Rapid Responses to:

HEAD TO HEAD: Geoff Hinchley Is infant male circumcision an abuse of the rights of the child? Yes BMJ 2007; 335: 1180 [Full text]

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Rapid Responses published:

Medical Propaganda

Thomas Flett   (7 December 2007)

Baloney on 'the snip'

Paul Rosswick   (8 December 2007)

Individual bodily rights and patient autonomy

A. D. Fontain   (8 December 2007)

Re: Medical Propaganda

A. D. Fontain   (8 December 2007)

No reason not to wait

Eleanor Snape   (8 December 2007)

Questionable argument

Jake H Waskett   (8 December 2007)

Infant male circumcision IS abuse

Heather M Longanecker   (8 December 2007)

Hinchley understates his case

George Hill   (8 December 2007)

Re: Medical Propaganda

J D Poff   (8 December 2007)

Parents have the right and obligation to choose what they consider best for their children

Norton Pérez, MD   (9 December 2007)

Psychological damage from circumcision

Janet Menage   (9 December 2007)

circumcision should not be done to any minor.

troy l horenziak   (9 December 2007)

Updating circumcision

David B G Hawker   (9 December 2007)

Is infant male circumcision an abuse of the rights of the child? Yes

NAZAR R DESSOUKI   (9 December 2007)

Re: Baloney on 'the snip'

Ivy Paul, West Bromwich B71 4HJ   (9 December 2007)

Do no harm

Iris B. Fudge   (9 December 2007)

Is infant circumcison abuse?

Tandy Huighes   (9 December 2007)

Circumscision is justified

Mujibur Rahman   (9 December 2007)

Is infant male circumcision an abuse of the rights of the child?

Jan J van der Bank   (9 December 2007)

Re:Questionable argument

A.D. Fontain   (9 December 2007)

Don't do it!

George W Terrell Jr.   (9 December 2007)

Circumcision or retraction?

Oscar Luis Pereira   (9 December 2007)

Circumcision may also be painful for the surgeon

Roger H Armour   (9 December 2007)

Circumcision’s lawfulness is in doubt and there is a conflict of rights

John D Dalton   (10 December 2007)

Male circumcision is cosmetic surgery.

Andras Heijink   (10 December 2007)

Hard to imagine adolescent boys lining up to be circumcised

Trevor Schroder   (10 December 2007)

Circumcision IS a good practice

Anthony B Ainley   (10 December 2007)

Male & Female circumcision

Sikander A Arshad   (10 December 2007)

prophylactic amputation should only be consensual

Laura J MacDonald   (10 December 2007)

Questionable Argument

IRIS B. FUDGE   (10 December 2007)

Better to provide a safe environment

Shalini Pooransingh, Sam Ramaiah   (10 December 2007)

Human Rights either exist or they do not..time for us to decide.

Mark W Savage   (10 December 2007)

Circumcision - an essential surgical 'vaccine'

Brian Morris   (11 December 2007)

What's sauce for the gander.....

Laura J MacDonald   (11 December 2007)

Of course it is

janice page   (11 December 2007)

Parents' rights

Jean Davies   (11 December 2007)

Women's Rights

Dr John Glazebrook   (11 December 2007)

Male Circumcision-way forward?

Babajide O. Olubaniyi   (11 December 2007)

Genital Integrity not Medicalization

Dan Bollinger   (11 December 2007)

Gloves?

Michael Bunbury   (11 December 2007)

Male circumcision

Ishaq Mohammed   (12 December 2007)

A Sensible Solution

Phyllis C Mervine   (12 December 2007)

Human rights are relative

Santosh A Gholkar   (12 December 2007)

Personal evidence

David J Grant   (12 December 2007)

Doctors need to update

David Smith   (12 December 2007)

Ritual circumcision – a service that should be provided by the NHS

Colin R Butler, Simon Clarke   (12 December 2007)

Many circumcised persons have a compulsion to repeat the trauma

George Hill   (12 December 2007)

Circumcision soon after birth, or once they can consent?

Salwa Kamourieh, Eyston Vaughan-Huxley   (12 December 2007)

A surgical 'vaccine'?

A.D. Fontain   (12 December 2007)

Financial issues we should consider

Laura J MacDonald   (13 December 2007)

Commonsense

Richard N Duncker   (13 December 2007)

Infant Male Genital Mutilation Should be Banned

Bradley L Stueber   (13 December 2007)

And later, would you really give him the choice?

Anthony B Ainley MCSD   (13 December 2007)

BMJ circumcision debate continued in the New York Times

Trish Groves   (13 December 2007)

The overwhelming benefits of circumcision

richard a sturdy   (13 December 2007)

May I make this clear?

Van Lewis   (13 December 2007)

Foreskin has important sexual function

Mike Cooper   (13 December 2007)

objectively...it's wrong

Justin A Williamson   (14 December 2007)

An informed choice

janice page   (14 December 2007)

Male Circumcision is a Female Issue

Felicity A Milner   (14 December 2007)

Dangers of male circumcision

Tim J Sladden   (14 December 2007)

Bancroft J. Human Sexuality and its Problems

J D Poff   (14 December 2007)

Whose foreskin is it?

Michael Glass   (15 December 2007)

"uncircumcised penis"

J D Poff   (15 December 2007)

Circumcision is sadistic sexual assault on children

Michael Steffe   (15 December 2007)

The ethics of circumcision

Michael H Mitchell   (17 December 2007)

Qualified rights in conflict with absolute rights

John D Dalton   (17 December 2007)

Medical Activism

Rajesh K Choudhary   (17 December 2007)

Let's Stop Selling Men Back Their Foreskins

Ron J Low   (17 December 2007)

Higher Love Consciousness will ban Circumcision world wide

Michael Steffe   (17 December 2007)

Is infant male circumcision an abuse of the rights of the child?

Lotte Newman   (19 December 2007)

Very uncertain sexual benefits, beware!

Sigi Sigismond   (4 January 2008)

What are the glans and foreskin for?

Kenneth N Wilkinson   (4 January 2008)

Re: What are the glans and foreskin for?

