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For many centuries, circumcision has incited great fervour in opposing parties debating whether the medical benefits of the procedure outweigh any potential psychological side-effects resulting from it. Admittedly, in the world of medical ethics the question may not quite polarise opinion as widely as would a question on end-of-life decisions and terminal care, yet for one obvious reason alone it remains as pertinent an issue to a large proportion of the world's population today — religion; Jews and Muslims are renowned for the religious obligation to circumcise newborn boys at birth, yet still this issue is often denigrated to the realms of humour and satire, most commonly aided by phrases such as ‘the cruellest of cuts’ and ‘the snip’.
Medically, circumcision is the removal of the sleeve of skin and mucosal tissue which normally covers the glans of the penis, known as the foreskin. The word circumcision derives from the Latin circum (meaning ‘around’) and caedere (meaning ‘to cut’). It is one of the oldest surgical operations known to have been performed, with the earliest available records dating this ancient procedure back to at least 6000 years BC, and anecdotal evidence suggesting it as a rite of puberty in aboriginal tribes before 10 000BC.1
There are many reasons why circumcisions are still carried out today. These vary from medical and health indications right through to the adherence of cultural and religious obligations. Traditionally, the US medical establishment promoted male circumcision as a preventative measure for an array of pathologies including reduced risks of penile cancer, urinary tract infections, sexually transmitted diseases, and even cervical cancer in sexual partners.2,3 This consequently led to the advocating of routine neonatal circumcision. However, in recent times this notion has attracted great controversy, with opponents questioning the true extent of the documented benefits.
In view of this ongoing debate, in its latest policy, the American Academy of Paediatrics (AAP) Taskforce on Circumcision affirms that although current scientific evidence demonstrates potential benefits of neonatal male circumcision, the data is not substantial enough to recommend routine neonatal circumcision.4 Notably, these recommendations were made prior to research carried out earlier this year which purported to show that circumcision could reduce sexual transmission of HIV from women to men by 60%.5 This consequently led the World Heath Organisation (WHO) to describe the efficacy of circumcision as ‘proven beyond reasonable doubt’, and they now recommend routine circumcision in countries most at risk from epidemics of AIDS. It is estimated that in the next 10 years male circumcision in Africa could avert a staggering 2 million new HIV infections and 300 000 deaths alone.6,7
Having noted the results of these recent randomised controlled studies in Africa, the American Urological Association have stated that although the results of studies in the African nations may not necessarily be extrapolated to men in the US at risk of HIV infection, they would recommend circumcision as an option for its health benefits.8 Nevertheless, despite what current and any subsequent policies may dictate, this whole controversy is only applicable to those individuals who have an element of choice in the matter. For those in whom it is a religious necessity, the debate holds no value or significance; for the religious, the matter remains purely academic.
In Judaism, the Covenant of Circumcision — the Brit Milah — is one of the most universally observed commandments. The commandment to circumcise was a covenant made with Abraham and is recorded in Genesis 17:10–14, reading:
‘And God spoke to Abraham saying: … This is my covenant which you shall keep between me and you and thy seed after you — every male child among you shall be circumcised.’9
The biblical explanation for this commandment states quite clearly that the circumcision acts as an outward physical sign of the eternal covenant between God and the Jewish people. The religion decrees the penalty of spiritual excision, or kareit, for a person who is uncircumcised regardless of how observant they have been otherwise of the laws of Judaism.
The Jewish circumcision is routinely performed on the eighth day of the child's life and can only be performed during daylight hours. It can, however, be postponed for health reasons and Jewish law states that when the child's health is an issue, circumcision must wait until 7 days after the child is deemed fit enough to undergo the procedure. It is forbidden to postpone the Brit Milah for any reason other than the health of the child and it can even be conducted on the Jewish holy days of Shabbat and Yom Kippur.
The circumcision itself must be performed by a Mohel, a pious, observant Jew educated in circumcision techniques as well as in the relevant Jewish law and tradition. Circumcision performed by any other individual does not qualify as valid regardless of whether a rabbi is presiding over it. This is because the removal of the foreskin is itself a religious ritual that must be performed by someone religiously qualified.
In Islam the performance of circumcision is one of the rules of cleanliness. Islam is a religion that encompasses all aspects of life and circumcision is an act pertaining to the ‘Fitrah’. Fitrah is an Arabic term used to represent the innate disposition and natural character and instinct of the human creation. Prophet Muhammad is reported to have said:
‘Five are the acts quite akin to fitrah: Circumcision, shaving the pubic hair, cutting the nails, plucking the hair under the armpits and clipping (or shaving) the moustache.’10
As regards the juristic views on circumcision, many Muslim scholars maintain that circumcision is an obligatory necessity with others stating that it is not obligatory but a highly recommended practice.
