Medical and Ethical Positions on Circumcision
No medical association in the world recommends routine infant circumcision. Medical associations from cutting cultures tend to view circumcision as having slight benefits, whereas medical associations from non-cutting cultures tend to recognize circumcision as a human rights violation and take active stances against the practice.
The Canadian Pediatric Society published a position statement on September 8, 2015, and reaffirmed it on February 28, 2018, and again on January 1, 2021.
They do not recommend cutting children’s genitals.
“In cases in which medical necessity is not established or a proposed treatment is based on personal preference, interventions should be deferred until the individual concerned is able to make their own choices. With newborn circumcision, medical necessity has not been clearly established.”
“It is important to remember that most data regarding the benefits and outcomes following circumcision come from countries other than Canada, which can make application to our population difficult.”
“The CPS does not recommend the routine circumcision of every newborn male.”
Newborn male circumcision – Canadian Paediatric Society
“…the aim should as far as possible be that the child / young man himself should be allowed to take a position on circumcision.”
Related ARC Announcement from 2012:
The BMA published a “practical guide for doctors” in 2019. On page 13 they state:
“Although they usually coincide, the interests of the child and those of the parents are not always synonymous. Doctors should be alert to situations in which parents’ decisions appear to be contrary to their child’s interests.”
“The BMA cannot envisage a situation in which it is ethically acceptable to circumcise a child or young person, either with or without competence, who refuses the procedure, irrespective of the parents’ wishes.”
“Parental preference alone does not constitute sufficient grounds for performing NTMC on a child unable to express his own view.”
And on page 14:
“Furthermore, the harm of a person not having the opportunity to choose not to be circumcised or choose not to follow the traditions of his parents must also be taken into account, together with the damage that can be done to the individual’s relationship with his parents and the medical profession, if he feels harmed by an irreversible non-therapeutic procedure.”
BMA 2019 guidance document:
Nontherapeutic male circumcision NTMC of children guidance 2019
The Urological Society of Australia and New Zealand published a statement on August 18, 2018, in which they say:
“USANZ contributed to the development of the Royal Australasian College of Physicians (RACP) Statement on Circumcision of Infant Males and supports that statement.”
“…parents/guardians must be informed that legally, they may only consent to medical procedures on their child that have a proven medical benefit. Since the medical benefit for request circumcision is disputed, this is currently a grey area in law.”
DASAIM opposes the infliction of foreskin amputation on healthy children under the age of 18:
“It is DASAIM’s position that circumcision of healthy persons requires informed consent, that is, an age limit of 18 years.”
They also state that “…surgery, such as circumcision of boys, performed on children without general anesthesia, is considered by DASAIM to be below good and safe professional standard.”
“Given the socioeconomic, educational status, and health demographics of our population, universal neonatal circumcision cannot be justified based on the current evidence available.”
Canadian Urological Association Guideline Abridged Version 12-17
Canadian Urological Association Guideline Full Version 12-17
A Belgian federal government committee has ruled against the circumcision of infant boys for reasons other than medical necessity.
The Committee for Bio-Ethics ruled that bodily integrity was more important than religious faith.
“As circumcision is irreversible and therefore a radical operation, we find the physical integrity of the child takes precedence over the belief system of the parents,” said Marie-Geneviève Pinsar, the committee’s chair.
Belgian federal committee rules against ritual circumcision
Report by Intact Denmark:
Related ARC Announcement from 2014, regarding the both the DMA and the Danish College of General Practitioners:
“…the Finnish Ombudsman for Children Tuomas Kurttila proposed that Finland should enact an act prohibiting the non-medical circumcision of young boys. On 8 October 2015, the Ombudsman for Children submitted an initiative on the matter to the Ministry of Social Affairs and Health.”
The Swedish Medical Association’s Code of Ethics and Liability Council now stands unanimously behind a statement about ending male circumcision without prior consent. It should not be done before the boy is 12 or 13 years of age, must take place in a hospital, and only after information about the pain and the risks that surgery entails has been provided.
The Norsk Sykepleierforbund opposes “exposing healthy children to an irreversible, painful and risky intervention, without their own consent.”
An overall child health professional environment wants an age limit for circumcision of boys. The Norwegian Nursing Association also supports this requirement…
…There is no medical indication for the procedure. In our view, it is problematic to establish different legal standards depending on gender. Circumcision / genital mutilation of women is criminalized, while circumcision of boys is proposed institutionalized through the public health system.
