Dear Editor,

Non-therapeutic foreskin removal on the NHS? NO! At the establishment of the NHS in the 1940s, it was correctly decided that abandoning the ritualistic and cosmetic procedure was best both for the child and the service which had better things to on which to spend time and money.

Of course, I realise that foreskin removal has a long history, but 4000 years ago human rights were largely non-existent, even 1000 years ago, it was freely admitted that removing the foreskin damaged the sexual sensitivity of the penis.

It is surely time to discontinue this ancient and ignorant practice.
Bear in mind that the binding of a girls feet persisted in China for about 800 years, until the Imperial era was swept away by revolution.

Allowing foreskin removal on the NHS can only encourage the retention of something which should be swept away into the garbage can of history.

It is simple to present male circumcision as the scientific and sensible thing to do. Indeed, the foreskin is one of those parts of the body, like wisdom teeth and the appendix, that seem to be ripe for the plucking.

However, those who argue both for and against circumcision are likely to overstate their case. Guy Cox pointed out that some people have religious and philosophical objections to circumcision. However, characterising this opposition as “anti-Semitic or anti-Islamic” makes as much sense as calling someone who opposes slavery as anti-Christian, anti-Islamic and anti- Semitic because the Bible and the Koran allow it.

The human foreskin is a natural part of a man’s penis. It is therefore not surprising that many people question the idea of removing it. Far from being as simple as an inoculation, circumcision is far from risk-free. Unless the operator is competent, and can control or eliminate infection and bleeding, the procedure is dangerous and even life-threatening.

The basic objection to infant circumcision is that the owner of the foreskin is the one to decide what to do with it. Medical huxterism may persuade a grown woman that a ‘designer vagina’ is what she needs; however, the law strictly prohibits genital cutting of underage girls. Paradoxically, the genital cutting of boys is accepted by custom and two powerful religions and even the mildest criticism of male circumcision is likely to be decried as an attack upon faith.

Commonsense dictates that circumcisers must be up to the task. However, Great Britain may thank Omunnakwe Amechi for showing every quack in the land that you don’t need medical qualifications to circumcise in Britain. Even better, quacks' handiwork isn't subject to oversight by the General Medical Council. <http://news.bbc.co.uk/2/low/uk_news/england/london/3244925.stm>

A judge in Ireland went one better. He instructed a jury not to bring what he called their white western values to bear on Osagie Igbinedion. As a result, he was found not guilty of reckless endangerment after his 4 week old son had bled to death after Igbinedion circumcised him. <http://www.rte.ie/news/2005/1007/igbinediono.html>

In the United States, cases have gone either way. Edwin Baxter, a fervent Christian was sentenced to jail for assault for circumcising his son <http://www.cirp.org/news/thecolumbian12-16-04/> but the case against Jeffrey Henderson for circumcising his child was dismissed. Henderson said that he was Hebrew and circumcised the child out of religious duty. The judge found nothing in California’s legal code about circumcising a male child, so he got off. <http://www.cirp.org/news/inlandvalleynews02-14- 05/>

Whether we are for or against circumcision, the procedure is not part of a Monty Python script. Circumcision needs to be properly regulated. And, despite the advantages that are claimed for the procedure, the owner of the foreskin should ordinarily be the one to decide the fate of his foreskin.

Sirs:

This is a timely and important article. Pretermitting whether parental consent can ever be valid for non-therapeutic surgeries on minors, certainly Mr. Wheeler is correct that at the very least the permission of both parents should be necessary for the circumcision of a male child. Too often here in the U.S. the matter ends up in court. I have been involved in one way or another in seven such cases in the last ten years. Quite often the matter is one of spite, although occasionally religion is involved. One such important case is presently wending its way through the Oregon courts. The child is invariably placed in the middle, where he does not belong. The real solution is statutory. Parliament (and in the U.S., Congress or the state legislatures) should pass legislation requiring the consent of both parents (unless the parental rights of one parent have been entirely forfeited) for the non- therapeutic circumcision of male minors, whether the circumcision be secular or religious. (In cases of divorce where one parent has custody but the other parent might obtain custody automatically upon the death of the custodial parent, the consent of both parents should be required). However, regardless of the statutory or common law, basic ethics require that the surgeon ascertain the wishes of both parents and refrain from circumcising a boy if either parent, or the boy himself, objects.

There is a curious paradox in this debate. Male circumcision is, like immunisation, prophylactic medicine. Its benefits (protection against UTIs, HIV, balanitis, phimosis and penile and cerivcal carcinoma) are well established. The risks of circumcision are lower than those of most immunisations, and in at least some cases (where the diseases in question are now rare) its benefit is greater.

Yet if a parent's religious beliefs proscribe immunisation there is huge pressure to over-ride that belief, whereas when that belief prescribes circumcision the pressure is in the opposite direction!

In the English-speaking world male circumcision was widely recognized as beneficial until relatively recent times, and paradoxically it has become less popular even as the evidence of its benefits has grown. The main driving factors against circumcision in western countries seem to be beliefs which are either religious (anti-semitic or anti-islamic) or 'quasi-religious' - that is, based on philosophical or irrational grounds rather than science.

We do need to recognize that male circumcision has a valid place in preventative medicine, and that parents should be able to make a free and informed decision for or against the procedure. And, living in the real world, we must also realise that religious issues may help to sway the decision in either direction.

Dragging so-called 'female circumcision' into the debate is a red herring. The term is used in such a vague and broad way, covering a number of totally different operations, that it has become meaningless. And what on earth sterilization has to do with the issue is quite beyond me.

Guy Cox, MA, D.Phil (Oxon)

Robert Wheeler discusses the complexities of consent for non- therapeutic male circumcision, especially when both parents may not be in agreement and specifically in the religious context. The discussion could also include the wider question of whether the treatment of children is an issue for the family alone or whether society as a whole has a right or a duty to interfere in family life, for the protection of children.

For female circumcision there seems no question that the practice should be outlawed, whatever religious, cultural or other beliefs may be invoked to support it. Consent is not an issue. Parliament is still considering to what extent physical punishment of children in the UK is wrong. For male children, some would question whether consent other than that of the patient is ever appropriate for this non therapeutic amputation, whatever the parents' religious, cultural or hygienic beliefs.

I think I can understand why the author might be reluctant to carry out this surgery privately. My question, though, is what justification can there be for undertaking this non-therapeutic intervention on the NHS?