At a single stroke you will stop all qualified Jewish doctors, who are also Mohels, from performing home ceremonial religious circumcision on babies! It has been shown time and again that Jewish religious neonatal male circumcision can be carried out under aseptic technique, with minimal morbidity and mortality and primary healing [5-7]. The singular advantage of neonatal circumcision is the reduced infective and technical burden. I am somewhat embarrassed to say the Muslim community, as far as I am aware, has no such internal system of training and accreditation and hence benchmarking. There is ample work done to show that paediatric circumcision is a safe office procedure and not requiring an "environment capable of fulfilling guidelines for surgical procedure in children" This is neither necessary nor cost-effective.The bare minimum appears to be it must take place under hygienic conditions [8-17]. There is not much good research published to determine complications rates, especially when those done in the community are not often reported - BMJ Best Treatment. A commonly quoted range is 2-10% [18]. Looking at the international experience, complications rates are indeed quite high [19] . But a casual review indicates that the operators are mainly non medics with no ideas of surgical technique or infection control The procedure itself is relatively straightforward [20]: when this is done in hospital and so under general anaesthetic .To help prevent complications four principal factors have to be adhered to attention to aseptic conditions, adequate but not excessive excision of inner and outer preputial layers, meticulous haemostasis, and protection of glans and urethra [21]. References 1. Brian Hurwitz. How does evidence based guidelines influence determinations of medical negligence? BMJ 2004;329:1024-1028 2. American Academy of Pediatrics, Policy Statement, Committee on Medical Liability: Guidelines for Expert Witness Testimony in Medical Malpractice Litigation Pediatrics 2002;109:974-979 3. Medical Expert Witnesses, Guidance from the Academy of Medical Royal Colleges, July 2005. 4. R Mussell, Ethics department B.M.A. The development of professional guidelines on the law and ethics of male circumcision. Journal of Medical Ethics, 2004; 30:254-25. 5. Dr J Spitzer, The Surgery of Bris Milah. Published under the auspices of The Initation Society, London .1996 6. Ben-Chaim-Jacob et al. The Israel Medical Association Journal, June 2005;7:368-70 7. Samuel Menahem. Complications arising from ritual circumcision: pathogenesis and possible prevention. Israel Journal of Medical Science, January 1981;17:45-48 8. General Medical Council, Guidance for Doctors asked to circumcise male children: (procedure must take place in ?hygienic? conditions), September 1997. 9. Heart of Birmingham N.H.S religious circumcision service protocols, 2005. 10. Iftikhar Ahmad, Circumcision in babies and children with the Plastibell technique: an easy procedure with minimal complications. Pakistan Journal of Medical Sciences, 2004;20:175-180 11. John Krieger et al. Adult male circumcision: results of a standardized procedure in Kisumu District, Kenya. Reconstructive Urology, BJU international, 2005;96:1109-1113 12. Jayanthi et al. Post-neonatal circumcision with local anaesthesia: a cost effective alternative: NHS Economic and Evaluation Database, The centre for Reviews and Dissemination, University of York. Journal of Urology, 1999:161: 1301-1303 13. Schmitz RF et al. Good results from circumcisions of Muslim boys performed outside the hospital. Ned Tijdschr Geneeskd. 1999; 143: 627-30. 14. Metcalf et al, Circumcision: a study of Current Practices. Clinical Pediatrics, August 1983; 22:575-579 15. Smith C et al. Office pediatric urologic procedures from a parental perspective. Feb 2000. Urology: 2:272-6 16. Clair DLet al. Pediatric office procedures. Urol Clin North Am, Nov 1988:15, 715-23 17. Personal reply from the Department of Health to an e-mail, 7 June 2006. 18. Williams and Kapila. Complications of circumcision. British Journal of Surgery, 1993;80:1231-1236 19. Ozdemir. Significantly increased complications risks with mass circumcisions. British Journal of Urology, July 1997;80;136-139 20. R Wheeler. Legal challenges in Paediatric Surgery. New law Journal ,November 2001 21. Gerharz et al. Medicolegal aspects of male circumcision. British Journal of Urology, International. August 2000:86.3 Dr Noor Ahmad June 2006 <h3>Addendum D: Response from the Association of Reform & Liberal Mohelim</h3> The ARLM is a group of doctors who perform religious, ritual and non-therapeutic circumcisions, mostly for the Jewish Reform & Liberal communities, but extending to other communities (non-Jewish) as well. We start from the premise that circumcision is required by our religion, is not illegal in this country, and therefore must be allowed. However, our particular association dictates that we must all be doctors, all trained to an appropriate level, and we all agree to abide by certain standards of performance and conduct in relation to circumcision. All of the standards we agree to are encompassed in the GMC guidelines, and in particular we agree that the interest of the child are paramount, safe medical practice must be observed, and religious requirements must never override medical requirement when the safety of the child is at risk. We believe that circumcision in the home is a safe procedure (having taken appropriate steps to ensure sterility of instruments etc) and analgesia is necessary, though can be provided by a variety of conventional medical approaches. Pre-op assessment, consent, method of circumcision, post-op care and note keeping must follow standard medical guidelines. We disagree with the complication rates quoted in the position paper: home circumcision in the neonatal period does not produce the level of complications quoted, and we have yearly internal audits which can demonstrate this. The complication rate is only at the level quoted when older children, hospital circumcisions, medical (therapeutic) circumcisions and adult circumcisions are all mixed in the figures. We therefore believe that circumcisions in the community can and should be a safe procedure, although would agree that standards (such as those drawn up by our association) should apply to all doctors performing circumcisions in the community. Those standards are more akin to minor surgery in General Practice that the standards that apply to hospital surgical procedures. Nigel Zoltie, MB, ChB, FRCS, FCEM Chairman, ARLM <h2> <a id="working" name="working"></a>Working Party Members</h2> Mr Prasad Godbole, Consultant Paediatric Urologist, Sheffield, Chairperson Mr Patrick Duffy, Consultant Paediatric Urologist, London Miss Su-Anna Boddy, Consultant Paediatric Urologist, London Mr Ewen MacKinnon, Consultant Paediatric Urologist, Sheffield Mr Alan Bailie, Consultant Paediatric Urologist, Belfast Mr Rob Wheeler, Consultant Paediatric Surgeon, Southampton Dr Mark Thomas, Consultant Paediatric Anaesthetist, London Miss Kalpana Patil, Consultant Paediatric Urologist, London Addresses for correspondence Miss Su-Anna Boddy Mr Prasad Godbole <a class="__cf_email__" data-cfemail="0f6760617c6a6c4f6d6e7f7c21607d68217a64" href="/cdn-cgi/l/email-protection">[email protected]</a> St George's Hospital Dept of Paediatric Surgery LONDON Sheffield Children's Hospital SHEFFIELD This statement refers to management of foreskin conditions and circumcision in male children. Female circumcision is prohibited by law: LASSL (2004)4: Female Genital Mutilation Act 2003, DoH, published 27.2.2004 Statement from the Royal College of Paediatricians and Child Health: This document addresses an important clinical area for which there are no existing guidelines or practise statements. Whilst this statement is not evidence based on a consensus, it provides information of relevance to paediatricians SOURCE: The full statement can be <a href="http://baps.org.uk/page14/page14.html">downloaded from the BAPS website</a> as a PDF. </div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource British Association of Paediatric Urologists: foreskin care and management darby Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Robert Darby Subject The topic of the resource Circumcision history Description An account of the resource Archive of the work published by Robert Darby Creator An entity primarily responsible for making the resource Robert Darby Source A related resource from which the described resource is derived circinfo.org historyofcircumcsion.org Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Text Any textual data included in the document <div class="intro" id="intro"> In a landmark judgement, the High Court of England and Wales has ruled that children should not be circumcised until they are old enough to decide for themselves. The case arose when the Muslim father of the boy wanted him to be circumcised in accordance with his own religious beliefs, but the English mother disagreed. Top female Family Division judge Mrs Justice Roberts agreed with their mother’s wish to leave it for the boys, aged six and four, to make up their own minds when they are older whether they wish to have it done. The father, 36, was born in Algeria but is now separated from the 34-year-old mother. The couple met in 2006, lived together in a North London flat, and went through an Islamic ceremony of marriage in 2009 before the boys were born. In July 2012 the mother fled the flat with the boys following violent attacks on her by the father. The judge said the father came to England in 2001 on false documents, but had now been given British passport. In reaching her decision, Justice Roberts said: "First and foremost, this is a once and for all, irreversible procedure. There is no guarantee that these boys will wish to continue to observe the Muslim faith with the devotion demonstrated by their father although that may very well be their choice. They are still very young and there is no way of anticipating at this stage how the different influences in their respective parental homes will shape and guide their development over the coming years. There are risks, albeit small, associated with the surgery regardless of the expertise with which the operation is performed. There must be clear benefits which outweigh these risks which point towards circumcision at this point in time being in their best interests before I can sanction it as an appropriate course at this stage of their young lives." She added: "Taking all these matters into account, my conclusion is that it would be better for the children that the court make no order at this stage in relation to circumcision. I am simply deferring that decision to the point where each of the boys themselves will make their individual choices” Circumcision choice should be left until children are old enough to decide for themselves. <a href="http://www.telegraph.co.uk/news/2016/04/19/circumcision-choice-should-be-left-until-children-are-old-enough/" rel="noopener" target="_blank">The Telegraph, 19 April 2016</a> Jonathan Wells, Should religious circumcision be banned? <a href="http://www.telegraph.co.uk/men/health/should-religious-circumcision-be-banned/" rel="noopener" target="_blank">The Telegraph, 19 April 2016</a> <a href="http://www.bailii.org/ew/cases/EWHC/Fam/2016/849.html" rel="noopener" target="_blank">Read the full judgement</a> <h2>Analysis: Decision in circumcision case has wide implications for children's rights</h2> The decision of Justice Roberts in the case of L & B in the High Court of England and Wales has important implications for child rights and protection of children against genital surgeries desired by their parents or other adults. In a landmark judgement, the court ruled that children should not be circumcised until they are old enough to decide for themselves. The case arose when the Muslim father of the boy wanted him to be circumcised in accordance with his own religious beliefs, but the English mother disagreed. Top female Family Division judge Mrs Justice Roberts agreed with their mother’s wish to leave it for the boys, aged six and four, to make up their own minds when they are older whether they wish to have it done. The father, 36, was born in Algeria but is now separated from the 34-year-old mother. The couple met in 2006, lived together in a North London flat, and went through an Islamic ceremony of marriage in 2009 before the boys were born. In July 2012 the mother fled the flat with the boys following violent attacks on her by the father. The judge said the father came to England in 2001 on false documents, but had now been given British passport. The importance of the court’s judgement is that it confirms and extends earlier rulings that where parents disagree about whether a child should be circumcised, he or she should not be circumcised, but protected until he or she is old enough to make an informed decision. It further implies that for circumcision of a child t be lawful, both parents must give consent. This confirms the earlier ruling in the case of Re J that where the parents disagree, the best interests and possible future wishes of the child will need to be considered, which will normally dictate that the child should be free to decide for itself when older). The case represents a perceptible change towards giving priority to the child’s rights and possible future wishes, thus