Intact Denmark has written an argumentation paper that sums up our argumentation in the debate about circumcision. The paper has been sent to members of the Danish Parliament in context with the upcoming interpellation debate in the Parliament, which SF has initiated, and is expected to take place at the end of May 2018.
The paper goes through circumcision methods, complications, pain and anaesthesia, spreading, legal matters, Intact Denmark’s citizens initiative, including the question of punishment, and also discusses the debate about circumcision. In relation to these points, the argumentation paper raises a number of relevant questions which the politicians should ask the minister of health.

The argumentation paper follows hereunder and can also be downloaded here: Intact-Denmark_Argumentation_Sheet

For more information look here: Intact Denmark’s rapport to the UNCRC

Non-Therapeutic Circumcision

Intact Denmark – NGO against circumcision of children works for the imposition of an age limit of 18 years for circumcision and other genital surgery on healthy children, no matter their gender, culture or religious background.

In some cultures, circumcision is a central and highly valued ritual. This must be recognised. No parent has their child circumcised with evil intent, but out of love. Unfortunately, circumcision is so invasive and permanent, that we believe that the central individual – the child – should have their bodily integrity and autonomy secured, along with their personal choice of religion, without being permanently marked from childhood. Therefore, circumcision should be postponed until the individual can personally give their qualified consent as a legal 18-year-old. The decision must be made by the person who has to live with the consequences and possible complications.

Methods

Non-therapeutic circumcision (also known as ritual circumcision) is carried out on children of different ages and under different circumstances. Circumcision of healthy children has not been carried out in Danish hospitals since 2002, because of ethic and economic reasons. Nowadays, they take place in clinics, in private homes and in religious communities.

No matter what method all circumcisions follow the same steps:

Possible anaesthesia
Possible disinfection
The foreskin is separated from the glans by cutting it
Clamping/crushing of the tissue with the intention of stopping blood supply
Cutting/clamping of the foreskin also known as amputation of the foreskin
Possible rinsing of the wound with alcohol
Bandaging
The healing period

On smaller children, the foreskin’s mucous membrane is attached to the glans with the same type of tissue which attaches the nails to the fingers. In connection with circumcision, the foreskin will have to be scraped from the glans (the penis head) which is left skinless in connection with the procedure.

In some types of circumcision (e.g. Plasticell and the Gomco method) the foreskin is scraped free of the penis head before the actual amputation. This is done with a metal instrument called a probe. In other methods, e.g. the traditional Jewish method as described in Talmudic guidelines, the foreskin is amputated first, whereafter the performing mohel scrapes the remaining mucous membrane from the child’s glans penis with the nails.

In Jewish congregations, the circumcision is done on the eighth day, while other circumcision cultures typically circumcise older children up to the age of 10-12. It is claimed that the execution of this ritual is invariable because of religious reasons for Jewish congregations, but internationally a rising number of Jewish parents have altered the ritual to the peaceful gender-neutral Brit Shalom ritual, which does not entail circumcision. In other religious persuasions, among others Mormons, Muslims and branches of Catholicism, circumcision is not invariable.

Parents who do not wish to have their son circumcised traditionally choose a circumcision done in a clinic. There is no solid survey of when and under which circumstances that circumcision of children residing in Denmark typically occurs, but since circumcisions, in e.g. Turkish and North African cultures often take place around the age of 6 as an initiation ritual, one must assume that the average age for circumcision can be 4-7 years.

Apart from these forms of circumcision, there are a number of unknown illegal circumcisions being performed, where it is unknown which methods being used and if there is any form of pain relief.
Circumcision clinics as e.g. the Copenhagen based UroKlinik inform that, “it can take up to 6 weeks before the wound is completely healed and you can see the final result of the circumcision.”

Complications

A survey carried out by the National Hospital of Denmark has established an acute complications rate of about 5.1% for ritual circumcision, which among other things include acute bleeding and infections requiring hospitalisation. A new American study has concerned itself with all the complications that have been reported of all circumcisions performed in the entire state within a period of two years from the time of circumcision. It concludes that the complication rate is remarkably higher than the expected 12%. Additionally comes the potential long-term complications which are ascertained later in life.

