Non-therapeutic penile circumcision of minors: current controversies in UK law and medical ethics

Abstract

The current legal status and medical ethics of routine or religious penile circumcision of minors is a matter of ongoing controversy in many countries. We focus on the United Kingdom as an illustrative example, giving a detailed analysis of the most recent British Medical Association guidance from 2019. We argue that the guidance paints a confused and conflicting portrait of the law and ethics of the procedure in the UK context, reflecting deeper, unresolved moral and legal tensions surrounding child genital cutting practices more generally. Of particular note is a lack of clarity around how to apply the “best interests” standard—ordinarily associated with time-sensitive proxy decision making regarding therapeutic options for a medically unwell patient—to a parental request for a medically unnecessary surgery to be carried out on the genitalia of a healthy child. Challenges arise in measuring and assigning weights to intended sociocultural or religious/spiritual benefits, and even to health-related prophylactic benefits, and in balancing these against potential physical, functional, and psychosexual risks or harms. Also of concern are apparently inconsistent safeguarding standards being applied to children based on their birth sex categorization or gender of rearing. We identify and discuss recent trends in British and international medical ethics and law, finding gradual movement toward a more unified standard for evaluating the permissibility of surgically modifying healthy children's genitals before they can meaningfully participate in the decision.

Comments by opponents on the British Medical Association’s guidance on non-therapeutic male circumcision of children seem one-sided and may undermine public health

“…Lempert et al [ 19 ] support particular statements in the BMA’s guidance[ 1 ] disfavoring NTMC. They refer to negative NTMC policies by Dutch (Kindermishandeling en huselijk geweld [KNMG]: Royal Dutch Medical Association), Danish and Finish medical bodies.…”

“…Various local bodies fighting the epidemic have also endorsed the procedure[ 21 - 26 ]. But presumably Lempert et al [ 19 ] had in mind socio-economically advantaged countries such as the UK and North America that have a relatively low HIV prevalence. The negative Canadian Paediatric Society policy nevertheless concluded that in Canada “there may be a benefit [from NTMC] for some boys in high-risk populations and circumstances ” [ 27 ].…”

“…Lempert et al [ 19 ] quote the KNMG as saying “it is reasonable to put off circumcision until the age at which [the] boy himself can decide about the intervention or can opt for any available alternatives”. But this disregards the fact that, in early infancy, risk is minimized, and lifetime health benefits are maximized by NTMC.…”

“…The BMA guidance attracted the attention of NTMC opponents Antony Lempert, Chair of the Secular Medical Forum which advises the United Kingdom’s National Secular Society, in an article with ethicist Brian Earp as author for correspondence, and two others[ 19 ]. The aim of the present article is to evaluate their arguments.…”

Child genital cutting and surgery across cultures, sex, and gender. Part 2: assessing consent and medical necessity in “endosex” modifications

“…In other words, even if one accepts the general evaluative framework depicted in Fig. 1, which is based on commonly accepted norms or standards within Western medical, pediatric, and sexual ethics [33][34][35], the question of where exactly to locate any given genital intervention vis-à-vis the axes of consent and medical necessity may in some cases remain controversial.…”