abandoning the old legal view of children as little more than objects in the possession of their parents. More obviously than in the <a href="http://www.cirp.org/library/legal/UKlaw/" rel="noopener" target="_blank">case of Re J</a>, the Court was receptive to the real risk of harm resulting from circumcision, largely owing to the evidence presented by the mother’s counsel, who was well versed in the recent medical literature. While noting them, Justice Roberts did not give priority to the prophylactic health benefit arguments, but rather correctly evaluated the risks and harms involved as the key factor. The vital thing is that the court accepted the primacy of the children’s right to make their own decisions about their lives. A key statement from the central argument of the judge (para 142-3): “First and foremost, [circumcision] is a once and for all, irreversible procedure. There is no guarantee that these boys will wish to continue to observe the Muslim faith ... although that may very well be their choice. They are still very young and there is no way of anticipating at this stage how the different influences in their respective parental homes will shape and guide their development over the coming years. ... I am ... deferring that decision to the point where each of the boys themselves will make their individual choices once they have the maturity and insight to appreciate the consequences and longer term effects of the decisions which they reach.” These comments are essentially consistent with the principle of the <a href="https://www.circinfo.org/ethics.html#OpenFuture">child’s right to an open future</a>. Justice Roberts also referred to <a href="https://www.circinfo.org/Brit_judge_on_FGM_and_circumcision.html" rel="noopener" target="_blank">Lord Justice Munby’s comment</a> from the Re B & G case last year: that when considering the legal questions around non-therapeutic circumcision, particularly the question of “significant harm” and comparisons with FGM, is to wade into “deep waters” - a suggestion that there is some wider concern about the tenability of this area of the law. Perhaps the most useful element of the case will turn out to be the factual findings. After hearing at length from an expert of Islamic Studies, the judge was quite satisfied that nothing in Islam requires Muslim parents to circumcise their boys or that a boy’s circumcision is obligatory at any particular age. On the contrary, she found that that even if not uncircumcised they will still be able to participate fully in their father’s Muslim culture. Given that most circumcision cases now involve Islam more than any other faiths, this finding is an important one on which subsequent cases will probably rely. </div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource British court: Circumcision choice should be left until children old enough to decide for themselves darby Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Robert Darby Subject The topic of the resource Circumcision history Description An account of the resource Archive of the work published by Robert Darby Creator An entity primarily responsible for making the resource Robert Darby Source A related resource from which the described resource is derived circinfo.org historyofcircumcsion.org Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Text Any textual data included in the document <div class="intro" id="intro"> In a landmark judgement, the High Court of England and Wales has ruled that children should not be circumcised until they are old enough to decide for themselves. The case arose when the Muslim father of the boy wanted him to be circumcised in accordance with his own religious beliefs, but the English mother disagreed. Top female Family Division judge Mrs Justice Roberts agreed with their mother’s wish to leave it for the boys, aged six and four, to make up their own minds when they are older whether they wish to have it done. The father, 36, was born in Algeria but is now separated from the 34-year-old mother. The couple met in 2006, lived together in a North London flat, and went through an Islamic ceremony of marriage in 2009 before the boys were born. In July 2012 the mother fled the flat with the boys following violent attacks on her by the father. The judge said the father came to England in 2001 on false documents, but had now been given British passport. In reaching her decision, Justice Roberts said: "First and foremost, this is a once and for all, irreversible procedure. There is no guarantee that these boys will wish to continue to observe the Muslim faith with the devotion demonstrated by their father although that may very well be their choice. They are still very young and there is no way of anticipating at this stage how the different influences in their respective parental homes will shape and guide their development over the coming years. There are risks, albeit small, associated with the surgery regardless of the expertise with which the operation is performed. There must be clear benefits which outweigh these risks which point towards circumcision at this point in time being in their best interests before I can sanction it as an appropriate course at this stage of their young lives." She added: "Taking all these matters into account, my conclusion is that it would be better for the children that the court make no order at this stage in relation to circumcision. I am simply deferring that decision to the point where each of the boys themselves will make their individual choices” Circumcision choice should be left until children are old enough to decide for themselves. <a href="http://www.telegraph.co.uk/news/2016/04/19/circumcision-choice-should-be-left-until-children-are-old-enough/" rel="noopener" target="_blank">The Telegraph, 19 April 2016</a> Jonathan Wells, Should religious circumcision be banned? <a href="http://www.telegraph.co.uk/men/health/should-religious-circumcision-be-banned/" rel="noopener" target="_blank">The Telegraph, 19 April 2016</a> <a href="http://www.bailii.org/ew/cases/EWHC/Fam/2016/849.html" rel="noopener" target="_blank">Read the full judgement</a> <h2>Analysis: Decision in circumcision case has wide implications for children's rights</h2> The decision of Justice Roberts in the case of L & B in the High Court of England and Wales has important implications for child rights and protection of children against genital surgeries desired by their parents or other adults. In a landmark judgement, the court ruled that children should not be circumcised until they are old enough to decide for themselves. The case arose when the Muslim father of the boy wanted him to be circumcised in accordance with his own religious beliefs, but the English mother disagreed. Top female Family Division judge Mrs Justice Roberts agreed with their mother’s wish to leave it for the boys, aged six and four, to make up their own minds when they are older whether they wish to have it done. The father, 36, was born in Algeria but is now separated from the 34-year-old mother. The couple met in 2006, lived together in a North London flat, and went through an Islamic ceremony of marriage in 2009 before the boys were born. In July 2012 the mother fled the flat with the boys following violent attacks on her by the father. The judge said the father came to England in 2001 on false documents, but had now been given British passport. The importance of the court’s judgement is that it confirms and extends earlier rulings that where parents disagree about whether a child should be circumcised, he or she should not be circumcised, but protected until he or she is old enough to make an informed decision. It further implies that for circumcision of a child t be lawful, both parents must give consent. This confirms the earlier ruling in the case of Re J that where the parents disagree, the best interests and possible future wishes of the child will need to be considered, which will normally dictate that the child should be free to decide for itself when older). The case represents a perceptible change towards giving priority to the child’s rights and possible future wishes, thus abandoning the old legal view of children as little more than objects in the possession of their parents. More obviously than in the <a href="http://www.cirp.org/library/legal/UKlaw/" rel="noopener" target="_blank">case of Re J</a>, the Court was receptive to the real risk of harm resulting from circumcision, largely owing to the evidence presented by the mother’s counsel, who was well versed in the recent medical literature. While noting them, Justice Roberts did not give priority to the prophylactic health benefit arguments, but rather correctly evaluated the risks and harms involved as the key factor. The vital thing is that the court accepted the primacy of the children’s right to make their own decisions about their lives. A key statement from the central argument of the judge (para 142-3): “First and foremost, [circumcision] is a once and for all, irreversible procedure. There is no guarantee that these boys will wish to continue to observe the Muslim faith ... although that may very well be their choice. They are still very young and there is no way of anticipating at this stage how the different influences in their respective parental homes will shape and guide their development over the coming years. ... I am ... deferring that decision to the point where each of the boys themselves will make their individual choices once they have the maturity and insight to appreciate the consequences and longer term effects of the decisions which they reach.” These comments are essentially consistent with the principle of the <a href="https://www.circinfo.org/ethics.html#OpenFuture">child’s right to an open future</a>. Justice Roberts also referred to <a href="https://www.circinfo.org/Brit_judge_on_FGM_and_circumcision.html" rel="noopener" target="_blank">Lord Justice Munby’s comment</a> from the Re B & G case last year: that when considering the legal questions around non-therapeutic circumcision, particularly the question of “significant harm” and comparisons with FGM, is to wade into “deep waters” - a suggestion that there is some wider concern about the tenability of this area of the law. Perhaps the most useful element of the case will turn out to be the factual findings. After hearing at length from an expert of Islamic Studies, the judge was quite satisfied that nothing in Islam requires Muslim parents to circumcise their boys or that a boy’s circumcision is obligatory at any particular age. On the contrary, she found that that even if not uncircumcised they will still be able to participate fully in their father’s Muslim culture. Given that most circumcision cases now involve Islam more than any other faiths, this finding is an important one on which subsequent cases will probably rely. </div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource British court: Circumcision choice should be left until children old enough to decide for themselves darby Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Robert Darby Subject The topic of the resource Circumcision history Description An account of the resource Archive of the work published by Robert Darby Creator An entity primarily responsible for making the resource Robert Darby Source A related resource from which the described resource is derived circinfo.org historyofcircumcsion.org Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Text Any textual data included in the document <div class="intro" id="intro"> <h1>Male circumcision can be worse than female genital mutilation</h1> Circumcision of boys is “significant harm” and more damaging than mild forms of female genital mutilation (FGM). This is the considered opinion of Sir James Munby, President of the British Family Court, expressed during his judgement on a case involving a girl from a Muslim family suspected of having undergone FGM. If she had been subjected to FGM, the law provides that she should be placed under care and the parents charged with a criminal offence. But since the girl had a brother who had been or was likely to be circumcised in accordance with Muslim tradition, the judge observed that the case inevitably brought up the question of male circumcision and its very different status in British law. He noted that “circumcision involved the removal of a significant amount of tissue, created an obvious alteration to the appearance of the genitals, and leaves a more or less prominent scar around the circumference of the penis.” Accordingly, it can readily be seen that while severe forms of FGM are more invasive than male circumcision, mild forms (such as Type IV in the <a href="http://www.who.int/mediacentre/factsheets/fs241/en/" rel="noopener" target="_blank">WHO classification</a>), “are on any view, much less invasive than male circumcision.” Sir James further observed that any form of FGM, no matter how mild, constituted “significant harm” – this being the threshold condition for placing a child in care under the Childrens Act 1989 – and asked what this meant for male circumcision: Mr Hayes points to the recognition, both by Wall J, as he then was, and by the <a href="http://www.cirp.org/library/legal/Re_J/" rel="noopener" target="_blank">Court of Appeal in Re J</a> (Specific Issue Orders: Muslim Upbringing and Circumcision) [1999] … that male circumcision does involve harm, or the risk