London – Male circumcision is one of the simplest operations. Indeed, it’s deemed so simple that in Britain you don’t even need a medical qualification to perform it on newborns or children.
Circumcision has been practised for centuries, with the earliest evidence dating from the time of the pharaohs.
Yet it’s become a highly controversial procedure, and one that stirs strong passions – the actor Russell Crowe famously caused a Twitter storm in 2011 when he described the procedure as ‘barbaric and stupid’. He later apologised.
But medical experts are increasingly divided over whether circumcision should be performed.
On one side of the debate is the US Centers for Disease Control and Prevention (CDC) – America’s leading public health organisation. In December it issued draft guidelines recommending the procedure for all boys, arguing circumcision protects against the risk of urinary tract infections in infants and sexually transmitted diseases in adulthood. This may be because it reduces the risk of bacteria lodging within the foreskin and reduces the risk of tiny tears to the foreskin that become an entry point for infections.
The CDC guidelines also suggest that circumcision lowers the risk of men contracting herpes and the human papilloma virus, in turn protecting them against penile cancer – and cutting the risk of their passing the virus on to women, reducing their risk of cervical cancer.
The CDC concluded that ‘the scientific evidence is clear that the benefits outweigh the risks of physical or mental harm that may be involved’.
Those in the ‘no’ camp say all this is based on flawed studies from Africa that have no relevance to Western populations. Furthermore it ignores research that shows no link between circumcision and the risk of sexually transmitted diseases.
Over the past five years, doctors’ groups in Sweden, Norway, Denmark, Finland, Holland, Iceland and Australia have spoken out against the procedure.
Their various national organisations have called for bans on the op unless it is needed on strictly medical grounds.
'A VIOLATION OF CHILDREN'
The Council of Europe recently passed a resolution condemning the practice as a ‘violation of the physical integrity of children’. It said circumcision can cause lifelong trauma, diminish sexual satisfaction and put children at risk of lasting physical damage.
And while the World Health Organisation advocates circumcision in regions with high levels of heterosexual HIV transmission – such as in Africa – it also warns that it can cause pain, excessive bleeding, excessive skin removal, scars and deformation.
The latest salvo in this debate has just been fired by Danish researchers, who claim circumcision before the age of five can double a boy’s risk of autism. Writing in the Journal of the Royal Society of Medicine in January, the researchers suggested this may be linked to stress caused by the pain of the procedure.
The study was led by Morten Frisch, a professor of sexual health epidemiology at the Statens Serum Institut, Copenhagen. ‘Circumcision trauma in infancy or early childhood might carry an increased risk of serious neuro–developmental and psychological consequences,’ he says.
Professor Frisch adds that, although painkillers are often used: ‘None of the most common drugs used to reduce circumcision pain completely eliminates it. Some boys will endure strongly painful circumcisions.’
However, the problem with statistical studies such as these is they only show a potential link, and don’t prove a causal link.
Despite male circumcision’s widespread use and long tradition, the experts cannot even agree on when it is best to perform the surgery. While the Danish study suggested that children below the age of five are most at risk from psychological damage, a study by the University of Washington published last May suggested the procedure should be done in the first year of life. After this, said the researchers, infants were 20 times more likely to suffer complications.
Dr Charbel El Bcheraoui, the epidemiologist who led the study, says: ‘We assume this is probably because aftercare for the children’s surgical wounds is more complicated between the ages of one and ten.’ This is mostly because younger babies are less active and less likely to damage the wound site.
WHEN CIRCUMCISION IS JUSTIFIED
Circumcision was rarely practised in Britain until the 19th century, when medical practitioners started to pronounce that it was more hygienic. As a result, routine medical circumcision became widespread in England.
It gradually became less common from the Thirties onwards, as many doctors began to argue that it had no real medical benefit in the vast majority of cases.
The figures began rising again in the Seventies, with the growth of UK Muslim and African Christian populations. Nearly one in five British boys is currently circumcised, compared with four in every five in the US.
