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.
- 1 Introduction of circumcision as a medical practice
- 2 Twentieth century
- 3 Reduction of practice
- 4 Legal matters
- 5 International human rights law in the United Kingdom
- 6 The ethics of non-therapeutic circumcision
- 7 General Medical Council
- 8 The guidance of the British Medical Association
- 9 Symposia
- 10 A source of information and aid
- 11 Circumcision deaths
- 12 Conclusion
- 13 References
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.
Sir Jonathan Hutchinson (1828 – 1913) was an English surgeon, dermatologist, ophthalmologist, pathologist and venereologist. Darby describes Hutchinson as a puritanical and gloomy Quaker who disapproved of masturbation on moral grounds. Sir Jonathan advocated circumcision to prevent syphilis.
Nathaniel Heckford, a paediatrician 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.
Sir Jonathan Hutchinson started to promote circumcision to prevent masturbation in 1890. He first published A Plea for Circumcison,, followed by On circumcision as a preventive of masturbation.
Sir Jonathan was not yet done. He published yet another article On Circumcision in 1893.
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. The practice of male circumcision was well established in the United Kingdom as the twentieth century began.
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.
Rickwood et al. (2000) reported that the incidence of boys circumcised reached 35 percent by the early 1930s.
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."
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.
Phimosis diagnosis issues
Fewer boys were being circumcised so there were more intact 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.
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." 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." 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. 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.
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.
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.
Decline in circumcision practice continues
Rickwood & Walker (1989) reported that 21,000 circumcision were done annually on boys under 15 years of age, so Cathcart et al. (2006) are finding a reduction of 53 percent, 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.
Early Development of circumcision law
A 1985 decision of the Law Lords ruled:
Having regard to the reality that a child became increasingly independent as it grew older and that parental authority dwindled correspondingly, the law did not recognise any rule of absolute parental authority until a fixed age. Instead, parental rights were recognised by the law only as long as they were needed for the protection of the child and such rights yielded to the child's right to make his own decisions when he reached a sufficient understanding and intelligence to be capable of making up his own mind.
Gillick affirmed the right and duty of parents to protect their child.
Sebastian Poulter, a legal writer, in a book entitled English Criminal Law and Ethnic Minority Customs (1986), stated:
"The basic right to bodily integrity which everyone possesses under the English common law means that any unlawful interference in this right amounts to an assault or battery, at the very least, and might in appropriate circumstances entail the statutory offence of grievous bodily harm. The question raised in cases of circumcision, excision or infibulation is whether the operation can be justified as constituting lawful as opposed to unlawful interference with this right."
"...although the matter is not entirely free from doubt, it seems that a parent may equally authorise a non-therapeutic operation, provided it is not actively against the child's interests. This would appear to have been the basis upon which the vast majority of male infants have been circumcised in this country with impunity from time immemorial.[sic]"
"It thus appears that, at common law, while the circumcision of male infants here is lawful, provided that parental consent has been given, no amount of parental agreement or support can legitimise the circumcision, excision or infibulation of a young girl in this country, unless the operation is for therapeutic purposes."
Poulter's claims are controversial. Recent court decisions cast further doubt on their legitmacy.
Parliament in 1989 passed the Children Act 1989. This is a very extensive act to provide for the care, welfare and protection of persons under 18 years of age. The Children Act 1989 introduced the legal term significant harm. One perhaps unexpected effect of the Children Act 1989 was to bring circumcision cases into family court when parents disagreed about circumcision of a son.
The Law Commission of England and Wales had proposed to recommend that circumcision of male children be made lawful. The late Christopher P. Price, solicitor, submitted a brief to the Law Commission in opposition to the proposal, after which the proposal was dropped.
The Guardian (1999) reported the family law case of Re J (child's religious upbringing and circumcision) in which the Muslim father wanted a son circumcised but the British mother did not. The Court of Appeals stated in part:
The judge said it was not in the best interests of the child to be circumcised, with its risk of pain and psychological damage which the boy would find hard to understand.
He said the boy might be traumatised by the operation. "The operation and the period leading up to it was also likely to be highly stressful to the mother."