of harm. Given the comparison between what is involved in male circumcision and FGM WHO Type IV, to dispute that the more invasive procedure involves the significant harm involved in the less invasive procedure would seem almost irrational. In my judgment, if FGM Type IV amounts to significant harm, as in my judgment it does, then the same must be so of male circumcision [Para 69]. The judge went on to observe that the only differences between FGM and male circumcision are that the latter is sanctioned by some religions and traditional cultures, while the former is merely a cultural tradition; and that certain health benefits are (controversially) claimed for circumcision, but not for FGM. Despite these points of similarity, the status of male circumcision and FGM in British law are strikingly different: the former tolerated and unrestricted, the latter legally prohibited under pain of severe penalties. The result is a paradoxical situation: In the present case the point [i.e. the paradox] arises in striking form. The family, as I have said are Muslims. I assume, therefore, that B [the boy] either has been or will in due course be circumcised. Yet, entirely understandably, and, if I may say so, entirely appropriately, this is not a matter that has been raised before me. There is no suggestion, nor could there be, that B’s circumcision can or should give rise to care proceedings. So, given the nature of the local authority’s case on this point, we are in this curious situation. G’s [the girl’s] FGM Type IV (had it been proved) would have been relied upon by the local authority, prior to its change of stance referred to above, as justifying the adoption of both children, even though on any objective view it might be thought that G would have subjected to a process much less invasive, no more traumatic (if, indeed, as traumatic) and with no greater long-term consequences, whether physical, emotional or psychological, than the process to which B has been or will be subjected [Para 63]. There is thus a crying anomaly in both law and custom. Although it constitutes significant harm and is more damaging than mild forms of FGM, non-therapeutic circumcision (NTC) of (non-consenting) male minors is both legally permitted and widely regarded as a legitimate aspect of “reasonable parenting”. Although the judge’s comments on circumcision in this case are strictly speaking obiter dicta (i.e. not directly related to the point being decided), they are of great importance as yet another recognition that non-therapeutic circumcision does involve significant harm, and are possibly the first such formal recognition in an Anglophone court. Sir James’ comments echo and reinforce the judgement of the <a href="https://www.circinfo.org/Circumcision_and_law.html">Cologne appeal court</a> in 2012 that NTC of minors was harmful and violated and violated the child’s right to both physical integrity and freedom of religion. It also supports the conclusion of the <a href="https://www.circinfo.org/Tasmania_law_reform.html">Tasmania Law Reform Institute</a> that NTC was sufficiently harmful (both physically and ethically) to warrant strict regulation and partial prohibition. The judge’s conclusion – – "that although both involve significant harm, there is a very clear distinction in family law between FGM and male circumcision. FGM in any form will suffice to establish ‘threshold’ in accordance with section 31 of the Children Act 1989; male circumcision without more will not" – – sends a very clear message to legislators that such a glaring inconsistency in the law cannot be tolerated indefinitely. Source (legal citation): Sir James Munby, President of the Family Division. <a href="http://www.judiciary.gov.uk/wp-content/uploads/2015/01/BandG_2_.pdf">In the matter of B & G (children)</a>. Case LJ13C00295, 14 January 2015. <h2>Further reading on male and female circumcision</h2> Robert Darby and J. Steven Svoboda. <a href="https://www.academia.edu/7104790/A_rose_by_any_other_name_Symmetry_and_asymmetry_in_male_and_female_genital_cutting" rel="noopener" target="_blank">A Rose by Any Other Name: Symmetry and Asymmetry in Male and Female Genital Cutting</a> Brian Earp. <a href="http://blog.practicalethics.ox.ac.uk/2014/02/female-genital-mutilation-and-male-circumcision-time-to-confront-the-double-standard/" rel="noopener" target="_blank">Female genital mutilation (FGM) and male circumcision: should there be a separate ethical discourse?</a> Brian Earp. <a href="http://aeon.co/magazine/philosophy/male-and-female-circumcision-are-equally-wrong/" rel="noopener" target="_blank">Is there any moral difference between male and female circumcision?</a> Aeon magazine, January 2015. Brian Earp. <a href="https://www.academia.edu/10197867/Between_moral_relativism_and_moral_hypocrisy_The_case_of_FGM">Between moral relativism and moral hypocrisy: The case of FGM</a> <a href="http://www.cirp.org/library/legal/" rel="noopener" target="_blank">Circumcision legal issues at CIRP</a> <h2>Male circumcision can be worse than female genital mutilation</h2> <h3>Report in British magazine, insideMan</h3> One of the country’s most senior judges has courted controversy by declaring that male circumcision can be more harmful than female genital mutilation (FGM). Sir James Munby acknowledged he was entering “deep waters” by highlighting inconsistencies in the law, but said it would be “irrational” to dispute the fact that male circumcision can be more harmful than some forms of FGM. The High Court judge made the comments as he passed judgment in care proceedings brought by a local authority seeking to take a brother and sister, from a Muslim family, into care on the grounds that the girl was a victim of Type IV FGM. While the case failed on the grounds that damage to the girl’s genitals was probably caused by a condition called vulvovaginitis, Munby, who is president of the family division, felt compelled to highlight the sexist double standard that the case brought to light. In summing up the judge noted that while subjecting a girl to Type IV FGM could result in that child being taken into care, male circumcision would not lead to a boy being removed from his family, even though the procedure is more harmful than at least some forms of Type IV FGM. An inconvenient truth Campaigners against male circumcision have long been hampered by the myth that subjecting girls to FGM is different and always worse than circumcising boys. The uncomfortable truth, to which Munby has now given judicial credibility, is that male circumcision is different and sometimes worse than FGM. This is particularly true of Type IV FGM which incorporates practices such as pricking, piercing and nicking the genitals, which are less harmful and invasive than removing the foreskin in it’s entirety. Male circumcision in the UK is often performed without anaesthetic, in non-medical conditions and can cause complications such as life threatening haemorrhage, shock, sepsis an in extreme cases death. In 2012 a Freedom of Information request revealed that two boys a week are admitted to the emergency department of Birmingham children’s hospital as a result of male circumcision. Society more tolerant of male circumcision However, despite Munby’s assessment that ”on any objective view” male circumcisions is sometimes worse than FGM, he also made clear that current judicial thinking is that there is no equivalence between the two practices. “In 2015 ,” he said in his judgment, “the law generally, and family law in particular, is still prepared to tolerate non-therapeutic male circumcision performed for religious or even for purely cultural or conventional reasons, while no longer being willing to tolerate FGM in any of its forms. “Given the comparison between what is involved in male circumcision and FGM WHO Type IV, to dispute that the more invasive procedure involves the significant harm involved in the less invasive procedure would seem almost irrational. In my judgment, if FGM Type IV amounts to significant harm, as in my judgment it does, then the same must be so of male circumcision.” The phrase “significant harm” is important as this is the first threshold that must be crossed before a child can be taken into care under section 31 of the Children’s Act 1989. There is another criteria which must also be considered in care proceedings and this is whether the care given to a child is “what would be reasonable to expect a parent to give”. Why the law is different According to Munby, while it can never be reasonable parenting to inflict any form of FGM on a child, the position is quite different with male circumcision. Munby argued that there are at least two important distinctions between the two practices. Firstly, that FGM has no basis in any religion, while male circumcision is often performed for religious reasons. Secondly, that while FGM is said to have no medical justification and confers no health benefits; male circumcision is seen by some people as providing hygienic or prophylactic benefits, although opinions are divided. Even taking the conflicting medical evidence on any perceived benefits into account, Munby concluded that “reasonable” parenting should be seen to permit male circumcision. And that is where UK law stands on the matter today. The Head of the Family Division of the Family Court has judged that while male circumcision is sometimes worse than FGM, it is deemed to be reasonable for parents of all backgrounds to circumcise their sons, while carrying out a less invasive and less harmful from of Type IV FGM on their daughters is not considered reasonable parental behaviour. A welcome coup for campaigners Having a senior judge acknowledge that FGM can be less harmful than male circumcision is a welcome coup for those of us who advocate for the right of every human being to enter adulthood with intact genitals, except in rare cases where therapeutic surgery is unequivocally unavoidable. The fact that our society, led by politicians and the judiciary, is still prepared to tolerate greater harm happening to boys than to girls, reveals a great deal about the sexist double standards we apply to the issues that affect men and boys in 2015. The fact that we are collectively more tolerant of the harm that happens to men and boys, than the harm that happens to women and girls, doesn’t begin and end at genital mutilation. Our shared cultural beliefs that “boys don’t cry”; that men should “man up”; that women have problems and men are problems; that females are the weaker sex and that we should always put the protection of women and girls first; is reflected in our inability to tackle a whole range of social issues that, predominantly impact men and boys, head on. Why this is a men’s issue These include male suicide; male homelessness; the high rate of male workplace deaths; men’s lower life expectancy; the expulsion of boys from school; the exclusion and marginalisation of separated fathers from their children’s lives; the way we respond to male victims of violence and the harsher treatment and sentencing of men and boys in the criminal justice system. What Sir James Munby has uncovered is an inconvenient and important truth about men, manhood and masculinity in 2015 which is simply this—while the harm that happens to men and boys in our society is different and sometimes worse than the harm that happens to women and girls, we still view any harm that women and girls experience more seriously. Munby is part of the problem he has raised, for while he acknowledges that male circumcision can be more harmful than FGM, he has essentially declared that while it’s reasonable for parents to harm their sons, it is never reasonable to harm their daughters. Glen Poole, <a href="http://www.inside-man.co.uk/2015/01/15/male-circumcision-can-be-worse-than-fgm-rules-senior-judge/" rel="noopener" target="_blank">Male circumcision can be worse than FGM, rules senior Judge</a>. insideMan (UK), 15 January 2015. Glen Poole author of the book, <a href="http://equality4men.com/book/" rel="noopener" target="_blank">Equality For Men</a>. <h3>Further discussion</h3> Brian Earp, On the supposed distinction between culture and religion: A brief comment on Sir James Munby’s decision in the matter of B and G (children). <a href="http://blog.practicalethics.ox.ac.uk/2015/02/on-the-supposed-distinction-between-culture-and-religion-a-comment-on-sir-james-munbys-decision-in-the-matter-of-b-and-g-children/" rel="noopener" target="_blank">Oxford Practical Ethics Blog, 8 February 2015</a>. </div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource British judge calls circumcision “significant harm” darby Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Robert Darby Subject The topic of the resource Circumcision history Description An account of the resource Archive of the work published by Robert Darby Creator An entity primarily responsible for making the resource Robert Darby Source A related resource from which the described resource is derived circinfo.org historyofcircumcsion.org Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Text Any textual data included in the document <div class="intro" id="intro"> <h1>Male circumcision can be worse than female genital mutilation</h1> Circumcision of boys is “significant harm” and more damaging than mild forms of female genital mutilation (FGM). This is the considered opinion of Sir James Munby, President of the British Family