Janet Menage   (7 January 2008)

Effect of circumcision on intromission and sexual satisfaction

John D Dalton   (7 January 2008)

Circumcision and European jurisprudence

Sigi Sigismond   (15 January 2008)

The 2nd commandment forbids circumcision

Sigi Sigismond   (15 January 2008)

Another reference

Sigi Sigismond   (15 January 2008)

Circumsexuals

Rood Andersson   (8 March 2008)

Medical Propaganda 7 December 2007
Thomas Flett, General Practitioner Retired, FY1 2QX Send response to journal: Re: Medical Propaganda	I was a General Practitioner for over 30 years, over which time, I have seen thousands of patients who were circumcised and never once did I hear a complaint from a child or adult who felt assaulted. I think Dr Hinchley has missed the entire rhyme and reason around the controversial issue of consent. Babies undergo a wealth of procedures and endurances, from having their heels pricked for the Guthrie Test, their hips stressed for DDH , vaccinations and even the chore of having to attend Nursery and worse still Kindergaten. None of these activities receive informed consent. To obtain a serum bilirubin for a jaundiced child involves stabbing the foot with a small knife that is quite a horrific experience for the parents and no doubt highly unpleasant for the baby. Nonetheless, I do not see Geoff Hinchley writing to have all these procedures banned. I would strongly recommend that as an A&E Consultant, in one of the UKs worst performing Trusts in infection control, that Geoff Hinchley focus his efforts on his task at hand, rather than trying to spread a frankly irrelevant message. After all, it may be that a child is brought to his department following a circumcision, with a complication. Of course it would be a tragedy if they were to pick up MRSA as a result! Competing interests: None declared
Baloney on 'the snip' 8 December 2007
Paul Rosswick, retired surgeon N3 3EG Send response to journal: Re: Baloney on 'the snip'	As a retired, circumcised,Jewish surgeon I cannot abide the ridiculous argument that my human rights were abused 75 years ago by my parents! I am proud to be a 'cavalier' and have never seen any significant problems in practice except where untrained persons perform.Jewish ritual circumcisors undergo training - so should all whatever their tradition. Let us have less, much less about human rights in this matter and much more about regulating for the safe performance of a traditional procedure. Competing interests: None declared
Individual bodily rights and patient autonomy 8 December 2007
A. D. Fontain, Independent Researcher Toronto, ON. Canada M5S 1A5 Send response to journal: Re: Individual bodily rights and patient autonomy	Is infant male circumcision an abuse of the rights of the child? Yes. In her article defending infant male circumcision as an acceptable practice in medicine, Kirsten Patrick seems to miss the mark. She states: "we cannot know for sure if men who grew up without a foreskin feel that they were assaulted." It does not require "robust research...examining the long term psychological effects of male infant circumcision" in order to be aware that there are a significant enough number of males who are dissatisfied and harmed to varying degrees by this medical custom. A fact made apparent by the existence of sufficiently widespread and sustained calls for it's eradication as a medical practice.[1] The more important question is whether or not it is an acceptable situation in medicine for a male to have genital anatomy removed, contrary to his will, in the absence of not only any medical need, but of even a likeliness (going on the claims off even the most ardent circumcision promoters) that he would have benefited from the procedure in any significant enough way as to justify the surgery. Contrary to Patrick's assertion, recent strong evidence shows that circumcision is medically beneficial only to a small minority of males who are circumcised, as well as carrying both known and unknown risks to a males. The blanket statement that the procedure is 'medically beneficial' is a distortion. Virtual all of the benefits she cites are related to STDs, which are primarily an issue of behavior and are not relevant to male until he would be able to make a decision to be circumcised for himself. There are far more effective and conventional non-surgical means to protect oneself from STDs; it cannot assumed that the surgery will be acceptable to an individual and not infringe upon his rights. It is puzzling indeed that bodily rights and patient autonomy can continue to be so casually disregarded in medicine because of 'cultural reasons'. The fact that there is an unlikely possibility a male may be afforded what amounts to mostly minor compensatory medical benefits is largely irrelevant. The nature of the much debated benefits, or lack thereof, associated with the surgery are such that they are rare and could be achieved far more easily via less invasive and ethically problematic means.[2] Physicians are not acting in accordance to their ethical duties to the patient by performing needless surgeries on a child's genitals simply because the child's parents want them to for the sake of culture, dressed up in medical rationalizations. Rationalizations that would likely not hold if the cultural impetus were not there to prop them up by over- exaggerating the benefits, dismissing the harms, and clouding the ethical/bodily rights implications of performing unnecessary genital surgeries on children. Assuming that circumcision gives men additional protection from becoming infected with HIV as recent research suggests: baby boys and children do not immediately need such protection and can choose for themselves, when they are capable, if they want to be circumcised. Adult male circumcision is a relatively safe minor procedure; pain can be effectively managed; and is associated with relatively short duration of recovery. [3] This inconvenience factor is not nearly too high a price to pay in order for the medical community to give due weight to principles of individual autonomy and bodily rights by preserving a males right to choose the procedure for himself. Placing little importance on individual bodily rights, a more compelling argument for allowing infant circumcision might be made in situations where a child will be raised within a cultural group which possesses stigmas towards natural/un-surgically altered human male genital anatomy.[4] However, what more appropriately ought to be be addressed by the medical community is the fact that these stigmas still exist in the first place, and what to do about them; not how these stigmas ought to be respected and catered to. Technically, circumcision compromises an individual's bodily integrity. It is only the degree to which it does so which is debatable. Nevertheless, circumcision constitutes a permanent removal of genital tissue and alteration of the appearance of the external male genitalia which can not be equated to a vaccination needle any more than male circumcision can be equated to a medicalized FGM/clitorectomy as a cultural practice. Concepts of bodily integrity can be subjective in nature. In cases where the procedure is seen as desirable or unimportant to the individual when he is grown it could be argued this is non-relevant. However, in cases where the procedure is unwanted, circumcision is a clear violation of an individual's bodily rights in which their bodily integrity is compromised - in the absence of appropriate medical/ ethical justification .[5] It can be reasonably argued that this runs counter to several of the ethical principles that govern medicine[6] as it is entirely unknowable if a male would accept or object to the surgery. Given the highly ethically questionable nature of non-therapeutic circumcision of minors, it is difficult to find much validity in Patrick's arguments that doctors would do better by assisting parents in obtaining a circumcision services for their sons. A physician is ethically bound to act in the best interest of the patient - the infant male child. Given that it is highly unlikely he would benefit from the surgery in any substantive enough way to justify genital surgery; and given that it is unknowable whether or not the irreversible procedure performed on a male infant is something he would want done to his body: The most ethically sound course of action for a physician to undertake would be to counsel parents against the procedure, not to have a hand in enabling it. --- [1] W Dekkers, C Hoffer, JP Wils - Bodily integrity and male and female circumcision Medicine, Health Care and Philosophy, 2005 [2] Somerville, M. 2000. "Altering Baby Boys� Bodies: The Ethics of Infant Male Circumcision", The ethical canary: science, society, and the human spirit. New York, NY: Viking Penguin Canada, 202�219. LCCN 2001- 369341. ISBN 0670893021. [3] Halperin DT, Bailey RC (1999) Male circumcision and HIV infection: 10 years and counting. Lancet 354: 1813�1815 [4] Benatar, D., and M. Benatar. 2003. 3:2 Target article authors respond to commentators: How not to argue about circumcision. The American Journal of Bioethics 3(2): W1-W9. [5] Povenmire R. Do parents have the legal authority to consent to the surgical amputation of normal, healthy tissue from their infant children? The practice of circumcision in the United States. Journal of Gender, Social Policy & the Law 1998;7:87-123. [6]George C. Denniston Circumcision and the Code of Ethics, , Humane Health Care Volume 12, Number 2 Competing interests: None declared