In England and Wales, the NHS guidelines say that it will only perform circumcision on children for medical reasons, such as severe phimosis, a tight foreskin that can’t be retracted, or recurrent balanitis, where the tip of the penis and foreskin become inflamed. The NHS does just 10,000 circumcisions a year. In Scotland, there are four NHS surgical theatres that circumcise all children whose parents request it, regardless of their reasons.
Under guidelines set by the Royal College of Surgeons and the British Association of Paediatric Surgeons, circumcision can be performed only by children’s surgeons in NHS operating theatres, where the patient is heavily sedated.
Most circumcisions in the UK are motivated by religious reasons or family tradition and are performed privately, often by GPs.
But circumcision can also be done informally by private individuals, and while it’s illegal in the UK for lay people to tattoo anyone under the age of 18, or to perform surgery on a pet, anybody can lawfully cut the foreskin off a child, even if they have no conventional medical qualifications. Last month, England’s most senior family judge, Sir James Munby, said male circumcision involved ‘significant harm’.
But in a High Court ruling over how councils should protect young girls who are victims of female genital mutilation – considered to be circumcision for girls – Sir James said that the law was ‘prepared to tolerate non–therapeutic [ie, non–medical] male circumcision performed for religious or even for purely cultural or conventional reasons, while no longer being willing to tolerate female genital mutilation in any of its forms’.
CALLS FOR STRONGER REGULATION
But should the authorities be supervising the practice more closely and ensuring it’s performed to medical standards?
Shiban Ahmed, a consultant paediatric surgeon at Alder Hey Hospital, Liverpool, says: ‘Male circumcision became an issue for me because of the number of cases I have seen in hospitals of children who have been harmed by circumcisions performed in GP practices and other places.
‘GPs working privately are doing it with local anaesthetic for around £90, all too frequently while the children are being held down, often screaming in fear.
‘These doctors would not be allowed to perform medical circumcisions, but they are doing cultural and religious ones.
‘The NHS guidelines for the hospital operation are the minimum standards of care for medical circumcision in this country,’ he maintains. ‘It is our duty to safeguard the interests of children. I believe that the operation should either be performed safely, or it should not be done at all.’
Ahmed says he has operated on about 26 children to repair damage done by GPs and, in one case, by an unqualified man posing as a GP. ‘One child had lost the tip of their penis and I had to reconstruct it,’ he says.
A report from Birmingham Children’s Hospital in 2009 said it had admitted 105 children with such difficulties. Ten had been taken into intensive care.
Last April, Taiwo Shittu, 55, was jailed for causing grievous bodily harm after a newborn baby she circumcised had to be rushed to hospital to stop life-threatening bleeding.
Shittu claimed to be a qualified nurse and midwife. She told investigators that over the previous decade she had performed many circumcisions in her south-east London home. The court, which heard she had no professional qualifications, jailed her for 30 months.
The case bears disturbing parallels with the death in 2010 from circumcision wounds of 27-day-old Goodluck Caubergs of Chadderton, Oldham. In 2012, the woman who performed the baby’s operation, Grace Adeyele, was convicted of manslaughter and given a 21-month suspended jail term.
That same year, the British Association for Community Child Health reported on injuries caused by unlicensed circumcision practitioners in Bristol. These included a fractured skull caused by a baby falling off a kitchen table.
The doctors’ insurance association, the Medical Protection Society, warns that GPs who perform circumcisions outside of hospitals ‘need to be aware that the procedure can carry considerable risks’.
However, the Royal College of General Practitioners (RCGP) does not want to prevent unqualified people conducting circumcisions.
As Dr Jonathan Botting, the RCGP’s clinical lead for minor surgery, explains: ‘I am not going to say that you should ban people who are not medically qualified from performing circumcisions, because they may be quite capable of performing what is a very simple procedure.’
Daily Mail