United Kingdom

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The United Kingdom (UK) was the scene of early efforts to promote male circumcision. It influenced the adoption of male circumcision in other English-speaking nations. Later it was the scene of efforts to reduce and eliminate the practice.

While Jews residing in the UK practiced ritual circumcision of boys on the eighth day of life in accordance with the Abrahamic covenant, the practice was nearly unknown among gentiles.

Introduction of circumcision as a medical practice

French physician Claude-François Lallemand (1790 – 1854) recommended circumcision as a treatment for spermatorrhea (excessive, involuntary ejaculation), which was then believed to be a disease. Lallemand influenced later English physicians such as William Acton.[1]

Edward H. Dixon (1845) advocated circumcision to prevent masturbation.[2]

Sir Jonathan Hutchinson (1828 – 1913) was an English surgeon, dermatologist, ophthalmologist, pathologist and venereologist.[3] Darby describes Hutchinson as a puritanical and gloomy Quaker who disapproved of masturbation on moral grounds.[4] Sir Jonathan advocated circumcision to prevent syphilis.[5]

Nathaniel Heckford, a pediatrician at the East London Hospital for Children, wrote Circumcision as a Remedial Measure in Certain Cases of Epilepsy, Chorea, etc. (1865), in which he argued that circumcision acted as an effective remedial measure in the prevention of certain cases of epilepsy and chorea.[6]

Sir Jonathan Hutchinson started to promote circumcision to prevent masturbation in 1890.[4] He first published A Plea for Circumcison,[7], followed by On circumcision as a preventive of masturbation.[8]

Sir Jonathan was not yet done. He published yet another article On Circumcision in 1893.[9]

Sir Frederick Treves (1853 – 1923), a prominent Harley Street surgeon, who is known to us by The Elephant Man film, wrote an operative manual in 1903 to educate other surgeons in the performance of the circumcision amputation.[10] The practice of male circumcision was well established in the United Kingdom as the nineteenth century ended.

The royal family and circumcision

There is a long-standing legend or legends about the royal family and its alleged practice of male circumcision that has long been circulated in the print media and orally. According to the legend:

Queen Victoria believed that she was descended from the Jewish King David of the Bible. She had her sons circumcised in accordance with Jewish practice. After Queen Victoria's death succeeding generations of the royal family continued the practice.
Both Edward VIII, later Duke of Windsor, and Prince Charles were ritually circumcised by Dr. Jacob Snowman, a medical doctor and mohel. The practice ended when Prince Charles and Princess Diana had children. Princess Diana objected to the practice, so Princes William and Harry were not circumcised. Prince George also was not circumcised.

Robert Darby and John Cozijn thoroughly investigated the legend and were unable to verify any of it. Moreover, they showed evidence that it cannot be true.[11]

Although this long standing legend cannot be proved to be true, it was generally believed to be true. It is probable therefore, that many parents had their sons circumcised because the royal family was believed to do it.

Twentieth century

Sir Jonathan Hutchinson (1900) opened the twentieth century with an article advocating male circumcision as a way to decrease the pleasure of sex, and hence to discourage sexual immorality.[12]

Cockshut (1935) published a letter in the British Medical Journal that urged circumcision of all male infants because the "glans of the circumcised rapidly assumes a leathery texture less sensitive than skin." The advantage, according to Cockshut, is that masturbation would be reduced.[13]

Rickwood et al. (2000) reported that the incidence of boys circumcised reached 35 percent by the early 1930s.[14]

Reduction of practice

A national election was held in the United Kingdom at the end of World War II. The Labour Party gained a majority of the seats in Parliament and its leader, Clement Atlee became prime minister. The party leaned to the left and supported social welfare. Aneurin Bevan was Minister of Health. The National Health Service (NHS) was created in 1948 to provide free medical treatment for all. Services were provided based on clinical need, not ability to pay.

Sir James Spence, a prominent senior British paediatrician, urged his younger colleague, Douglas Gairdner, to produce a paper on infant circumcision. The now famous classic paper, The fate of the foreskin: a study of circumcision, was published in the British Medical Journal on Christmas Eve, 1949. The paper reported 16 deaths per year from non-therapeutic infant circumcision and concluded in part: "The prepuce of the young infant should therefore be left in its natural state."[15]

The NHS provides male circumcision when there was a clinical need.[16] There is no clinical need for infant circumcision, so infant circumcision is not provided.[17]

The British Medical Journal, the house organ of the British Medical Association, in an unsigned editorial in 1979, slammed the practice of child circumcision, calling it unnecessary, and citing the danger of contracting staphylococcal infection in the newborn nursery. The editorial reported that the incidence of newborn circumcision in Britain had dropped from one-third in the 1930s to one fifth in 1949, to ten percent in 1963, and to six percent in 1975.[18]

Phimosis diagnosis issues

Fewer boys were being circumcised so there were more foreskinned boys. The general practitioners (GPs) in the UK seemed to be unable to distinguish between true phimosis and developmentally non-retractile healthy foreskin and were referring numerous boys for unnecessary circumcision.

