Male circumcision: ritual, science and responsibility.

INTRODUCTION AND OBJECTIVES: In Italy, four minors have died in the last year as a result of male circumcision (MC) procedures performed for cultural and religious reasons by unqualified persons in unhygienic conditions. RESULTS AND DISCUSSION: After illustrating the historical and ethical outlines of the moral admissibility of MC within a comparative perspective, we examine the features of the Italian healthcare system with particular regard both to the heterogeneity of services available in the various Regions and to the risks engendered by excluding MC from the public health setting. CONCLUSION: In order to adequately safeguard public health, particularly that of minors, there is a pressing need for thorough discussion of whether the National Health Service should perform MC on minors free of charge or, at least, for a reduced fee. The implementation of targeted campaigns may raise awareness of the importance of proper safety measures in MC.

Litigation involving pediatric surgical conditions.

PURPOSE: Malpractice litigation among pediatric surgeons is a subject of concern and interest, but minimal factual data are known. Our goal was to investigate national litigation trends regarding pediatric surgical conditions. METHODS: We queried WestlawNext database for malpractice cases involving pediatric (age ≤ 18) surgical conditions. Cases were included if they named a care provider or health center. We gathered data on diagnoses, procedures, care providers, allegations, location, and outcomes. RESULTS: Our search revealed 4754 cases, and 170 met inclusion criteria. These ranged from 1965 to 2017 and represented 40 states. 110 cases involved a surgeon (41% pediatric surgeons). Appendicitis was the most common diagnosis identified. Cases frequently involved delayed/missed diagnoses or interventions (45.9%), technical concerns (35.9%), mortalities (26.5%), negligent perioperative care (23.6%), and informed consent concerns (4.7%). Technical complication was the most common allegation against surgeons (49.1%), and nonsurgeon cases typically involved a delayed/missed diagnosis (78.3%). 39% of cases resulted in favor of the defendant, 35% plaintiff, and 14% had a split verdict. CONCLUSION: Litigation involving pediatric surgical conditions is diverse, but appendicitis and circumcision comprise almost a third of cases. A greater understanding of these trends can help steer efforts in quality and safety as well as guide improved communication with families. LEVEL OF EVIDENCE: N/A.

Non-therapeutic male genital cutting and harm: Law, policy and evidence from U.K. hospitals.

Female genital cutting (FGC) is generally understood as a gendered harm, abusive cultural practice and human rights violation. By contrast, male genital cutting (MGC) is held to be minimally invasive, an expression of religious identity and a legitimate parental choice. Yet scholars increasingly problematize this dichotomy, arguing that male and female genital cutting can occasion comparable levels of harm. In 2015 this academic critique received judicial endorsement, with Sir James Munby's acknowledgement that all genital cutting can cause 'significant harm'. This article investigates the harm occasioned by MGC. It is informed by a Freedom of Information (FoI) study which provides some empirical evidence of the nature and frequency of physical harm caused by MGC in U.K. hospitals. While acknowledging the challenges and limitations of FoI research, we outline important lessons that this preliminary study contains for medical ethics, law and policy. It provides some empirical evidence to support claims regarding the risks which accompany the procedure and the obligation of health professionals to disclose them, and reveals the paucity of measures in place to ensure that harms are recorded, disclosed and monitored.

The German debate on male circumcision and Habermas' model of post-secularity.

This paper considers Habermas' model of a post-secular political order in the light of the debate on male circumcision that arose in Germany after a court ruled that male circumcision was an unjustifiable act of bodily harm. Central to this model is the idea that religious reasons can only become effective in central legal institutions when they are translated into secular reasons. My paper demonstrates that there are two distinguishable readings of this proviso. On the one hand, there is a broad reading according to which it is only necessary to reach a conclusion that is in line with the democratic principle stating that all citizens can be regarded as co-legislators even if non-generalizable value orientations might then shape the interpretation of fundamental rights (in the case of circumcision, the right to bodily integrity). On the other hand, a truly secular (narrow) reading would avoid the inclusion of non-generalizable value orientations. The debate on circumcision demonstrates that these two interpretations lead to different and conflicting modes of justification. The broad reading allows for a justification of male circumcision, whereas the narrow reading makes such a justification unlikely. In addition, the filtering function of the proviso is weakened in a broad reading.

Addressing legal and policy barriers to male circumcision for adolescent boys in South Africa.

With millions of adolescents becoming infected with HIV globally, it is essential that barriers to much-needed interventions are reduced for at-risk adolescents. In this article we review the legal and policy framework in South Africa for adolescent access to male circumcision. We are of the view that the framework does confer protection for adolescent boys while enabling access to male circumcision; however, we identify ambiguities and tensions that exist between the Children's Act, regulations and national guidelines. We recommend reform to further enable access by this vulnerable group to this prevention modality.

Can we assess risk of psychiatric sequelae from perinatal injuries?

Medical malpractice litigation involving seven to nine figure settlements has been on the rise over the past decade. Given the life-altering scope of these incidents, forensic child psychiatrists may be asked to opine on the effects of a permanent perinatal injury on normal human development. Whether forensic child psychiatrists can assess risk of future psychiatric effects from such incidents is an important question. This paper is spurred by two separate cases, each involving a male infant having a portion of their genitals accidentally amputated by an obstetrician-gynecologist (OB/GYN) during a routine circumcision. In each case, the genitals were repaired, but permanent defects remained. The question arises how such injuries would affect these children as they matured. An analysis of the literature supported that there are risks of psychiatric effects of such birth-related injuries. Such predictions are made with reference to what is already known about human development, and by an exploration of the literature on the psychiatric effects of comparable injuries to children.