The following question is relevant to seek answered:
Within Judaism, have there been developed alternative rituals of welcoming, which do not involve circumcision? Is there any obstacle for these alternatives replacing the Jewish circumcision in Denmark?

Anaesthesia

Modern research shows that children experience the pain in the same magnitude as adults (new studies point to the fact that children even feel pain up to five times more than adults). Simultaneously, children do not have the psychological techniques to deal with pain.

The Danish Health and Medicines Authority’s guidance about circumcision at least states that there are the following conditions for pain relief: “The doctor has to make sure that the children, including infants, are pain relieved necessarily and sufficiently during the procedure and in the period after the procedure. With the choice of pain relief, the child’s age, the degree of maturity and other medical conditions must be taken into account. The pain relief that is chosen must furthermore be as good as possible with the least amount of risk of side effects and complications as possible.”

During circumcision different kinds of anaesthesia are used, e.g. penis blockade (locally anaesthetic injection at the root of the penis) or full general anaesthesia. Since all methods involve considerable risks they are not used on children under the age of 2 months, as complications with usage can be life-threatening. At therapeutic procedures, it rests with the doctor to weigh out the risk of anaesthesia related complications to possible treatment advantages.

Therefore, some circumcisers choose to use the surface anaesthetic Emla/Tarpin creme. This happens in direct conflict with guidelines from the European Medicines Agency and the Danish Medicines Agency; since the effectiveness of the pain coverage is not documented and the aid can be damaging for children at the usage on the genitals. This also appears in the Danish package insert which says: “Nor could there be proven sufficient local anaesthetic effect at circumcision. Emla may not be used on genitals (e.g. the penis) or mucous membranes in the genitals (e.g. in the vagina) on children (under the age of 12) because of insufficient data regarding absorption of the active narcotics”.

Here one might ask:

How is the usage of Emla/Tarpin creme in agreement with the guidelines in the instruction of circumcision as well from the European Medicines Agency and the Danish Medicines Agency?
How much pain is acceptable when it concerns a non-therapeutic procedure?
How big considerable risks are acceptable

Spreading

The Danish Health and Medicines Authority estimated in 2013 the proportions of non-therapeutic circumcision to around 1,000-2,000 boys per year, but which method that was used does not appear in the memorandum of circumcision. The estimate seems highly conservative considering that there in 2013 was born 3,640 boys of non-western parents, where a considerable part must be assumed to have a culture of circumcision as their background. In 2016 this number was 4,807. This means that there is talk of an increase in the number of newborn boys of non-western parents of 47%.

Population (Cf. Statistics Denmark) Citizens with a background in non-western countries	2007	2013	2016
	329,719	390,780	452,540

Livebirth boys of parents with a non-western background (cf. Statistics Denmark)	2007	2013	2016
	3,279	3,640	4,807

This raises the following questions:

Which method did the Danish Health and Medicines Authority use at the calculation of the ratio of circumcisions in 2013?
Can the estimate of the yearly number of circumcision of healthy boys in Denmark be projected with the same percentage rate as the development of the number of births of livebirth boys of parents with a non-western background?
How many registrations of non-therapeutic circumcisions take place on a yearly basis?
Provided that there is a difference in the number of estimated non-therapeutic circumcisions and the number of actual registered non-therapeutic circumcisions, how can this be explained if the occasion should arise?

What does the Danish and International Courts say?