Court, expressed during his judgement on a case involving a girl from a Muslim family suspected of having undergone FGM. If she had been subjected to FGM, the law provides that she should be placed under care and the parents charged with a criminal offence. But since the girl had a brother who had been or was likely to be circumcised in accordance with Muslim tradition, the judge observed that the case inevitably brought up the question of male circumcision and its very different status in British law. He noted that “circumcision involved the removal of a significant amount of tissue, created an obvious alteration to the appearance of the genitals, and leaves a more or less prominent scar around the circumference of the penis.” Accordingly, it can readily be seen that while severe forms of FGM are more invasive than male circumcision, mild forms (such as Type IV in the <a href="http://www.who.int/mediacentre/factsheets/fs241/en/" rel="noopener" target="_blank">WHO classification</a>), “are on any view, much less invasive than male circumcision.” Sir James further observed that any form of FGM, no matter how mild, constituted “significant harm” – this being the threshold condition for placing a child in care under the Childrens Act 1989 – and asked what this meant for male circumcision: Mr Hayes points to the recognition, both by Wall J, as he then was, and by the <a href="http://www.cirp.org/library/legal/Re_J/" rel="noopener" target="_blank">Court of Appeal in Re J</a> (Specific Issue Orders: Muslim Upbringing and Circumcision) [1999] … that male circumcision does involve harm, or the risk of harm. Given the comparison between what is involved in male circumcision and FGM WHO Type IV, to dispute that the more invasive procedure involves the significant harm involved in the less invasive procedure would seem almost irrational. In my judgment, if FGM Type IV amounts to significant harm, as in my judgment it does, then the same must be so of male circumcision [Para 69]. The judge went on to observe that the only differences between FGM and male circumcision are that the latter is sanctioned by some religions and traditional cultures, while the former is merely a cultural tradition; and that certain health benefits are (controversially) claimed for circumcision, but not for FGM. Despite these points of similarity, the status of male circumcision and FGM in British law are strikingly different: the former tolerated and unrestricted, the latter legally prohibited under pain of severe penalties. The result is a paradoxical situation: In the present case the point [i.e. the paradox] arises in striking form. The family, as I have said are Muslims. I assume, therefore, that B [the boy] either has been or will in due course be circumcised. Yet, entirely understandably, and, if I may say so, entirely appropriately, this is not a matter that has been raised before me. There is no suggestion, nor could there be, that B’s circumcision can or should give rise to care proceedings. So, given the nature of the local authority’s case on this point, we are in this curious situation. G’s [the girl’s] FGM Type IV (had it been proved) would have been relied upon by the local authority, prior to its change of stance referred to above, as justifying the adoption of both children, even though on any objective view it might be thought that G would have subjected to a process much less invasive, no more traumatic (if, indeed, as traumatic) and with no greater long-term consequences, whether physical, emotional or psychological, than the process to which B has been or will be subjected [Para 63]. There is thus a crying anomaly in both law and custom. Although it constitutes significant harm and is more damaging than mild forms of FGM, non-therapeutic circumcision (NTC) of (non-consenting) male minors is both legally permitted and widely regarded as a legitimate aspect of “reasonable parenting”. Although the judge’s comments on circumcision in this case are strictly speaking obiter dicta (i.e. not directly related to the point being decided), they are of great importance as yet another recognition that non-therapeutic circumcision does involve significant harm, and are possibly the first such formal recognition in an Anglophone court. Sir James’ comments echo and reinforce the judgement of the <a href="https://www.circinfo.org/Circumcision_and_law.html">Cologne appeal court</a> in 2012 that NTC of minors was harmful and violated and violated the child’s right to both physical integrity and freedom of religion. It also supports the conclusion of the <a href="https://www.circinfo.org/Tasmania_law_reform.html">Tasmania Law Reform Institute</a> that NTC was sufficiently harmful (both physically and ethically) to warrant strict regulation and partial prohibition. The judge’s conclusion – – "that although both involve significant harm, there is a very clear distinction in family law between FGM and male circumcision. FGM in any form will suffice to establish ‘threshold’ in accordance with section 31 of the Children Act 1989; male circumcision without more will not" – – sends a very clear message to legislators that such a glaring inconsistency in the law cannot be tolerated indefinitely. Source (legal citation): Sir James Munby, President of the Family Division. <a href="http://www.judiciary.gov.uk/wp-content/uploads/2015/01/BandG_2_.pdf">In the matter of B & G (children)</a>. Case LJ13C00295, 14 January 2015. <h2>Further reading on male and female circumcision</h2> Robert Darby and J. Steven Svoboda. <a href="https://www.academia.edu/7104790/A_rose_by_any_other_name_Symmetry_and_asymmetry_in_male_and_female_genital_cutting" rel="noopener" target="_blank">A Rose by Any Other Name: Symmetry and Asymmetry in Male and Female Genital Cutting</a> Brian Earp. <a href="http://blog.practicalethics.ox.ac.uk/2014/02/female-genital-mutilation-and-male-circumcision-time-to-confront-the-double-standard/" rel="noopener" target="_blank">Female genital mutilation (FGM) and male circumcision: should there be a separate ethical discourse?</a> Brian Earp. <a href="http://aeon.co/magazine/philosophy/male-and-female-circumcision-are-equally-wrong/" rel="noopener" target="_blank">Is there any moral difference between male and female circumcision?</a> Aeon magazine, January 2015. Brian Earp. <a href="https://www.academia.edu/10197867/Between_moral_relativism_and_moral_hypocrisy_The_case_of_FGM">Between moral relativism and moral hypocrisy: The case of FGM</a> <a href="http://www.cirp.org/library/legal/" rel="noopener" target="_blank">Circumcision legal issues at CIRP</a> <h2>Male circumcision can be worse than female genital mutilation</h2> <h3>Report in British magazine, insideMan</h3> One of the country’s most senior judges has courted controversy by declaring that male circumcision can be more harmful than female genital mutilation (FGM). Sir James Munby acknowledged he was entering “deep waters” by highlighting inconsistencies in the law, but said it would be “irrational” to dispute the fact that male circumcision can be more harmful than some forms of FGM. The High Court judge made the comments as he passed judgment in care proceedings brought by a local authority seeking to take a brother and sister, from a Muslim family, into care on the grounds that the girl was a victim of Type IV FGM. While the case failed on the grounds that damage to the girl’s genitals was probably caused by a condition called vulvovaginitis, Munby, who is president of the family division, felt compelled to highlight the sexist double standard that the case brought to light. In summing up the judge noted that while subjecting a girl to Type IV FGM could result in that child being taken into care, male circumcision would not lead to a boy being removed from his family, even though the procedure is more harmful than at least some forms of Type IV FGM. An inconvenient truth Campaigners against male circumcision have long been hampered by the myth that subjecting girls to FGM is different and always worse than circumcising boys. The uncomfortable truth, to which Munby has now given judicial credibility, is that male circumcision is different and sometimes worse than FGM. This is particularly true of Type IV FGM which incorporates practices such as pricking, piercing and nicking the genitals, which are less harmful and invasive than removing the foreskin in it’s entirety. Male circumcision in the UK is often performed without anaesthetic, in non-medical conditions and can cause complications such as life threatening haemorrhage, shock, sepsis an in extreme cases death. In 2012 a Freedom of Information request revealed that two boys a week are admitted to the emergency department of Birmingham children’s hospital as a result of male circumcision. Society more tolerant of male circumcision However, despite Munby’s assessment that ”on any objective view” male circumcisions is sometimes worse than FGM, he also made clear that current judicial thinking is that there is no equivalence between the two practices. “In 2015 ,” he said in his judgment, “the law generally, and family law in particular, is still prepared to tolerate non-therapeutic male circumcision performed for religious or even for purely cultural or conventional reasons, while no longer being willing to tolerate FGM in any of its forms. “Given the comparison between what is involved in male circumcision and FGM WHO Type IV, to dispute that the more invasive procedure involves the significant harm involved in the less invasive procedure would seem almost irrational. In my judgment, if FGM Type IV amounts to significant harm, as in my judgment it does, then the same must be so of male circumcision.” The phrase “significant harm” is important as this is the first threshold that must be crossed before a child can be taken into care under section 31 of the Children’s Act 1989. There is another criteria which must also be considered in care proceedings and this is whether the care given to a child is “what would be reasonable to expect a parent to give”. Why the law is different According to Munby, while it can never be reasonable parenting to inflict any form of FGM on a child, the position is quite different with male circumcision. Munby argued that there are at least two important distinctions between the two practices. Firstly, that FGM has no basis in any religion, while male circumcision is often performed for religious reasons. Secondly, that while FGM is said to have no medical justification and confers no health benefits; male circumcision is seen by some people as providing hygienic or prophylactic benefits, although opinions are divided. Even taking the conflicting medical evidence on any perceived benefits into account, Munby concluded that “reasonable” parenting should be seen to permit male circumcision. And that is where UK law stands on the matter today. The Head of the Family Division of the Family Court has judged that while male circumcision is sometimes worse than FGM, it is deemed to be reasonable for parents of all backgrounds to circumcise their sons, while carrying out a less invasive and less harmful from of Type IV FGM on their daughters is not considered reasonable parental behaviour. A welcome coup for campaigners Having a senior judge acknowledge that FGM can be less harmful than male circumcision is a welcome coup for those of us who advocate for the right of every human being to enter adulthood with intact genitals, except in rare cases where therapeutic surgery is unequivocally unavoidable. The fact that our society, led by politicians and the judiciary, is still prepared to tolerate greater harm happening to boys than to girls, reveals a great deal about the sexist double standards we apply to the issues that affect men and boys in 2015. The fact that we are collectively more tolerant of the harm that happens to men and boys, than the harm that happens to women and girls, doesn’t begin and end at genital mutilation. Our shared cultural beliefs that “boys don’t cry”; that men should “man up”; that women have problems and men are problems; that females are the weaker sex and that we should always put the protection of women and girls first; is reflected in our inability to tackle a whole range of social issues that, predominantly impact men and boys, head on. Why this is a men’s issue These include male suicide; male homelessness; the high rate of male workplace deaths; men’s lower life expectancy; the expulsion of boys from school; the exclusion and marginalisation of separated fathers from their children’s lives; the way we respond to male victims of violence and the harsher treatment and sentencing of men and boys in the criminal justice system. What Sir James Munby has uncovered is an inconvenient and important truth about men, manhood and masculinity in 2015 which is simply this—while the harm that happens to men and boys in our society is different and sometimes worse than the harm that happens to women and girls, we still view any harm that women and girls experience more seriously. Munby is part of the problem he has raised, for while he acknowledges that male circumcision can be more harmful than FGM, he has essentially declared that while it’s reasonable for parents to harm their sons, it is never reasonable to harm their daughters. Glen Poole, <a href="http://www.inside-man.co.uk/2015/01/15/male-circumcision-can-be-worse-than-fgm-rules-senior-judge/" rel="noopener" target="_blank">Male