Happy anniversary

The Offences Against the Person Act 1861 is one hundred and fifty years old today, 6th of August 2011. The Act is very much alive and well, although much of the Act has been repealed it is still one of the cornerstones of our criminal laws that protect us from assault, wounding and harm.
The basis of all medical treatment is that there should be a disease or injury that needs treatment and that the patient should personally consent to such treatment.
There are of course exceptions (see the post Consent and circumcision) but informed personal consent becomes crucial when the treatment being sought is non-therapeutic. If a doctor treats a patient who has no disease or injury and cannot personally consent to such treatment then the doctor has no defence of reasonable surgery and is probably committing a crime under the Offences Against the Person Act 1861.
It would appear to folow that the non-therapeutic circumcision of boys who are healthy and, being minors, cannot personally consent to a non-therapeutic procedure, is a crime. It is quite surprising that no prosecutions have been brought to date.

Consent and circumcision

Our genitals are a part of our bodies about which we often have intense feelings. We describe them using many different words. Some of these may be considered offensive and can evoke strong emotional responses, whilst others have evolved for use in polite conversation. One of these is the phrase “Private Parts”.
A child’s private parts are considered more vulnerable and more precious than those of an adult. Society usually provides a very high degree of protection to children’s genitals from adult interference; however society waives that protection and accommodates adult demands that non-therapeutic genital surgery is performed on healthy children. Such surgery is known by various names including “Gender Assignment” for intersex children and “Circumcision” in males and females. By allowing these demands from adults to go unchallenged, we deny children the protection they deserve.

Freedom of choice
The freedom to make our own decisions is also something about which we have strong feelings. When it comes to our own bodies, many of us consider the freedom to make decisions for ourselves to be a fundamental right. Philosopher John Stuart Mill in his book “On Liberty” expressed freedom of choice in this way: “Over himself, over his own body and mind, the individual is sovereign.”
The decisions we have to make in order to exercise our freedom of choice require us to have good quality information and the maturity and ability to process that information and come to an informed decision. Mill’s definition of freedom of choice has helped to develop the concept of informed consent, which has become a cornerstone of modern medical practice and the application of the law.

Any exceptions?
Medicine requires us to make some allowances; a surgeon could justify amputating a patient’s leg without their consent in certain circumstances – for example if the leg had been badly crushed in an accident and if the patient was unconscious and amputation was the only way to save him or her from death. This could be seen as an example of presumed consent, in that the doctor can presume that the patient would rather survive without a leg than die. However, in all cases where the patient is able, or will be able to understand, the doctor is required to provide suitable information and allow the decision to be made by him or her. This is particularly applicable where the patient is undergoing unnecessary surgery, for example cosmetic surgery.

Children
As children are not considered able to understand the information required to give informed consent they are treated as being in a similar situation to an unconscious patient. The surgeon must act if the child’s health is under immediate threat from disease or injury, but a healthy child deserves the same degree of protection from unnecessary surgery that would be accorded to any other patient unable to give informed consent. How do doctors justify removing healthy genital tissue from non-consenting children?

Medical ethics
The General Medical Council, the doctors’ regulatory body (G.M.C.) has a bizarre take on consent in relation to circumcision. Right at the top of the guidelines, where it should be is the following:

1. In our core guidance, Good Medical Practice, we advise doctors that: You must make the care of your patient your first concern.

The above echoes the doctors’ oath to “do no harm”.  The policy sounds as though it should protect anyone from being operated on when they have no disease or injury and have not requested or consented to the procedure. Sadly further on in section fourteen there is this piece of advice:

14. If you are asked to circumcise a male child, you must proceed on the basis of the child’s best interests and with consent. An assessment of best interests will include the child and/or his parents’ cultural, religious or other beliefs and values. You should get the child’s consent if he is competent. If he is not, you should get consent from both parents if possible, but otherwise from at least one person with parental responsibility.

The first sentence of section fourteen sounds as though it offers a child protection – no consent means no surgery. Whatever “assessment” the G.M.C. may make about the child’s “best interests” it cannot be proper to circumcise a child on the basis of his parents’ beliefs and values as they are not necessarily the beliefs that the child may hold in the future. This not a situation in which presumed consent could apply as the child is not under any immediate threat from disease and has no injury. Lastly how can it be right to accept the consent of two parents as valid consent? Neither parent is the patient, the patient has no disease or injury and therefore they have no right to consent to and the doctor has no justification for carrying out a medically unnecessary procedure. Doctors must remember that the child is their patient, not the parents and also remember their oath to do no harm.