Forward into the 21st century
The family law case of Re B and G (children) (No 2) EWFC 3 (2015) was about two children in need of care. This required Judge Munby to consider both male and female circumcision. Judge Munby realised that male circumcision inflicted at least as much harm as lesser forms of female circumcision. This caused him to rule that male circumcision caused significant harm, which now allows courts to issue care orders to prevent male circumcision.
The case of L and B (2016) was a case in which parents disagreed about the circumcision of two boys. The Muslim father wanted the boys circumcised, however the court ruled that no order should be issued so the boys could decide for themselves when they are of age. In this highly significant case, Mrs. Justice Roberts took the decision away from either parents and gave it to the boys, thereby recognising the boys' right to self-determination. Her conclusion is entirely consistent with the rights of the child under human rights law. Her order also is entirely in accord with Resolution 1952 of the Council of Europe.
International human rights law in the United Kingdom
United Nations multi-lateral human rights treaties
The UK signed the International Covenant on Civil and Political Rights (ICCPR) on 16 September 1968 and formally ratified the ICCPR treaty on 11 December 1968. Article 2 of the ICCPR requires the UK to apply and enforce the provisions of the ICCPR within its territory. See Application of the ICCPR to non-therapeutic circumcision of children for detailed information on the rights applicable to non-therapeutic circumcision of children.
The UK signed the Convention on the Rights of the Child (CRC) on 19 April 1990 an formally ratified the CRC treaty on 16 December 1991. Article 2 of the CRC require the UK to respect and ensure the rights specified in the CRC to each child within its jurisdiction. See Application of the CRC to non-therapeutic circumcision of children for detailed information on the rights applicable to non-therapeutic circumcision of children.
Human Rights Act 1998
The United Kingdom became a founder-member of the Council of Europe on 5 May 1949 and therefore subject to the European Convention on Human Rights (1950). Under that Convention the United Kingdom may be sued in the European Court of Human Rights (Strasbourg) 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.
- Article 8: Everyone has the right to respect for his private and family life, his home and his correspondence.
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.
The case clearly established the right of children in the UK to protection under the ECHR. 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.
Resolution no. 1952 (2013) 'Children's right to physical integrity' of the Parliament Assembly of the Council of Europe, which includes the issue of physical integrity of intersex children for the first time, was adopted on October 1, 2013 following an initiative of the German SPD politician Marlene Rupprecht.
The resolution includes other topics such as the female genital mutilation, the male circumcision for religious reasons, and the submission or coercion of a child to piercings, tattoos or cosmetic surgery.
The resolution calls on all member States to "examine the prevalence of different categories of non-medically justified operations and interventions impacting on the physical integrity of children in their respective countries, as well as the specific practices related to them, and to carefully consider them in light of the best interests of the child in order to define specific lines of action for each of them; initiate focused awareness-raising measures for each of these categories of violation of the physical integrity of children, to be carried out in the specific contexts where information may best be conveyed to families, such as the medical sector (hospitals and individual practitioners), schools, religious communities or service providers; [...]."
This first resolution of its kind by a European institution is not legally binding, but an important signal for further debate and action. It shifts the approach of the point of view of the topic from the current medical domain towards a human rights approach and identifies the right to bodily integrity, autonomy and self-determination. It calls the for the end of non-therapeutic cosmetic medical and surgical interventions.
The ethics of non-therapeutic circumcision
The Journal of Medical Ethics (London) devoted its entire July 2013 issue to the question of non-therapeutic circumcision of children, where a variety of views are presented.
General Medical Council
The General Medical Council (GMC) regulates medical practitioners in the United Kingdom.
The GMC issued an "interim guidance" on the [non-therapeutic] circumcision of male children in 1997.
The GMC emphasises the importance of protecting children and young people, but has not prohibited non-therapeutic circumcision of non-consenting minors.
Although the UK has been a member of the Council of Europe, a human rights organisation since 1949, a state-party to the ICCPR since 1976, and the CRC since 1991, the General Medical Council has not revised its policies and procedures to recognise the human rights of child patients to the physical security of their person.