circumcision can be worse than FGM, rules senior Judge</a>. insideMan (UK), 15 January 2015. Glen Poole author of the book, <a href="http://equality4men.com/book/" rel="noopener" target="_blank">Equality For Men</a>. <h3>Further discussion</h3> Brian Earp, On the supposed distinction between culture and religion: A brief comment on Sir James Munby’s decision in the matter of B and G (children). <a href="http://blog.practicalethics.ox.ac.uk/2015/02/on-the-supposed-distinction-between-culture-and-religion-a-comment-on-sir-james-munbys-decision-in-the-matter-of-b-and-g-children/" rel="noopener" target="_blank">Oxford Practical Ethics Blog, 8 February 2015</a>. </div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource British judge calls circumcision “significant harm” darby Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Robert Darby Subject The topic of the resource Circumcision history Description An account of the resource Archive of the work published by Robert Darby Creator An entity primarily responsible for making the resource Robert Darby Source A related resource from which the described resource is derived circinfo.org historyofcircumcsion.org Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Text Any textual data included in the document <div class="intro" id="intro"> <h2>British Medical Journal: A ritual operation</h2> British Medical Journal, 1949 <h3>Editorial: A ritual operation</h3> Little is known of the origin of circumcision, despite the very considerable literature on the subject. (1) At its inception the practice seems to have had an essentially religious connotation and to have arisen independently in the continents of Africa, America,* and Australia. Among the Semitic races it is probable that circumcision started as act of consecration to the goddess of fertility with the object of winning her favour and thus ensuring the birth of children. Circumcision in ancient Egypt was certainly not undertaken for hygienic reasons, and probably it served as a sanctification of the reproductive faculties and a ceremonial initiation. It is likely that the ancient Pharaohs were circumcised, the circumcised state being a necessary qualification for the priesthood. It is reported that Pythagoras had himself circumcised while in Egypt so he might be fully initiated into the esoteric religious rites of the Egyptians. Among others, notably the American Indians, circumcision was mainly adopted as an alternative to human sacrifice. Although circumcision is widespread in Moslem communities the Koran contains no specific ordinance on this subject. Mohammed is said to have been born without a prepuce, and the possession of a foreskin was regarded as a disgrace amongst the Arabs. It is reported that after one of the Prophet's battles a slain Thaquafite tribesman was found uncircumcised, and great pains were taken to prove that he was a Christian and not truly a member of the tribe. In Arab communities the operation is performed with scissors, a razor, or a split reed, and there is a tradition that Abraham used an axe and was rebuked for his haste. Some of the methods of disposal of the foreskin are more a matter for interest than emulation. The Levites during the Exodus piled their foreskins in the wilderness and covered them with earth; in parts of West Africa, where the operation is performed at about 8 years of age, the prepuce is dipped in brandy and eaten by the patient; in other districts the operator is enjoined to consume the fruits of his handiwork, and yet a further practice, in Madagascar, is to wrap the operation specifically in a banana leaf and feed it to a calf. In happy contrast to some of these macabre practices is the habit of the Bani Chams in Australia with a wooden knife and leave their victims unscathed. In Britain, while the practice of circumcision is widespread, there are rather different reasons for its performance, and, though exact figures are difficult to obtain, it would seem that more than half the male members of the population are circumcised. Many doctors have for long rebelled against the wholesale and somewhat primitive lopping of the infant foreskin which goes on in some out-patient departments and surgeries. On these occasions the technique of the operation is frequently deplorable ; sacrifice of skin is often too generous, and attendant damage to the glans penis or fraenum is not unknown. If these criticisms are valid then it may well be asked why large numbers of doctors permit and encourage a practice which so savours of the barbaric. Religious considerations apart, it is not easy to find a rational argument for circumcision in most cases, and the operation is more often performed because it is de rigueur in certain districts or a habit in some families. Dr. Douglas Gairdner's valuable study, "<a href="http://www.cirp.org/library/general/gairdner/">The Fate of the Foreskin</a>," which appears at page 1433 in this issue, will, we believe, make many readers pause for reflection. Though medical opinion about circumcision may be more conservative than it used to be, yet even to-day the attitude of the profession in general to the subject is too often based upon false ideas of the anatomy and physiology of what is a useful cutaneous appendage. Of the value of the prepuce in the first two or three years of life there is no doubt, for it has an important function in covering and protecting the glans penis. Contrary to widespread belief, non-retractability, a frequent finding, is not synonymous with phimosis. There can be little medical justification for routine circumcision of the infant, and the operation is only occasionally necessary under the age of 3. After this age operation is indicated for cases of non-retractability with true phimosis and for those with recurrent preputial inflammation or paraphimosis. Circumcision should be limited in extent: the fraenal region must not be damaged, and sufficient skin must be left to cover the very sensitive corona glandis. Although the operation of dorsal slit is unpopular with some, it is both satisfactory and simple to perform, and the ultimate cosmetic outcome is good. Apart from the local reasons for circumcision it is argued by some that it will reduce the incidence of venereal disease, cancer of the penis, and cancer of the cervix uteri. The evidence supporting the first of these contentions is inconclusive ; the second is established beyond doubt ; while the available data on cancer of the cervix do not warrant the conclusions which have been drawn by some authorities. As Dr. Gairdner points out, it is likely that lack of cleanliness is more important than lack of circumcision in the case of venereal diseases and cancer of the penis. If the latter was not a very uncommon disease in this country it alone might provide justification for widespread emulation of the Jewish custom. The Mosaic law enjoins the practice of circumcision on the eighth day, and it appears certain that this ritual circumcision affords complete protection against carcinoma of the penis. Furthermore it has been shown that circumcision between the third and fourteenth years of life does not give complete protection against penile carcinoma.** (2) In the absence of more convincing evidence about carcinoma of the cervix it is difficult to describe its low incidence in Jewesses to the circumcision of their spouses. As Kennaway (3) has pointed out, the data are inadequate, and the low incidence in certain other races cannot be explained by circumcision. It seems safe to say that if Dr. Gairdner's recommendations are accepted much circumcisional morbidity and mortality will be avoided and, further, that there is no good reason to fear increased incidence of venereal disease or genital cancer as a result of this policy. * None of the indigenous societies in the Americas (north or south) ever practised circumcision, though there is some evidence that the Aztecs had a ritual which involved nicking the penis to draw blood. ** The statement that "ritual circumcision affords complete protection against carcinoma of the penis" was generally believed in 1949, but this is now known to be false. For more information see <a href="http://www.cirp.org/library/disease/cancer/" rel="noopener" target="_blank">pages on circumcision and cancer</a> 1 Hastings J., Encyclopaedia of Religion and Ethics, 1910, vol. 3 2 Kennaway, E.L., Brit. J. Cancer, 1947, 1, 335. 3 Ibid, 1948, 2, 177. SOURCE: "A ritual operation" (Editorial), British Medical Journal, 24 December 1949, pp. 1458-9 <h3>EDITORIAL: The case against neonatal circumcision</h3> British Medical Journal, 5 May 1979 Part of the North American way of life is removal of the foreskin within a few hours of birth. Nearly two million boys are born each year in the United States and in some centres 80%-90% are circumcised, [1] using vast amounts of medical and nursing time and costing parents equally vast amounts of money. In Scandinavia, on the other hand. routine circumcision is almost unknown, [2] and in Britain it is becoming unusual. In the 1930s about one-third of British boys were circumcised, [3] but by 1949 the proportion had fallen to one-fifth, [4] and by 1963 only 10% of schoolboys in Rochdale had been circumcised. [5 In hospitals in England and Wales in 1975 the rate was about 6% [6]; this represents some 20,000 circumcisions a year. The mortality is negligible. Practice in Britain may have been affected by Gairdner's important paper, [4] published in the BMJ in 1949. He showed that while 90% of boys have an unretractable foreskin at birth by the age of 3 the proportion has dropped to only 10%. Other studies have confirmed this natural development. In over 9000 schoolboys examined in Denmark [7] phimosis was found in 8% of 5-year-olds but in only 1% of secondary pupils. Among 152 teenage English boys only one had a non-retractable foreskin, although full retraction was prevented by an adherent prepuce in 22. Most circumcisions performed on the newborn are therefore unnecessary â€“ in the sense that in time nearly all boys become able to retract their foreskin and wash underneath it. The North American arguments in favour of mass circumcision are that many uncircumcised men do not perform this toilet, that they run a risk of developing carcinoma of the penis, and that their wives may run an increased risk of developing carcinoma of the cervix. These last two arguments could be weighty ones, but some careful studies [8, 9] have failed to show any difference in the incidence of cervical carcinoma in the wives of circumcised and uncircumcised husbands. Circumcision in infancy does virtually prevent penile carcinoma â€“ there are only six recorded examples of this neoplasm in circumcised Jews. [10] Even in the uncircumcised, however penile carcinoma is rare. In Sweden, which has a male population of 3.7 million (few of whom are circumcised), there are but 15 deaths from carcinoma of the penis in a year. [2] Some 5600 men die each week in England and Wales but only two of these deaths are due to penile carcinoma â€“ only 0.14% of all deaths for malignant disease in men. [11] Surgeons who work in areas where ritual circumcision is not available are sometimes asked to don rabbinical robes on the eight day to circumcise a Jewish baby, and they may have been impressed by the lack of distress as the baby sucks on a teat containing some brandy. There is however a big difference between these rites and routine circumcision of newborn boys. Too often this is seen as an uninteresting chore to be passed to inadequately trained junior staff, which evidently is not without risk. There are many reports of removal of most of the skin of the penile shaft, injuries to the glans, circumcision of hypospadiacs, and the need to perform a second circumcision on as many as 10% of babies because inadequate removal of mucosa has been followed by secondary phimosis. [1, 12] The present day hospital nursery, often colonised by antibiotic-resistant organisms, is a dangerous place for a newborn baby with a raw penile wound â€“ as is shown by two recent papers. [13,14] These record three babies who developed staphylococcal septicaemia (one fatal) and one with spreading septic gangrene of the scrotal skin after circumcision in the first week of life. Haematogenous osteomyelitis and lung abscess have also been reported as complications. Furthermore, all babies who lose their foreskin lose the natural protection of the glans penis, which prevents it being burnt by ammoniacal urine on the wet nappy. Meatal ulceration is a painful condition and meatal stenosis a serious one. Presumably most Americans are satisfied with their present practice, and some justify it most forcefully. Others, however do have misgivings, [16] in so far as there is really no rational case for general neonatal circumcision. On the other hand, surgeons and urologists know that many men conceal a dirty mess beneath the foreskin and that in some the discomforts of phimosis make circumcision necessary, and that this is an embarrassing and uncomfortable procedure in adult life. These problems can be forestalled. Examination of the penis, as well as the testes should be a standard part of school medical inspections. This would allow the few boys with true phimosis to be treated early, and at secondary school would provide an excellent opportunity to back up or amplify parental instruction in personal hygiene. Many surgeons who are not willing to perform circumcision much before three years of age accept that after that age operation is justified for phimosis and recurrent balanitis. The parents' wishes, both for and against the operation, must be taken into account; but the operation between 3 and 5 is probably the best compromise since it avoids the discomforts of circumcision later in life. Unfortunately only one-third of the operations in England and Wales are before 5 years. [6]. Nevertheless the circumcision rate of about 6% is probably the correct proportion in a Western country today. NOTE: This editorial expresses the view that about 6% of men need circumcisions. In a later editorial, <a href="http://www.cirp.org/library/general/gordon/" rel="noopener" target="_blank">Saving the normal foreskin</a>, published on 2 January 1993, the BMJ expressed the view that "overall between 1% and 2% of boys need circumcision for medical indications. Since this was before the development of alternative effective conservative treatments for phimosis and balanitis, it may be inferred that the editors of BMJ would put the rate much lower today, perhaps at 0.1% to 0.2% or 1 or 2 per 1000 boys. This would make the arguments expressed in this paper apply with even greater force. <h4>References</h4> 1. Gee, W F, and Ansell, J S, Pediatrics, 1976; 58: 824. 