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Circumcision of girls is a punishable act. The child protection authorities must be notified of the circumcision performed or planned in Finland to the child protection authorities. The parents requesting ritual circumcision of the boy should be discussed with giving up the procedure or postponing it to a time when the boy is able to decide for himself. Even if ritual circumcisions are accepted in health care, the physician 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. CIRCULAR SECTION 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 he or she trying to oblige it. The Finnish Medical Association recommends that with parents requesting ritual circumcision discussing the abandonment of the measure or its postponement to a time when the boy is himself capable decide to carry out the operation.
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