Re: Medical Propaganda 8 December 2007
A. D. Fontain, Independent Researcher Toronto, ON. Canada M5S 1A5 Send response to journal: Re: Re: Medical Propaganda	"I was a General Practitioner for over 30 years, over which time, I have seen thousands of patients who were circumcised and never once did I hear a complaint from a child or adult who felt assaulted" It should be noted that knowledge and awareness of circumcision, and sexual health issues in general, is much greater in recent times than it was in the past which might contribute to an 'ignorance is bliss' phenomenon you witnessed. Of course not all males are unhappy about being circumcised, but enough of them are to warrant a change of conduct within the medical profession. Namely - allowing males to make the decision to be circumcised for themselves. The principles of individual autonomy and bodily rights in medicine are not based on majority rules. It is irrelevant what you believe 'most people' you came in contact with in your career who were circumcised may have felt about it - when the procedure is entirely unnecessary and in which all its touted benefits can be achieved in less invasive ways. ie bathing, and practicing safe sex which people should be doing anyways en lieu of surgery. It could be argued that 'most' (whatever that entails) males are not bothered by having the surgery as children - But an individual is not 'most people', and deserves to have their autonomy over their body respected when it comes to genital modification. Removing sexual anatomy without any medical need is not equatable to vaccination. Incidentally how would you be aware if any of you patients were dissatisfied with being circumcised. What would they say to you if they weren't to embarrassed to talk about it? And to what purpose would it serve them to tell you they didn't like it in the first place? I fail to see how ethical issues that need to be addressed in medicine amount to 'Medical Propaganda'. A term which I think could more appropriately be applied to culturally fueled medical justifications given to validate a social custom. Competing interests: None declared
No reason not to wait 8 December 2007
Eleanor Snape, Resource Assistant University of Brighton, BN1 9PH Send response to journal: Re: No reason not to wait	I think the comparison to immunisations and the like is faulty because these 'abuses' of the child are for his or her protection against things which cannot be realistically prevented in other ways. The argument that it may have sexual health benefits adds no weight to the case for infant circumcision as these children will not be sexually active for years to come, by which time they can make a more informed decision of their own regarding whether to be circumcised. Furthermore, there are other and more effective ways of practicing safe sex which are not irreversible, painful and potentially hazardous. I see no good reason why circumcision cannot wait until the child is old enough to make his own decision about it. Competing interests: None declared
Questionable argument 8 December 2007
Jake H Waskett, Founder Circumcision Independent Reference and Commentary Service, M26 1JR Send response to journal: Re: Questionable argument	Hinchley argues that it cannot be in the best interests of a child to perform a procedure "which will provide no medical benefit but which has proved adverse consequences both in terms of potential complications for some and reduced penile sensation in adulthood for all."[1] The evidence, however, does not support his implication that circumcision is such a procedure. The medical benefits of circumcision include reduction in risk of urinary tract infection,[2] penile cancer,[3][4] phimosis,[5-6] balanitis,[5-7] and several sexually transmitted diseases.[8-11] These benefits are recognised in the position statements of several medical organisations, such as that of the American Academy of Pediatrics (AAP).[12] While Hinchley compares female genital mutilation to circumcision, the AAP state that "[the] critical distinction between female genital mutilation and male circumcision is the potential medical benefits of male circumcision. These potential benefits warrant a parental role in decision making about this procedure."[13] Similarly, "the circumcision of male children did not concern the United Nations as only female circumcision was deemed a harmful practice to be eradicated. Consequently, it would seem inappropriate to consider under one head both female circumcision which is harmful to health and male circumcision which has no undesirable effect and [is] even considered to be beneficial."[14] In support of his claim of reduced penile sensation, Hinchley cites indirect evidence in the form of a study which claimed that the foreskin contained the most sensitive parts of the penis.[15] When data from this study were properly analysed, there were in fact no statistically significant differences.[16] Curiously, Hinchley did not consider evidence which directly addressed this issue. A study of adult circumcision patients found that only 18% reported reduced penile sensation, while 38% reported improved sensation.[17] Hinchley is correct, however, in noting that potential complications exist; their incidence is estimated at 0.2% and 0.6%.[12] Hinchley claims that "[far] from being a harmless traditional practice, circumcision damages young boys." If this were so, one would expect to find significant dissatisfaction among circumcised males. Yet in fact, studies of circumcision patients consistently reveal high rates of satisfaction.[8-9,17,19-21] Indeed, one study suggests that circumcised males may in fact be more satisfied than their uncircumcised peers.[22] Hinchley appears to believe that it is sufficient to describe circumcision as 'mutilation', and pretend that the benefits of this procedure do not exist. Yet as Benatar and Benatar observed in 2003, "whether circumcision is a mutilation and, if it is, whether it is an unacceptable mutilation can be established only by argument and not by mere assumption. Potential harms and benefits must be examined and weighed against one another. [...] To think that a moral judgment can be made without considering these is to adopt what sounds like a dogma rather than a reasoned conclusion."[18] References 1. Hinchley G. Is infant male circumcision an abuse of the rights of the child? Yes. BMJ 2007;335:1180 2. Singh-Grewal D, Macdessi J, Craig J. Circumcision for the prevention of urinary tract infection in boys: a systematic review of randomised trials and observational studies. Arch Dis Child. 2005 Aug;90(8):853-8 3. Schoen EJ, Oehrli M, Colby C, Machin G. The highly protective effect of newborn circumcision against invasive penile cancer. Pediatrics. 2000 Mar;105(3):E36. 4. Maden C, Sherman KJ, Beckmann AM, Hislop TG, Teh CZ, Ashley RL, Daling JR. History of circumcision, medical conditions, and sexual activity and risk of penile cancer. J Natl Cancer Inst. 1993 Jan 6;85(1):19-24. 5. Fergusson DM, Lawton JM, Shannon FT. Neonatal circumcision and penile problems: an 8-year longitudinal study. Pediatrics. 1988 Apr;81(4):537-41. 6. Herzog LW, Alvarez SR. The frequency of foreskin problems in uncircumcised children. Am J Dis Child 1986; 140: 254-256 7. Fakjian N, Hunter S, Cole GW, Miller J. An argument for circumcision. Prevention of balanitis in the adult. Arch Dermatol. 