The Parliamentary Assembly is particularly worried about a category of violation of the physical integrity of children, which supporters of the procedures tend to present as beneficial to the children themselves despite clear evidence to the contrary. This includes, among others, female genital mutilation, the circumcision of young boys for religious reasons, early childhood medical interventions in the case of intersex children, and the submission to, or coercion of, children into piercings, tattoos or plastic surgery.
Also see this 2016 update from Ron Goldman:
Unless there are compelling medical reasons to operate before a boy reaches an age and a level of maturity at which he is capable of providing informed consent, the decision to alter the appearance, sensitivity and functionality of the penis should be left to its owner, thus upholding his fundamental rights to protection and bodily integrity.
Norway, Sweden, Finland, Denmark, Iceland, Greenland
Circumcision, performed without a medical indication, on a person who is incapable of giving consent, violates fundamental medical-ethical principles, not least because the procedure is irreversible, painful and may cause serious complications. There are no health-related reasons for circumcising young boys in the Nordic countries. Circumstances that may make circumcision advantageous for adult men are of little relevance to young boys in the Nordic countries, and on these matters the boys will have the opportunity to decide for themselves when they reach the age and maturity required to give consent.
English translation of Nordic ombudsmen’s statement:
Text below by Google Translate
Circumcision of girls is a punishable act. The child protection authorities must be notified of the circumcision performed or planned in Finland.
The parents requesting ritual circumcision of the boy should be given a discussion about the abandonment of the measure or its postponement until the boy is able to decide for himself.
Even if ritual circumcisions are accepted in health care, the doctor should always be able to refuse to perform them.
GIRLS CIRCULAR SURGERY
There have been cases in Finland where a foreign patient has requested services from a doctor that are foreign or questionable to Finnish culture and healthcare. For example, circumcision of girls is an ancient rite aimed at controlling women’s sex lives. The measure is justified by the risk of an uncircumcised woman being discriminated against by her own, which would increase the anxiety of a refugee in a difficult life situation.
A doctor cannot engage in activities that cause immediate and chronic pain as well as permanent harm and threat to health. There is no medical basis for circumcision of girls. Under Finnish law, circumcision of girls is mutilation and a punishable act. Traditions change only through education and knowledge, but are most likely to survive if doctors agree to continue the tradition. The WHO and many other health care organizations are fighting female circumcision.
The challenge for healthcare professionals is to prevent circumcision. The starting point is to raise the issue when confronting families who come from cultures that engage in female circumcision. This is especially important in counseling so that parents can also be educated and told about the legislation. In these situations, as well as in the case of otherwise circumcised persons, it is advisable to record the findings or discussions for possible further action. If it turns out that the girl has been circumcised in Finland or is planned to be performed either in Finland or abroad, the matter must be reported to the child protection authorities.
Corrective opening surgery for the most radical circumcision provides relief from many of the problems caused by circumcision. Telling and recommending the benefits of corrective surgery is a step towards breaking the tradition of circumcision.
CIRCUMCISION OF BOYS
Circumcision of boys has a long tradition in Judaism and Islam. Circumcision is an initiation rite in Judaism. In Islam, a man is not considered sovereign if he has not been circumcised. In Anglo-Saxon countries, the practice of circumcision is widespread for cultural reasons, as circumcision is thought to have health and chastity benefits.
Circumcision always exposes the patient to complications. Taken in a preventive sense, the measure will not bring any health benefits other than the possible prevention of HIV in developing countries. Thus, it is comparable to female circumcision. Since proper consent cannot be obtained from a small son, both ethically and legally, circumcision violates an individual’s freedom and personal integrity. As such, the procedure is contrary to medical ethics.
CIRCUMCISION OF BOYS AS A LEGAL ISSUE
Legally, the right to physical integrity guaranteed by the Constitution (731/1999) and the freedom of religion guaranteed by the Constitution and the Law on Religious Freedom (453/2003) are subject to review. Admittedly, in the case of young boys, it must be borne in mind that this is not a freedom of religion based on their will, but the freedom of their parents to practice their religion. In the issue of circumcision, therefore, a choice must be made as to whether to emphasize the practice of circumcision, which derives from the tradition of religion, or the right of the individual to bodily integrity, which arises from medical ethics, human rights and the Constitution.