Rickwood et al. (1980) had provided guidance on diagnosis of phimosis. According to Rickwood et al. true phimosis occurs when the foreskin has been attacked by balanitis xerotica obliterans (BXO) (also known as lichen sclerosis). If BXO is not present then true phimosis does not exist.[19]

Several papers critical of phimosis diagnosis practice in the UK were published in the late 1980s and early 1990s. Rickwood & Walker (1989) reported that in the Mersey region (northwest England) "many boys are circumcised for development non-retractability of the prepuce rather than for true phimosis and that in consequence some two-thirds of the operations are unnecessary."[20] Griffiths & Frank (1992) also expressed concern regarding the apparent inability of general practitioners to distinguish between a true phimosis and a developmentally non-retractile foreskin. They pointed out, "Not surprisingly, the diagnostic inaccuracy was greatest when the referring doctor did not examine the patient."[21] Gordon & Collin (1993) attempted to cast some light in the darkness by providing factual information about actual indications for circumcision and how to distinguish between physiological and pathological phimosis.[22] Williams et al. (1993) complained that most of the 30,000 circumcisions that were being done in the UK were on boys under 15. They reported that of 69 boys referred by GPs, 29 had a healthy retractile foreskin, 30 had a healthy non-retractile foreskin, and only 9 had a phimosis requiring circumcision.[23]

In defence of the much criticised British GPs, it should be stated that the data they were provided by Douglas Gairdner regarding development of foreskin retractility was very inaccurate, however this was not known at the time.[24]

Cathcart et al. (2006) collected circumcision rates from 1997 through 2003. They reported a decline in the incidence of circumcision of about 20 percent over the period of their study, with about 10,000 circumcisions of boys per year at the end of the study. They commented that the circumcision rate for boys is still five times higher than the reported incidence of phimosis.[25]

Decline in cirumcision practice continues

Rickwood & Walker (1989) reported that 21,000 circumcision were done annually on boys under 15 years of age,[20] so Cathcart et al. (2006) are finding a reduction of 53 percent,[25] although still much higher than it should be. It should be noted that manual stretching of the foreskin with the aid of topical steroid ointment to relieve phimosis had not yet entered general use.

The 2000 British National Survey of Sexual Attitudes and Lifestyles (Natsal 2000) found that 15.8 percent of British males aged 16 to 44 reported being circumcised. The incidence of circumcision was highest in the men aged 40-44 at 19.6 percent [born 1956-60] and lowest in the group aged 16-19 [born 1981-84] at 11.7 percent. Men of ethnic minorities (except black Caribbeans) were significantly more likely to circumcised than those described as "white". Jews were 98.7 percent circumcised and Sikhs, Hindus, and Buddhists were only 9.8 percent circumcised.[26]

Legal matters

Development of circumcision law

The relevant statutes are the Offences Against the Person Act (1861) and the Children and Young Persons Act 1933.

Human Rights Act 1998

The United Kingdom has long been a member of the Council of Europe and therefore subject to the European Convention on Human Rights. Under that Convention the United Kingdom may be sued in the Court of Human Rights for alleged human rights violations.

Certain parts of the Convention seems applicable to the non-therapeutic circumcision of minor boys:

  • Article 3: Freedom from torture and inhuman or degrading treatment
  • Article 5: Everyone has a right to liberty and security of person.

The case of A v. United Kingdom (1998) involved the beating of a child with a garden cane. The court ruled:

States required to take measures designed to ensure individuals not ill-treated in breach of Article 3 by other private individuals – children entitled to protection, through effective deterrence, against such treatment.[27]

Nevertheless, no known cases have applied international human rights law specifically to the practice of non-therapeutic child circumcision in the UK.

The human rights provisions of the Convention have now been brought into domestic law by the Human Rights Act 1998, so violations of human rights law could be litigated in the domestic courts of the UK.