1990 Aug;126(8):1046-7. 8. Auvert B, Taljaard D, Lagarde E, Sobngwi-Tambekou J, Sitta R, Puren A. Randomized, controlled intervention trial of male circumcision for reduction of HIV infection risk: the ANRS 1265 Trial. PLoS Med. 2005 Nov;2(11):e298 9. Bailey RC, Moses S, Parker CB, Agot K, Maclean I, Krieger JN, Williams CF, Campbell RT, Ndinya-Achola JO. Male circumcision for HIV prevention in young men in Kisumu, Kenya: a randomised controlled trial. Lancet. 2007 Feb 24;369(9562):643-56. 10. Gray RH, Kigozi G, Serwadda D, Makumbi F, Watya S, Nalugoda F, Kiwanuka N, Moulton LH, Chaudhary MA, Chen MZ, Sewankambo NK, Wabwire- Mangen F, Bacon MC, Williams CF, Opendi P, Reynolds SJ, Laeyendecker O, Quinn TC, Wawer MJ. Male circumcision for HIV prevention in men in Rakai, Uganda: a randomised trial. Lancet. 2007 Feb 24;369(9562):657-66 11. Weiss HA, Thomas SL, Munabi SK, Hayes RJ. Male circumcision and risk of syphilis, chancroid, and genital herpes: a systematic review and meta-analysis. Sex Transm Infect. 2006 Apr;82(2):101-9 12. Circumcision policy statement. American Academy of Pediatrics. Task Force on Circumcision. Pediatrics. 1999 Mar;103(3):686-93 13. Lannon CM. Circumcision---The Debates Goes On [authors' reply]. Pediatrics 2000; 105(3):681-4 14. Warzazi HE. The implementation of the human rights of women traditional practices affecting the health of women and children: Follow- up report of the Special Rapporteur on traditional practices affecting the health of women and children. 1997. Available at: http://www.unhchr.ch/Huridocda/Huridoca.nsf/(Symbol)/E.CN.4.Sub.2.1997.10.En?Opendocument 15. Sorrells ML, Snyder JL, Reiss MD, Eden C, Milos MF, Wilcox N, et al. Fine touch pressure thresholds in the adult penis. BJU Int 2007;99:864 -9 16. Waskett JH, Morris BJ. Fine-touch pressure thresholds in the adult penis. BJU Int. 2007 Jun;99(6):1551-2 17. Masood S, Patel HR, Himpson RC, Palmer JH, Mufti GR, Sheriff MK. Penile sensitivity and sexual satisfaction after circumcision: are we informing men correctly? Urol Int. 2005;75(1):62-6. 18. Benatar M, Benatar D. Between prophylaxis and child abuse: the ethics of neonatal male circumcision. Am J Bioeth. 2003 Spring;3(2):35-48 19. Jensen MK. [Surgery for phimosis with Plastibell. A follow-up study]. Ugeskr Laeger. 1998 Jun;160(26):3920–3923. 20. Sobeh M, Junaid I, Marsh H, Fowler CG. Local anaesthetic circumcision in adults. Int J Clin Pract. 1999 Dec;53(8):637. 21. Stenram A, Malmfors G, Okmian L. Circumcision for phimosis: a follow-up study. Scand J Urol Nephrol. 1986;20(2):89–92. 22. Schlossberger NM, Turner RA, Irwin CEJ. Early adolescent knowledge and attitudes about circumcision: methods and implications for research. J Adolesc Health. 1992 Jun;13(4):293–297. Competing interests: None declared
Infant male circumcision IS abuse 8 December 2007
Heather M Longanecker, Stay at Home Mom Naperville, IL 60540 Send response to journal: Re: Infant male circumcision IS abuse	I would not cut off a perfectly healthy and necessary part of my son's penis for some possible benefits to future sexual health. Circumcised men get AIDS and every other sexually transmitted disease in America, where the circumcision rates are high. I think it more responsible to make a choice as a parent to teach our sons (and daughters) about condoms and safe sex. I wouldn't cut out my daughter's breast tissue at birth to prevent some future possibility of breast cancer either. It is a barbaric practice inflicted on our newborns so they look like daddy. Parents who want what is essentially cosmetic surgery on their son's genitals are either misinformed or out for their own best interests, not the child's best interests. The status of our children's sex organs is not our decision as parents. The whole practice needs to be done away with. Competing interests: None declared
Hinchley understates his case 8 December 2007
George Hill, Vice-President for Bioethics and Medical Science Doctors Opposing Circumcision, Suite 42, 2442 NW Market Street, Seattle, Washington 98107-4137 Send response to journal: Re: Hinchley understates his case	Geoffrey Hinchley understates his case.1 He should have looked at the UN International Covenant on Civil and Political Rights (ICCPR).2 That instrument of international law, now ratified everywhere, clearly states that everyone has a right to security of the person. It should be obvious to everyone, that male circumcision, which amputates and excises significant amounts of nerve-laden, sexually sensitive skin and mucosa from the male phallus,3 does not accord with this very fundamental principle of human rights. Moreover children are to be given special protection.2 What does this mean for medical doctors? Everyone has an ethical duty to respect the rights of others.2 International ethics experts have developed two international instruments with a goal of bringing medical practice into conformity with international human rights law. The Council of Europe’s Convention on Human Rights and Biomedicine (1997), now ratified and in force in 21 European nations, provides: No organ or tissue removal may be carried out on a person who does not have the capacity to consent under Article 54 UNESCO’s Declaration on Human Rights and Bioethics says: Individuals and groups of special vulnerability should be protected and the personal integrity of such individuals respected. 5 No one is more non-consenting and vulnerable than a child. The circumcision of children does not accord with these ethical priniciples. Non-therapeutic circumcision of children is thoroughly unethical under contemporary human rights and medical ethics.6 What does this mean for governments? The ICCPR imposes a duty on governments to protect the human rights of every person. 2. Where not already provided for by existing legislative or other measures, each State Party to the present Covenant undertakes to take the necessary steps, in accordance with its constitutional processes and with the provisions of the present Covenant, to adopt such laws or other measures as may be necessary to give effect to the rights recognized in the present Covenant.2 Every government has a duty to take measures to protect the rights of male children. The GMC exercises a quasi-governmental function and has a duty to act to protect male children from the excesses and abuses of medical doctors under its supervision and control. Its present policy regarding male circumcision, now a decade old, is outmoded and needs re-examination and amendment. George Hill Doctors Opposing Circumcision Web: http://www.doctorsopposingcircumcision.org References Hinchley G. Is infant male circumcision an abuse of the rights of the child? BMJ 2007;335:1180. International Covenant on Civil and Political Rights. Adopted and opened for signature, ratification and accession by General Assembly resolution 2200A (XXI) of 16 December 1966. entry into force 23 March 1976. Available at http://www.unhchr.ch/html/menu3/b/a_ccpr.htm Taylor JR, Lockwood AP, Taylor AJ. The prepuce: specialized mucosa of the penis and its loss to circumcision. Br J Urol 1996;77:291-5. Available at http://www.cirp.org/library/anatomy/taylor/ Council of Europe. European Convention on Human Rights and Biomedicine. Adopted at Oviedo, 4 April 1997. Available at http://conventions.coe.int/Treaty/en/Treaties/Html/164.htm Accessed December 4, 2007. UNESCO. Universal Declaration on Human Rights and Bioethics. Adopted by UNESCO General Council on 19 October 2005. Available at: http://portal.unesco.org/en/ev.php-URL_ID=31058&URL_DO=DO_TOPIC&URL_SECTION=201.html Accessed November 24, 2007. Clark PA. To circumcise or not to circumcise. Health Prog 2006;87:30-39. Available at http://www.chausa.org/Pub/MainNav/News/HP/Archive/2006/09SeptOct/Articles/Features/HP0609d.htm Competing interests: None declared
Re: Medical Propaganda 8 December 2007