2. Apt, A, Acta Medica Scandinavica, 1965; 178: 493. 3. Carne, S, British Medical Journal, 1956, 2, 19. 4. Gairdner, D, <a href="http://www.cirp.org/library/general/gairdner/" rel="noopener" target="_blank">British Medical Journal</a>, 1949, 2 1433. 5. Kalcev, B, Medical Officer, 1964, 112, 171. 6. DHSS, Hospital In-patient Enquiry, 1975, Series MB4 No 5. London, HMSO, 1978. 7. Ã˜ster, J, <a href="http://www.cirp.org/library/general/oster/" rel="noopener" target="_blank">Archives of diseases in childhood</a>, 1968, 43, 200. 8. Aitken-Swan, J, and Baird, D. British Journal of Cancer, 1965, 19, 217. 9. Terris, M. Wilson, F, and Nelson, J H, American Journal of Obstetrics and Gynecology, 1973, 117, 1056. 10. Leiter, E, and Lefkovits, A M, New York State Journal of Medicine, 1975, 75, 1520. [Note: Modern research has established the role of the human papilloma virus and smoking in the etiology of carcinoma of the penis and of the cervix. The foreskin has been cleared of blame.] 11. Office of Population Censuses and Surveys, Mortality Statistics: Cause, 1975, Series DH 2 no 2. London HMSO, 1977. 12. Leitch, I O W, <a href="http://www.cirp.org/library/general/leitch1/" rel="noopener" target="_blank">Australian Paediatric Journal</a> 1970, 6 , 59. 13. Annunziato, D, and Goldblum, L M, <a href="http://www.cirp.org/library/complications/annunziato1/" rel="noopener" target="_blank">American Journal of Diseases of Children</a>, 1978, 132, 1187. 14. Sussman, S J, Schiller, R P, and Shashikumar, V L, <a href="http://www.cirp.org/library/complications/sussman1/" rel="noopener" target="_blank">American Journal of Diseases of Children</a>. 1978, 132, 1189. 15. Dagher, R, Selzer, M L, and Lapides, J. Journal of Urology 1973, 110, 79. 16. Gellis, S S, <a href="http://www.cirp.org/library/general/gellis1/" rel="noopener" target="_blank">American Journal of Diseases of Children</a>. 1978, 132, 1168. SOURCE: "The case against neonatal circumcision", (Editorial), British Medical Journal, 5 May 1979, pp. 1163-4 </div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource British Medical Journal Darby darby Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Robert Darby Subject The topic of the resource Circumcision history Description An account of the resource Archive of the work published by Robert Darby Creator An entity primarily responsible for making the resource Robert Darby Source A related resource from which the described resource is derived circinfo.org historyofcircumcsion.org Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Text Any textual data included in the document <div class="intro" id="intro"> The following article by Geoff Hinchley was published in the British Medical Journal in December 2007. <h2>Is infant male circumcision an abuse of the rights of the child? Yes</h2> Improved understanding of the normal anatomy of the infant foreskin means there is now rarely a therapeutic indication for infant circumcision, [1] and the procedure is not supported by international medical opinion. [2] Ritual (non-therapeutic) male circumcision, however, continues unchecked throughout the world, long after female circumcision, facial scarification, and other ritual forms of infant abuse have been made illegal. The law and principles pertaining to child protection should apply equally to both sexes, so why do society and the medical profession collude with this unnecessary mutilating practice? Ritual male circumcision is an ancient religious rite for Muslims and Jews, and the crux of this debate revolves around the primacy of parental religious conviction versus the primacy of the human rights of the child, the preservation of its bodily integrity, and its right of self determination. In addition to religious justification, there have been many spurious and now unsupported health claims for circumcision — including the prevention of penile cancer, masturbation, blindness, and insanity [3] — most of which, like reduction in HIV transmission identified more recently, relate to adult sexual behaviour and not to the genital anatomy or best interest of a child. There may be a case that male circumcision reduces HIV risk in sexually active adults, but the decision about whether to have this procedure should be left until the person is old enough to make his own informed healthcare choices. Male genital mutilation is not a risk-free procedure. There are potential anaesthetic risks, and the short term risk of bleeding and infection associated with any surgical procedure. [4] Longer term potential complications include pain on erection, penile disfigurement, and psychological problems. [5] A recent report shows that the non-circumcised adult penis is more sensitive than the circumcised penis, largely because the five most sensitive areas, identified in the study, are removed during circumcision. [6] This implies a reduction in future sexual sensitivity for circumcised adults. Far from being a harmless traditional practice, circumcision damages young boys. <h3>Legal protection</h3> Article 24(3) of the UN convention on the rights of the child commits all ratifying states to "take all effective and appropriate measures with a view to abolishing traditional practices prejudicial to the health of children" and article 19(1) says: "States shall take all appropriate legislative administrative social and educational measures to protect the child from all forms of physical or mental violence, injury or abuse." [7] UK courts have interceded in the past to protect the best interests of children whose parental belief systems have put children at risk. However, male circumcision remains lawful if both parents consent. [8,9,10] Since the Human Rights Act has been implemented, however, single parental consent has been found to be insufficient to show that the procedure is in the child’s best interest. [11] As far as female genital mutilation is concerned, in the United States the Federal Prohibition of Female Genital Mutilation Act states that in applying the law, "no account shall be taken . . . that the operation is required as a matter of custom or ritual." These terms are closely mirrored in the UK Female Genital Mutilation Act 2003. Both the US and the UK legal systems therefore discriminate between the sexes when it comes to protecting boys and girls from damaging ritual genital mutilation. The UK’s General Medical Council abdicates all responsibility for male circumcision to society as a whole, [12] but in June 2007 the BMA, which had previously offered general guidance, [13] decided that "any decision to provide medical or surgical treatment to a child, or any decision to withhold medical or surgical treatment from a child, should: consider the ethical, cultural and religious views of the child’s parents and/or carers, but without allowing these views to override the rights of the child to have his/her best interests protected.” [14] Male circumcision was not specifically mentioned, but it cannot be in the best interest of a child to be subjected, without its consent, to an irreversible surgical procedure, often without anaesthetic, which will provide no medical benefit but which has proved adverse consequences both in terms of potential complications for some and reduced penile sensation in adulthood for all. <h3>Religious perspective</h3> Some faiths view male circumcision, often done by people who are not medically qualified, as important for entering a covenant with their God. However, given the age of the children involved it cannot be said that this covenant is freely entered into by the individual concerned. In the US, elements of the Jewish community are beginning to rethink this issue. [15] They suggest bringing Jewish boys into the covenant symbolically, with the potential for the child to be circumcised when old enough to consent to the procedure himself. Muslims already circumcise boys at an older age, and further delay to allow the child to consent could equally be considered. How much stronger would that covenant be, when entered into by a fully competent young man with full knowledge of its religious implications and the potential risks involved. The unpalatable truth is that logic and the rights of the child play little part in determining the acceptability of male genital mutilation in our society. The profession needs to recognise this and champion the argument on behalf of boys that was so successful for girls. <h3>References</h3> 1. British Association of Paediatric Surgeons, Royal College of Nursing, Royal College of Paediatrics and Child Health, Royal College of Surgeons of England and Royal College of Anaesthetists. Statement on male circumcision. London: RCS, 2001. 2. Hofvander Y. Circumcision in boys: time for doctors to reconsider. World Hosp Health Services 2002;8(2):15-7. 3. Smith J. <a href="http://www.cirp.org/library/legal/smith/">Male circumcision and the rights of the child</a>. Netherlands Institute of Human Rights, 1998. 4. Williams N, Kaplia L. <a href="http://www.cirp.org/library/complications/williams-kapila/">Complications of circumcision</a>. Br J Surg 1993;80:1231-6.[Web of Science][Medline] 5. Peterson SE. <a href="http://www.historyofcircumcision.net/index.php?option=content&task=view&id=93">Assaulted and mutilated. A personal account of circumcision trauma</a>. In: Denniston GC, Hodges FM, Milos MF, eds. Understanding circumcision. New York: Kluwer Academic, 2001;271. 6. Sorrells ML, Snyder JL, Reiss MD, Eden C, Milos MF, Wilcox N, et al. <a href="http://www.cirp.org/library/anatomy/sorrells_2007/">Fine touch pressure thresholds in the adult penis</a>. BJU Int 2007;99:864-9.[CrossRef][Web of Science][Medline] 7. United Nations. Convention on the rights of the child. 8. Re J (A Minor) (prohibited steps order: circumcision). [2000] 1 FLR 571. 9. <a href="http://www.cirp.org/library/legal/Re_J/2000.html">Re J (child’s religious upbringing and circumcision)</a>. [2000] 1 FCR 307. 10. Re J (specific issue orders: Muslim upbringing and circumcision). [2000] 52 BMLR 82. 11. Re S. (Children) (Specific issue: circumcision) [2005] 1 FLR 236. 12. General Medical Council. Guidance for doctors who are asked to circumcise male children. London: GMC, 1997. 13. BMA. <a href="http://www.bma.org.uk/ethics/consent_and_capacity/malecircumcision2006.jsp">The law and ethics of male circumcision — guidance for doctors</a>. London: BMA, 2006. 14. BMA. Annual representative meeting policies, June 2007. Ethics and professional responsibilities. 