'The clinic is staffed by specially trained GPs'

Circumcision, the surgical removal of the foreskin, is one of the oldest surgical operations, and it is estimated that between 5 and 6 per cent of males in the UK have had the procedure, which can be done for both medical and religious reasons.1,2

Medical circumcisions are usually done in males between the ages of one and 15 for indications such as balanitis, phimosis and redundant prepuce.

About 30,000 medical circumcisions are carried out annually in the UK.1 But male circumcision for religious reasons is not widely available on the NHS.

Religious circumcision of infant males is an ancient tradition practised by many cultures, including those of Islamic and Jewish faiths.3 As it holds religious and ritual significance, the procedure is often carried out in non-hospital environments by religious leaders - trained or untrained - and practitioners selected by religious leaders (particularly Muslim) on infant males aged between eight days and four months.

Unfortunately, the number of children seen by accident and emergency staff and GPs presenting with post-operative complications from circumcisions undertaken in a non-hospital environment has been rising. Problems include convulsions and septicaemia. An example was highlighted by doctors Madden and Boddy in a letter to the British Medical Journal in 1991 and examples were also found in a survey in Bolton.4,5

With a growing Muslim population in the UK it is time to address the issue of religious male circumcision and what solutions are available to health authorities and trusts.

The options

Allow religious circumcisions to continue to be undertaken by religious communities, with the consequences of these operations to be picked up by the NHS. This should not be an option for HAs and trusts serving multicultural communities.

A service is made available under the auspices of the NHS which caters for religious male circumcision. Such a service could be incorporated into existing medical circumcision services undertaken in specialist clinics or as paediatric day case surgery.

Trusts and HAs work in partnership with the minority communities to ensure that their cultural needs are met while minimising post-operative complications.

Collaborative working has provided a solution in at least three areas of the UK.

The collaborative approach

Following concerns expressed by paediatricians and surgeons in Bolton about the provision of non-NHS circumcisions, a study was commissioned by Wigan and Bolton HA in 1996 to review how religious circumcision was undertaken in the local Muslim community.5 It involved collaboration between local ethnic minority leaders, surgeons and parents. A postal questionnaire to 73 families who had had their children circumcised for religious reasons found more than a third had experienced post-operative problems. The study showed:

There were no scheduled arrangements for religious circumcision.

Arrangements to have boys circumcised were made by contacting religious leaders at the mosque. The leaders then arranged for practitioners to run sessions at which at least 10 circumcisions were carried out.

Those performing the circumcisions were not necessarily medically trained.

Circumcisions were done at a variety of locations, including family homes and even the backs of cars.

It was not known whether the instruments used for the procedure were sterilised.

No aftercare was available to the family.

There was an increased incidence of post-operative problems, including bleeding and infection. Children with such problems were taken to their GP or the local A&E department for help.

Following this study, the HA launched an initiative in partnership with the local Muslim community, Bolton Hospitals trust, Community Healthcare Bolton trust and Bolton metropolitan council to address the issue of religious circumcision.5 The aim was to provide a service by trained staff in a sterile environment which supported the rights of parents to follow their religion and have their male children circumcised, while reducing complications.

The service - funded with£24,340 provided by the HA, local authority and Muslim community, is run collaboratively by the local community and local service providers. Wigan and Bolton HA funded the training of the GPs and nurses who would provide the service, Bolton Muslim Forum rented clinic space, bought nurses' time from Community Healthcare Bolton trust and purchased sterile equipment from Bolton Hospitals trust, which also oversees the training of clinic staff. Funding was also provided by Bolton metropolitan council.

The service was launched in May 1996 to provide religious circumcision on boys typically aged under four months and is run on alternate Saturdays. A total of 400 operations have been carried out so far.

The clinic is staffed by specially trained GPs who do the operations, and nurses who assist them and provide an aftercare service for the patient and his parents (including a post-operative visit). The GPs are paid£40 per circumcision. The nurses are employed by Community Healthcare Bolton trust.

Parents pay a fee of£45 per circumcision, as the service is seen as a non-health related intervention. But the fee is acceptable to members of the local Muslim community as they can be assured their children are circumcised by trained staff in a safe environment. Any child circumcised in the clinic is visited by a nurse at home within 24 hours of the operation.

Similar circumcision clinics have been set up in Bradford and Peterborough, where they are run by local NHS trusts in collaboration with the local community. Again, parents pay a fee to help with costs.

The incidence of post-operative complications is likely to be reduced by providing a sterile surgical environment, trained staff and post-operative care. The cost to a HA of setting up such a service is minimal compared with the costs incurred by trusts in treating children with complications following circumcision in a non-hospital environment.

We believe that this is an example of a truly healthy alliance between the local community, trusts and HAs and that this is the way forward to meet the needs of the communities we serve, including minority communities which aspire to follow religious beliefs and will be able to do so without detriment to their health.

REFERENCES

1 Harbinson M. The arguments for and against circumcision. Nursing Standard 1997; 11 (32): 42-47.

2 Rickwood A, Walker J. Is Phimosis over-diagnosed in boys and are too many circumcisions performed as a consequence? Ann RC Surg. Eng 1989; 71 (5): 272-277.

3 L'Archevesque C, Goldstein-Lohman H. Updates & Kidbits. Ritual circumcision: educating parents. Paediatric Nursing 1996; 22 (3): 228, 230-234.

4 Madden N , Boddy S-A. Should religious circumcisions be performed on the NHS? Br Med J 1991; 302 (6767): 47.

5 Memon M. Religious Circumcision. Wigan and Bolton Health Authority annual report. 1996.