- (2009) Volume 6, Issue 3
Consultant Surgeon Manor Hospital, Walsall, UK
Consultant Microbiologist, North West London Hospitals Trust, Harrow, UK
Professor of Primary Care Research and Development, Division of Community Health Sciences: GP Section, University of Edinburgh, UK
Received: 3 August 2004 Accepted: 12 December 2004
Male infant circumcision is the most common surgical procedure in the world. Although in some cases performed for clinical reasons, it is today in Britain most commonly performed for religious reasons in Jewish and Muslim infants. This procedure is, however, currently not available on the NHS in most parts of Britain, resulting in difficulties for parents in accessing suitably trained practitioners and consequently increasing the risk of potentially avoidable complications associated with the procedure. This paper considers the faith background to male circumcision in Muslim communities and discusses approaches to reducing the risks associated with it.
circumcision, male, Muslims, religious, safety
Male circumcision, which entails removal of the penile foreskin, is the most common surgical procedure in the world (Maxwell, 1996; Gallaher, 2000). Circumcision is performed either for clinical reasons such as a pathological phimosis, preventative reasons such as reducing risk of developing HIV/AIDS, or to comply with religious practice. Within a faith context, circumcision is considered beneficial not only because of the resulting improved genital hygiene, but also for offering additional benefits relating to sense of identity.
We have previously discussed the ethics and legality of male infant circumcision, exploring these issues with particular reference to the European Human Rights Act (Articles 3, 8 and 9), and concluded that parents are within their rights to request that their male children be circumcised (Gatrad et al, 2002).Our experiences suggest that the lack of NHS availability for religious circumcisions, however, often makes it difficult for parents to have the procedure safely performed.
Against this backdrop, this article explains the faith background to circumcision and then presents a discussion of key steps that need to be taken to improve the safety profile of this procedure in Britain.
The Book of Genesis (17:10–13) recalls that a key condition of God’s Covenant with Abraham in making ‘him a great nation’ was that ‘every male amongst ABSTRACT Male infant circumcision is the most common surgical procedure in the world. Although in some cases performed for clinical reasons, it is today in Britain most commonly performed for religious reasons in Jewish and Muslim infants. This procedure is, however, currently not available on the NHS in most parts of Britain, resulting in difficulties for parents in accessing suitably trained practitioners and consequently increasing the risk of potentially avoidable complications associated with the procedure. This paper considers the faith background to male circumcision in Muslim communities and discusses approaches to reducing the risks associated with it. Keywords: circumcision, male, Muslims, religious, safety you in every generation shall be circumcised on the eighth day’. The majority of Jews continue to respect this covenant and so have their male infants circumcised on the eighth day of life.
Although initially observed by the followers of Christ, it was largely under the influence of St Paul’s interpretation, which saw Christ as representing aNew Covenant thereby rendering Old Testament practices null and void, that the Church departed from this old Judaic practice. As Paul notes:
For freedom, Christ has set us free; stand fast therefore, and do not submit again to a yoke of slavery. Now I, Paul, say to you that if you receive circumcision, Christ will be of no advantage to you. I testify again to every man who receives circumcision that he is bound to keep the whole law. You are severed from Christ, you who would be justified by the law; you have fallen away from grace. For through the Spirit, by faith, we can wait for the hope of righteousness. For in Christ Jesus neither circumcision nor uncircumcision is of any avail, but faith working through love. (Galatians 5:1–6)
As for Islam, circumcision is seen by Muslims as a continuation of the Abrahamic tradition. Muhammad, the Prophet of Islam, reinforced the message of male circumcision almost 600 years after Jesus. Although there is no clear mention of this practice in the Holy Qur’an, it is noted in the ‘Ahadith’ (the sayings and actions of Prophet Muhammad) as necessary for male infants. Circumcision is seen as a symbol of spiritual purity and religious identity in which many Muslim (and Jewish) parents take great pride. It has furthermore always been the belief of Muslims that the foreskin is unclean and may harbour disease.
The 2001 census revealed that Britain is now home to approximately 1.6 million Muslims of whom almost 50% are British born (National Statistics Online, 2005). Evidence suggests that the vast majority of these male British Muslim infants continue to be circumcised and it is likely that this pattern will continue for the foreseeable future (Bhopal et al, 1998).
Although there are some areas in the UK where Muslims are circumcised by Jewish Mohels (trained Rabbis), more typically, general practitioners (GPs) perform the procedure at an average cost of £50–£100 (Circumcision Agency, 2005). British Muslims generally circumcise their infants within a few days of birth (in keeping with the Prophetic dictum recommending circumcision on the seventh day of life). Delays are, however, not uncommon; these either represent cultural variations in preferred timing or, more commonly, difficulties in accessing an appropriately qualified doctor.
The General Medical Council advises clinicians that (see Box 1 for best practice guidelines from the General Medical Council):
... if you decide to circumcise a male child you must have the necessary skills and experience, both to perform the operation and use appropriate measures, including anaesthesia, to minimise pain and discomfort (General Medical Council, 1997).