J D Poff, researcher Auckland 0629, NZ Send response to journal: Re: Re: Medical Propaganda	Thomas Flett's ad hominem response to Dr Hinchley's discussion of circumcision: "I would strongly recommend that as an A&E Consultant, in one of the UKs worst performing Trusts in infection control, that Geoff Hinchley focus his efforts on his task at hand" is about par for proponents of male genital mutilation. I think Dr Flett has missed the entire rhyme and reason around the simple meaning of consent. None of the gallery of tortures and neonatal traumas he mentions involve the pointless amputation of healthy body parts. Babies, like the rest of us, are guaranteed security of person under the Universal Declaration of Human Rights. His construction of this straw man: "I do not see Geoff Hinchley writing to have all these procedures banned" only serves to draw attention to the inadequacy of his case. Equally feeble is his appeal to the failure of circumcised patients to feel satisfactorily assaulted. I suggest to Dr Flett that if Masters and Johnson were unaware of the existence, anatomy and natural function of the male prepuce, it is unlikely that many adults circumcised in childhood will be any better informed. Most will not be conscious of their loss or aware of its significance. Does that make it acceptable? Those of us who are aware of damage done to our bodies feel violated and angry, and will not be silenced by attacks on our personal credibility. The facts are readily available for any who care to face them. _________________________________ Competing interests: None declared
Parents have the right and obligation to choose what they consider best for their children 9 December 2007
Norton Pérez, MD, General Surgeon & Critical Care Medicine Hospital Departamental de Villavicencio, Meta, Colombia, South America Send response to journal: Re: Parents have the right and obligation to choose what they consider best for their children	As parents we take decisions for the best of our children. Vaccination, school, clothes, friends, etc. Some have decided to offer our children the benefits of circumcision without religious considerations. My parents also chose for me and I have always been grateful with them. Besides, I have no memories of the procedure it self. So I took the same decision for my son like my parents did for me. I am sure he will be grateful when he grows up. Competing interests: None declared
Psychological damage from circumcision 9 December 2007
Janet Menage, GP Bulkington Surgery CV12 9JB Send response to journal: Re: Psychological damage from circumcision	Puppies are now protected from tail-docking but human babies can still have a normal, healthy, functioning part of their genitalia amputated at the drop of a hat (1). Loss of a body part is psychologically traumatic (2). When it occurs without consent it is perceived as an assault. When it attacks the penis it constitutes a sexual assault. And when done without anaesthetic it may be experienced as sexual torture. There is much published work on the subject (3). My research into obstetric and gynaecological procedures in women (4) showed that where the patient experiences a genital procedure, without informed consent, in an unsympathetic environment, associated with pain and an experience of powerlessness, there is a risk of Post Traumatic Stress Disorder similar to that experienced by victims of war, rape and childhood sexual abuse. Preliminary research into the psychological effects of circumcision revealed similar findings of PTSD on a clinical scoring system validated on Vietnam war veterans (5). Dr Flett may well not have heard any complaints from circumcised men as they would be reluctant to trust the medical profession, would fear ridicule, and likely feel ashamed of their condition, as per other victims of sexual assault. Genital mutilation of healthy, unconsenting children is an anachronism in the 21st century: balanitis is treatable by antibiotics, phimosis by steroids, vaccines prevent cervical cancer, condoms are prophylactic against HIV, and religious belief is not a valid medical indication to amputate normal healthy tissue. So what is left? – only transgenerational irrationality and tradition. Whatever happened to E.B.M? References: (1) 6 April 2007 in England, and 28 March in Wales, the mutilation of animals is banned under the Animal Welfare Act 2006 (2) Adler, Alfred. (1958) Individual Psychology; Harper & Row (1 Jun 1958) (3) Goldman,R.(1997) Circumcision: The Hidden Trauma; Vanguard, Boston (4) Menage,J. (1993) Post Traumatic Stress Disorder in Women who have undergone Obstetric and/or Gynaecological Procedures, Journal of Reproductive and Infant Psychology (Oct) (5) Menage,J. (1999) Post Traumatic Stress Disorder after Genital Medical Procedures, Male and Female Circumcision: Medical, Legal and Ethical Consideration in Pediatric Practice; Kluwer Academic/Plenum Publishers Competing interests: None declared
circumcision should not be done to any minor. 9 December 2007
troy l horenziak, agriculture 48741 Send response to journal: Re: circumcision should not be done to any minor.	it has been shown to remove pleasure and lower pain thresholds.doing this to a boy or girl is wrong and should be left up to them to decide on their own when they grow up.it should be illegal to perform on a child. Competing interests: None declared
Updating circumcision 9 December 2007
David B G Hawker, retired GP/Anaesthetist PL30 5LA Send response to journal: Re: Updating circumcision	It is good that such an important and misunderstood topic as circumcision is in the open for debate. Malone and Steinbrecher, in their "Clinical Debate" (BMJ 8/12/07) are limited to completed clinical trials, ideally having others to compare with. This standard technique inevitably ignores incompleted trials as well as individual papers and anecdotes. It serves well, but is often a decade out of date for the front line worker. The past 10 years has brought much new evidence to the circumcision debate. No longer is phimosis the prime reason for circumcising infants. Circumcision results in a wide range of disease prevention, ranging from urinary tract infections in infancy, phimotic and infective diseases of childhood, a reduction in the ever growing numbers of STIs in our "liberated" society, through to a reduction in Prostatic cancer and ease of nursing especially incontinent older men. I feel that Dr Hinchly is in danger of repeating the mantras of the anti- circumcision advocates, often quoting out-of-date evidence, and using emotive rather than medically sound arguments. It is an issue, though whether it is right to remove such a personal thing as a foreskin without permission or disease, and parents neeed to be given enough information for them to be able to make an informed choice, as they do with vaccinations, which have far more and serious side effects than circumcision. Dr Patrick seems to me to bring us right up to date. We have to confront major diseases such as HIV (uncommon at present in UK) and HPV (very common). Removal of the foreskin removes the Langerhan cells which are responsible for the spread into the body. The warm moist environment also encourages the spread aand multiplication of these along with syphilis, chlamydia,and rarely chanchroid. A recent IPPR report suggested that 38% of our under15s have had penetrative sex, an alarming pool of infection. We are about to vaccinate our girls, at a cost of at least £200 each, against Human Papilloma Virus (HPV). Infant circumcision has as much protective effect against HPV at a cost of £60, bringing all the other benefits along with it. The South Korean and Phillippino boys arrange their own circumcision at age 12, and have a 90% uptake. That would satisfy those who want the individual to choose. As we have seen, that choice has to be made before sexual activity takes place. In our culture, a 10 minute procedure using a Plastibell or (beloved of Americans) a Gomco clamp with local anaesthetic provides a cheap and simple solution in early childhood, a technique easily learned by a competent GP. Prof Brian Morris of Sydney puts the relative risk of circumcising as 1: 100 compared with lifetime uncircumcision. Personally, I am delighted that my son and grandson were circumcised as infants. I believe that is as responsible a decision as to have them vaccinated. We need to make it easy for those who desire it. Competing interests: None declared
Is infant male circumcision an abuse of the rights of the child? Yes 9 December 2007