On December 22 the Ministry of Ecclesiastical Affairs answered, with the help of the Ministry of Justice, a question from the Parliament about whether circumcision is protected by the Act of the Constitution’s provision of freedom of religion. The decision of the ministries was that an age limit for the practice of religion such as circumcision is entirely up to the Parliament to decide:
“The Constitution § 67, 2nd limb, contains the restriction for freedom of religion that it does not protect worshipping which is in contrary to morality or the public order. It is assumed in this connection that legislative power is left to a wide judgement of deciding the boundaries that follow in consideration of morality or the public order…”

The European Convention on Human Right (ECHR) about freedom of religion has even more extensive exceptions than the Danish Constitution in connection to the practice of religion, as it, cf. ECHR article 9 paragraphs 2, highlights exceptions with an eye to protect the other persons right, freedom and last but not the least their health:
“Freedom to practice your religion or faith shall only be subjected to such limitations that are prescribed by law and are necessary in a democratic society in consideration to the public safety, to protect the public order, health or morality or to protect other people’s rights and freedoms“.

The imposition of an age limit of 18-years-old for circumcision and other kinds of genital surgery on healthy children is thereby in complete agreement with both the Constitution and conventions.

All of the Nordic children’s ombudsmen and a number of doctors- and children’s rights organisations have also recommended the imposition of an age limit at the legal age.
In Norway, Germany and Sweden they have chosen from a political side to disregard these recommendations while, right now, an 18-year age limit is under consideration in Iceland’s Althing. It is now in the consultation phase. A Nordic country can thereby become the first country in the world to protect all children against involuntary genital surgery.

Already in 2014, in Malta, there was imposed a law which specifically protects intersex people against non-therapeutic genital surgery as recommended by the UN. However, it has not been tested yet if the law also protects boy children. The wording is unclear. Therefore, it is not certain that Malta, in reality, is the first country in the world that has protected the bodily integrity of all children no matter their gender. The fact that the gender-neutral principle actually is the intention for the UN is nonetheless the impression you get from the wording in the recommendations from the UN’s Children Committee to Denmark from October 2017, wherein it says: “Ensure that no one is subjected to unnecessary medical or surgical treatment during infancy or childhood, guarantee bodily integrity, autonomy and self-determination to children concerned, and provide families with intersex children with adequate counselling and support“.

Consent and the Bioethics Convention

In connection with the discussion about rights, consent is a central question. The principle of consent is established in the Bioethics Convention Article 6 paragraph 1. It establishes that “an intervention will only be done to a person who lacks the ability to give consent if it is a direct advantage to this person”. In the Council of Europe’s guide til the Bioethics Convention, it is made clear that what is meant by a direct advantage is a direct health-related advantage.

This is in direct extension of the Hippocratic oath “primum non nocere” which can be translated as “first do no harm”.

This principle is put aside in Danish Health and Medicines Authority’s Guide about circumcision of boys (2014), which allows circumcision under the condition that it is performed under the supervision of a doctor and with both parents consent. The guideline is thus in contrary to the Convention.

However, the guidelines stipulate that children over the age of 15 are able by themselves to give or not give their consent to non-therapeutic circumcision, while children under the age of 15 must be involved in the decision to the extent that they understand the situation.
The last-mentioned stipulation is however unclear in relation to the boy’s age and in relation to what must be understood by the boy must be involved in the process of decision.

Notice, that a number of Danish and Scandinavian health- and children’s rights organisations since then have declared circumcision of healthy boys an infringement of rights and unethical. This includes the National Council for Children, the Danish Medical Association, the Nordic children’s ombudsman, Danish Nurses’ Organization, The Danish Family Planning Association (DFPA), among others. several have directly recommended the imposition of an age limit. See enclosure.

Citizen Initiative – Imposition of an age limit of 18-years-old for circumcision of healthy children

Intact Denmark’s citizen initiative has been worked out with the intention of securing all children’s basic right to bodily integrity, no matter the gender, cultural background or the parents’ religion.

The citizen initiative recommends that an age limit of 18-years-old is imposed because it is the same as the personal legal age, which is also valid in relation to other cosmetic procedures, such as breast implantations. Intensifying elements that are especially important to take into consideration at circumcision include social control, provided that the age limit is set too low. Furthermore, the average age of sexual debut is 16.7-years-old, which speaks in favour of an age limit which ensures a sufficient basis of experience before the choice is made.

