January 13, 2003

The unkindest of cuts

By Simon Crompton

Circumcision is often unnecessary, damaging and performed without consent, says our correspondent

THERE IS ONE OPERATION being carried out on thousands of British children by NHS doctors without any clinical need---and without the patient's consent. This procedure has an irreversible physical effect, yet there has been minimal public debate about the extent to which it is being performed.

The procedure is non-religious circumcision, carried out on "therapeutic" grounds on 4 to 6 per cent of boys under 15. Increasingly, the expert consensus is that most non-religious circumcisions are carried out for reasons of family history, medical myth and professional laziness. Some campaigners claim that as many as five in six of these circumcisions are unnecessary and potentially traumatising.

Circumcision has become the subject of bitter debate in the US, where 80 per cent of men are circumcised. Doctors Opposing Circumcision is one of a range of groups challenging the medical orthodoxy of circumcision at birth; their campaign has been buoyed by a statement from the American Medical Association that there is insufficient evidence of benefit to recommend routine neonatal circumcision.

Here, the British Medical Association is reviewing its guidelines and is due to announce its findings in March; current guidance makes it clear that it is unethical to circumcise for therapeutic reasons where research shows that less invasive techniques are available.

Norm-UK, an organisation which campaigns against circumcision, estimates that fewer than 1 per cent of boys require the operation, and that most of those performed on the NHS are unnecessary. Dr John Warren, a consultant physician and founder of Norm-UK, says that the main problem is that GPs and general surgeons are unaware of research indicating when circumcision is medically required. Specialist paediatric urological surgeons are better informed, but not all children are seen by these experts.

Most non-religious circumcisions are performed on children whose parents are concerned about a tight foreskin that will not retract, a condition known as phimosis. "They think there is something wrong, even if it's causing the child no problems," says Warren, who works at the Princess Alexandra Hospital in Harlow, Essex. Yet research published as long ago as 1968 showed that 90 per cent of tight foreskins had resolved themselves by the age of four, and 99 per cent had developed normally by 17. "The message never filtered through, and a lot of people didn't accept it," says Warren.

Family tradition also plays a part. Fathers and grandfathers who were circumcised may want their boys circumcised too (often on the basis that it is "cleaner"), and use the possibility of phimosis to get doctors to perform the procedure. Duncan Wilcox, consultant paediatric urologist at Great Ormond Street Hospital and Guy's Hospital in London, believes that this is the main reason why so many circumcisions are carried out unnecessarily.

"As many as half of the parents who come to see me want their child to have a circumcision," he says. "But when I tell them that there is a risk, as with all operations, the majority are happy to wait and see if the foreskin retracts normally. Doctors are certainly pressurised, and there is always the occasional parent who will get through with pure persistence, or by saying that their child keeps getting infections." The issue would be less important if foreskin removal did not have physical and social implications which carry on into adulthood.

Alex was circumcised at 25 during an operation to correct a bend in his penis. The surgeon decided---without Alex's consent---to remove the foreskin, an action that other surgeons have subsequently confirmed as unnecessary. "There was a huge reduction in erogenous tissue," says Alex, now 29, a systems analyst from Oxfordshire. "The feeling of pleasure has changed so much that I haven't been able to achieve orgasm since the operation. It had a disastrous effect on my relationship: my partner wondered whether it was her fault, and that contributed to the end of our relationship. Since then I've found it hard to get into a new relationship.

"I am conscious of how I look, and girlfriends have given me quizzical looks. They are not used to seeing circumcised men. I haven't had the confidence to go into a public changing room since the operation." The foreskin contains a rich variety and concentration of specialised nerve receptors. In May 2002, a study in the British Journal of Urology reported that circumcision appears to result in decreased erectile function and penile sensitivity: 38 per cent of men circumcised as adults reported harm to sexual function.

The practice of medical (as distinct from religious) circumcision began in Victorian times as a deterrent to masturbation, then thought to be the cause of insanity, epilepsy, hysteria, tuberculosis, short-sightedness and death. The practice became popular in the 1920s for reasons of hygiene and peaked in the 1940s. In 1949, researchers began to question whether a nonretracting foreskin was abnormal, and numbers have declined.

Norm-UK has received hundreds of calls from men who feel ashamed or mutilated by the procedure. For young boys, the potential embarrassment of having a penis that looks different from those of their friends is obvious. Yet the psychological issues are complex: in a largely Jewish or Islamic community, this argument works as much in favour of circumcision as against it. Dr Lotte Newman, a former president of the Royal College of General Practitioners who chairs the circumcision working party of the Board of Deputies of British Jews, is troubled by developments in Sweden which may lead to a ban on child circumcision there. "The trend against circumcision affects those religions which practise it traditionally," she says.

Such sensitivities may account for the neutral stance of mainstream medical organisations such as the General Medical Council, which states only that its soundings "demonstrated widely conflicting views in society, which neither doctors nor the GMC can resolve."

But perhaps the issue ultimately comes down to one of consent. Adults need to know about the alternatives to have an accurate basis for decision-making. But Norm-UK's concern is that no one should consent to a circumcision on someone else's behalf, even if it is their own child. That means doing everything possible to treat conditions non-invasively until the patient can make an informed choice.

"When I was a kid I had a circumcision and my brother didn't," says Warren. "It made me conscious of the issue as a medical student. Then I had to conduct the operation myself, and was horrified at what I was doing. I thought, one day I will stop this ridiculous practice."

CIRCUMCISION LINKS

Norm-UK: www.norm-uk.org

NHS Online: Information on circumcision and balanitis www.nhsdirect.nhs.uk/nhsdoheso