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Should you provide emergency care after circumcision when partner has refused?

case history

One of your partners has had a blazing row with a family over the circumcision of their newborn baby. They are having it done for religious reasons and your partner said it was 'barbaric' as the person performing the procedure is a

non-medic. In addition, he has warned them that if the child develops complications the practice would not treat him and would tell them to go to A&E. The family ask you if you would be prepared to treat the child if there are complications.

Dr Patricia Cahill

'The practice may have a policy on religious circumcision'

It is unfortunate that my partner has had this row with the family. This is obviously an emotive issue for him. He may have been forcibly circumcised himself as a child, he may be stressed and short-tempered for completely unrelated reasons or just feel strongly about this and believe that it is a barbaric practice.

He has every right to hold an opinion but it is not appropriate that he expresses it by getting furious with patients.

If a young girl who had been taken abroad for circumcision by a non-medic later presented to my practice with complications I imagine that he would carry out his duty of care towards the child sympathetically, even though female circumcision itself is internationally condemned.

I do understand that my partner doesn't want to collude with the parents in a practice he believes is morally wrong. But it is

also wrong to deny the baby medical help if he needs it.

Ideally the practice will already have a policy on treating babies after religious circumcision. If I am lucky, this row may have been discussed at a practice meeting, and I will be ready to answer this family's request.

If not, I am in a difficult position with

regard to my partner. I may not know his side of the story. I cannot give the family a full answer until I have spoken to him. I would explain this and that I would talk to him at the earliest opportunity and then get back to them.

I would tell the family that if the baby had any major bleeding after the circumcision, then being seen in A&E would be the safest option. I would also tell them that at present this is still the baby's practice, and that they should feel free to contact us if they are

worried about their child's health as usual, regardless of what might be the cause of

the problem.

Dr Nigel de Kare-Silver

'You may need advice from your medical defence organisation or LMC'

There are several things going on here and it is imperative to plan your response carefully. The family is likely to be highly emotionally charged following a 'blazing row' and the birth of their new baby. This is unlikely to give you much space for calm problem solving with them.

Much of medical practice is a conflict

between personal beliefs and the accepted norms of the society we live in, with abortion and contraception being two examples.

It is important to establish if the baby is a boy or a girl as this may affect your actions. Where there may be a growing lobby arguing that neonatal male circumcision is a form of child abuse, such calls do not reflect its current acceptance within the ethics of British society. To use words like 'barbaric' here is pejorative and will create conflict.

Conversely, female circumcision is

regarded by most of British society as 'barbaric'. This is a different matter entirely.

Social services and child protection units will need to be contacted if this is planned.

The threat to withhold medical treatment if complications develop sounds alarming and goes against normal expectations of medical practice. You need to check this with your partner. If he confirms this you have no choice but to ring your medical defence organisation for guidance on whether this step can be taken.

Document their answer and share it with other members of the practice team.

It is one of your key responsibilities to be supportive to your partner and be careful not to take sides in this matter until you have spoken to him privately. If you believe his words or attitudes were inappropriate then plan how to broach this with him and, if necessary, involve another member of your practice team who may have a stronger relationship with him.

If you get a negative or dismissive response then seek advice from the LMC as to whether your opinions are reasonable or are in themselves inappropriately judgmental. Use their advice on how to proceed.

Dr Keli Thorsteinsson

'It is my duty to treat the baby whatever my personal views'

Infant circumcision for religious and cultural reasons has been practised for thousands of years and is a fact of modern life. More than half of the male population of the US and around 2 per cent of UK males are circumcised for 'non-medical' reasons. It is a subject that elicits strong sentiments on both sides of the fence and it is difficult to write about it without upsetting somebody.

Now, I happen not to agree with the practice of cutting off a normal part of a child's anatomy, but I understand why it is done. I don't think any parent of sound mind puts their child under the knife without due consideration of the risks and benefits.

The risks are easier for me to understand, as they include easily digestible medical terminology, like pain, bleeding, infection and accidental, sometimes serious, injury to

unintended parts of the penis. On the other hand, there seems to be some evidence that circumcision reduces the incidence of

penile carcinoma, UTIs and HIV/HPV

transmission.

It has to be said that these don't seem persuasive arguments in favour of removing the foreskin in infancy. Other potential benefits are more difficult for me, an atheist, to understand. But I can empathise with a parent who is told by their family, friends and religious leaders that it must be done for the child's well-being, in this life or the next.

So, I will agree to treat the child if complications arise and this lands on my doorstep. In the same way I expect a doctor to treat my daughter's rib injury when I force her to go skiing with me. I don't expect him to condone the practice of placing a five-year-old on two slippery planks and pushing her down an icy mountainside.

It is simply his duty to treat her. It is my duty as a parent to research the risks of skiing before deciding it is in my daughter's best interest to take those risks. Ultimately, the subject of 'non-medical' infant circumcision, and other parental risk behaviour, is a debate for society and not for the

consulting rooms of doctors.

what does this incident teach us?

Learning checklist

Must you treat this child?

• Yes; if asked to do so where post-operative complications constitute an emergency.

• The GP contract says you must treat anyone in your practice area who seeks your help in an emergency, even if you do not want to accept them on to your list of registered patients.

• The GMC says you must1. This assistance might include advice that the child does indeed need to go to A&E but, if approached, you must provide appropriate advice/care.

• But where you are asked to participate in medical care that may be illegal (such as facilitating female circumcision) or raises child protection issues, you should speak to your partners/employer and your medical defence organisation promptly.

How are practice policies decided?

• Practices should have policies on issues which may arise frequently, for example on whether to offer a local enhanced service for violent and vexatious patients or the provision of services to drug users.

• Practice policies must comply with relevant legislation, for example the GMS contract, child protection and equal opportunity laws.

• Policies should be written, clearly stated and easily available to prevent misunderstandings for staff and patients; they should be reviewed regularly.

• Individual GPs may have conscientious objections to providing certain services (for example referral for termination of pregnancy); practices must make alternative arrangements.

• Some ethical dilemmas are rare and unforeseen, and GPs may need to make a snap decision. If possible, it is usually better to inform the patient that you wish to discuss the matter with colleagues, and to undertake to inform them of the decision promptly.

• A doctor who appears to be unduly upset or angry to the extent of

behaving unprofessionally may

trigger a complaint. Although the complaint may be justified and should be dealt with appropriately, the

doctor's behaviour may indicate underlying personal issues or a need for support.

Melanie Wynne-Jones is a GP and GP trainer in Marple, Cheshire

1 GMC Good Medical Practice 2006

www.gmc-uk.org/guidance/good_ medical_practice/index.asp

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