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 The Act is very much alive and well, although much of the Act has been repealed it is still one of the cornerstones of our criminal laws that protect us from assault, wounding and harm.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.

Cardiff demo

Men do complain is proud to have stood shoulder to shoulder with members of NORM-UK and others outside the British Medical Association’s annual representatives meeting in Cardiff.
The ethical, medical and legal issues surrounding  the circumcision of male children not competent to consent are issues that will not go away. The number of enlightened doctors is growing and the numbers of doctors from the dark ages is falling.
See the BBC news web site for a report on the protest in Cardiff. In the report Dr Antony Lempert details the ethical anomalies and dangers of cutting the genitalia of non-consenting children.

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.

U.N. demands the end of female genital mutilation

February the sixth is the day the United Nations has chosen to promote its campaign to protect females from genital mutilation. There is only one thing wrong with this excellent campaign and that is the word female. To discriminate on the grounds of gender in any other area of life would not be tolerated, so why are males discriminated against when it comes  to genital mutilation? The answer is that the myths surrounding the cutting of boys’ genitals are still not seen for the myths that they are.

End FGM Day graphic

The current excuse for circumcising children is that the circumcision of males will slow the spread of HIV. Circumcision may be partially effective (the science is not universally accepted) but there is still no reason to circumcise healthy non-consenting children as they are not sexually active and therefore need no protection from sexually transmitted diseases; circumcision can wait until the child in question can give his proper informed consent to this irreversible surgery.

UN BuildingThere is a myth that cutting the genitals of healthy boys is somehow acceptable and the cutting of girl’s genitals is unacceptable. There may be differences between the sexes but the violation starts the moment someone takes hold of a shard of glass, razor blade or scalpel and uses it to cut a healthy child’s genitals. This is not an issue of competitive suffering. Some girls lose less than some boys and vice versa, that is the not the point. Just like the crime of rape the violation is the lack of consent. It makes little difference whether it is a man or a woman who is raped it is that the person in question has not consented. The U.N. should promote equal treatment and protection for males and females, the U.N. should not discriminate against anyone in any area of life on the grounds of their gender.