At the same time, the question arises as to whether boys are on an equal footing, on the one hand with regard to physical integrity and on the other with regard to religious freedom. The Constitution ensures that no one’s physical integrity can be violated on religious grounds. Ritual around the practice of omission contradicts this. The protection of personal integrity is a fundamental right that is also closely linked to the protection of privacy enshrined in the Constitution. This includes the right to determine oneself and one’s body. International human rights regulations established in Finland also prohibit such religious-related measures that endanger health.
This principle has been confirmed in a court case where circumcision by a doctor has been considered as an assault within the meaning of the Penal Code (decision of the public prosecutor Päivi Hirvelä on 29 June 2004, no. R 02/15). This decision equates the circumcision of boys and girls with equal violations of bodily integrity, which can be considered from a legal point of view as the mutilation mentioned in the preamble to the fundamental provisions of the Constitution (HE 309/1993). The explanatory memorandum refers to the fact that, under the obligation of equality, the protection of the physical integrity of boys cannot be inferior to that of girls. In that case, however, the charges were dismissed on grounds of reasonableness.
Since then, the Supreme Court (KKO 2008: 93) has ruled in a similar case that the person who arranged the circumcision of his son was not guilty of assaulting his son. In principle, it was found that circumcision, which is not performed for a medical reason, can be considered to fulfill the characteristics of assault. However, the decision was based on the fact that the measure had been taken for reasons acceptable to the boy on religious grounds and that in the present case the measure was considered to have interfered as a whole with a limited degree of assessment of the boy’s physical integrity.
The Supreme Court decision described above does not take into account in its reasoning the fact that a man who has grown up may consider circumcision as a child to be traumatic and adversely affecting sexuality. There are studies where the harmfulness has emerged. Thus, the interference with bodily integrity cannot be considered unequivocally minor. Nor does the reasoning address the fact that, from the point of view of religious freedom, circumcision performed as a child may be perceived as alien and perhaps contrary to the perceptions adopted in adulthood. The irreversibility of the measure is then a particular problem.
Following a preliminary ruling from the Supreme Court, the Helsinki District Court issued a judgment on 30 December 2011 on the beating of a man who circumcised two sons and did not have approved health care education in Finland. The boys’ parents were found guilty of inciting the assault, but were left unpunished. In its reasoning, the District Court stated that the 2008 preliminary ruling of the KKO did not mean to allow circumcision and, moreover, that the Council of Europe Convention for the Protection of Human Rights and Dignity of the Human Being with regard to Biology and Medicine had entered into force on 1 March 2010. It states that health measures may be taken against a person who is unable to give consent only if they are of immediate benefit to him. Referring to this, the district court pointed out that a person must be able to decide for himself about circumcision.
The ethics and practice of circumcision have also been discussed in other Nordic countries. In Sweden, the law allows ritual circumcision when a child is under two years of age, if the procedure is performed by a doctor or other person who has received a special permit from the social welfare board. Denmark has a similar law.
THE ROLE OF PUBLIC HEALTHCARE IN CIRCULAR SECTIONS
Attempts have been made in Finland to make ritual circumcision a public health measure as a measure to be taken in public health care. It is argued that otherwise circumcisions would be performed under inappropriate conditions, which would increase the risk of complications. This problem has come to the fore with Muslim immigrants, with circumcisions being performed at home, among other things. In Finland, about 200 boys are circumcised every year for non-medical reasons, although there are no reliable statistics. On the other hand, the Parliamentary Deputy Ombudsman has already in his 1999 statement (Dnro 462/4/99) treated the ritual circumcision of boys “with great caution” from a legal point of view and questioned their legitimacy in public health care.
Also, according to the prioritization rationale, it is considered natural that ritual circumcision should not be paid for from public health funds.
The working group of the Ministry of Social Affairs and Health, which examined the need for legislation on the practice of circumcision of boys in 2003, believes that the aim should be to continue discussions with religious communities to abandon circumcision and to create legislation on circumcision. The Finnish Medical Association has considered that guidelines can be issued on the basis of current legislation.
From the point of view of medical ethics, the duties of a doctor should not include performing a religious ritual. In the opinion of the Finnish Medical Association, society should not legislate for such taking medical procedures or medical procedures that do not have a health significance. The doctor should always have a clear right to refuse to perform such a procedure if an attempt is made to oblige him to do so.
The Finnish Medical Association recommends that parents who request ritual circumcision be given a discussion about giving up the procedure or postponing it until the boy is able to decide on the procedure.
