4.19 Male Circumcision

1. Introduction

Unlike female genital mutilation, male circumcision is not an illegal act in itself and is not normally a child protection or safeguarding issue. This procedure provides practitioners in Buckinghamshire with an understanding of when male circumcision may raise safeguarding children concerns and how to respond if such concerns arise.

2. What is Male Circumcision

Male circumcision is the surgical removal of the foreskin on the penis. The procedure is usually requested for social, cultural or religious reasons (e.g. by families who practise Judaism or Islam). Additionally, there are 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.

Male circumcision is a non-reversible procedure.

3. Circumcision for Therapeutic or Medical Reasons

It is rare for circumcision to be recommended for medical reasons in boys. This is because other less invasive and less risky treatments are usually available. See Circumcision in Boys (NHS). Doctors should be aware of this and reassure parents accordingly.

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

Doctors/health professionals should ensure that any parents seeking circumcision for their son in the belief that is 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 himself, if Gillick competent.

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.

4. Non-therapeutic Male Circumcision

Male circumcision that is performed for any reason other than physical clinical need is termed ‘non-therapeutic male circumcision’ or NTMC.

See also Section 7, Non-therapeutic Male Circumcision – Principles for Good Practice.

5. Legal Position

Practitioners may assume that the circumcision procedure (therapeutic or non-therapeutic) is lawful provided that:

• it is performed competently, in a suitable environment that reduces the risk of infection, cross-infection and contamination;
• it is in the child’s best interests;
• there is valid consent from both parents with parental responsibility (or, in cases of dispute, it is authorised by a court) and the child, if Gillick competent.

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

6. Consent

Consent for circumcision is valid only where the people (or person) giving consent have the authority to do so and understand the risks and implications, including that it is a non-reversible procedure.

The British Medical Association (BMA) and General Medical Council (GMC) recommend that consent should be sought from both parents having parental responsibility. Non-therapeutic male circumcision has been described by the courts as an ‘important and irreversible’ decision that should not be taken against the wishes of a parent. It follows that where a child has two parents with parental responsibility, doctors considering circumcising a child must satisfy themselves that both have the necessary parental authority and have given valid consent. Where people with parental responsibility for a child disagree about whether the child should be circumcised, the child should not be circumcised without the leave of a court.

7. Non-therapeutic Male Circumcision – Principles of Good Practice

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

• the child’s own ascertainable wishes, feelings and values
• the child’s ability to understand what is proposed and to 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 (physical and emotional)
• the views of the parents and family
• the implications for the child and family of performing, and not performing, the procedure
• relevant information about the child and family’s religious or cultural background.

8. Medical Response

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 circumcisions have legal implications for the doctor responsible. In responding to requests to perform male circumcision, doctors should follow the guidance issued by professional organisations:

• General Medical Council
• British Medical Association
• Royal College of Surgeons
• British Association of Paediatric Surgeons.

9. Recognition of Harm or Abuse

Circumcision may constitute significant harm to a child if the procedure was carried out in such a way that :

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

Significant harm is defined in Section 31 Children Act 1989 and is referred to in accordance with the statutory guidance Working Together to Safeguard Children.  Where it is believed that a child has suffered, or is likely to suffer, significant harm, concerns should be shared with Children’s Social Care as a referral (see Referrals).

Harm may stem from clinical practice being incompetent (including lack of anaesthesia) and/or clinical equipment and facilities being inadequate, not hygienic, etc. The professionals most likely to become aware that a boy is at risk of, or has already suffered from, harm from circumcision are health professionals (GPs, health visitors, A&E staff or school nurses), and childminding, day care and teaching staff. Others with responsibilities or roles within the wider community may also become aware, e.g. members of faith groups or sports/voluntary groups.

10 Multi Agency / Service Response

If anyone becomes aware, through something a child discloses, or another means, that the child has been, or may be, harmed through male circumcision, a referral must be made to children’s social care.

Children’s social care should assess the degree of harm and determine whether the likely or actual harm is significant for the child in question. Possible risks for other children in the family (including unborn babies) should also be considered

Where a criminal offence is suspected, e.g. sexual abuse or unjustified deliberate injury, the police must also be notified.

If any professional considers that their concerns are not being responded to appropriately, the Escalation, Challenge and Conflict Resolution Procedure should be followed.

If concerns relate to a professional or other person in a position of trust, concerns must be discussed with the Local Authority Designated Officer (LADO).

11. Community / Religious Leaders

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