The guidance of the British Medical Association
The British Medical Association (BMA) is a medical trade association. It represents and protects the interests of its doctor-members. Unlike American medical trade associations, the BMA do not claim to be an authority on medical science. Its advice to members address ethical and legal issues to assist members in staying out of legal difficulties. The BMA have provided several statements regarding child circumcision to inform its members since 1996:
The case of Re J (1999), Re S, and the Human Rights Act 1998 caused the BMA to revise its guidance to doctors and issued a new guidance in 2003.
Keele University law professors Fox & Thomson 2005 reviewed the 2003 BMA statement and cited legal deficiencies in that statement. The BMA accepted the criticism, so the guidance was further revised in 2006.
- 2003 (with changes in 2006 indicated) The law & ethics of male circumcision - guidance for doctors
The cases of Re R and B and Re L and B (CHILDREN) so alarmed the BMA's lawyers that a new guidance was issued in 2019. The new guidance advises extreme caution regarding performance of non-therapeutic circumcision of boys.
The 2019 BMA guidance regarding non-therapeutic circumcision of boys is divided into twelve “cards”. Card Four discusses law. Human rights law is recognised but the BMA fail to understand the significance of human rights law. The BMA do not clearly state that human rights law grants rights to children which helps to define the best interests of the child and should be respected and protected.
The United Kingdom has been the site of several symposia regarding sexual integrity.
- The Fifth International Symposium convened at the University of Oxford, Oxford, England, United Kingdom on 5-7 August 1998.
- The Tenth International Symposium on Circumcision, Genital Integrity and Human Rights convened at the University of Keele, Keele, Newcastle, Staffordshire, England, United Kingdom on September 4-6, 2008.
- The Fourteenth International Symposium on Genital Autonomy and Children's Rights convened at the University of Keele, Keele, Staffordshire, England, United Kingdom on September 14-16, 2016.
A source of information and aid
15 Square is a registered charity that provides information and aid to parents and both intact and circumcised males. The name refers to the approximate area of the male foreskin in square inches. 15 Square is based in Stone, Staffordshire.
Gairdner (1949) reported 16 deaths per year. Death from circumcision still occurs.
- Amitai Moshe, seven-days-old, stopped breathing and died after having been circumcised by a mohel (2007), who was a member of the Initiation Society, at Golders Green Synagogue in North London. It was thought that the infant had cardiac arrest, perhaps brought on by the painful circumcision.
- Celian Noumbiwe, a nine-week-old baby, died in his mother's arms in 2007, after circumcision surgery at a doctor's surgery in Reading, apparently from loss of blood.
- Goodluck Caubergs, four-weeks-old, bled to death in Oldham after Grace Adeleye circumcised him in April 2010. Adeleye was found guilty of manslaughter by gross negligence at Manchester Crown Court.
- Raju Miah: Death by circumcision. July 1991, Birmingham, England, United Kingdom.
- Boma Oruitemeka: Death by circumcision, severe hemorrhage. 1990, London, England, United Kingdom.
The BMA (2019) reports that the NHS therapeutically circumcises about 10,000 boys under 18-years-of-age per year.
The incidence of non-therapeutic circumcision of boys in the United Kingdom has been substantially reduced from its former peaks in the 1930s and early 1940s. Non-therapeutic circumcision of boys remains lawful provided that both parents grant consent. The practice seems to be concentrated among ethnic minorities. Ethical and human rights concerns about the surgery persist.
Non-therapeutic circumcision usually is not covered by the NHS, so parents must find a private medical or non-medical operator such as a mohel to perform the foreskin amputation and must pay the fee out of pocket as third-party payment is not available. Given the recent legal cautions uttered by the BMA, it may not be easy to find a medical practitioner willing to accept the risk.
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Listen to those with parental responsibility and give careful consideration to their views. You are not obliged to act on a request to circumcise a child, but you should explain if you are opposed to circumcision other than for therapeutic reasons. You should also tell those with parental responsibility that they have a right to see another doctor.
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