FOR MORE INFORMATION
Hurme T, Reunanen M. Circumcision of boys. Survey on pediatric surgeon care practices. Finland Medical Journal 2008; 35: 2781–86. Preliminary ruling of the Supreme Court (2008: 93). www.kko.fi Memorandum from the Working Party on the Need for Legislation on Boy Circumcision. Ministry of Social Affairs and Health Working Group Memoranda 2003: 39. Pälve H. Ritual circumcision is not in accordance with medical ethics. Suomen Lääkärilehti 2008; 35: 2763. Stenman Kaarina. Circumcision of boys. A study of international and domestic practices. Handouts from the Ministry of Social Affairs and Health 2004: 3. The symposium is a circumcision. J Med Ethics 2004; 30: 237–263. Tiilikainen M, (ed.). Circumcision of girls and women in Finland. Recommendations of the expert group social health care. Human Rights Association, Kajaani 2004. www.ihmisoikeusliitto.fi Finnish Medical Association Finnish Dental Association © Finnish Medical Association
Note: The AAP’s 2012 policy statement and technical report both expired in 2017 after 5 years.
The AAP issued a policy statement in 2012 that was widely criticized in its own journal. This policy statement claimed that the benefits of circumcision outweighed the risks, but not enough to recommend routine infant circumcision. Curiously, the AAP admitted that the risks were “unknown.” However, the AAP did recommend that third-party insurance cover routine infant circumcisions and gave the green light for the American Congress of Obstetricians and Gynecologists (who perform roughly 70% of all routine infant circumcisions) to continue to perform routine infant circumcisions.
“Although health benefits are not great enough to recommend routine circumcision for all male newborns, the benefits of circumcision are sufficient to justify access to this procedure for families choosing it and to warrant third-party payment for circumcision of male newborns.”
-Task Force on Circumcision. Circumcision policy statement. Pediatrics 2012;130:585-6. DOI: 10.1542/peds.2012-1989 (since expired)
“The true incidence of complications after newborn circumcision is unknown…”
-Task Force on Circumcision. Male circumcision. Pediatrics 2012;130:e756-e785. DOI: 10.1542/peds.2012-1990 (since expired)
In 2013, ARC’s Steven Svoboda published a response together with Robert Van Howe in the Journal of Medical Ethics:
“The policy statement and technical report suffer from several troubling deficiencies, ultimately undermining their credibility. These deficiencies include the exclusion of important topics and discussions, an incomplete and apparently partisan excursion through the medical literature, improper analysis of the available information, poorly documented and often inaccurate presentation of relevant findings, and conclusions that are not supported by the evidence given.”
Svoboda JS, et al. Out of Step: Fatal Flaws in the Latest AAP Policy Report on Neonatal Circumcision. J Med Ethics 2013;00:1–8. doi:10.1136/medethics-2013-101346
A group of over 30 physicians from Europe and Canada also published a critical response in Pediatrics:
“Seen from the outside, cultural bias reflecting the normality of nontherapeutic male circumcision in the United States seems obvious, and the report’s conclusions are different from those reached by physicians in other parts of the Western world, including Europe, Canada, and Australia.”
Frisch, et al. Cultural Bias in the AAP’s 2012 Technical Report and Policy Statement on Male Circumcision. Pediatrics 2012. 2013 Apr;131(4):796-800. DOI: 10.1542/peds.2012-2896
Religious rules must not influence doctors in the way they care for their patients – and in this case underage children deserve special care. Boys have, according to our sense of justice, the same basic constitutional legal rights to physical integrity as girls, they must not be disadvantaged due to their sex (Art. 3 GG – of the German Constitution). The parents right to educate and freedom of religion end here, where the rights to physical integrity of an underage person and child who is incapable of giving consent are infringed (Art. 2 GG), without there being a clear medical indication. This is applicable according to the opinion of all paediatric associations in Germany and applies to other injuries to intact body surfaces such as piercing, tattooing and ear piercing.
English translation of BVKJ statement:
…The right to religious freedom cannot justify interfering with the right to the physical integrity of another, so we believe that for non-medical reasons, circumcision is permissible only with the child’s consent, under the conditions laid down in the Patient Rights Act, that is, as a rule, after the age of 15.”
KNMG regards the non-therapeutic circumcision of male minors as a violation of physical integrity, a constitutional right that protects individuals against unwanted internal or external physical modifications. According to the KNMG, minors should only be subjected to medical procedures in the event of illness or abnormalities, or if a convincing case can be made that the procedure is in the interests of the child (such as vaccination).