NAZAR R DESSOUKI, CONSULTANT SURGEON ST BERNARDS HOSPITAL GIBRALTAR Send response to journal: Re: Is infant male circumcision an abuse of the rights of the child? Yes	The answer is NO Male circumcision has been associated with a lower risk for HIV infection in international observational studies and in three randomized, controlled clinical trials. Male circumcision could also reduce male-to- female transmission of HIV to a lesser extent. It has also been associated with a number of other health benefits. While there are risks to male circumcision, serious complications are rare. Accordingly, male circumcision, together with other prevention interventions, may play an important role in HIV prevention in settings similar to the clinical trials. Male circumcision may also have a role for the prevention of HIV transmission in the United States. With the results of three clinical trials showing that male circumcision decreases the risk for HIV infection, CDC is undertaking additional research and consultation to evaluate the potential value, risks, and feasibility of circumcision as an HIV prevention intervention in the U.S. Competing interests: None declared
Re: Baloney on 'the snip' 9 December 2007
Ivy Paul, A&E doctor (locum) sandwell hospital, West Bromwich B71 4HJ Send response to journal: Re: Re: Baloney on 'the snip'	The debate on the usefulness or the disadvantages of male circumcision has been going on in the western society for a long time, because circumcision is neither culturally mandatory nor a religious practice, therefore still an arguable issue. Without being biased I would like to quote an article in a journal called 'The Aids Reader' under the heading of "Male Circumcision and the Risk of HIV Infection". The article can be found at www.medscape.com and mentions reports about the potential protective effect of male circumcision in the sub Saharan African continent. I believe, in view of providing good health care in any form, it would be better for us to start thinking beyond 'abuse', which is a matter of debate, and strive to take any measures that could possibly decrease the risk of infections like HIV Competing interests: None declared
Do no harm 9 December 2007
Iris B. Fudge, RGN Retired LONDON SE24 0DQ Send response to journal: Re: Do no harm	Any medical practitioner carrying out a surgical operation upon a person must ask himself - what is the necessity and the reason for this procedure and what is the benefit to the patient which justifies any harm that may ensue. Competing interests: Member of NORM-UK and FORWARD.
Is infant circumcison abuse? 9 December 2007
Tandy Huighes, retired 15235 Send response to journal: Re: Is infant circumcison abuse?	Of course it is. And to pretend that there are valid medical reasons for it is fallacious. Studies claiming any benefit for infant circumcision are flawed correlational statistics only. No where in the real world outside of the studies themselves are these benefits ever seen. Many countries that do not circumcise have the same rates (or lower rates) for all claimed beneits as do circumcising countries.. when this is brought up, there is never a rebuttal, just a lot of vague and unproven excuses. SCIENCE does not accept excuses! Science and Circumcision Basic principals of science: These can be used as a litmus test for claimed benefits Conclusions based solely on known flawed data cannot be considered valid All studies have known flaws—flaws of commission and/or flaws of omission Flaws = not scientifically compelling The worth of a theory is determined by its ability to make accurate predictions No predicted reduction or elimination is found in real world Failure to fulfill prediction = not scientifically credible Competing interests: None declared
Circumscision is justified 9 December 2007
Mujibur Rahman, Assistant Professor 5400 Send response to journal: Re: Circumscision is justified	Yes, it is justified to have cicumscision of male infant or child. It not only keeps best sexual life in later life rather prevents many diseases like cancer or other sexual diseases. There are many publications on the matter. Parents have to do many things for the better future of the child. Why should the parents send them to school when they like to play only. It is for their better future. In this way a child should not be exposed to anything that should be exposed to adults only e.g. sex education in school life that is practised in so called most modern western country. It is one of the common causes of HIV or other sexual diseases those prevelent in those people. Many things that should not be exposed to them may make them curious to perform or practise it in inappropriate time and bringing dangerous effect. If parents do not control them or teach them religion they will be worse than animals. I think muslim religion is best in this sense. HIV/AIDS is least among the muslims in the world. Competing interests: None declared
Is infant male circumcision an abuse of the rights of the child? 9 December 2007
Jan J van der Bank, Religious Researcher Pretoria, 0186, RSA Send response to journal: Re: Is infant male circumcision an abuse of the rights of the child?	Yes: Every person is entitled to their own opinion when and how and if. The baby does not have that right to choose. Even the parent may not decide even if it's religious of nature. The ONLY time it may happen is when the child is actually in <b>immediate</b> danger and/or can/will be in danger before the age of adolescence is reached, and even then there are certain procedures and/or rules to work upon. Competing interests: Religion
Re:Questionable argument 9 December 2007
A.D. Fontain, Independent Researcher Toronto, ON. Canada M5S 1A5 Send response to journal: Re: Re:Questionable argument	The AAP holds that the existence of potential benefits associated with male circumcision justifies a parental role in making the decision. However, what the AAP fails to address is the question of how/why the mere existence of potential benefits alone adequately justifies the allowance of parental consent. And consequently, results in the usurping of individual bodily rights in relation to an unnecessary genital modification. Should a male object to the removal of healthy genital tissue from his body, this rational provides little in the way of appropriate justification for the infringement upon his individual bodily rights that has occurred. Policies which fail to adequately address the issue of individual bodily rights in this matter represent more of an artifact of cultural inheritance than they do any kind of sound policy. Compensatory potential benefits which are not compelling enough for the AAP (or any other national medical organization for that matter) to make positive recommendations upon are given far too much weight in the current equation. The AAP position, along with Benatar and Benatar's arguments[1], might more appropriately apply to religious circumcisions performed by a mohel. Physicians, on the other hand, are bound to a specific code of conduct unique to their position as health care providers. They are required to respect a patient's autonomy and act solely in the patient's best interest. It is quite a stretch indeed for a physician to claim that he/she is acting in accordance with his/her ethical duties when removing healthy genital anatomy from a patient before the patient's will regarding this action can be known. Aside from the matter of principle, there is the fact that circumcision is no longer an unquestioned cultural norm within Western society as it once was. - which makes any assumption that a male will have wanted to be/or will be neutral about being circumcised in infancy even more questionable. To justify this conduct by the fact that a male infant's will cannot be known, despite the fact that he will be capable to make this decision at a later date, does not constitute a need for proxy consent to be sought and undermines it's validity. The uncertainty surrounding the best interests of a child when he will be raised in a cultural setting that may possess stigmas towards natural male genital anatomy is not so much a matter of whether or not surgery should be performed on him. - But a question of how to eliminate these unfair and harmful stigmas that are directed towards boys simply because they have not had their genitals surgically altered. In societies where male circumcision has been culturally normalized, it is often simply assumed that the removal of genital tissue from an un- consenting minor is acceptable. From this starting point: if it is not on par with FGM in terms of harmfulness; and if it is associated with a collection of (mostly minor) potential health benefits(that are rare) - it therefore must be an acceptable practice. Unfortunately, this outdated logical tangent continues to be reflected in many of the policies throughout the world. Given the cultural history involved, it is not surprising that the AAP, along with many other medical societies hold confused policy statements on the issue. Benatar and Benatar, merely parrot the AAP position statement as it pertains to ethics. Kirsten Patrick, in her defense of the procedure, does the same; while at the same time cherry picking studies that would paint circumcision in a favorable light - a tactic that is necessary in order to give circumcision advocacy any semblance of credibility. However, even taking these claims at face value, virtually all of the potential health benefits cited are either 1. Not relevant to male until he would old enough to make a choice for himself (STD data).; 2. Are mostly minor and rarely associated with a need for any surgical intervention whatsoever (infection). 