SCOPE OF THIS CHAPTERThis chapter provides information for practitioners in relation to male circumcision. It explains the difference between circumcision for therapeutic / medical purposes and non therapeutic circumcision. It explains the legal position around male circumcision, including issues around consent. If practitioners have any concerns that a child has suffered or is likely to suffer significant harm as a result of circumcision, they must make a referral to Children's Social Care. The guidance was added to the procedures manual in December 2019.
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.
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.
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:
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:
If doctors or other professionals are in any doubt about the legality of their actions, they should seek legal advice.
The welfare of the child should be paramount and all professionals must act in the child's best interests. Children who are able to express views about circumcision should always be involved in the decision making process.
An assessment of best interests in relation to non-therapeutic circumcision should include consideration of:
Consent for circumcision is valid only where the people (or person) giving consent have the authority to do so and understand the implications (including that it is non-reversible procedure) and risks. Where people with Parental Responsibility for a child disagree about whether he should be circumcised, the child should not be circumcised without the leave of the court.
Doctors are under no obligation to comply with a request to circumcise a child and circumcision is not a service which is provided free of charge. Nevertheless, some doctors and hospitals are willing to provide circumcision without charge rather than risk the procedure being carried out in unhygienic conditions.
Poorly performed circumcision has legal implications for the doctor responsible in responding to requests to perform male circumcision, doctors should follow any guidance issued by the:
Circumcision may constitute Significant Harm to a child if the procedure was undertaken in such a way that he:
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.
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.
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.
Only valid for 48hrs