Male circumcision as defined by Islamic Law (Shariah) is the removal of ‘the round portion on the rim, above the conical vascular body of the penis’. The religion recommends performing circumcision at an early age. Ideally, the chosen time is the seventh day after birth, but it can be carried out up to 40 days after birth or thereafter until the age of 7 years, depending upon the health of the infant or child at the time. For Muslims, aside from the many highlighted medical benefits of circumcision, the wisdom of performing such an act is highlighted in the Qur'an (holy book) which states:
‘It is the basis of inbred nature, a symbol of Islam, an indication of the law of the Lord, and the attainment of the true society.’11
According to Muslim belief, the prophet Abraham was the first person to perform circumcision, and it has continued thereafter as a highly recommended practice of the messengers. ‘Abraham circumcised himself at the age of eighty, using a hatchet’. God says, ‘then we inspired you: Follow the creed of Abraham.’11 Circumcision, therefore, is a practice which Muslims, generation after generation, observe and are accustomed to. The circumcision does not constitute a part of a religious ceremony, and therefore unlike Judaism, can be carried out by any appropriately qualified personnel.
There are several surgical techniques that can be employed in the circumcision of the neonate. The most common devices used to date are the Gomco clamp (67%), the Plastibell device (19%) and the Mogen clamp (10%).12 The majority of Islamic circumcision service providers in the UK currently use the Plastibell technique as their preferred method of circumcision. This technique induces tissue necrosis by means of suture compression of the foreskin over a plastic ring that protects the glans; within 7 days the ring separates and the skin sloughs off.
The birth of a Muslim/Jewish boy brings with it the added pressures for the parents of arranging the obligatory circumcision. It comes as an absolute surprise that even in the modern multicultural era in which we live, these parents still have a limited number of potential service providers. With demand for services far outweighing the current supply, an unhealthy balance of compromise is created for the parents. A lucrative private sector is currently the only available choice and this in itself leaves parents vulnerable in acceptance.
In an ever-increasing consumerist society, many parents are inadvertently forced to turn a blind eye on many fronts in order to get the best ‘deal’ possible. This is purely a monetary benefit with many parents having to compromise on aspects such as experience and professionalism. Every parent should have the right to ensure that the procedure is carried out by an experienced surgeon conforming to agreed regulatory standards. Unfortunately, the reality does not quite conform to the above expectations.
Much more commonplace current UK practice is a doctor travelling over 130 miles to a house-cum-operating theatre fully equipped with a dining–cum-theatre table. With families arriving with their precious newborns every 20 minutes or so, a typical day can involve up to eight circumcisions. Whatever technique is employed, circumcision remains a surgical procedure, and like any surgery it has associated with it risks. Circumcision performed by inexperienced practitioners leads to a higher rate of subsequent errors and complications.13
A typical follow up for these babies includes a revisit the following day, to make sure there are no immediate complications. The parents are then verbally educated on how to provide continued care for their loved ones and discharged back into the community. The subsequent burdens of any complications are then left for the NHS-led services to address. The incidence of these complications is controversial, worsened by the wide disagreement that exists on what actually constitutes a complication. In any case, many researchers estimate that a realistic rate of medical complications from neonatal circumcision ranges from 2% to 10%.14
If it is accepted that circumcision should not be regarded as a minor procedure, then the modern day NHS should endeavor to address the health needs of its nation. Multicultural Britain should cater for the medical needs of the many different cultural and religious groups that make our country a truly blissful cosmopolitan centre. The GMC at present does not prohibit any doctor from performing religious circumcision although they state that they will take action if they are carried out incompetently.15 Furthermore they do not clearly define the minimum standards required of doctors carrying out this procedure and also provide inconclusive advice pertaining to financial charges and facility requirements. This current medico-legal greyness directly leaves parents open to exploitation by the relatively unregulated circumcision service providers currently in practice in the UK.16 Would it therefore be fair to assume that the NHS is currently failing those individuals for whom a religious neonatal circumcision is obligatory?
While accepting that the NHS is currently overwhelmed, there remains a great necessity for practical manifestations such as religious circumcision to be incorporated into it in some way, shape or form. Whether the best method of achieving this would be to offer circumcision on religious grounds as part of the NHS's remit of free treatment at the point of care or whether to audit and regulate the practices of current circumcision practitioners with more rigor, the decision remains in the hands of the politicians heading the state. With Muslims now constituting established minority ethnic groups in western societies, in the current political and social context, an inclusive attitude may be important in preventing marginalisation of Muslims and further reducing well recognised health disparities that exist as a result of these prejudices.17
In summary, at least from a medical point of view, our duty as doctors should remain the welfare of patients; it is not our duty to tell a patient which decision to make, but merely to carry out said decision to the best of our ability. Perhaps what is needed is a principled and collaborative all-encompassing healthcare system that complements the diversity of the UK in the 21st century.