References

  1. ↑ REFjournal Darby, Robert. Pathologizing Male Sexuality: Lallemand, Spermatorrhea, and the Rise of Circumcision. J Hist Med Allied Sci. July 2005; 60(3): 283-319. PMID. DOI. Retrieved 4 September 2021.
  2. ↑ REFbook Dixon, Edward H. (1845): A Treatise on Diseases of the Sexual Organs. New York: Stringer & Co. Pp. 158-165. Retrieved 9 June 2011.
  3. ↑ REFweb Zhang, Gary (2020). Jonathan Hutchinson, Life in the Fast Lane. Retrieved 4 September 2021.
  4. ↑ a b REFweb Darby, Robert. The crotchets of Sir Jonathan Hutchinson, The History of Circumcision. Retrieved 4 September 2021.
  5. ↑ REFjournal Hutchinson, Jonathan. On the Influence of Circumcision in Preventing Syphilis. Medical Times and Gazette. 1855; 32(844): 542-543. Retrieved 4 September 2021.
  6. ↑ REFjournal Heckford N. Circumcision as a remedial measure in certain cases of epilepsy and chorea. Clinical Lectures and Reports by the Medical and Surgical Staff of the London Hospital. 1865; 2: 58-64.
  7. ↑ REFjournal Hutchinson, Jonathan. A plea for circumcision. Archives of Surgery. 1890; II: 15. Retrieved 4 September 2021.
  8. ↑ REFjournal Hutchinson, Jonathan. On circumcision as a preventive of masturbation. Archives of Surgery. 1890; II: 267-9. Retrieved 4 September 2021.
  9. ↑ REFjournal Hutchinson, Jonathan. On circumcision. Archives of Surgery. 1893; IV: 379-80. Retrieved 4 August 2021.
  10. ↑ REFbook Treves, Frederick (1903): Chapter VI, in: Circumcision. Work: A Manual of Operative Surgery, II.. London: Cassell. Pp. 670-3. Retrieved 4 September 2021.
  11. ↑ REFjournal Darby, Robert, Cozijn, John. The British Royal Family’s Circumcision Tradition: Genesis and Evolution of a Contemporary Legend. Sage. 13 October 2013; DOI. Retrieved 4 September 2021.
  12. ↑ REFjournal Hutchinson J. The advantages of circumcision. The Polyclinic. September 1900; 3(9): 129-131. Retrieved 4 September 2021.
  13. ↑ REFjournal Cockshut RW. Circumcision. BMJ. 19 October 1935; 2(3902): 764. Retrieved 4 September 2021.
  14. ↑ REFjournal Rickwood AMK, Kenny SE, Donald SC. Towards evidence based circumcision of English boys: survey of trends in practice. BMJ. 2000; 321: 792-3. PMID. PMC. DOI. Retrieved 5 September 2021.
  15. ↑ REFjournal Gairdner DMT. The fate of the foreskin: a study of circumcision. British Medical Journal. 1949; 2(4642): 1433-7. PMID. PMC. DOI. Retrieved 28 October 2019.
  16. ↑ REFweb (5 November 2018). Circumcision in men, National Health Service. Retrieved 5 September 2021.
  17. ↑ REFweb (20 November 2018). Circumcision in boys, National Health Service. Retrieved 5 September 2021.
  18. ↑ REFjournal Anonymous. The case against circumcision. BMJ. 5 May 1979; 6172: 1163-64. PMID. PMC. Retrieved 5 September 2021.
  19. ↑ REFjournal Rickwood AMK, Hemalatha V, Batcup G, Spitz L. Phimosis in boys. Brit J Urol. April 1980; 52: 147-60. PMID. DOI. Retrieved 5 September 2021.
  20. ↑ a b REFjournal Rickwood AMK, walker, Jenny. Is phimosis overdiagnosed in boys and are too many circumcisions performed in consequence?. Ann R Coll Surg Engl. September 1989; 71(5): 275-7. PMID. PMC. Retrieved 5 September 2021.
  21. ↑ REFjournal Griffiths D, Frank JD. Inappropriate circumcision referrals by GPs. J R Soc Med. 1992; 85: 324-5. PMID. PMC. Retrieved 5 September 2021.
  22. ↑ REFjournal Gordon, Andrew, Collin, Jack. Save the normal foreskin. BMJ. 2 January 1993; 306(6869): 1-2. PMID. PMC. DOI. Retrieved 5 September 2021.
    Quote: A better understanding of the normal physiology, developmental anatomy, and pathology of the prepuce could prevent the removal of thousands of normal foreskins over the next 20 years.
  23. ↑ REFjournal Williams, Nigel, Chell, Julian, Kapila, Leela. Why are children referred for circumcision?. BMJ. 2 January 1993; 306(6859): 28. PMID. PMC. DOI. Retrieved 5 September 2021.
  24. ↑ REFjournal Denniston GC, Hill G. Gairdner was wrong.. Can Fam Physician. October 2010; 56(10): 986-7. PMID. PMC. Retrieved 5 September 2021.
  25. ↑ a b REFjournal Cathcart P, Nuttall M, van der Meulen J, Emberton M, Kenny SE. Trends in paediatric circumcision and its complications in England between 1997 and 2003. BJS. July 2006; 93(7): 885–890. PMID. DOI. Retrieved 5 September 2021.
  26. ↑ REFjournal Dave SS, Fenton KA, Mercer CH, Erens B, Wellings K, Johnson AM. Male circumcision in Britain: findings from a national probability sample survey.. Sex Trans Infect. December 2003; 79(6): 499-500. PMID. PMC. DOI. Retrieved 5 September 2021.
  27. ↑ REFdocument A. v United Kingdom. [1998 2 FLR 959], Circumcision Reference Library. (1998). Retrieved 7 September 2021.
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