Diversity – Cultural/Religious practices with babies and infants Tessa Oughton GPST3

The 8 week baby check Can I be referred for my baby to be circumcised? Birth rites across the main religions, then discuss the issues surrounding infant circumcision, when and how this can be done and the debates surrounding this.

Muslim birth rites First words a baby should here - Muslim call to prayer(Adhaan) First thing a baby tastes; Date juice/honey rubbed into gums After 7th day; Head is shaved The baby is named ‘Aqueeqa’ – sacrifice of a sheep. Circumcision – 7 days until puberty Adhaan; Whispered into the right ear by the father Sweet taste – thought to kick-start the digestive system Cleanliness As a sign the child is a servant of Allah Weight of the hair is donated as silver to charity It is also essential for a man to be circumcised to lawfully make the pilgrimage to Mecca, one of the five pillars of Islam

Hindu birth rites Birth Head shaved Namakarana – naming ceremony Jatakarma – putting some honey in the mouth Whispering the name of God in the child’s ear Head shaved Namakarana – naming ceremony 3-5 years Ear piercing Hindu birth rituals vary depending on castes and regional practices. Ear piercing is traditionally both for males and females though more modern practice usually does not involve boys.

Jewish Culture Circumcision (Brit Milah) Traditionally on day 8, performed in the Synagogue Male babies are named at the time of their circumcision Female babies are named at the first public reading of the Torah at the Synagogue Almost universal in Israel as well as the Uk and US

Christianity Baptism Symbol of welcome and belonging to the Church. Water is sprinkled on the baby's head as a symbol of new life and of being washed clean from sin.

Male infant circumcision: Prevalence WHO: ~30% of males over the age of 15 are circumcised worldwide (69% of which are Muslim) Non-religious circumcision US – 75% UK – 6% Earliest records depicting the practice coming from Egyptian tomb work and wall paintings dating from around 2300 BC Despite the US being predominantly Christian, there is a very high prevalence of circumcision

Male infant circumcision Indications; Religious/cultural Proposed health benefits Social Medical; Phimosis (90%) Paraphimosis balanitis xerotica obliterans Recurrent balanitis (Hypospadias) Muslims, Jewish In Hypospadias – foreskin is usually used to reconstruct the urethra therefore causing circumcision Balanitis xerotica obliterans – atrophic white patches to glands/foreskin/urethra leading to phimosis. Can be treated with steroids but may progress to need circumcision.

Benefits of male circumcision? Proposed medical benefits; Reduction in STI’s including HIV*, genital herpes, genital warts, syphilis, chancroid Reduction in penile cancer Reduced UTI’s Reduced risk of BV & Trichomoniasis in women Reduced risk of cervical cancer in women (due to reduction in HPV in men) Lots of varying research into this with very different results. Generally the advice from the WHO is that there are much better ways of minimising these risks with safe sex advice etc than surgical intervention and the risks of surgery outweigh the benefits. ?Increased risk taking behaviour after circumcision US Centres for disease control and prevention published article on 2nd December summarising 3 studies in Sub-saharan Africa showing a 50-60% reduction in HIV transmission following male circumcision, however it acknowledges that the risk of HIV transmission in the US is much lower than in Africa and that it is usually transmitted by MSM relationships whereas these studies predominantly looked at heterosexual relationships.

Male infant circumcision Complications Bleeding/Haematoma Pain Infection Swelling Removal of insufficient or excess tissue Decrease in sensation during intercourse Urethral stricture Psychosocial problems Accidental amputation of the head of the penis (very rare)! 0.2-0.4% in neonates, 2-4% in adults. Method – usually local (or no) anaesthetic for neonates, done using a clamp which minimises or eliminates bleeding. Usually fully healed within 1 week. Although it is not too difficult to find a practitioner in the UK, many infant circumcisions are still done by unregulated or non-medically trained practitioners such as religious leaders. Brother in Law is surgical trainee and tells me in the last two years in HRI he has seen a significant number of acute and elective referrals following complications of private circumcisions.

Male infant circumcision; funding NHS Choices; ‘It is important to note that some CCGs in England do currently fund religious or ritual circumcision on the NHS. The decision is based on priorities that relate to its own local population’

Male infant circuCIsion Where? Bradford road, Fartown Brikby Health Centre Clarendon medical centre, Bradford BMI/Spire Leeds children’s circumcision centre Some UK CCG’s do offer funding The Wirral Circumcision centre – offers as a package for Eid/Christmas

BMJ arguments ‘Allowing male genital mutilation is a discrimination between the sexes’ ‘An abuse of the rights of the child’ ‘The unpalatable truth is that logic and the rights of the child play little part in determining the acceptability of male genital mutilation in our society. The profession needs to recognise this and champion the argument on behalf of boys that was so successful for girls’ Comparing to FGM – although I think most would argue that the motivation for male circumcision is very different and usually has less drastic results. Should wait till the child is old enough to make the decision for religious and cultural reasons – child may not have the same beliefs

The law and ethics of male circumcision: guidance for doctors Male circumcision is generally assumed to be lawful provided that: it is performed competently it is believed to be in the child’s best interests there is valid consent (both parents)* GMC guidance but withdrawn in 2007 *Where people with parental responsibility for a child disagree about whether he should be circumcised, doctors should not circumcise the child without the leave of a court

Summary Widely practiced procedure Possible health benefits Increasingly common in the UK due to increasing cultural diversity Widely available safely in the UK for relatively low cost On going unregulated practice worldwide with associated increased complication risk Does remain a controversial topic, however if performed safely the overall acute and long term risks are low. Controversy mainly surrounding lack of patient consent and on the other hand the argument that if it were available on the NHS there would be less unregulated practice and therefore less complications.

References http://whqlibdoc.who.int/publications/2007/9789241596169 _eng.pdf?ua=1 http://www.bbc.co.uk/religion/religions/islam/islamethics/ malecircumcision.shtml http://www.nhs.uk/conditions/Circumcision/Pages/Introducti on.aspx http://www.bmj.com/content/335/7631/1206 http://www.bmj.com/content/335/7631/1181 http://jme.bmj.com/content/30/3/259.full#ref-4 http://www.gmsafeguardingchildren.co.uk/417626/gmcircum cisionleaflet