In a hard-hitting statement issued on 27 May 2010, the Royal Dutch Medical Association (KNMG) has condemned non-therapeutic circumcision of male minors and urged its members to discourage the practice. The statement points out that prophylactic or preventive circumcision of normal male infants and boys confers no health benefit; carries many risks of harm and damage; has an adverse effect on sexual function and bodily appearance; and is a violation of the child’s right to physical integrity.
The press release issued by KNMG and a summary of the policy statement is printed below.
Utrecht, 27 May 2010 – The official standpoint of KNMG and other related medical/scientific organisations is that non-therapeutic circumcision of male minors is a violation of children’s rights to autonomy and physical integrity. KNMG is urging a strong policy of deterrence. The reason for the adoption of an official standpoint regarding this matter is the increasing emphasis on the protection of children’s rights. Contrary to popular belief, circumcision can also cause complications – bleeding, infection, urethral stricture and panic attacks are particularly common. Full or partial penile amputations have also been reported as a consequence of complications.
KNMG is calling upon doctors to actively and insistently inform parents who are considering the procedure of the absence of medical benefits and the danger of complications. “The rule is: do not operate on healthy children”, says Arie Nieuwenhuijzen Kruseman, chairman of the KNMG. “It is an unfortunate fact that any surgical procedure can cause complications. Doctors accept this to a certain extent because there are medical reasons for the procedure. However, no complications can be justified that occur as the result of an operation that is medically unnecessary.”
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).
The KNMG sees good reasons for the statutory prohibition of non-therapeutic circumcision of male minors, but fears that the procedure will then be driven underground, leading to an increase in the number of complications. The Medical Association is aware that the practice of circumcision of male minors has deep religious, symbolic and cultural meaning for some ethnic and religious groups. The KNMG respects this, and is calling for dialogue among medical associations, experts and the relevant religious groups.
The following medical and scientific organisations officially support the standpoint of the KNMG: the Dutch Urological Association (Nederlandse Vereniging voor Urologie), the Dutch College of General Practitioners (Het Nederlands Huisartsengenootschap), the Dutch Paediatric Surgery Association (Nederlandse Vereniging voor Kinderchirurgie), the Dutch Plastic Surgery Association (Nederlandse Vereniging voor Plastische Chirurgie), the Association of Surgeons of the Netherlands (Nederlandse Vereniging voor Heelkunde) and the Dutch Paediatric Association (Nederlandse Vereniging voor Kindergeneeskunde).
Royal Dutch Medical Association, Policy statement, May 2010
Non-therapeutic circumcision of male minors is a practice that has been carried out for centuries by a variety of different cultures for a variety of different reasons. It is estimated that 13 million boys around the world are circumcised each year. In the Netherlands, the annual figure is between ten and fifteen thousand. Following on from other medical organisations, the Royal Dutch Medical Association (KNMG) has adopted an official viewpoint with regard to this issue. This viewpoint was formulated following consultation with relevant scientific organisations, who also support this stance. This ensures that this viewpoint has a broad basis of support from the relevant professional associations.
The reason for our adoption of an official viewpoint regarding this matter is the increasing emphasis on children’s rights. It is particularly relevant for doctors that children must not be subjected to medical proceedings that have no therapeutic or preventative value. In addition to this, there is growing concern regarding complications, both minor and serious, which can occur as a result of circumcising a child. A third reason for this viewpoint is the growing sentiment that there is a discrepancy between the KNMG’s firm stance with regard to female genital mutilation and the lack of a stance with regard to the non-therapeutic circumcision of male minors, as the two have a number of similarities.
The initial objective of this viewpoint is to initiate public discussion of this issue. The ultimate aim is to minimise non-therapeutic circumcision of male minors. The KNMG realises that this particular practice has deep religious, symbolic and cultural meaning. For this reason, it is unrealistic to expect that this practice can be eradicated, even if it was prohibited by law. However, the KNMG does believe that a powerful policy of deterrence should be established. As long as this practice takes place, the KNMG aims to reduce the number of complications as much as possible. The KNMG therefore emphasises that circumcision is a surgical procedure covered by the Individual Healthcare Professions Act. This means that circumcision may only be performed by qualified professional practitioners, in this case, doctors. Doctors who perform circumcisions must also follow all applicable scientific guidelines.