The British Medical Association (B.M.A) holds a similar position to that of the G.M.C. Although the B.M.A. goes so far as to acknowledge, in their guidelines, that there is a downside to circumcising children.

In the past, circumcision of boys has been considered to be either medically or socially beneficial or, at least, neutral. The general perception has been that no significant harm was caused to the child and therefore with appropriate consent it could be carried out. The medical benefits previously claimed, however, have not been convincingly proven, and it is now widely accepted, including by the B.M.A, that this surgical procedure has medical and psychological risks. It is essential that doctors perform male circumcision only where this is demonstrably in the best interests of the child. The responsibility to demonstrate that non-therapeutic circumcision is in a particular child’s best interests falls to his parents.

The last two sentences are where the profession washes its hands of responsibility, if the parents convince the doctor that they will get the child circumcised elsewhere the doctor can say it is in the child’s best interests for him or her to do the circumcision and so limit the potential damage. The way to limit the harm to a child known to be at risk from abuse however is to inform the child care agencies and if necessary, get the child put on the child protection register so that the authorities can protect the child with court injunctions or other methods. It is not for members of the medical profession to collude with parents in an act that the profession itself says “has medical and psychological risks“. Surely exposing a healthy child to unnecessary medical and psychological risk can only be considered an abuse.

Everywhere you look in the National Health Service the emphasis is on freedom of choice, the right to choose your consultant, the right to choose your hospital; but if you are a young boy few in the medical profession will uphold your right to freedom of choice by protecting you from being subjected to unnecessary non-consensual genital surgery. If children were left intact until they could make an informed choice this sorry practice of cutting children’s genitals would probably come to an end as within a generation there would be no more mutilated parents pressurising doctors to violate children’s rights.

Blood loss

One of the favourite myths of those who forcibly circumcise children is that it is safer to circumcise a baby rather than waiting till the child grows up (and can give or withhold his consent). The evidence points to the opposite being the case. It is riskier to circumcise a baby than it is to operate on an adult. Just one such risk to a child’s safety is loss of blood.

If a surgical procedure goes wrong, the amount of blood that can be lost from a newborn baby without endangering its life or causing it to enter shock is remarkably small. Approximately 71ml, or just a little over four tablespoons is all it takes (left). Considering this, the period shortly after birth is far from the safest time to perform a circumcision: an infant’s penis is small and not fully developed, the circumciser cannot accurately estimate the amount or type of tissue that they are removing, the severed blood vessels are tiny (and therefore difficult to close) and consequently the potential for unsafe levels of blood loss is considerably higher than in an adult. Furthermore, anaesthetising newborn babies is risky in itselfand studies have shown that the alternative (unanaesthestised circumcision) causes the stress hormone levels in baby boys to increase by a factor of three or four during circumcision [1] [2], making infant circumcision a dangerous and stressful event for a baby even before something goes ‘wrong’ and blood loss becomes an issue.

In contrast, if a surgical procedure goes wrong on an adult, the amount of blood that can be lost before they go into shock is about two pints. Two pints of blood is very visible, it demands attention and remedy in the way that only four tablespoons simply does not. Should an adult need, or choose, to be circumcised the blood vessels are clearly visible and much easier for the surgeon to manage. The adult is also properly anaesthetised and so not suffering the levels of stress that an infant would. Further, there is a greatly reduced risk of psychological damage, an adult will have given his informed  consent for the surgery to be carried out. To force circumcision on a non-consenting child exposes him to great risk of psychological damage. The mental health charity Mind is one organisation that recognises this risk.

It is unfortunate for anyone whose surgery does not go entirely according to plan. It is a tragedy if the patient is left worse off than before the operation. It is a shameful aspect of our society that we allow non-consenting children to undergo non-therapeutic genital cutting that is by definition only harmful.

Connections

Can you spot the connection between these items?

Odd One Out

They have all been used in the cutting of boy’s genitals in the U.K.

In a previous post I stated that I did not like to use the word circumcision because it gives the impression of something normal, I hope this post will show you that in the U.K. today the word circumcision is used to conceal some gruesome acts done to little boys.

