TLRI Non therapeutic Male Circumcision by 4d94nw


									                     Tasmanian Law Reform Institute
                            Issues Paper 14
                    Non-Therapeutic male circumcision

Responses should be made in writing by the 28th August 2009.
If possible, responses should be sent by email to:
Alternatively, responses may be sent to the Institute by mail or fax:
Address: TLRI
Private Bag 89
Hobart TAS
Fax: (03) 62267623

                     Response of the Secular Medical Forum

Dear Sir/Madam,

1) I write on behalf of The Secular Medical Forum (SMF) in response to Issues
Paper 14: relating to non-therapeutic male circumcision. The SMF advocates
equality of care for all patients, irrespective of their or their doctors’ own
personal beliefs. We are especially concerned that patients, healthcare workers
and the wider public are not disadvantaged by the imposition of other people’s
personal religious views.

2) For an operation to be performed on any individual there has to be valid
consent. This is particularly important when the procedure is regarded as
irreversible. It is beyond reasonable debate that infants and young children
generally lack the capacity to give informed consent to significant surgical
operations. They are not capable of understanding the advantages and
disadvantages of a surgical procedure in any meaningful way. They are also
vulnerable to external pressures and to coercion.

3) Parents or guardians of young children who have the responsibility of giving
consent on their behalf should always act in the best interests of their wards. It is
only on this basis that their consent can be valid as a guide for medical
practitioners to proceed in the best interests of the child.

4) In the UK, the Doctors' regulatory body, the General Medical Council (GMC) has
issued guidance on 'Making decisions when a patient lacks capacity'. As this is
directly relevant to non-therapeutic childhood male circumcision I would like to
draw your attention to paragraph 76 of this guidance which states:
'You must also consider:

   a. whether the patient's lack of capacity is temporary or permanent
   b. which options for treatment would provide overall clinical benefit for the
   c. which option, including the option not to treat, would be least restrictive of
      the patient's future choices '

i) With regard to section 76a) in most cases the lack of capacity of the child will
be temporary. Therefore any decision about an irreversible, non-
therapeutic surgical procedure should be delayed until such time as the child later
gains capacity to decide for himself whether he would like a part of his penis to be
surgically removed.

ii) Decisions about overall clinical benefit for the patient (section 76b)) should be
made on evidence based medical grounds. There is no evidence to suggest that
routine infant or childhood male circumcision confers benefit on the
child. Respected medical organisations such as the Australasian Association of
Paediatric Surgeons and the Australian Medical Association have stated that there
is no medical indication for neonatal male circumcision or that circumcision of
baby boys should be discouraged. Internationally, the situation is similar. The
American Medical Association (AMA) and the British Association of Paediatric
Surgeons disagree with non-therapeutic childhood circumcision. The AMA was
quoted in 1999 as saying that 'Virtually all current policy statements from
specialty societies and medical organizations do not recommend routine neonatal
circumcision' .

iii) It is of note that Section 1(5) of the UK Female Genital
Mutilation (FGM) legislation 2003 explicitly excludes custom or ritual from being
acceptable reasons for performing irreversible surgery on little girls' genitalia. The
same protection in law should be afforded to boys.

iv) It is self-evident that the 'least restrictive' option (section 76c) suggested
by the GMC guidelines would be to defer the irreversible circumcision operation
unless there are compelling medical reasons to act immediately. By definition
with regard to non-therapeutic male circumcision there can never be a compelling
medical reason or it would cease to be a non-therapeutic procedure.

5) If parents or guardians are considered to be placing their own interests over
and above those of their wards then their consent should not be considered valid.
In such cases underlying medical principles of beneficience and medical best
practice will over-ride parental wishes. In some cases where parents are
considered to be placing their wards in actual danger of harm then child
protection procedures should be invoked in order to best protect the child.

6) A further consideration arises with respect to childhood circumcision. Pre-
pubertal boys will not have sufficient understanding of sexual function to be able
to give any meaningful consideration to the impact of the removal of the sexually-
innervated skin of the prepuce. Adult males who themselves have had no ability
to compare the function of the erect penis with or without the prepuce will be
similarly unable to give any reasonable consideration to the impact of its removal
on the sexual or other function of other people's penises.

7) Recently there has been some research done on 3 cohorts of adult men in
Africa. The Cochrane Collaboration now regards the evidence as strong for adult
male circumcision as one extra tool in the armoury of reducing female to male
adult heterosexual HIV transmission. The Cochrane Collaboration was also quoted
as saying that the risk of bias in these studies was high. However, whatever the
interpretation this research has no bearing on infant circumcision. Evidence-
based research on adults is not transferrable to children. Even if such research
were transferrable, then it would be for the child themself to weigh up the
advantages and disadvantages at such a time as they were approaching sexual
maturity. For example, there is no evidence to suggest that HIV transmission is
reduced in male to male sex involving circumcised men. Nor is there evidence to
suggest that male to female HIV transmission is reduced in men circumcised as

8) There is already a large cohort of men circumcised as babies from which we can
make observations. In the USA where the infant male circumcision rate has
approached 80% the rate of HIV and AIDS infection is the highest in the Western
World. This observation suggests that infant circumcision is not protective against
the transmission of HIV/AIDS.

9) Members of the SMF are of the opinion that the boy's body including his penis
belongs to the boy himself and not to his parents or culture. As an adult he may
make an informed decision about circumcision- before that time, the onus is on
his guardians and medical attendants to ensure that he reaches adulthood having
been protected from unnecessary harm and interventions.

10) Members of the SMF are pleased to see this in-depth analysis of such an
important subject and hope that in due course it will inform other legislative
bodies around the world to take the necessary action to protect young boys from
harm and to place male sensitivity above religious sensibility.

We have no objection to our comments being published in full.

Yours Sincerely,

Antony Lempert

Dr Antony Lempert
Secular Medical Forum
25 Red Lion Square
London WC1R 4RL

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