Religion should not be a roadblock to child safeguarding in healthcare

In the UK, as in many countries, the cutting of a child's genitals for no medical reason is broadly divided into two camps.

For girls, it is rightly illegal, regardless of severity. The law is clear that religion or culture is no defence for subjecting a girl to female genital mutilation (FGM).

But for boys, there are practically no legal or medical restrictions on who, where or why the procedure is carried out. In the UK, we know it is regularly carried out by religious clerics with no medical qualifications, in non-clinical and often unsuitable settings including people's homes, just to satisfy parents' religious or cultural beliefs.

Ethical guidance for doctors largely mirrors these legal distinctions between female and male genital cutting. The UK doctors' regulatory body, the General Medical Council (GMC), asserts it has no position regarding medically unnecessary penile circumcision, and offers no child safeguarding concerns. This position is shared by the main doctors' professional body, the British Medical Association (BMA).

However, increasing concern about the circumcision of male infants and children has been expressed from many quarters. And with good reason: circumcision is painful, perilous and permanent. It raises serious ethical questions regarding the right to self-determination and to choose one's own belief or culture affiliations, the avoidance of harm, individual autonomy, sex equality, child safeguarding and maximising a person's future choices.

Both the GMC and the BMA produce wide-ranging and detailed ethical guidance. Doctors who fail to follow GMC advice risk losing their licence to practise medicine. Why, therefore, have the GMC and the BMA refused to highlight the obvious ethical and safeguarding concerns in their circumcision guidance? That's what my new paper, published last month in Clinical Ethics, aims to uncover – and to challenge.

An "active and singular exclusion of young boys" from safeguarding

Both the GMC and the BMA champion the involvement of patients, including children, as much as possible in decisions that affect their care – except when it comes to male circumcision.

Doctors are required to offer the most effective, least restrictive treatments; to safeguard patients, especially children and vulnerable adults, from harm; and to maximise patients' future choices. Even when patients give valid consent, doctors are reminded to be cautious about the possibility of underlying coercion or dependence on others with ulterior motives. The GMC has acknowledged that parents' freedom to bring up their children in line with their religious and cultural practices or beliefs may itself become a child safeguarding concern.

In this context, the steadfast assertion by both the GMC and the BMA that they have no position on non-therapeutic circumcision is self-contradictory. The statement itself serves as an active and singular exclusion of young boys from existing principles and safeguards which would otherwise protect them.

My paper details some of the roadblocks faced when myself and others have tried to encourage reform of guidance on circumcision towards a more consistent policy. It has become increasingly apparent that the assumption of inherited religion or culture appears to guide GMC and BMA policy. Both sets of guidance lean heavily on an argument premised on a child's best interests. Though laudable in principle, their "best interests" arguments ultimately rely on forceful persuasion from parents united in the belief that circumcision is required. Only where there is parental disagreement is it considered prudent to defer.

In other words, for children with the most pressing safeguarding concerns, usual protections are removed.

"You have no idea how offended the chief rabbi would be."

In 2010, I met with the GMC's head of policy to discuss this issue of bringing its policy on circumcision in line with its other guidance. Her response was: "You have no idea how offended the chief rabbi would be."

That the GMC considers the views of a religious leader to be more important than accepted medical ethical and child safeguarding principles is deeply concerning.

That meeting also demonstrated GMC reliance on BMA policy; BMA guidance was quoted to me several times throughout. I have been a BMA representative since 2009 and chair the Shropshire BMA division (although I do not write here in that capacity). Each year since, the Shropshire division has submitted a motion regarding circumcision to be debated at the BMA's annual representatives meeting (ARM). Motions passed at the ARM automatically become BMA policy.

None of my motions concerning circumcision have been chosen for debate.

In the absence of formal debate, I have sometimes mentioned circumcision during related ARM debates. When doing so, I have been heckled. One time I was even dismissed by the then chair of the BMA's medical ethics committee, who asked representatives to disregard my "interesting comments" which he asserted were irrelevant to a debate urging the BMA to do more to protect children within communities.

I have also discussed the issue with a former BMA president, who was previously the Children's Commissioner for England. In 2016 he subsequently recommended a thorough and transparent BMA review of circumcision policy involving all members and representatives.

This did not happen. Instead, I was invited to a private meeting with the same chair of the ethics committee who had earlier misrepresented my ARM speech; presumably other private meetings took place with chosen stakeholders.

In 2019, a new non-therapeutic male circumcision toolkit was published reasserting BMA neutrality. One section of the toolkit is incomprehensible, possibly because it is a failed attempt to address an ethical contradiction I had highlighted in the draft version. BMA policy is clearly going nowhere. And the main roadblock is deference to religious demands.

As my paper concludes, we can only prevent serious harms to children by remaining focussed on the children themselves. At present, fears about religious reactions have pushed both GMC and BMA guidance on non-therapeutic male circumcision out of line with the general body of ethical guidance that doctors must follow. It's time to bring the guidance back in alignment. It's time to put children's welfare first, not the feelings of the chief rabbi.