3. Can be achieved via more effective, ethically sound and non-surgical means (practicing a modicum of care in relation to hygiene and sexual conduct). And 4. Are exceedingly rare and are associated with far more significant risk factors that are primarily behavior related(penile cancer). Only in some cases would circumcision avert a male having to be circumcised for health reasons - the exact same procedure, only slightly more complicated as the prevention. This is the upside-down logic in the argument of why circumcising infants is acceptable or even desirous. I do believe there might be some truth to George Hill's observation that some circumcised men who are doctors use the medical literature to justify their loss... which results in a voluminous, confused, and chaotic literature as other doctors refute the fantasy claims of circumcised doctors. - There must be at least some degree of psychologically driven fanaticism at play when an advocate of circumcision takes a microscope to statistical data and translates, say, a 0.4%circ versus 0.8%uncirc rate of an adverse health event like a skin infection; Trumpets the study as proof that uncircumcised boys are "twice as likely!" to get said skin infection; Goes on to collect as many circumcision- positive studies that would support their pre-determined hypothesis that they can find; Tally their figures; Omit any conflicting evidence; Weigh the result against the smallest risk figures that can be found within medical literature; And then go on to claim that circumcision is associated with 'significant health benefits' which therefore make it a perfectly acceptable practice. Nevermind the fact that, in reality, whether or not 1% or 10% of males get some small benefit from the surgery is only one consideration - the fact remains that 90%-99% of infant males will not benefit in anyway from having part of their genital anatomy removed. Nevermind the fact that most of the benefits are irrelevant to a child and that in most cases the prevention is more drastic then would be the treatment. And nevermind the fact that there are males (enough at the least to give rise to widespread and sustained calls to put an end to the practice) who strongly object to having their bodily rights infringed upon via the removal of healthy genital tissue by doctors acting as cultural agents. It is far too facile to say that the crux of the matter rests upon: 1. Whether or not it is true that male circumcision reduces a males sexual sensitivity in the remaining anatomy (of which there exists conflicting research). 2. Whether the potential compensatory health benefits outweigh the risks and harms of the procedure. 3. How male circumcision differs from FGM. 4. Whether or not more males than not prefer, or are indifferent towards being circumcised in childhood. Regarding the first point: It should be noted that many men find the foreskin to be a pleasurable part of the penis that a circumcised male will never experience. Conflicting research into the matter aside, to claim that there is not at least some inherent loss in terms of sexual sensory experience, which can be of detriment to the capacity for sexual pleasure in a male, is utter denial. Some men may well claim to enjoy sex more after being circumcised. However, it should be noted that most men who chose to get circumcised in adulthood were likely experiencing a health problem with their foreskin, or felt some psychological desire to be circumcised. Two factors which would strongly contribute to the perception of increased sexual contentment. If a males is unsatisfied with being uncircumcised he can do something about it via a simple minor procedure. A circumcised male does not have any choice in that respect because his autonomy over his body has been taken from him, in the absence of any medical indication. Regarding the second and third point: There are many parts of the anatomy that could hypothetically be removed from a healthy child which might result in some potential compensatory benefits down the road. Nor might it necessarily be considered to be as injurious as FGM. Yet, as a general rule, as per the fundamental ethical principles that govern medicine, physicians do not interfere with a patient's bodily integrity when the patient cannot consent unless there is a clear and pressing medical need(or perhaps in cases of anatomical deformity). In addition, as mentioned earlier, the nature of the medical benefits are such that they are mostly minor and for the most part irrelevant to a male until he would be able to decide. Regarding the fourth point: Principles of individual autonomy and bodily rights in medicine, as they relate to a patient, have little to do with how other people might be culturally inclined to perceive a genital/body modification performed on them in childhood. Waskett states that "studies of circumcision patients consistently reveal high rates of satisfaction". This might be relevant in understanding how circumcision is perceived within a circumcising culture, but does little to address the nature of ethical arguments being put forward by abolitionists. I would not go so far as to equate the practice of FGM with infant male circumcision; but it is worth mentioning that within cultures that practice FGM, similar high rates of satisfaction coming from recipients of the custom can be observed.[2]. This only serves to illustrate that a culturally influenced and widespread favorable perception surrounding a body modification custom does little to provide any significant validity to it's ethical acceptability as it relates to an individual. Patrick and other infant circumcision apologists are apt to describe opposition to the circumcision of minors as being far too nebulous (citing a lack of any large scale studies looking into the matter) to deserve any consideration when it comes to policy. However, it is generally becoming accepted within the medical world that these men do indeed exist in sufficient number as to warrant a re-examination in policy. One recent example can be found in the College of Physicians & Surgeons of British Columbia's Resource Manual for Physicians pertaining to infant male circumcision[3] which states: "Under the Canadian Charter of Rights and Freedoms and the United Nations Universal Declaration of Human Rights, an infant has rights that include security of person, life, freedom and bodily integrity. Routine infant male circumcision is an unnecessary and irreversible procedure. Therefore, many consider it to be “unwarranted mutilating surgery”. "Many adult men are increasingly concerned about whether their parents had the right to give consent for infant male circumcision. They claim that an infant’s rights should take priority over any parental rights to make such a decision. This procedure should be delayed to a later date when the child can make his own informed decision. Parental preference alone does not justify a non-therapeutic procedure." Of course, one must also consider the point which Mr. Rosswick has raised: He is happy that he was circumcised 75 years ago, so all this discourse in the year 2007 on the ethics of neonatal circumcision within the context of health care ought to just disappear. --- [1] Benatar, D., and M. Benatar. 2003. 3:2 Target article authors respond to commentators: How not to argue about circumcision. The American Journal of Bioethics 3(2): W1-W9. [2] Morison et al - The long-term reproductive health consequences of female genital cutting in rural Gambia: a community-based survey. Tropical Medicine & International Health Volume 6 Issue 8 Page 643- 653, August 2001 [3] College of Physicians & Surgeons of British Columbia - Resource Manual for Physicians - Circumcision (Infant Male) Competing interests: None declared Competing interests: None declared
