ROYAL DUTCH MEDICAL ASSOCIATION ON NON-THERAPEUTIC CIRCUMCISION OF MALE MINORS

Position of the Royal Dutch Medical Association (KNMG) with regard to non-therapeutic circumcision of male minors

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 view point 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

MAIN POINTS

• 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 surroundthe 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.

This viewpoint by the KNMG is jointly endorsed by the following scientific associations:

• The Netherlands Society of General Practitioners
• The Netherlands Society of Youth Healthcare Physicians
• The Netherlands Association of Paediatric Surgeons
• The Netherlands Association of Plastic Surgeons  
• The Netherlands Association for Paediatric Medicine
• The Netherlands Urology Association
• The Netherlands Surgeons’ Association

Contact details KNMG PO Box 20051, 3502 LB Utrecht, The Netherlands - +31(0)30 282 3800 www.knmg.nl/english

Texts from this publication may be reproduced, provided the source is acknowledged in full: The non-therapeutic circumcision of male minors, KNMG, May 2010.