This entails, amongst other matters, that circumcisions can only be carried out under local or general anaesthetic, after thorough and precise advice and information has been given to the child’s parents. The fact that this practice is not medically necessary and entails a genuine risk of complications means that extra-stringent requirements must be established with regard to this type of information and advice.
27 May 2010
Prof. Dr. Arie Nieuwenhuijzen Kruseman,
Chairman of KNMG
There is no convincing evidence that circumcision is useful or necessary in terms of prevention or hygiene. Partly in the light of the complications which can arise during or after circumcision, circumcision is not justifiable except on medical/therapeutic grounds. Insofar as there are medical benefits, such as a possibly reduced risk of HIV infection, it is reasonable to put off circumcision until the age at which such a risk is relevant and the boy himself can decide about the intervention, or can opt for any available alternatives.
Contrary to what is often thought, circumcision entails the risk of medical and psychological complications. The most common complications are bleeding, infections, meatus stenosis (narrowing of the urethra) and panic attacks. Partial or complete penis amputations as a result of complications following circumcisions have also been reported, as have psychological problems as a result of the circumcision.
Non-therapeutic circumcision of male minors is contrary to the rule that minors may only be exposed to medical treatments if illness or abnormalities are present, or if it can be convincingly demonstrated that the medical intervention is in the interest of the child, as in the case of vaccinations.
Non-therapeutic circumcision of male minors conflicts with the child’s right to autonomy and physical integrity.
The KNMG calls on (referring) doctors to explicitly inform parents/carers who are considering non-therapeutic circumcision for male minors of the risk of complications and the lack of convincing medical benefits. The fact that this is a medically non-essential intervention with a real risk of complications makes the quality of this advice particularly important. The doctor must then record the informed consent in the medical file.
The KNMG respects the deep religious, symbolic and cultural feelings that surround the practice of non-therapeutic circumcision. The KNMG calls for a dialogue between doctors’ organisations, experts and the religious groups concerned in order to put the issue of non-therapeutic circumcision of male minors on the agenda and ultimately restrict it as much as possible.
There are good reasons for a legal prohibition of non-therapeutic circumcision of male minors, as exists for female genital mutilation. However, the KNMG fears that a legal prohibition would result in the intervention being performed by non-medically qualified individuals in circumstances in which the quality of the intervention could not be sufficiently guaranteed. This could lead to more serious complications than is currently the case.
The full policy in English can be downloaded as a PDF from the Royal Dutch Medical Society website
Dutch medical alliance moves to change thinking on male circumcision
by Tony Sheldon
A broad alliance of medical organisations in the Netherlands has officially adopted the view that circumcision of underage boys without a medical reason violates children’s human rights and contravenes the Dutch constitution. The Dutch Medical Association has spearheaded the move, arguing that the medical benefits of circumcision are unproved whereas complications are underestimated, and urging “a strong policy of deterrence.” Doctors should "actively and insistently" inform parents seeking to have their child circumcised about the association’s stance.
It is estimated that up to15,000 circumcisions of boys under 16 years of age are carried out each year in the Netherlands — largely for religious or cultural reasons — among Jewish, Muslim, and African Christian communities. [Or more precisely, on account of the cultural, ethnic or religious adherence of the parents; the boys, now living in a secular and multicultural society, may well have other ideas.]
The association thinks there are good reasons to ban the practice — female circumcision was outlawed in 2004 — but fears that this might force it underground, leading to a greater number of complications. Instead, it calls for a dialogue between doctors and religious leaders in recognition of the “deep religious, symbolic, and cultural sensitivity” surrounding circumcision.
The Dutch Medical Association’s stance was taken on the basis of the argument that “non-therapeutic circumcision” of underage boys amounts to a violation of a child’s physical integrity, and so contravenes Article 8 of the European Convention on Human Rights and Article 11 of the Dutch constitution. It believes circumcision can lead to complications, including haemorrhage, infection, urethral stricture, and panic attacks. There are also reported cases of amputation of part, or all, of the penis as a result of complications involving necrosis.
