Experts identify “serious weaknesses” in medical guidance on circumcision

Experts have criticised “serious weaknesses” in guidance issued by The British Medical Association (BMA) on the non-therapeutic male circumcision of children. 

The guidance, which was released in 2019, is intended to aid physicians in deciding whether to perform the procedure. 

The BMA has consistently claimed to be “neutral” on the ethics of non-medically necessary circumcision performed on male children for religious or cultural reasons. However, a recently published academic paper has described this claim as inaccurate, arguing that the BMA’s guidance is permissive of the practice and premised on an “incoherent and impracticable analysis of the child’s best interests”.

The authors of the paper, a number of professionals in the academic, legal and medical fields, call upon the BMA – which the UK’s largest doctors union – to change this “permissive” stance on non therapeutic male circumcision on infants and children. 

The article describes the guidance as a “missed” opportunity to “accurately reflect current ethical, legal, safeguarding, or medical concerns” regarding infant circumcision. The authors also note that they are “not aware” of any other non-therapeutic invasive procedures on children involving “significant harm” that the BMA treats as “ethically neutral”.

The article raised a number of specific concerns with the BMA guidance, including:

• The guidance has the effect of tilting parents’ personal, religious and cultural preferences for circumcising their child against the child’s best interests.
• The BMA says it is committed to non-discrimination in terms of sex. But the guidance “undermines this commitment by affording differential protection to children on the basis of sex” because it does not apply the same protections afforded to girls from genital cutting (female genital mutilation, or FGM) to boys.
• The BMA advocates for “increased acceptance into a family or society” as a “strong social or cultural benefit” of circumcision, despite rightly rejecting this argument for female genital cutting.
• The guidance states without any supportive evidence that male infant circumcision “does not require medical expertise”. The article explains how this “contradicts the BMA’s own exposition of the numerous clinical, anaesthetic and hygiene standards required of a doctor carrying out the procedure.” This may mean the BMA is “tacitly accepting that the minimal standards of care for non-doctor circumcisers should be lower than the standards of care for doctors”. It called this guidance “disturbing”.
• The BMA says it “cannot envisage a situation where it is ethically acceptable to circumcise a child…who refuses”, but does not offer the same ethical judgment on circumcision on neonates who are “even more vulnerable” than children who can speak.
• The BMA is “inconsistent” in that while it warns that parents “can exert great influence on their child’s view of a procedure”, it remains silent on the “much more extreme danger” to neonates and very young children who parents want to circumcise.

The article warned that the BMA’s guidance would, if applied to female genital cutting, yield the conclusion that cutting healthy tissue from a non-consenting child’s vulva “could permissibly be performed if the parents request it for cultural or religious reasons”.

It concluded that a “consistent application of widely-accepted medical ethics, safeguarding, legal and human rights principles should result in equal protection for all children from all forms of non therapeutic genital cutting practices to which they cannot consent”.

Dr Antony Lempert, chair of the National Secular Society’s Secular Medical Forum and one of the report’s authors, said: 

“The BMA has produced guidance that is inconsistent, confusing and at times, incoherent, reflecting the deeper, unresolved moral and legal tensions surrounding child genital cutting more generally.

“Childhood ritual male circumcision is an anomaly. There is no other case where the law and medical guidance would countenance such an invasive, painful and often unsafe procedure on a non consenting minor.

“Instead of circumventing good medical practice so as not to offend religious sensibilities, ethical and legal consistency would strengthen arguments against all ritual genital cutting practices. Ultimately, this would protect boys and girls since advocates of female genital cutting are increasingly emboldened by inconsistent guidance permissive of ritual male cutting.”