HC 1048-III Health CommitteeWritten evidence from Mr James Douglas (PH 48)

Summary

There has been a concerted effort in the professional literature, from a small cabal within the medical fraternity, to argue the case for reinstating non-therapeutic circumcision at the expense of the NHS, frequently using professed concern for the well-being of boys of certain ethnic or religious backgrounds receiving circumcision in non-medical settings, as a pretext.

Recently, there has been a string of mainstream media items favourable to male circumcision, which amount to nothing less than a marketing campaign to motivate parents to have their sons circumcised. Many of these articles draw upon established marketing concepts (in turn derived from insights of behavioural science), most notably, the use of “experts”. In the context of promoting circumcision to parents, such “experts” generally include medical practitioners who work at private circumcision clinics and religious officials.

Regardless of whether it is performed in a medical or non-medical setting, a significant number of boys subjected to the practice of circumcision will later fulfill the DSM-IV criteria for a diagnosis of Post-Traumatic Stress Disorder.

Circumcision removes the most sexually sensitive parts of a boy’s penis, including the foreskin, the frenulum, and the ridged band of nerves. The male foreskin is also designed to protect the glans of the penis throughout a man’s life, ensuring that the internal mucosal tissue remains moist and sensitive (much the same way that a woman’s clitoral hood protects the clitoris). In addition, the foreskin acts as a natural gliding mechanism to reduce chafing and dryness during intercourse.

The British Medical Association advises against routine male circumcision, and no national medical association in the world recommends that boys be forcefully circumcised for preventive health reasons.

There has been little incentive for the medical profession to investigate the long-term effects on men’s sexual and psychological health and well-being, but the growth of groups such as NORM-UK (an organisation registered with the Charities Commissioners for England and Wales), suggests that a substantial number of men genuinely resent being circumcised.

It is imperative that Department of Health and Public Health England mandate that all staff, contractors, agencies, facilities and departments under their auspices, including GPs and GP practices: Must not offer among their services the harmful male genital mutilation known as circumcision; Must not permit on their premises individuals or organisations promoting the harmful male genital mutilation known as circumcision; Must not be refer patients explicitly for the harmful male genital mutilation known as circumcision; Must not be employed or associated with any facility offering the harmful male genital mutilation known as circumcision; Must not allow their facilities to be used for the harmful male genital mutilation known as circumcision.; and Must not stock or allow on their premises literature or other material promoting the harmful male genital mutilation known as circumcision.

Given the dearth of research in this area, it would be appropriate for the Department of Health and Public Health England to partner with registered charities such as NORM-UK and to create incentives for medical researchers to investigate the long-term effects of circumcision on men’s sexual and psychological health and well-being.

1. There has been a concerted effort in the professional literature, from a small cabal within the medical fraternity, to argue the case for reinstating non-therapeutic circumcision at the expense of the NHS, frequently using professed concern for the well-being of boys of certain ethnic or religious backgrounds receiving circumcision in non-medical settings, as a pretext,1 a call loudly echoed in sections of the mainstream media.2 Regardless of whether it is performed in a medical or non-medical setting, a significant number of boys subjected to the practice of circumcision will later fulfill the DSM-IV criteria for a diagnosis of Post-Traumatic Stress Disorder.3 Further, circumcision removes the most sexually sensitive parts of a boy’s penis, including the foreskin, the frenulum, and the ridged band of nerves.4 The male foreskin is also designed to protect the glans of the penis throughout a man’s life, ensuring that the internal mucosal tissue remains moist and sensitive (much the same way that a woman’s clitoral hood protects the clitoris). In addition, the foreskin acts as a natural gliding mechanism to reduce chafing and dryness during intercourse.5