15. Moss L. <a href="http://www.nocirc.org/symposia/second/moss.html">The Jewish roots of anti-circumcision arguments</a>. Second international symposium on circumcision, San Francisco, California, 30 April-3 May 1991. The author is an accident and emergency consultant at Barnet and Chase Farm NHS Trust, Enfield, Middlesex EN2 8JL. Email: <a class="__cf_email__" data-cfemail="7017151f16165e18191e13181c1509301213165e1e18035e051b" href="/cdn-cgi/l/email-protection">[email protected]</a> <a href="http://www.bmj.com/cgi/content/full/335/7631/1180" rel="noopener" target="_blank">British Medical Journal 2007;335:1180</a> (8 December 2007) </div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource British Medical Journal debates ethics of non-therapeutic circumcision darby Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Robert Darby Subject The topic of the resource Circumcision history Description An account of the resource Archive of the work published by Robert Darby Creator An entity primarily responsible for making the resource Robert Darby Source A related resource from which the described resource is derived circinfo.org historyofcircumcsion.org Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Text Any textual data included in the document <div class="intro" id="intro"> The following article by Geoff Hinchley was published in the British Medical Journal in December 2007. <h2>Is infant male circumcision an abuse of the rights of the child? Yes</h2> Improved understanding of the normal anatomy of the infant foreskin means there is now rarely a therapeutic indication for infant circumcision, [1] and the procedure is not supported by international medical opinion. [2] Ritual (non-therapeutic) male circumcision, however, continues unchecked throughout the world, long after female circumcision, facial scarification, and other ritual forms of infant abuse have been made illegal. The law and principles pertaining to child protection should apply equally to both sexes, so why do society and the medical profession collude with this unnecessary mutilating practice? Ritual male circumcision is an ancient religious rite for Muslims and Jews, and the crux of this debate revolves around the primacy of parental religious conviction versus the primacy of the human rights of the child, the preservation of its bodily integrity, and its right of self determination. In addition to religious justification, there have been many spurious and now unsupported health claims for circumcision — including the prevention of penile cancer, masturbation, blindness, and insanity [3] — most of which, like reduction in HIV transmission identified more recently, relate to adult sexual behaviour and not to the genital anatomy or best interest of a child. There may be a case that male circumcision reduces HIV risk in sexually active adults, but the decision about whether to have this procedure should be left until the person is old enough to make his own informed healthcare choices. Male genital mutilation is not a risk-free procedure. There are potential anaesthetic risks, and the short term risk of bleeding and infection associated with any surgical procedure. [4] Longer term potential complications include pain on erection, penile disfigurement, and psychological problems. [5] A recent report shows that the non-circumcised adult penis is more sensitive than the circumcised penis, largely because the five most sensitive areas, identified in the study, are removed during circumcision. [6] This implies a reduction in future sexual sensitivity for circumcised adults. Far from being a harmless traditional practice, circumcision damages young boys. <h3>Legal protection</h3> Article 24(3) of the UN convention on the rights of the child commits all ratifying states to "take all effective and appropriate measures with a view to abolishing traditional practices prejudicial to the health of children" and article 19(1) says: "States shall take all appropriate legislative administrative social and educational measures to protect the child from all forms of physical or mental violence, injury or abuse." [7] UK courts have interceded in the past to protect the best interests of children whose parental belief systems have put children at risk. However, male circumcision remains lawful if both parents consent. [8,9,10] Since the Human Rights Act has been implemented, however, single parental consent has been found to be insufficient to show that the procedure is in the child’s best interest. [11] As far as female genital mutilation is concerned, in the United States the Federal Prohibition of Female Genital Mutilation Act states that in applying the law, "no account shall be taken . . . that the operation is required as a matter of custom or ritual." These terms are closely mirrored in the UK Female Genital Mutilation Act 2003. Both the US and the UK legal systems therefore discriminate between the sexes when it comes to protecting boys and girls from damaging ritual genital mutilation. The UK’s General Medical Council abdicates all responsibility for male circumcision to society as a whole, [12] but in June 2007 the BMA, which had previously offered general guidance, [13] decided that "any decision to provide medical or surgical treatment to a child, or any decision to withhold medical or surgical treatment from a child, should: consider the ethical, cultural and religious views of the child’s parents and/or carers, but without allowing these views to override the rights of the child to have his/her best interests protected.” [14] Male circumcision was not specifically mentioned, but it cannot be in the best interest of a child to be subjected, without its consent, to an irreversible surgical procedure, often without anaesthetic, which will provide no medical benefit but which has proved adverse consequences both in terms of potential complications for some and reduced penile sensation in adulthood for all. <h3>Religious perspective</h3> Some faiths view male circumcision, often done by people who are not medically qualified, as important for entering a covenant with their God. However, given the age of the children involved it cannot be said that this covenant is freely entered into by the individual concerned. In the US, elements of the Jewish community are beginning to rethink this issue. [15] They suggest bringing Jewish boys into the covenant symbolically, with the potential for the child to be circumcised when old enough to consent to the procedure himself. Muslims already circumcise boys at an older age, and further delay to allow the child to consent could equally be considered. How much stronger would that covenant be, when entered into by a fully competent young man with full knowledge of its religious implications and the potential risks involved. The unpalatable truth is that logic and the rights of the child play little part in determining the acceptability of male genital mutilation in our society. The profession needs to recognise this and champion the argument on behalf of boys that was so successful for girls. <h3>References</h3> 1. British Association of Paediatric Surgeons, Royal College of Nursing, Royal College of Paediatrics and Child Health, Royal College of Surgeons of England and Royal College of Anaesthetists. Statement on male circumcision. London: RCS, 2001. 2. Hofvander Y. Circumcision in boys: time for doctors to reconsider. World Hosp Health Services 2002;8(2):15-7. 3. Smith J. <a href="http://www.cirp.org/library/legal/smith/">Male circumcision and the rights of the child</a>. Netherlands Institute of Human Rights, 1998. 4. Williams N, Kaplia L. <a href="http://www.cirp.org/library/complications/williams-kapila/">Complications of circumcision</a>. Br J Surg 1993;80:1231-6.[Web of Science][Medline] 5. Peterson SE. <a href="http://www.historyofcircumcision.net/index.php?option=content&task=view&id=93">Assaulted and mutilated. A personal account of circumcision trauma</a>. In: Denniston GC, Hodges FM, Milos MF, eds. Understanding circumcision. New York: Kluwer Academic, 2001;271. 6. Sorrells ML, Snyder JL, Reiss MD, Eden C, Milos MF, Wilcox N, et al. <a href="http://www.cirp.org/library/anatomy/sorrells_2007/">Fine touch pressure thresholds in the adult penis</a>. BJU Int 2007;99:864-9.[CrossRef][Web of Science][Medline] 7. United Nations. Convention on the rights of the child. 8. Re J (A Minor) (prohibited steps order: circumcision). [2000] 1 FLR 571. 9. <a href="http://www.cirp.org/library/legal/Re_J/2000.html">Re J (child’s religious upbringing and circumcision)</a>. [2000] 1 FCR 307. 10. Re J (specific issue orders: Muslim upbringing and circumcision). [2000] 52 BMLR 82. 11. Re S. (Children) (Specific issue: circumcision) [2005] 1 FLR 236. 12. General Medical Council. Guidance for doctors who are asked to circumcise male children. London: GMC, 1997. 13. BMA. <a href="http://www.bma.org.uk/ethics/consent_and_capacity/malecircumcision2006.jsp">The law and ethics of male circumcision — guidance for doctors</a>. London: BMA, 2006. 14. BMA. Annual representative meeting policies, June 2007. Ethics and professional responsibilities. 15. Moss L. <a href="http://www.nocirc.org/symposia/second/moss.html">The Jewish roots of anti-circumcision arguments</a>. Second international symposium on circumcision, San Francisco, California, 30 April-3 May 1991. The author is an accident and emergency consultant at Barnet and Chase Farm NHS Trust, Enfield, Middlesex EN2 8JL. Email: <a class="__cf_email__" data-cfemail="86e1e3e9e0e0a8eeefe8e5eeeae3ffc6e4e5e0a8e8eef5a8f3ed" href="/cdn-cgi/l/email-protection">[email protected]</a> <a href="http://www.bmj.com/cgi/content/full/335/7631/1180" rel="noopener" target="_blank">British Medical Journal 2007;335:1180</a> (8 December 2007) </div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource British Medical Journal debates ethics of non-therapeutic circumcision darby Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Robert Darby Subject The topic of the resource Circumcision history Description An account of the resource Archive of the work published by Robert Darby Creator An entity primarily responsible for making the resource Robert Darby Source A related resource from which the described resource is derived circinfo.org historyofcircumcsion.org Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Text Any textual data included in the document <div class="intro" id="intro"> <h1>Sore point</h1> <h3>Circumcision "a source of great anguish"</h3> Circumcision - beloved by the Victorians, crucial to two of the world's great religions, arguably a health boon - can be a cause of great anguish. Richard Johnson meets men finding ways to reverse a cut they wish they'd never had Guardian, Saturday October 29, 2005 Skin constantly renews itself. Foreskin is no different: stretch it, and it will grow. Which is why eight circumcised men are meeting in Watford town hall. They want new foreskins. "When people come to my house," says Laurie, "I don't go 'Hello there, I'm Laurie, I'm growing my foreskin', but I've often got research papers out on the table, so word gets out. I do find people are really very interested in what I'm doing." Laurie is sharing his experience of restoration, as the process of foreskin renewal is called, with fellow members of NORM-UK. In the US, where NORM was born (and where circumcision rates are somewhere around three-quarters of the male population, far higher than in Britain), it stands for National Organisation of Restoring Men. NORM-UK is about more than that, but Laurie is on a roll. And the others don't want to interrupt him - after all, in two and a half years, Laurie has achieved glans coverage when flaccid. In the world of restoration, that is major. NORM-UK meetings are small and intimate. Not usually as small and intimate as this one, but there's been a pile-up on the M1. There are a few handshakes, but otherwise little in the way of physical display - "People are always worried we're going to drop our trousers," says general manager David Smith. Laurie wouldn't be averse to the idea, to show off his stretching. Women stretch skin for reconstruction after a mastectomy. So why shouldn't men stretch a foreskin? Some men can't restore - they are too tightly circumcised and have no tissue left to grow, but others can and are availing themselves of products such as the TLC Tugger, Tug Ahoy and the Your-Skin cone. Some have found their own DIY solutions, using funnels and gaskets to stretch the foreskin, and sash-window weights to provide traction. The whole idea of restoration sounds funny, like the time that Laurie was having a go with sticky tape, the most primitive of the restoration methods. He pulled what skin he had left over his glans, and taped it down. "I only had the tape on for half an hour", says Laurie, "but it was hell. I was walking down the high street and suddenly had to dive into the nearest toilet to check my penis hadn't gone black, green or blue. Or dropped off altogether." It sounds funny, but it isn't. Not if it's happening to you. Smith remembers sitting through the scene in the film East Is East in which the father tries to catch the son and take him to be circumcised. "I remember the cinema was in hysterics," says Smith, "and they were laughing when he was wheeled into the operating theatre, but all I could hear was the boy's screams. My wife turned to me and said, 'I've got to go - I can't watch this.'" When the foreskin is removed, it leaves the glans exposed and that can be difficult - removing a protective layer and sometimes creating soreness. "I always had a problem with my penis giving me stimulation I didn't want," says Kevin, recalling how, as a boy, "I had to keep adjusting it through my pocket. I was near the climbing frame in the playground when, all of a sudden, everyone started chanting 'Kevin is dirty - he's always playing with himself'. I didn't like the feeling of being odd, of being deformed. Suicide would have been a good option." Kevin is now 56 with a fully restored foreskin. But he's left with the question, why was he circumcised in the first place? His mother read the Bible and went to Sunday school. "But I was conceived out of wedlock when she was 17. And my father was a divorcee. They wanted to get married in church, so I think I was circumcised as some kind of apology to Jesus. My father wasn't circumcised himself, so I really don't understand." And that is a feeling he shares with many members of NORM-UK. Meetings are on a first-name-only basis because members don't like to be identified. "Many men who come to meetings won't even speak to their families about the pain they're suffering - we are dealing with victims of abuse here," says Smith. NORM-UK currently has just short of 300 members. Less than one inquiry in 10 results in membership, but it isn't strictly about the numbers. "Men often want the information to restore," says Smith, "but they want to keep it to themselves. They are frightened about being found out. When