Dr Tom de Jong, head of paediatric urology at Wilhelmina Children’s Hospital, Utrecht, sees around 50 cases of complications after circumcision every year. Although there is no systematic registration of complications in the Netherlands, his belief, on the basis of published research, is that long term complications can occur in between 8% to 20% of cases, whereas complications arise in 3% to 5% of cases immediately after surgery
The association believes that studies that suggest that circumcision reduces the risk of urinary tract infections or HIV/AIDS are inconclusive. Any preventive benefits should be balanced against less invasive forms of prevention, such as good personal hygiene, antibiotics, condom use, and information on safer sex, it argues. The possible medical advantages are “insufficient to justify circumcision on grounds of prevention.”
The Dutch Medical Association’s chair, Dr Arie Nieuwenhuijzen Kruseman, said: “With every surgical procedure there is a risk of complications. The rule is not to operate on a healthy child. Children should only be exposed to medical intervention if there is an illness, abnormality, or it can be shown that it is in the interests of the child, such as vaccination.”
A survey by the association, carried out to coincide with the new stance, found that two thirds (65%) of a representative sample of 1500 members believe that non-therapeutic circumcision violates physical integrity.
The Dutch associations of paediatric medicine, paediatric surgery, surgery, and the college of general practitioners are backing the Dutch Medical Association’s stance.
British Medical Journal, 7 June 2010
BMJ 2010;340:c2987
Antony D. Lempert, GP Principal and Co-ordinator of the Secular Medical Forum
Wylcwm Street Surgery, Knighton, Powys LD7 1AD
I welcome the principled statement by the Dutch Medical Association and their colleagues advocating an end to ritual circumcision. Without the caveat of religious privilege, a debate about whether or not to surgically interfere with the normal genitalia of little children would be largely unnecessary. There is no reason for gender discrimination when considering child protection. Clinically unnecessary surgical excision of normal genital skin violates a child's human right to an intact body and to be protected from harm [1]
In 2007, Sorrells et al [2] demonstrated that circumcision ablates the most sensitive parts of the male penis. There is a risk of further harm [3] when the operation goes wrong. This is sad enough when the circumcision was considered clinically necessary; it is tragic when the operation was done for reasons of conforming to the parents’ religious or cultural views.
Many children do not later share their parents’ beliefs or even their cultural values. The bodies of children must be protected from those who would brand them when they are too young to either consent or object. This protection must extend to their genitalia or it is no protection at all.
All intervention carries a degree of risk. This is why surgery should only be contemplated where there is a potential for greater good than harm, particularly on non-consenting infants to whom society owes a duty of care and protection. This basic principle ordinarily guides our day to day practice. Were it not for the demands of traditional religious privilege it would not be up for discussion.
In January 2010, The SMF approached the doctors’ regulatory body in the UK, the General Medical Council (GMC), asking for them to reconsider their stated non-position on Ritual male circumcision [4] and [5]. The first principle of GMC guidance is “Make the care of your patient your first concern”. With regard to ritual non-therapeutic circumcision, we were advised by the GMC that they had no immediate plans to amend their current guidance.
It is time that both the GMC and the BMA followed the Dutch Medical Association’s excellent example of putting patient welfare ahead of the varied chosen beliefs of their parents. Legislation should accompany this to prevent all non-therapeutic surgery on non-consenting children. And let’s call it what it is: Non-therapeutic excision of the foreskin.
[1] UN Convention on the Rights of the Child 1989
[2] Morris L Sorrells et al, Fine-touch pressure thresholds in the adult penis, BJUI 2007; 99: 864-869.
(3) Williams N, Kapila L. Complications of circumcision. Brit J Surg 1993;80:1231-6.
[4] Circumcision of Male Children for Religious or cultural reasons
[5] Ritual Circumcision, Letter to the GMC March 2010
Competing interests: I co-ordinate the Secular Medical Forum (SMF) in the UK. We campaign for equality of care for all patients irrespective of their own or their doctors’ own personal beliefs.
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