Although many of these circumcisions appear to be competently performed, there are grounds for concern that, in some cases, infants continue to be put at risk of complications by a failure to undertake a satisfactory pre-operative assessment, poor technique and/ or inadequate follow-up (McManus, 2001).
Box 1: Best practice guidance from the General Medical Council, 1997
This has led to a number of complaints received by defence unions of potentially avoidable problems such as a failure to obtain informed consent, inadequate analgesia, excessive haemorrhage and sepsis (Lipley, 1997). Similarly, a recent study has found that over a period of 20 months, 31 circumcision-related complications (of which 19 represented bleeding problems, five of whom needed transfusion) were recorded presenting to one hospital in the north of England (Corbett and Humphrey, 2003; see Box 2 for possible complications of circumcisions). Furthermore, parental reports reveal that British community practitioners use a range of analgesics, either singly or in combination; these include: paracetamol, vallergan, chloral hydrate and pethidine (Gatrad, 2002). On occasions, the post-operative application of a local anaesthetic gel may also be used and we are also aware that some do use a ‘ring block’ with a local anaesthetic. There are, however, practitioners who do not use any anaesthetic for babies less than eight weeks (Cohen and Zoltie, 1991) in the (mistaken) belief that ‘babies do not feelmuch pain’ and/or that the ‘procedure only takes a few minutes’. Research has, however, confirmed that there is a well developed pain pathway in the neonate and that circumcisions can cause severe pain (Stevens et al, 2000).
Performing these procedures within hospitals appears to be far safer. Reassuringly, in a series of 500 000 consecutive circumcisions performed in a hospital in the USA, no deaths were reported (King, 1982). Furthermore, a separate north of England study has, for example, found that the complication rate for circumcisions performed in hospital is less than 1%, and this finding has been echoed in other large case series which have found complication rates of about 0.2% (Wiswell and Geschke, 1989). Also of note are results from Bradford where advanced nurse practitioners officially carry out this procedure with low complication rates (Shah et al, 1999).
Box 2:Possible complications of circumcisions.
In our centre in Walsall, circumcisions have been performed for the past three years on Muslim boys (age range 2–24 months) by one of the authors (AK), a consultant surgeon, working for theNHS and on NHS premises without charge to the patient. A detailed preoperative assessment is made and written informed consent is obtained. The procedure, which takes approximately 20 minutes, is carried out in a sterile environment with an anaesthetic ring block followed by the ‘Plastibell method’ and a local application of 2% lignocaine (Instagel) post-operatively. A paediatric trained nurse is in attendance. Instagel and paracetamol are given to the parents to take home, with clear instructions on bringing the child back to the paediatric surgical ward in case of any complications. In over 300 procedures carried out, we have a known complication rate of less than 1%, none of which were life threatening.
Considering the difficulties many parents face in finding a suitable practitioner, the safety concerns around the performance of some of these procedures in the community, and the comparative reassuring data which show that the procedure is very safe when performed in a hospital setting, we believe that much wider NHS availability is the key step to improving safety. It is, furthermore, important that the procedure be performed by practitioners who are adequately trained (see Box 3 for contraindications to circumcisions), who keep a log of all procedures performed that can be subject to analysis if the need should so arise, and who commit to regular audit and periodically undergo reassessment. Registers of appropriately trained clinicians can then be published and made available to national and local religious organisations that are frequently approached to provide information on the availability of circumcisions in their area.
Box 3:Contraindications to circumcisions.
At the Muslim Council of Britain, we regularly receive queries from anxious parents wanting to circumcise their newborn males. From these interactions and the limited published evidence, we can conclude that there is a considerable demand for this procedure from British Muslim parents, many of whom would like to have it performed on the NHS. This demand comes both from a recognition that, as tax payers, they feel that they have a right to services that better meet their needs (a position that is likely to gain strength as we move to a health service which is predicated on a ‘choice’ agenda), and also because they have either had or knowof a previous bad experience with community circumcisions.
There is, however, currently something of a ‘postcode lottery’ in operation as circumcisions are currently available on the NHS in only some regions. Greater availability on the NHS is now needed where minimum standards of care can be set, monitored and, where found to be lacking, enforced. This is likely to need registration of practitioners wishing to carry out this procedure, and training provisions.
While the debate on issues of ethical, therapeutic, legal and parental choice for circumcision continues, we believe that there is a need for this procedure to be made safer. Although in many hands it is already safe, steps need to be taken to ensure that minimum standards of competence can be achieved in relation to all male circumcisions performed in Britain. The Muslim Council of Britain (MCB) is willing and will support initiatives to this end, and we invite healthcare professionals to work with us in helping us realise this vision.
Shuja Shafi chairs the Health and Medical Committee of the MCB and Aziz Sheikh chairs its Research and Documentation Committee; Rashid Gatrad is an advisor to the Research and Documentation Committee of the MCB.
