Medical and Legal Positions on Circumcision

No medical association in the world recommends routine infant circumcision. Medical associations from cutting cultures tend to view circumcision has 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 aim should as far as possible be that the child / young man himself should be allowed to take a position on circumcision.”

Reference:
https://www.barnlakarforeningen.se/2019/10/11/uttalande-angaende-icke-medicinskt-motiverad-omskarelse-av-pojkar/ (Swedish)

Related ARC Announcement from 2012:
https://www.arclaw.org/news/swedish-docs-in-circumcision-protest

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

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.”

Reference:
https://intactdenmark.dk/anaestesilaeger/ (Danish)

The Canadian Pediatric Society published a position statement on September 8, 2015, and reaffirmed it on February 28, 2018. 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.”

Reference:
https://www.cps.ca/en/documents/position/circumcision

“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.

Reference:
https://www.secularism.org.uk/news/2017/09/belgian-federal-committee-rules-against-ritual-circumcision

“The Medical Association believes that circumcision of boys without medical indication is ethically unacceptable if the procedure is carried out without the informed consent of the person who gets the procedure. Thus, circumcision of boys should not be undertaken until the boy has obtained authority to independently elect the intervention. ”

Source:
https://www.laeger.dk/laegeforeningens-politik-vedroerende-omskaering-af-drengeboern-uden-medicinsk-indikation (Danish)
Report by Intact Denmark:
https://intactdenmark.dk/2016/12/02/laegeforeningen-omskaering-af-raske-drenge-er-uetisk/ (Danish)
Related ARC Announcement from 2014, regarding the both the DMA and the Danish College of General Practitioners:
https://www.arclaw.org/news/danish-doctors-call-circumcision-mutilation

“…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.”

Reference:
https://www.tasa-arvo.fi/web/en/-/circumcision-of-boys-tas-143-2016-issued-on-23-august-2016-

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.

References:
http://www.huffingtonpost.com/2014/01/27/circumcision-ban-sweden-denmark_n_4674547.html
http://www.fyens.dk/article/2445175:Udland–Svenske-laeger-vil-skaerpe-regler-for-omskaeringer (Danish)

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.

Reference:
https://www.nsf.no/vis-artikkel/1556374/17036/Horing:-Onsker-aldersgrense-for-omskjaering-av-gutter- (Norwegian)

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.

Announcement: https://www.arclaw.org/news/more-good-news-from-europe-council-of-europe-condemns-male-circumcision

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.

https://arclaw.org/wp-content/uploads/2013-10-10-nacs-statement-on-ritual-circumcision-of-boys-press-release.pdf

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.

Announcement: https://www.arclaw.org/news/exciting-news-from-norway-five-nordic-childrens-ombudsmen-pass-resolution-to-work-for-ban-on-non-therapeutic-circumcision

English translation of Nordic ombudsmen’s statement:
https://www.arclaw.org/wp-content/uploads/Nordic-Ombudsmen-for-Children-Joint-Statement-Let-the-Boys-Decide-on-Circumcision-Cosigned-by-Norway-nursing-union-9-13.pdf

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.

ARC Announcement:
https://www.arclaw.org/news/german-pediatric-association-cites-arc-in-statement-to-parliament-attacking-circumcision

English translation of BVKJ statement:
https://www.arclaw.org/wp-content/uploads/BVKJ_Statement_Official_Translation.pdf

“However, if the circumcision of a child is not medically indicated, but is merely the result of the belief of his or her parents (religious or otherwise), such an intervention has no legal basis. It does not even matter whether the child explicitly opposed the intervention. Interfering with the physical integrity of the child solely because of the desire of his or her legal representatives or guardians, therefore, constitutes an inadmissible intervention in his or her body and, in our opinion, also has signs of criminal conduct…

…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.”

Source:
http://www.varuh-rs.si/medijsko-sredisce/aktualni-primeri/novice/detajl/obrezovanje-fantkov-iz-nemedicinskih-razlogov-je-krsitev-otrokovih-pravic/

ARC Announcement:
https://www.arclaw.org/news/slovenias-human-rights-ombudsman-says-male-circumcision-violates-human-rights

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).

KNMG Statement:
https://www.doctorsopposingcircumcision.org/wp-content/uploads/2016/09/knmg-non-therapeutic-circumcision-of-male-minors-27-05-2010.pdf

Read more:
https://www.knmg.nl/actualiteit-opinie/nieuws/nieuwsbericht/international-physicians-protest-against-american-academy-of-pediatrics-policy-on-infant-male-circumcision.htm

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:
http://www.racp.edu.au/docs/default-source/advocacy-library/circumcision-of-infant-males.pdf

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.

Reference:
http://www.cirp.org/library/statements/cpsbc2009/cpsbc-circ-stmt2009.pdf

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.

Source:
Finland Central Union for Child Welfare Statement 9-30-03

Read more:
http://www.cirp.org/library/statements/finland2003/

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.

Read more:
https://yle.fi/uutiset/3-5142149

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.

Reference:
http://www.cirp.org/library/statements/sask2002/

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.

Reference:
http://www.cirp.org/library/ethics/gulbrandsen1/

Norwegian Council for Medical Ethics Summary in English 2001

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.

Reference:
http://www.cirp.org/library/statements/manitoba/

The AAP issued a new policy statement in 2012 that was widely criticized in its own journal. The new policy statement states that the benefits of circumcision outweighs the risks, but not enough to recommend routine infant circumcision. Curiously, the AAP admits that the risks are “unknown.” However, the AAP does recommend that third-party insurance cover routine infant circumcisions and gives 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

“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

Criticism

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