they ring me up, they say, 'Please ensure that the information is in plain envelopes and don't put me on a mailing list.'" John D was like that. He felt abused because his circumcision was unnecessary - a course of antibiotics had already cleared up his urinary infection. "But my father agreed with the doctor, and told me I was going to have a minor operation," he says. "I remember the nurses giggling as I was taken off to theatre. They wore these big sickly grins, and said, 'We're taking you to be done up now. Hee hee hee.' I was eight, but suffice it to say that they knew what was happening to me and I did not ... I remember waking up," says John D, "after the general anaesthetic had worn off, and looking down. My beloved penis had been replaced with wrinkled skin, a collar of thorns - the black stitches - and an ugly great dome on top. I experienced shock at first, later deep anger and resentment. The stitches disappeared, but the mutilation didn't. My father said, 'I didn't think it would look like that.' It was misinformed consent." There are lots of horror stories about circumcision. Like the time in Baltimore in 1964 that it went so badly wrong that the doctors decided to change the child's sex. Or the time in London in 1991 when a 16-year-old was circumcised so badly that he bled all night and died. But these cases are extraordinary, and far from typical. Even for adults, circumcision is reckoned a safe and easy operation. Opponents of the procedure, however, don't see it like that. John E is blind. But it's not his blindness that keeps him from meetings. "It's the fact I feel I've been more devastated than everyone else," he says. "They've got their lives in order. And they've got sexual partners. I haven't. My life has been ruined by circumcision, although I hate that word. I prefer 'foreskin amputation'. It's not an operation - there's no medical benefit. It's a rite. A faith crime." In the Bible, circumcision was God's covenant with Abraham and the Jewish people. Of all of the commandments in Judaism, the brit milah (literally, covenant of circumcision) is probably the most universally observed. And although circumcision isn't actually mentioned in the Qur'an, it is mentioned in other Islamic texts. Most Muslims believe it's fundamental because Allah ordered Muhammad to follow the way of Abraham. Asked if NORM-UK has Jewish and Muslim members, Smith replies, "Yes we do, but it is difficult to estimate the number because if someone joins us we do not ask their religion, nor are we really interested." Religious circumcisions are frequently performed without anaesthetic, and are painful, even when performed on newborn babies. Adults can testify to the pain for themselves and can give their informed consent - but children can't. If, as opponents claim, circumcision is traumatic, and can result in lifelong damage - including psychological problems and a reduced sex drive - why are religious circumcisions still allowed? NORM-UK says, actually, they aren't allowed: the UN Convention on the Rights of the Child declares that violence to children cannot be justified on grounds of "religion, culture or tradition". Children are not the possessions of their parents to do with as they please - or submit to surgery unless absolutely necessary. We make an exception for circumcision because it's mentioned in Genesis. Dr Zuhair Zarifa, from Docklands in east London, is one of the few surgeons prepared to advertise the fact that he will circumcise males for religious or ethnic reasons. "Why not?" he says. "The operations are permitted by the General Medical Council. And they will happen whether I do them or not. It's much better for the operations to happen in my surgery under clinical conditions with anaesthetic, where I can provide all the necessary aftercare." Even nonpractising Jews tend to circumcise their sons. It was, after all, the first command given to Abraham and the defining physical mark of the Jewish people. Circumcision involves "Hatafat Dam Brit" - a drop of blood that seals a covenant. Which does, for some, suggest that removing the foreskin goes beyond what is required by God. But, according to Rabbi Dr Jeremy Rosen, that is to miss the point. "People are always trying to find rational reasons for Jewish laws," says Rosen. "They ask if our dietary laws improve hygiene. They ask if observing the Sabbath helps mental relaxation. And they ask if circumcision prevents STDs. But even if these rational reasons stood up to objective scrutiny, they wouldn't be a reason for keeping - or abandoning - our laws. One keeps to these rules out of religious commitment. I have no medical expertise," adds Rosen, who runs the London branch of the liberal Yakar Educational Foundation, "but I am convinced that circumcision is harmless, and not traumatic. But even if it is, we Jews have done pretty well on it over the years - and so indeed have Muslims." Circumcision on females was made illegal in the UK in 1985. The same protection is not extended to males precisely because it would involve taking on two of the world's great religions. Most forms of female circumcision are, certainly, more damaging than male circumcision, but the distinction in law between male and female circumcision just can't be justified objectively. It is a double standard. Circumcision was not practised in Britain until the 18th century and it really only gained popularity in the 19th century, after claims that it stopped the vile habit of masturbation. By stopping masturbation, Victorians thought circumcision would cure everything from epilepsy and hip trouble to asthma and alcoholism. In the first world war it was hailed as a defence against venereal disease, and by the second world war it had become an emblem of status; most of the middle and upper classes were eagerly circumcising their sons. Only in the late 1940s, with the introduction of the National Health Service, did numbers begin to fall - it is now estimated that around 20% of the current male population in the UK are circumcised. But whenever a new disease becomes a matter of social concern, circumcision is wheeled out as the cure. A recent paper in the British Medical Journal found a link between an intact foreskin and HIV infection - but a paper in the British Journal Of Urology found exactly the opposite. There is clear medical evidence that circumcision reduces the incidence of cancer of the penis, and of the cervix for the women whose partners are circumcised, but even this is disputed by NORM-UK. It argues that the research is out of date and that a lack of cleanliness is more important to the transmission of disease than the lack of a foreskin. The organisation doesn't want to see circumcision banned altogether. It accepts there are a few medical conditions where it is necessary. The others can be treated by simple, nonsurgical means."We need to educate the medical profession," says Smith, "because they seem unaware of the alternatives to circumcision. They are certainly unaware of the problems that it is causing." John D is typical of NORM-UK members in that circumcision when he was a young boy changed his entire persona. "I became less sociable, and I started talking to myself. I was fearful of changing rooms. I had no close relationship with the opposite sex until I was 41, and I still haven't been able to reach orgasm through sexual intercourse. Over the years, I've had real problems with depression, and I'm sure I could trace it back to that day." These are not the issues foremost in doctors' minds. Take a look at the General Practice notebook, an online medical encyclopaedia used by GPs, and its listing for phimosis - a condition where the foreskin won't retract. Most infants are born with a foreskin that can't be retracted and the foreskin is often tight until after puberty. Phimosis disappears in almost all cases given time. A fully retractable foreskin occurs on its own in 99% of 18-year-olds. But the notebook recommends circumcision. The notebook makes no mention whatever of the noninvasive solutions to the problem - such as stretching, steroid cream or a simpler operation. Similarly, there are nonsurgical solutions to balanitis, a condition where the foreskin retracts too tightly, causing the glans to swell. "It sounds silly," says John D, "but balanitis can be cured by putting the penis in a bowl of sugar. The swelling goes down, and the foreskin returns to its resting position." Zarifa isn't sure about the bowl of sugar - but he insists that doctors always explore noninvasive options first. "The truth of the matter is that stretching can be quite painful," he says. "And it's quite an undertaking for a small child. For some boys, the pain of the stretching is as bad as the pain of the circumcision. And I would say that 40-50% of boys who use steroid cream end up having a circumcision in the end. But it's always the last option." The BMA supports conservative solutions where possible. But unnecessary circumcisions are still happening. And, as the Commons health committee noted, they are happening "because doctors don't understand the natural history of the foreskin". Circumcision for babies and for older people is dismissed as "the snip", but it can still result in serious bleeding, or an adverse reaction to the anaesthetic. "And you cannot cut off normal, healthy, sexually-functioning tissue without cutting off normal, healthy, sexual functioning," says Marilyn Milos, a nurse and director of the National Organisation of Circumcision Information Resource Centres in the US. "It's a sexual issue, and it's a human rights issue." The foreskin isn't a useless flap that evolution should have got rid of long, long ago - it's skin that is rich with blood vessels, highly innervated, and uniquely endowed with stretch receptors. These contribute greatly to the sexual response of the intact male. The stretching of the foreskin over the glans activates nerve endings, enhances sexual excitability, and contributes to the ejaculatory reflex. There's no escaping it - the foreskin is sexual tissue. Laurie can laugh now, but he missed his foreskin (it was removed when he was two). He was getting on for 60, and rapidly losing the feeling in his penis. "To be honest," he says, "sex was like pushing a rolling pin in. And I'm not referring to size when I say 'rolling pin' - you can get little rolling pins. I just could not feel a thing." His glans had been badly desensitised after years of rattling around - so much so that he could have an orgasm and not even feel it. That is when he approached NORM-UK. During heterosexual intercourse with a circumcised man, the penis removes natural lubrication as it moves in and out of the vagina. "So my poor wife was buying artificial lubricant by the gallon," says Laurie. During heterosexual intercourse with an uncircumcised man, the glans moves but the foreskin stays put. And so does the lubrication. The woman doesn't feel friction at all - what she does feel is a variation in pressure. Laurie is delighted. "And so is my wife," he says. "The skin grew in jumps. I did a lot of work for a long time and nothing happened, like with the sticky tape, but suddenly I woke up one morning and thought 'Where's that come from?' " The new foreskin didn't have the nerve endings it once did, but the glans recovered all its sensitivity. "For 40 years my wife and I had to use lubrication. Not any more. We're delighted." David Smith is NORM-UK's one paid employee. He started admitting he worked for the charity only after his parents died - he couldn't bear the questions. (The Charity Commission put the organisation on probation for 12 months to ensure that it was not a cover for pornography.) Smith's wages come out of a grant from Lloyds TSB. But, apart from him, the trustees are all volunteers. Running NORM-UK is a big job: liaising with Great Ormond Street to correct the circumcision "fact file" on the hospital website, setting up meetings with the Family Planning Clinic, and doing mail-outs to midwives, recommending the alternatives to circumcision. Meet the members of NORM-UK and you'll understand that it's more important to look at the complications of circumcision, and its physical and psychological side effects. In time, campaigners hope that routine circumcision will come to be seen as yet another deluded fad, along with bleeding, electro-convulsive therapy and the frontal lobotomy. --- In response to a letter agreeing that circumcision was immoral but questioning the comparison with female genital mutilation, the Guardian published the following letter from John Dalton. As a victim of male circumcision and a subject of Richard Johnson’s article (Sore Point, October 29), I have no wish to belittle the suffering of circumcised girls. I would, however, like to respond to Catherine Long’s objection to male circumcision being compared to female genital mutilation (Letters, November 5). Male and female circumcision both remove normal tissue from normal children without therapeutic need or personal consent. The time has come for children to be protected from non-therapeutic circumcision without prejudice in respect of race, religion or gender. John D Dalton Frizington, Cumbria <a href="http://www.guardian.co.uk/weekend/story/0,3605,1639243,00.html">Guardian Weekend Magazine, 12 November 2005</a> </div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource British men seek compensation for circumcision darby