We represent the victims of a failure to protect children from unnecessary genital surgery. Our concern is that the medical authorities and law enforcement agencies continue to tolerate a practice, the non-therapeutic circumcision of males that violates the autonomy of children.
Tomorrow the 6th of August is the 150th anniversary of the Offences Against The Person Act 1861. Although much of the detail in the Act has been repealed it remains the basis of the criminal law concerning assault, wounding and actual bodily harm.
We would argue that a child who has no disease, no injury or no dangerous abnormality has no need of any type of treatment or irreversible surgery. Irrespective of any proxy consent from parents soliciting treatment, any surgery that is performed without the patient’s personal consent and without therapeutic need is clearly an assault. Any cut made without consent or therapeutic need “that breaks the continuity of the skin” is a wounding under the Act. The excision of a normal healthy body part which is performed without such therapeutic need or consent would in any other circumstances be considered to be actual bodily harm. There can be no defence of “reasonable surgery” where there is no disease or injury to treat.
The current attitude of the medical authorities towards circumcision is inappropriate in an era where children’s individual rights are increasingly recognised. Adults have a duty of care and responsibility to nurture their children but this does not extend to a power to authorise non-therapeutic removal of a body part, however trivial a doctor may consider it to be. It is hard to see how protecting children from unnecessary genital surgery is not in the public interest when prosecutions for touching the genitals of children are vigorously pursued. In a non-therapeutic circumcision such touching is done with impunity.
Numerous studies that have been carried out and published since the middle of the twentieth century show the male foreskin to be a vital component of the normal genitals and we call upon all medical practitioners to recognise the significance of such studies. Often patients who can consent are not told that there is a possible downside to circumcision. It may well be that a man with a severe pathological phimosis will have a more enjoyable sex life after circumcision but patients should be told that there are other less invasive ways of treating phimosis and they must be informed that some men report sexual experience to be worsened following circumcision.
Treatment of children should be selected to be the least restrictive to their future options. A child left intact and unhappy with his foreskin has an easy remedy whereas a child who has been circumcised before being able to give or withhold his consent has no such remedy available to him.
To quote the British Medical Association’s own guidelines on the subject of male circumcision:
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.
It can never be in the best interests of the child to have a normal healthy body part removed. To do this to non-consenting children ignores the rights of the child to protection and freedom from harm.
Doctors have argued that it is the child’s religion that should be respected and therefore he is entitled to be circumcised. This ignores the fact that a child who is not competent to consent to surgery is unlikely to have reached a reasoned and considered position on religious belief and so has no religion to be respected.
In the fifteen years since we last wrote on this subject [BMJ. 1996 February 10; 312(7027): 377.]. We felt that any caring professional noting that men objected to treatment that was damaging – and for which in most cases there was little if any therapeutic need – would have seen the need to cease the practice. But nothing has changed. Thousands of boys have been needlessly deprived of functional tissue, and a complete body, and also an unknown number have been left with some degree of psychological damage. Your continued support of the practice of non-therapeutic circumcision confers a degree of credibility on a practice that is invariably to some degree harmful and potentially very harmful. At the very least circumcision significantly alters the appearance of the penis and denies both partners in the act of intercourse the intromission function of the foreskin. Your members, as you quite rightly point out in your guidelines, are operating in an uncertain legal climate and it is our aim to hold them to account for the harm they are causing or risking, the National Health Service resources they are squandering and the crimes they may be committing. With our supporters we will seek to achieve redress for such victims through the courts by setting up a fund to fight for the rights of boys and the men they will become. We insist that your organisation alters its guidelines so that boys with no disease or injury who are not capable of giving competent informed personal consent to an elective treatment are left intact to enjoy a full and healthy life of which your members are currently depriving them.
We would welcome an opportunity to meet your Chair of the Ethics Committee, before 6 December 2011 to discuss the issues raised in this letter.
Richard Duncker, John Warren, Peter Ball and David Smith