The citizen initiative establishes consideration to a number of relevant articles of the convention and also the Danish legislation. There has been accounted further for the underlying considerations in Intact Denmark’s NGO report to the UNCRC of 2016.

Range of punishment

Centrally in the citizen initiative is the range of punishment. There has been taken a starting point in the penal code §245 which is wished to be gender-neutral and specified. The range of punishment here is up to six years.

As of right now, there is a precedent for both boy circumcision and girl circumcision to fall under this paragraph and that there as such will be passed sentence in both cases. There has not been passed like-wise sentence for genital circumcision on non-consenting inter-sexed children.

Derailment of the rights debate

The central question of rights in the debate about circumcision is often attempted to be derailed with the focus on a number of alleged advantages at circumcision.

Often mentioned in this derailment is the alleged prevention of sexually transmitted diseases such as HIV and HPV (which can lead to rare cases of penile cancer). But a surgical removal of a healthy part of the body is not an acceptable method to prevent diseases which might only possibly occur later in life. Additionally, it must be maintained that these diseases are not relevant to children since they are not sexually active. When they do become so, they will have easy access to condoms, which unambiguously is the safest method of prevention. If they, as adults, should want to have the non-therapeutic circumcision performed they are able to choose it themselves.

In a similar attempt to derail the debate about gender-neutral fundamental rights it is likewise claimed that circumcision of girls is incommensurable with circumcision of boys. However, what is being talked about is the exact same violation of rights and ethical principles, no matter if the focus is on genital surgery on girls, boys or inter-sexed children.

Usually, there is talk of an unequal standard of comparison. At the circumcision of girls, there is usually referred to the most invasive kind, performed under the harshest and unsafe conditions, with the most drastic consequences as result. At the circumcision of boys, people assume an uncomplicated procedure performed under healthcare secure circumstances, while inter-sexed children’s rights are rarely mentioned. If you want to compare genital surgery on boys, girls and inter-sexed children it should be done so on the same premises of healthcare secure circumstances.

Enclosure: Overview over organisations (all links in original languages)

The Danish Medical Association: “The Danish Medical Asociation believe that circumcision of boys without medical indication is ethically unacceptable if the procedure is performed without informed consent from the person who is having the procedure done. Circumcision of boys should therefore in be performed before the boy has reached legal authority to independently choose to have the procedure done.”

Danish Nurses Organization: “Circumcision of boys without medical indication of ethically unacceptable when the procedure is performed without informed consent from the young person and such consent can only be given when the young person is of legal age. The procedure is marked as being in variance with the UNCRC.”

The Danish Family Planning Association: “The Danish Family Planning Association believes that the ritual circumcision of boys should be placed legally side by side with the ritual circumcision of girls since they are both cases of the removal of vital tissue from healthy children. The Danish Family Planning Association finds it reasonable that the decision of ritual circumcision of boys should be made by the boy himself, for which reason you should wait to perform the procedure until he is 18-years-old and can give his informed consent.”

The Danish Association of Midwives: “The Danish Association of Midwives’ executive committee believe that boys, completely equal with girls, have the right not to be subjected to surgical procedures which are not for a medical reason – and we find that this right must mean exemption from the procedure.”

The Professional Society for Health Visitors: “The Professional Society for Health Visitors, therefore, want to maintain, with support from the UN Convention on the Rights of the Child, that the child’s rights, health and well-being must be the essence of this problem, and that the child must be of an age where they are capable of making an informed choice before a ritual circumcision may be discussed. In Denmark the age limit for an informed choice is 15-years-old.”

The Ombudsman for Children: “Circumcision of boy children is at variance with the UN Convention on the Rights of the Child. The Nordic ombudsman for children and paediatrician experts, therefore, wish to work towards circumcision only being performed if a boy, who have reached the age and maturity which is necessary to understand medical information, choose to give consent to the procedure.”

The National Council for Children: “Ritual circumcision of young boys is a procedure which is at variance with the UN Convention on the Rights of the Child. Ritual circumcision should only happen when the child is mature enough to give informed consent, at the earliest age of 15.”