2. Recently, there has been a string of mainstream media items favourable to male circumcision, which amount to nothing less than a marketing campaign to motivate parents to have their sons circumcised.2,6,7,8 Many of these articles draw upon established marketing concepts (in turn derived from insights of behavioural science), most notably, the use of “experts”. An “expert”, in a marketing context, is an individual who, because of their occupation, or perceived experience, is uniquely placed to lend credence to the product or service that an advertisement promotes.9 In the context of promoting circumcision to parents, such “experts” generally include medical practitioners who work at private circumcision clinics6,8 and religious officials.7 Following complaints from the public, the Press Complaints Commission has reached resolutions noting the inappropriate implication in media items that religious officials are qualified to offer medical advice in regard to circumcision, the minimisation of the inherent risks of circumcision as a medical procedure, and the implication that circumcision is of minimal discomfort through the impression that it is legitimate practice to conduct the procedure without anaesthesia.10,11 Both the hospital and doctor (who is also a Consultant Urological Surgeon at Royal Liverpool University Hospital NHS Trust) featured in a recent episode of the Channel 4 television series Embarrassing Bodies,8 linked to the video on the Channel 4 website from their respective web-pages,12,13 effectively by-passing the General Medical Council Guidelines about how medical practitioners should promote and publish information about their services .14 It is unsurprising that such symbiotic relationships should form between private doctors seeking to promote their practice and mainstream media outlets who want to appease advertisers by keeping such a high-profile controversial social issue alive, since advertising is the force which has historically sustained all commercial media.15

3. The British Medical Association advises against routine male circumcision,16 and no national medical association in the world recommends that boys be forcefully circumcised for preventive health reasons. The Royal Dutch Medical Association’s very up-to-date policy on circumcision states that “KNMG is calling upon doctors to actively and insistently inform parents who are considering the procedure of the absence of medical benefits and the danger of complications”, and that there is a good case for making it illegal.17 Female genital mutilation has been illegal for a number of years now.18 There has been little incentive for the medical profession to investigate the long-term effects on men’s sexual and psychological health and well-being, but the growth of groups such as NORM-UK (an organisation registered with the Charities Commissioners for England and Wales), suggests that a substantial number of men genuinely resent being circumcised.19

4. A recent statement from the British Association of Paediatric Urologists on behalf of the British Association of Paediatric Surgeons and The Association of Paediatric Anaesthetists admitted that some doctor’s under its charge “have been willing to provide non therapeutic circumcision without charge rather than risk the procedure being carried out in unhygienic conditions.”20 In its statement on the law and ethics of male circumcision, the British Medical Association has concluded that “it is for society to decide what limits should be imposed on parental choices.”16

5. It is therefore imperative that Department of Health and Public Health England mandate that all staff, contractors, agencies, facilities and departments under their auspices, including GPs and GP practices: Must not offer among their services the harmful male genital mutilation known as circumcision; Must not permit on their premises individuals or organisations promoting the harmful male genital mutilation known as circumcision; Must not be refer patients explicitly for the harmful male genital mutilation known as circumcision; Must not be employed or associated with any facility offering the harmful male genital mutilation known as circumcision; Must not allow their facilities to be used for the harmful male genital mutilation known as circumcision.; and Must not stock or allow on their premises literature or other material promoting the harmful male genital mutilation known as circumcision.

6. To best develop and enhance the availability, accessibility and utility of public health information and intelligence regarding the harmful male genital mutilation known as circumcision, it is imperative that the Department of Health and Public Health England establish a central information store of the harm caused by male circumcision, which will form the basis for establishing a dictate that staff, contractors, agencies, facilities and departments under its auspices, including GPs and GP practices, will not perform nor refer patients for circumcision; and to make use of the insights of behavioural science to research and implement strategies which discourage parents from subjecting their sons to the harmful male genital mutilation known as circumcision, without lending to its prestige by implying that it is a practice worthy of its own policy statement or the subject of a legitimate “debate”.

7. To counteract the mainstream media marketing of circumcision to parents, it is appropriate that the Department of Health and Public Health England mandate that staff, contractors, agencies, facilities and departments under its auspices, including GPs and GP practices, will not perform nor refer patients for circumcision; and should use the insights of behavioural science to research and implement strategies which discourage parents from subjecting their sons to the harmful male genital mutilation known as circumcision, without lending to its prestige by implying that it is a practice worthy of its own policy statement or the subject of a legitimate “debate”.

8. It would be appropriate to invite appropriately registered charity organisations such as NORM-UK to partner with the Department of Health and Public Health England to contribute to compiling and improving the use of public health evidence to counteract the mainstream media marketing of circumcision to parents and discourage parents from subjecting their sons to the harmful male genital mutilation known as circumcision, without lending to its prestige by implying that it is a practice worthy of its own policy statement or the subject of a legitimate “debate”.

9. Given questions raised about the professional conduct of some medical practitioners with regard to the continuing practice of male circumcision, whatever system of voluntary regulation may be implemented, it is appropriate that the Department of Health and Public Health England mandate that staff, contractors, agencies, facilities and departments under their auspices, including GPs, GP practices and other public health specialists, will not perform nor refer patients for the harmful male genital mutilation known as circumcision.