[Forensic issues raised by circumcision: Review and case report]. / Aspects médicolégaux de la circoncision : à propos d'une observation.

Circumcision is defined as the partial or total excision of the prepuce. It is one of the most frequently performed surgical procedures around the world. This practice primarily involves minors. The aim of this study was to review the legal aspects of ritual circumcision in France. We report the cases of an 11-year-old and a 15-year-old boy examined in the forensic unit at the Hôtel-Dieu hospital in Paris, after their father complained to the Minors Protection Brigade of Paris following the discovery of their circumcision. The examination conducted in the forensic unit found that the two boys had undergone recent circumcision. The total incapacity of work (ITT) was assessed as 5 days for the 15-year-old boy and 1 day for the 11-year-old boy. Ritual "medicalized" circumcision is legal in France, and does not fall under article 222-1 of the Criminal Code (torture and acts of barbarism) or article 16-1 of the Civil Code (inviolability of the human body). Circumcision is treated as a "serious act" by several areas of jurisprudence, which means it is imperative to obtain the consent of both parents. Moreover, it must be performed in a hospital by knowledgeable staff.

Non-therapeutic infant male circumcision. Evidence, ethics, and international law perspectives.

OBJECTIVES: To review the evidence of the benefits and harms of infant male circumcision, and the legal and ethical perspectives of infant male circumcision. METHODS: We conducted a systematic search of the literature using PubMed, EMBASE, and the Cochrane library up to June 2015. We searched the medical law literature using the Westlaw and Lexis Library law literature resources up to June 2015. RESULTS: Male circumcision significantly reduced the risk of urinary tract infections by 87%. It also significantly reduced transmission of human immunodeficiency virus among circumcised men by 70%. Childhood and adolescent circumcision is associated with a 66% reduction in the risk of penile cancer. Circumcision was associated with 43% reduction of human papilloma virus infection, and 58% reduction in the risk of cervical cancer among women with circumcised partners compared with women with uncircumcised partners. Male infant circumcision reduced the risk of foreskin inflammation by 68%.  CONCLUSION: Infant male circumcision should continue to be allowed all over the world, as long as it is approved by both parents, and performed in facilities that can provide appropriate sterilization, wound care, and anesthesia. Under these conditions, the benefits of infant male circumcision outweigh the rare and generally minor potential harms of the procedure.

Circumcision Is Unethical and Unlawful.

The foreskin is a complex structure that protects and moisturizes the head of the penis, and, being the most densely innervated and sensitive portion of the penis, is essential to providing the complete sexual response. Circumcision-the removal of this structure-is non-therapeutic, painful, irreversible surgery that also risks serious physical injury, psychological sequelae, and death. Men rarely volunteer for it, and increasingly circumcised men are expressing their resentment about it.Circumcision is usually performed for religious, cultural and personal reasons. Early claims about its medical benefits have been proven false. The American Academy of Pediatrics and the Centers for Disease Prevention and Control have made many scientifically untenable claims promoting circumcision that run counter to the consensus of Western medical organizations.Circumcision violates the cardinal principles of medical ethics, to respect autonomy (self-determination), to do good, to do no harm, and to be just. Without a clear medical indication, circumcision must be deferred until the child can provide his own fully informed consent.In 2012, a German court held that circumcision constitutes criminal assault. Under existing United States law and international human rights declarations as well, circumcision already violates boys> absolute rights to equal protection, bodily integrity, autonomy, and freedom to choose their own religion. A physician has a legal duty to protect children from unnecessary interventions. Physicians who obtain parental permission through spurious claims or omissions, or rely on the American Academy of Pediatrics' position, also risk liability for misleading parents about circumcision.

A DANGEROUS MUDDYING OF THE WATERS? THE 'SIGNIFICANT HARM' OF RE B AND G (CHILDREN) (CARE PROCEEDINGS)[2015] EWFC 3.

The academic debate rages on as to whether male circumcision really is in the best interests of the child or if it constitutes an abusive practice. This commentary discusses the recent case of Re B and G (children) (care proceedings) [2015] EWFC 3, delivered by the current President of the Family Division of the High court, Sir James Munby. Two key issues are raised by this judgment. First, that President Munby's obiter comments constitute an attack on the legally accepted act of male circumcision by suggesting a similar nature between the illegal act of female genital mutilation (FGM) and that of male circumcision as well as the suggestion that male circumcision can be classed as a significant harm. Second, that this case reflects the woefully unprepared condition of the UK medical profession in dealing with FGM.

Constituting children's bodily integrity.

Children have a constitutional right to bodily integrity. Courts do not hesitate to vindicate that right when children are abused by state actors. Moreover, in at least some cases, a child's right to bodily integrity applies within the family, giving the child the right to avoid unwanted physical intrusions regardless of the parents' wishes. Nonetheless, the scope of this right vis-à-vis the parents is unclear; the extent to which it applies beyond the narrow context of abortion and contraception has been almost entirely unexplored and untheorized. This Article is the first in the legal literature to analyze the constitutional right of minors to bodily integrity within the family by spanning traditionally disparate doctrinal categories such as abortion rights; corporal punishment; medical decisionmaking; and nontherapeutic physical interventions such as tattooing, piercing, and circumcision. However, the constitutional right of minors to bodily integrity raises complex philosophical questions concerning the proper relationship between family and state, as well as difficult doctrinal and theoretical issues concerning the ever-murky idea of state action. This Article canvasses those issues with the ultimate goal of delineating a constitutional right of bodily security and autonomy for children.