Male Circumcision Policy and Procedure

1. Introduction

This is a complex decision making process and must balance all the factors including religious and cultural significance for the individual and families, alongside the medical perspective.

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

There is no requirement in law for professionals undertaking male circumcision to be medically trained or to have proven expertise. Traditionally, religious leaders or respected elders may conduct this practice.

2. Circumcision for Therapeutic / Medical Purposes

The British Association of Paediatric Surgeons advises that there is rarely a clinical indication for circumcision. Doctors should be aware of this and reassure parents accordingly.

Where parents request circumcision for their son for assumed medical reasons, it is recommended that circumcision should be performed by or under the supervision of doctors trained in children's surgery in premises suitable for surgical procedures.

Doctors / health professional should ensure that any parents seeking circumcision for their son in the belief that it confers health benefits are fully informed that there is a lack of professional consensus as to current evidence demonstrating any benefits. The risks / benefits to the child must be fully explained to the parents and to the child / young man himself, if he is Gillick competent and Fraser Guidelines should apply to medical advice or treatment.

The medical harms or benefits have not been unequivocally proven except to the extent that there are clear risks of harm if the procedure is done inexpertly.

3. Non Therapeutic Circumcision

This would include when circumcision is requested on cultural, social and religious reasons and is a common practice in the Jewish and Islamic faiths, and is also practiced by many African communities as a tribal or ethnic tradition.

Note: female circumcision (also known as Female Genital Mutilation) has no medical benefits and is illegal under the Female Genital Mutilation Act (2003). For more information, please see: Derby and Derbyshire Safeguarding Children Partnership, Safeguarding Children at Risk of Abuse Through Female Genital Mutilation (FGM) Procedure.

The British Medical Association (BMA) advise that Doctors must act in a child's best interest:

• A child's best interests include not only a child's health but also their social and cultural interests. If the patient is a child, proceed on the basis of the best interests of the child and with consent. Assessing best interests will include the child's and/or the parents' cultural, religious or other beliefs and values. The child should give consent if they have the maturity and understanding to give it. If not, consent from all those with parental responsibility must be sought;
• Children who are able to express views about Non Therapeutic Circumcision should be involved in the decision-making process;
• Where a child (with or without competence) refuses Non Therapeutic Circumcision, the BMA cannot envisage a situation in which it will be in a child's best interests to perform circumcision, irrespective of the parents' wishes;
• Parental preference alone does not constitute sufficient grounds for performing Non Therapeutic Circumcision. It is the parents' responsibility to explain and justify requests for circumcision, in terms of the individual factors in relation to that child's best interests;
• Consent for Non Therapeutic Circumcision is valid only where the people (or person) giving consent have (or has) the authority to do so and understand(s) the implications and risks;
• Where a child lacks competence, and where there are two parents, both must give consent for Non Therapeutic Circumcision;
• Where people, and/or agencies, with parental responsibility for a child disagree about whether he should be circumcised, doctors should not circumcise the child without the leave of a court;
• As with all medical procedures, doctors must act in accordance with good clinical practice and provide adequate pain control and aftercare, including being registered in England with the Care Quality Commission, in Wales with HIW and in Scotland with HIS;
• Doctors must make accurate, contemporaneous notes of discussion, details of best interest assessments, consent, pre-operative clinical assessments, the procedure itself and its after care.

4. Legal Position

In all cases, legal advice must be sought. In circumstances where the child is subject to court proceedings, the view of the court must be sought. Each case needs to take into account the views of those with parental responsibility

Decision making needs to consider that:

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

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

5. Principles of Good Practice

The welfare of the child should be paramount and all professionals must act in the child's best interests. Children who are able to express views about circumcision should always be involved in the decision making process.

• Even where they do not decide for themselves, the views that children express are important in determining what is in their best interests;
• Parental preference alone does not constitute sufficient grounds for performing a surgical procedure on a child unable to express his own view. Parental preference must be weighed in terms of the child's interests;
• When the courts have confirmed that the child's lifestyle and likely upbringing are relevant factors to take into account;
• Each individual case needs to be considered on its own merits.

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

• The child's own ascertainable wishes, feelings and values;
• The child's ability to understand what is proposed and weigh up the alternatives;
• The child's potential to participate in the decision, if provided with additional support or explanations;
• The child's physical and emotional needs;
• The risk of harm or suffering for the child;
• The views of the parents and family;
• The implications for the child and family of performing, and not preforming, the procedure; and
• Relevant information about the child and family's religious or cultural background.

Consent for circumcision is valid only where the people (or person) giving consent have the authority to do so and understand the implications (including that it is non-reversible procedure) and risks. Where people with Parental Responsibility for a child disagree about whether he should be circumcised, the child should not be circumcised without the leave of the court.

6. Doctors' Responsibilities

Doctors are under no obligation to comply with a request to circumcise a child and circumcision is not a service which is provided free of charge. Nevertheless, some doctors and hospitals are willing to provide circumcision without charge rather than risk the procedure being carried out in unhygienic conditions.

Poorly performed circumcision has legal implications for the doctor responsible in responding to requests to perform male circumcision, doctors should follow any guidance issued by the:

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

7. Recognition of Harm

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

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

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

Harm in this instance may stem from the fact that clinical practice was incompetent (including lack of anaesthesia) and/or clinical equipment and facilities are inadequate, not hygienic etc.

The professionals most likely to become aware that a boy is at risk, or has already suffered, harm from circumcision are health professionals (GP's, health visitors, A&E staff or school nurses) and childminding, day care and teaching staff.

8. Multi-Agency Responsibility

If a professional in any agency becomes aware, through something a child discloses to another means that the child has been or may be harmed through male circumcision, a referral must be made to Children's Services under the Requests for Support Procedure. Children's Services should assess the risk of harm to other male children in the same family, including unborn children.

9. Role of Community / Religious Leaders

Community and religious leaders should take a lead in the absence of approved professionals and develop safeguards in practise. This could include setting standards around hygiene, advocating and promoting the practise in a medically controlled environment and outlining best practice if complications arise during the procedures.