The Scalpel.

Obvious — probably what you would expect to be used, along with other surgical instruments some of which look like the equipment of a skilful torturer.

MouthThe Mouth.

The mouth is sometimes used in a ritual that surrounds circumcision. The circumciser sucks the blood from the baby’s wounded penis. Not surprisingly this has lead to complications of infection, herpes, and the circumciser now often uses a glass tube and gauze to prevent the transfer of germs. Intriguingly this shows that a ritual, supposedly rigid, is variable and capable of change, perhaps another change should be the raising of the age of the circumcision so that the child can give or withhold his consent.

RazorThe Razor Blade.

A widely available circumcision implement, all you need is a couple of adults to restrain the victim and the blade. The number of backstreet circumcisions performed annually in the U.K. is unknown, but complications are regularly seen in the A&E departments of the NHS. Sometimes the incident is referred to the police but a prosecution “would not be in the public interest”.

The Thumbnail.

In infancy the foreskin is fused to the glans (head) of the penis by a layer of special, epithelial, cells; the thumbnail, specially grown, is sometimes used to rip the foreskin from the head of the penis. This process is of course extremely painful.

The Soldering Iron.

The soldering iron has been used on at least one occasion to cauterize, that means sealing with a burn, the circumcision wound on a baby’s penis. The mechanic who did this on a kitchen table was not charged or arrested because he had not impersonated a doctor.

That we should permit all this to be carried out on non-consenting children in the twenty first century seems extraordinary. We rightly consider the exploitation of children to gratify adult wishes as abuse and society treats such abuse very seriously. Turning a blind eye to the abuse I have outlined above is un-justifiable. The existing law and child protection agencies should act to protect boys from what can only be called genital mutilation.

A controversial junction between politics, religion, science and sex

To get things clear my view of this particular junction is very personal. My foreskin was amputated when I was a baby. I have hated this fact ever since I was old enough to understand what had happened to me. Now I hear you say, “It probably had to be done”. Well I don’t think so. I asked my mother why I was different to my dad and she said that I had had “a little operation to avoid trouble later on”. So I think that there was, in my case, no medical necessity for the amputation of perfectly healthy tissue. I have taken my path from victim to campaigner and now I work to end all unnecessary genital surgery on children.

You will have noticed that I have not yet used the word circumcision, the reason is that the word provides a cosy image of something relatively normal and not very invasive. The “snip” is another favourite. It makes circumcision sound like having your nails cut. The amputation of the foreskin removes 50% of the skin system of the penis. Just check any anatomy textbook that shows the adult penis intact and make your own estimation. Beware though as some textbooks do not show the foreskin, they airbrush it out of natural history. The foreskin has been present in mammals for about 65 million years to aid sexual intercourse because the mechanical function of the foreskin reduces the force needed for the insertion of the penis into the vagina, intromission, by a factor of 10 [4](Taves D. “The intromission function of the foreskin”. Med Hypotheses. 2002;59(2):180.). When the foreskin is amputated an important erogenous structure is lost: the tissue removed contains the most sensitive bit of the penis (Sorrells BJU International 2007)[3]. These are facts published in peer reviewed scientific journals. So the word circumcision hides the fact that a significant change has been made to the penis.

To make a significant change to a person’s body without their consent demands that you provide a very good reason, medical necessity for example; in this context necessity means that a serious disease is present and failure to treat it will have immediate and dire consequences. Worldwide there is not a single medical body that recommends routine amputation of the healthy foreskin, and cases where there is a disease present that necessitates the amputation of the foreskin are thankfully very rare. So why is the NHS performing thousands, over 1500 a year in Birmingham alone, of non-therapeutic circumcisions on children under fourteen each year, without the consent of the owner of the penis? Some are due to parents and doctors following outdated medical advice and some are sadly due to the religious beliefs of parents.

There is a human right to “manifest your religion” (Article 9 of the Human Rights Act 1998) and this is used as the justification for circumcising children. Although all human beings have human rights from birth children are not born with religious beliefs but may be born into families who hold certain beliefs. A baby or young child has no religion to “manifest” and therefore has no right that needs the protection of article 9. To impose a religious belief on another involving physical interference with that person’s body cannot be part of article 9 protection for that person. Article 9 provides that the right to manifest religion may be limited to protect another person’s rights.

