Doctor, spare that foreskin

A campaign has begun to forbid British physicians from performing ritual male circumcisions. Oliver Gillie reports

THE General Medical Council, the authority on medical ethics in Britain, is considering whether doctors should be forbidden from performing ritual male circumcisions. The council has been asked to examine the ethics of circumcision by a doctor who says it is not a treatment but a mutilation which is accompanied by substantial risks and no benefits.

Religious groups have argued that circumcision has health benefits, but modern research has failed to find evidence to support these claims. And new research has found that specialised sensory tissue in the penis is removed when a child is circumcised, so jeopardising capability for a full sexual experience.

The request for a medical ban on circumcision has been made by Dr John Warren, a chest physician at Princess Alexandra Hospital, Harlow, Essex, who was himself circumcised as a child. He is a founder of a campagning group of men, called Norm UK, who feel they have suffered as a result of being circumcised as children and are now regrowing their foreskins. Regrowth is achieved by taping the skin over the end of the penis and attaching a small weight.

Currently between 5 and 10 per cent of British boys are circumcised by the age of 16, many for medical reasons. However, the British Association of Paediatric Surgeons says that circumcision is only necessary in rare cases and that, in the vast majority, problems should be treated by more conservative methods such as stretching of the foreskin.

Dr Warren's request comes at an awkward time for members of the Jewish and Muslim communities, who are increasingly asking for doctors rather than religious officers to perform the initiation rite. Parents seeking ritual circumcisions have become acutely aware of the risks since seeing a Channel 4 documentary It's a Boy! broadcast last September. In the programme, an African mother told of the death of her baby as a result of infection following a ritual circumcision in Britain; a Muslim father described how his son needed extensive plastic surgery when ritual circumcision performed in Britain was followed by gangrene which ate away much of his penis; and a Jewish boy ended up in a hospital in the Midlands fighting for his life after he was circumcised by a mohel [official circumciser] in a religious ceremony.

A recent review of complications worldwide by two British doctors, Nigel Williams and Leela Kapila, published in the British Journal of Surgery in 1993, estimated the complication rate to be between 2 and 10 per cent, and noted that the medical literature abounds with reports of morbidity and even death as a result of circumcision.

Dr Kapila, who is a surgeon at University Hospital, Nottingham, said: "I know of one death recently in London, and three cases over the past few years in Britain where part of the penis itself was cut off. But there are no records of what happens. Jewish and Muslim people say that circumcision is healthy, but their laws are more than 2,000 years old and were made for people who lived in the desert without soap and water. Everybody has soap and water today. I just wish that they would reconsider what they are doing."

Other complications include removal of insufficient skin, causing formation of a heavy scar and a fibrous ring. Sometimes too much skin is removed, making a skin graft necessary to cover the naked flesh of the penile shaft. Protracted bleeding, infection, and retention of urine causing kidney damage may also occur. In the United States, where some 80 per cent of men are circumcised (generally by doctors), a number of cases of severe injury to the penis have been caused by an electric instrument which is used to stop bleeding (electrocautery). In several of these cases, restoration of the penis was considered impossible and the child was reconstructed surgically as a girl.

Even when circumcision is uncomplicated the child is damaged by the loss of sensitive tissue, says Dr Warren. The tissue which is removed in circumcision is not skin but a specialised mucosa (mucous membrane) containing cells called Meissner's corpuscles, which are similar to the highly sensitive nerve endings in the fingertips and lips. Three Canadian doctors who have made the first detailed studies of this mucosa, published earlier this year in the British Journal of Urology, believe that it plays an important part in providing sensation during the sexual act. The foreskin itself also has the important function of enabling gentle penetration and movement in intercourse because the skin slides on the shaft of the penis.

Dr Warren says in his letter to Sir Donald Irvine, president of the General Medical Council: "At the very least, circumcision exposes a child to an unnecessary risk of surgical complications. At the worst, it robs him of a useful part of his penis, full of specialised sensory cells, which supplies a reserve of shaft skin to provide for motility [movement] mobility during sexual function, and protects the glans [end of the penis] maintaining its sensitivity. If circumcision is harmful, not necessarily to all, but even to some, then we must recall Hippocrates' words: 'I will prescribe regimen for the good of my patients according to my ability and my judgement and never do harm to anyone.'

"And if you respond with a plea of necessity that religious zeal is such that this mutilation will be carried out anyway, and so it is better that it should be done by a doctor than by someone less trained, I will respond with William Pitt's words in the House of Commons: 'Necessity is the plea for every infringement of human freedom. It is the argument of tyrants; it is the creed of slaves.' "

Dr Warren says that he has been urged to question the role of doctors in religious circumcision by Jewish men who feel that they have suffered as a result of the rite. The Jewish Socialist Association has held a meeting to discuss the issue, and some of its members are offering to support Jewish parents who are having difficulty deciding whether or not to have their children circumcised.

The General Medical Council has sent Dr Warren's letter to five of its members and has received five different and conflicting opinions. The issue will now have to be discussed by the five to see if agreement can be found, and ultimately a ruling on the issue may be given by the council itself.

n Female clitoral circumcision, illegal in Britain since 1985 but still practised in some African, Asian and Middle Eastern societies, is regarded by many in the West as mutilation and has been the subject of campaigns to have it banned worldwide.