Don't do it! 9 December 2007
George W Terrell Jr., college professor Gadsden State Community COllege 35901 Send response to journal: Re: Don't do it!	Since it can't be easily reversed, circumcision should be the choice of the OWNER of the penis it is to be performed on! SO many nerves are removed that sensation HAS to be significantly diminished as a result. If it is not ok to MUTILATE girls (ie the new US law) then why is it still ok to do it to boys? Let them decide when old enough is my call. I was clipped at birth, as that was the trend at the time in the USA. I would advise parents now to NOT... George W. Terrell Jr. Competing interests: None declared
Circumcision or retraction? 9 December 2007
Oscar Luis Pereira, Pediatrics 10500 Send response to journal: Re: Circumcision or retraction?	When circumcision has a medical indication (very low), I think that it is not a child abuse because it is a treatment, but preputial retraction which is not indicated: yes it is. Competing interests: None declared
Circumcision may also be painful for the surgeon 9 December 2007
Roger H Armour, Retired Consultant Surgeon, Lister Hospital Stevenage 88 Wymondley Road, Hitchin, Hertfordshire SG4 9PX Send response to journal: Re: Circumcision may also be painful for the surgeon	Whatever the pros and cons of circumcision (1, 2), it is a painful business. In my last years as consultant I gave all my day-surgery patients my personal pager and home telephone numbers so they should not feel abandoned. In one typical year*, 130 operations were performed, 64 on children on dedicated paediatric lists. Twenty-three children underwent circumcision under general anaesthesia and a caudal block. To reduce anxiety to a minimum the children entered and left the operating theatre in their outdoor clothes. Circumcision was performed with a microsurgical technique using 5X magnifying loupes, saline drops to keep the wound moist, bipolar diathermy to coagulate blood vessels before they were divided, and the utmost gentleness. That year I received six telephone calls, four from parents of circumcised boys in much pain after operation, and my House Surgeon received two calls, also from parents of distressed circumcised boys. Thus 6/23(26%) of the boys were so upset that their parents had to telephone for help. Surgeons who do not allow their patients direct access to them sleep blissfully unaware of the suffering they are causing. Acknowledgments. I thank Dr Indu Sockalingham, consultant anaesthetist, and the the day-surgery and district liason nurses for their support. *unpublished data available on request 1) Hinchley G, Patrick K.Is male circumcision an abuse of the rights of the child? BMJ 2007;335:1080-1081 2) Malone P, Steinbrecher H. Medical aspects of male circumcision. BMJ 2007;335:1206-1209 Competing interests: Circumcision at age eight
Circumcision’s lawfulness is in doubt and there is a conflict of rights 10 December 2007
John D Dalton, Trustee NORM-UK, PO Box 71, Stone, Staffs ST15 0SF Send response to journal: Re: Circumcision’s lawfulness is in doubt and there is a conflict of rights	The question is not whether circumcision is in breach of the rights of the child but how properly to resolve the conflict in rights between the parents and the child. NORM-UK is a charity established in response to the need to represent the interests of male patients to avoid therapeutically unecessary circumcision. We receive calls daily from patients who have been harmed by male circumcision for which there was little or no therapeutic need. Many of the men who contact us have been profoundly damaged either physically or psychologically. Male circumcision is in all cases harmful since it removes the part of the penis most sensitive to fine touch, destroys the gliding function of the penile skin and removes immunological tissue. As circumcision permanently alters the appearance of the body it meets he dictionary definition of disfigurement. Since it removes a normal functional body part it meets the dictionary definition of mutilation. To claim that the procedure is not harmful would be absurd. Since male circumcision cuts through the full thickness of the skin it would appear to be a wounding for the purposes of the Offences Against the Person Act 1861. This calls into question the lawfulness of the procedure when performed on normal unconsenting children for any reason other than absolute therapeutic need. A defence of reasonable surgery would imply that disease is present for which there is no non-invasive treatment, that circumcision would provide effective treatment of the disease and that there is valid informed consent. We recognise that male child circumcision is a traditional practice within some religious communities. Everyone has the right to manifest religious belief, however that right is not absolute. The right to manifest religious belief may be limited where necessary to protect the rights and freedoms of others.[1] NORM-UK considers that circumcision of normal unconsenting children, when done for non-therapeutic reasons, infringes a child’s rights to autonomy, privacy, dignity and protection from cruel, inhuman or degrading treatment. As such, limitations on religious freedom in order to forbid male child circumcision would appear to be legally admissible. A realistic rate of significant complications for male circumcision lies between 2% and 10%.[2} Given this high rate of complications, NORM-UK considers the practice of male child circumcision to be prejudicial to the health of children. In this case governments would be obliged to act with a view to abolishing the practice if they are to meet their obligations under the 1988 Declaration of the Rights of the Child.[3] The recent death of a child following ritual circumcision in North London (http://www.guardian.co.uk/uk_news/story/0,,2015181,00.html) also raises issues of the right to life.[4] To answer Kirsten Patrick’s question “Where’s the harm?”, NORM-UK retain copies of all the letters received by our charity. These letters have been made anonymous by removal of all personal details which could identify the author. We invite Doctor Patrick to come to our office and read those letters. The evidence of harm is there if she cares to look. NORM-UK considers that the present guidance documents on male circumcision from the BMJ or GMC are no longer supportable in view of the GMC’s new statement that doctors must respect the rights of the child. The UK Government must honour its commitment to the Convention on the Rights of the Child. If HM Government do not have the stomach for this, they must ensure that circumcisers are traceable and can be held accountable for their actions. John Dalton, NORM-UK, PO Box 71, Stone, Staffs ST15 0SF References   1.       European Convention on Human Rights Article 9.2.   2.       Williams N, Kapila L. Complications of circumcision. Br J Surg. 1993; 80:1231-1236.   3.       Convention on the Rights of the Child Article 24.3.   4.       European Convention on Human Rights, Article 2.   5.       http://www.gmc-uk.org/guidance/ethical_guidance/children_guidance/index.asp accessed 08 December 2007. Competing interests: None declared
Male circumcision is cosmetic surgery. 10 December 2007
Andras Heijink, Orthopedic Surgery resident Mayo Clinic Rochester, USA Send response to journal: Re: Male circumcision is cosmetic surgery.	Male cirumcision, if not performed for medical reasons, is a cosmetic procedure and is unnessecary. Parents can consent to medical and surgical procedures to be preformed on their child only when there is a medical necessity, in other words, when the child will benefit from it from a health perspective. Parents can not have their child undergo unnecessary medical or surgical treatment. Hence, parents can not have their child undergo circumcision. Just imagine what an outrage it would cause if one would present at a hospital to schedule a face-lift for his 7 year old daughter; or breast augmentation for his 14 year old; or calf implants for his 10 year old son? These examples may seem completely ridiculous, but are in principle identical to male circumcision. The reasoning is quite simple. The only argument that can be made for male circumcision is that religious people usually do not follow legal and moral principles if they don't suit them well and will resort to non-medically schoole