So what is the rush? The child in question can decide what they believe and what, if any, body part they would like to sacrifice as a result of that belief, at a time of their own choosing. That is the proper way to exercise the right to manifest one’s religious belief. To choose ritual surgery for yourself is fine. To choose ritual surgery for someone else is abusive, it is for this reason that Article 9 is a qualified right, in that it must be subject to the “…protection of the rights and freedom of others”.

Children very definitely have rights. The Human Rights Act 1998 Article 3 states that; “No one shall be subjected to torture or to inhuman or degrading treatment or punishment”. That is the full text of Article 3, no qualifications, no ifs and no buts. It is not a qualified right as Article 9 is. Bear in mind that non-therapeutic circumcision is by definition not curing anything therefore it can only be regarded as degrading to a healthy body. There are also the risks that anyone undergoing any surgery may incur. Then there is the issue of the pain involved in circumcision. In the community circumcision is regularly performed by lay, and sometimes un-trained, personnel and it is restraint which is commonly used during the procedure not anaesthesia. It is risky and complex to anaesthetise a young child but two adults can easily overpower an infant. The procedure does not always end safely and there are deaths, thankfully rarely, though these are recorded as “following circumcision” not “caused by circumcision” and the cause of death is always recorded as loss of blood, cardiac arrest or even sudden infant death syndrome. Each year the NHS treats over 100 boys from babies to teenagers for life threatening complications that are the result of circumcisions. These are not just treatments for an infection but sometimes involve surgery to ensure that the adult who the child will become has some kind of sex life. The NHS is understandably cagey about the figures that they release given the politically sensitive nature of the injuries. But please remember that these are children with no chance of making an informed choice and that is why there is such a rush. It is much harder to persuade an adult to consent to dispense with part of his penis.

Consent.

Babies do not come into the world crying out to have parts of them chopped off. Therefore we can say they don’t expressly choose to be circumcised. Babies cannot be said to tacitly consent because they do not express a preference, as they have no idea of their options or what sex is about. Can a doctor rely on implicit or implied consent? For example consenting to one medical procedure, say the removal of your appendix, might imply to a doctor that if they found that a section of your bowel was infected you would be happy to have it removed at the same time. As we have seen a baby cannot consent to any medical procedure and if there is no medical necessity then there should be no surgery and no reason for further surgery. Lastly there is presumed consent. This could be expressed as an assumption that to have been circumcised is what the baby or young child would have wanted when he was older. There is, however, no way to know what a person will want in the future. So this form of consent is not consent at all, it is merely forcing a choice on someone else.

If an adult were to attend hospital for a medical procedure and while under anaesthetic the doctor carried out a circumcision for no medical reason and without the informed consent of the patient this would make the doctor liable for damages in the civil courts. A man circumcised when he was a child could, as an adult, seek redress in the civil courts. Could circumcision be considered a crime? There being no medical necessity for the amputation of healthy tissue, circumcision, as it cuts through the full thickness of the skin, is a wounding under the Offences Against the Person Act 1861: a wounding is a criminal offence which is treated with great seriousness by the authorities. So where does the protection which the rest of us enjoy start? At what age do we start to protect little boys?

There is evidence of the psychological harm caused by circumcision. The British Medical Association and the mental health charity Mind both recognise this yet still a tolerance is extended to circumcision. Those in favour of circumcising young boys will be jumping up and down by now crying where is the evidence? There is plenty of anecdotal evidence building up as more and more men like me come forward and complain about what has been done to them, the men concerned come from all faith backgrounds or have no fixed belief.  The question I would like to pose to those in favour of circumcising children is where are the studies that show that no one is ever harmed by circumcision? There are of course none.

Even if you accept the recent studies about the protective effect against HIV provided by circumcision, it does not justify protecting a child from a disease he is unlikely to be exposed to through sexual activity until puberty; at which time the child concerned can make an informed choice about the balance between risk and any potential benefit. Circumcising an adult is relatively risk free, anaesthesia is practical and less dangerous. During infancy the foreskin is fused to the glans of the penis and the danger of removing too much tissue, or the wrong tissue is very real. After puberty the penis is fully developed, the foreskin has separated from the glans and the whole structure is properly defined and easier to operate on. An adult can also make a fully informed choice.