10. Given the dearth of research in this area, it would be appropriate for the Department of Health and Public Health England to create incentives for medical researchers to investigate the long-term effects of circumcision on men’s sexual and psychological health and well-being.

June 2011

References

1 Paranthaman K, Bagaria, J & O’Moore, E (2010) The need for commissioning circumcision services for non-therapeutic indications in the NHS: lessons from an incident investigation in Oxford J Public Health first published online July 14, 2010http://jpubhealth.oxfordjournals.org/content/early/2010/07/14/pubmed.fdq053.full

2 Campbell, D (2010) NHS urged to offer circumcisions to avoid botched operations in The Guardian Sunday 11 July 2010 http://www.guardian.co.uk/society/2010/jul/11/doctors-urge-circumcision-on-nhs

3 Samuel Ramos and Gregory J Boyle. Ritual and Medical Circumcision among Filipino boys: Evidence of Post-traumatic Stress Disorder Humanities & Social Sciences papers (2000). Available at: http://epublications.bond.edu.au/cgi/viewcontent.cgi?article=1120&context=hss_pubs

4 Morris L Sorrells, James L Snyder, Mark D Reiss, Christopher Eden, Marilyn F Milos, Norma Wilcox, Robert S Van Howe Fine-touch pressure thresholds in the adult penis British Journal of Urology International, Volume 99 Issue 4 Page 864 – 869 April 2007 http://www.nocirc.org/touch-test/bju_6685.pdf

5 Taylor, JP, AP Lockwood and AJ Taylor The prepuce: Specialized mucosa of the penis and its loss to circumcision Journal of Urology (1996), 77, 291-295 http://www.cirp.org/library/anatomy/taylor/

6 Renton, A (2010) It protects men (and women) against fatal diseases and sexual infections. So, should all boys be circumcised? in The Daily Mail http://www.dailymail.co.uk/health/article-1199472/It-protects-men-women-fatal-diseases-sexual-infections-So-boys-circumcised.html

7 Rich, B (2010) To snip or not to snip? in The Guardian http://www.guardian.co.uk/lifeandstyle/2010/oct/30/circumcision-jewish-son-ben-rich

8 Channel 4 (2011) Embarrassing Bodies Series 4 Episode 4http://www.channel4.com/programmes/embarrassing-bodies/episode-guide/series-4/episode-4

9 Schiffman, L Bednell, D O’Cass, A Paladino, A Kanuk, L (2005) Consumer Behaviour 3rd Edition Pearson Education Australia, Australia: Frenchs Forest

10 Press Complaints Commission (2011) Parkes vs The Guardianhttp://www.pcc.org.uk/news/index.html?article=NjkxNg==

11 Press Complaints Commission (2010) Warren vs Daily Mailhttp://www.pcc.org.uk/news/index.html?article=NjIyNA==

12 http://www.spirehealthcare.com/Liverpool/Our-Facilities-Treatments-and-Consultants/Our-Treatments/ Adult-circumcision/

13 http://www.spirehealthcare.com/Liverpool/Our-Facilities-Treatments-and-Consultants/Our-Consultants/Mr-P-Cornford/

14 General Medical Council (2011) Good Medical Practice: Providing and publishing information about your services http://www.gmc-uk.org/guidance/good_medical_practice/probity_information_about_services.asp

15 Cunningham, S & Turner, G (2002) The Media & Communications in Australia Allen & Unwin, Australia

16 British Medical Association. The law and ethics of male circumcision: guidance for doctors. London: BMA, 2006 http://www.bma.org.uk/ethics/consent_and_capacity/malecircumcision2006.jsp

17 KNMG (2010) Non-theraputic circumcision of male minors http://knmg.artsennet.nl/web/file?uuid=579e836d-ea83-410f-9889-feb7eda87cd5&owner=a8a9ce0e-f42b-47a5-960e-be08025b7b04&contentid=77976

18 LASSL (2004)4: Female Genital Mutilation Act 2003, DoH, published 27 February 2004

19 http://www.norm-uk.org/

20 British Association of Paediatric Urologists (2007) MANAGEMENT OF FORESKIN CONDITIONS Statement from the British Association of Paediatric Urologists on behalf of the British Association of Paediatric Surgeons and The Association of Paediatric Anaesthetists. http://www.apagbi.org.uk/sites/apagbi.org.uk/files/circumcision2007.pdf

Prepared 28th November 2011