After reviewing the currently available evidence, the RACP believes that the frequency of diseases modifiable by circumcision, the level of protection offered by circumcision and the complication rates of circumcision do not warrant routine infant circumcision in Australia and New Zealand.
RACP Position Statement – September 2010:
Update – reported in the media in February 2017, but with no evidence appearing on the RACP website itself:
“Physicians say the level of protection offered by circumcision does not warrant a change of policy on the infant surgical procedure in Australia, despite a leading researcher claiming it to be a “desirable” public health intervention…
“The RACP believes that the frequency of diseases modifiable by circumcision, the level of protection offered by circumcision and the complication rates of circumcision do not warrant routine infant circumcision for healthy male infants in Australia and New Zealand,”
…a RACP spokesperson said in a statement on Thursday.”
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.
Original 2004 statement:
Circumcision violates a boy’s sexual integrity and alters his body. . .no one has the right to consent to this invasive operation on a child’s behalf, except in relation to treatment of a disease.
The Constitution’s preparatory work explicitly establishes that religious freedom does not extend to violating the integrity of another person. Thus a child should be treated as an individual who is completely protected from birth until the age of majority. . .Circumcision should be permitted only on individuals who are of age, regardless of whether they are male or female, and only after determining they have consented freely, without coercion.
Finland Central Union for Child Welfare Statement 9-30-03
The Finnish Medical Association opposes the idea of using public funds to perform non-medical circumcisions on young boys. The FMA also says that non-medical circumcisions do not fit in well with Finnish culture, in which the inviolability of the body is respected.
After extensive review of the literature the RACP reaffirms that there is no medical indication for routine male circumcision.
Royal Australasian College of Physicians – 2002
In any dialogue you have with the patients about potential circumcision of newborn male infants, be sure that you accurately and effectively convey the message that this is not a recommended procedure.
…remember that you are under no obligation to perform any surgical procedure for which there are not valid medical indications. You can, and should respectfully decline to perform the procedure…
…a growing number of adult males and/or their parents are now expressing strong resentment against physicians who performed infant male circumcision many years ago at their request. The retroactive anger toward these physicians is generally based upon arguments that parents were given woefully inadequate information about potential adverse impact on adult male function, and inadequate information about normal infant penile development and hygiene…
While the College’s primary mandate is public protection, we do encourage physicians to give careful thought to the downstream risks they may incur by taking an inappropriately casual approach to infant male circumcision driven exclusively by parental preference without valid medical indication for the procedure.
Caution Against Routine Circumcision of Newborn Male Infants
Among other things, the council says that ritual circumcision of boys has no established medical benefit…
…circumcision of boys is not consistent with important principles of medical ethics…
…it is an important factor that the child cannot give consent.
According to the council, doctors should be allowed to refuse to perform ritual circumcision as a matter of conscience…
In line with the Code of Ethics for Doctors ¶ 12, it should not be paid for by the public health service.
Norwegian Council for Medical Ethics Summary in English 2001
Virtually all current policy statements from specialty societies and medical organizations do not recommend routine neonatal circumcision…
In the case of sexual transmission of HIV, behavioral factors are far more important in preventing these infections than the presence or absence of a foreskin.
A majority of boys born in the United States still undergo nonritual circumcisions. This occurs in large measure because parental decision-making is based on social or cultural expectations, rather than medical concerns.
Report 10 of the Council on Scientific Affairs
The CPSM states that “…medical indications for the performance of circumcision in the neonate are rare.”
Referring to spurious “benefits”, they nevertheless conclude:
The degree of benefit is small, however, and does not support a recommendation to circumcise neonates.
Neonatal Circumcision – College of Physicians and Surgeons of Manitoba
In Australia, the circumcision rate has fallen very considerably in recent years and it is estimated that currently only 10 percent of male infants are routinely circumcised.
The possibility that routine circumcision may contravene human rights has been raised because circumcision is performed on a minor and is without proven medical benefit.
The Australian College of Paediatrics Position Statement
The Australasian Association of Paediatric Surgeons does not support the routine circumcision of male neonates, infants or children in Australia…
In particular, we are opposed to male children being subjected to a procedure, which had they been old enough to consider the advantages and disadvantages, may well have opted to reject the operation and retain their prepuce.
AAPS Guidelines for Circumcision – 1996