Boys and young men are being circumcised unnecessarily by the NHS, risking sexual problems in later life, doctors at one of Britain’s leading children’s hospitals have warned.
Surgeons at Alder Hey Children’s NHS Trust, Liverpool, have broken ranks and criticised surgeons who offer the operation on medical grounds – suggesting they should be looking for less invasive alternatives.
In an official report, the hospital’s leading paediatric surgeon, Professor Simon Kenny, claims that more than half of the 9,500 circumcisions carried out for medical reasons each year in the UK should never have happened.
The analysis also found up to half of the boys who underwent medical circumcision at some trusts were under five, an age at which doctors agree the procedure is almost always unnecessary.
Prof Kenny, who is also NHS National Clinical Director for Children and Young People, declined to comment further when approached by The Mail on Sunday last week, but one of his colleagues told us: ‘There are a really large number of circumcisions happening in the UK, and often not for the right reasons.’
Circumcision – the removal of the foreskin, with a scalpel or other device – is offered on medical grounds if a boy has persistent problems such as discomfort and infections.
Left untreated, these can worsen, and even cause severe difficulties in later life.
But paediatric surgeon Rachel Harwood, who also works at Alder Hey, said: ‘There are many other treatments out there for boys with foreskin issues that should be considered first.
‘A circumcision is non-reversible, it’s a decision for life and many surgeons are effectively making that choice for parents when it’s not their decision to take.’
Child specialists at other hospitals have backed Alder Hey’s campaign and argue the problem is being driven by rural hospitals where there is a lack of surgeons who specialise in treating children.
The analysis also found up to half of the boys who underwent medical circumcision at some trusts were under five, an age at which doctors agree the procedure is almost always unnecessary. (Stock image)
‘It relates to training and experience. If a surgeon hasn’t handled many cases they might be more likely to go for circumcision as it’s seen as the simple option,’ says Dr Chris Driver, consultant paediatric surgeon and urologist at Royal Aberdeen Children’s Hospital.
But not all doctors agree. Some argue that the alternative treatments are ineffective and, at worst, more harmful than circumcision.
In many cases, they say, circumcision is the only option for children who are in considerable pain.
The vast majority of medical circumcisions are to treat a condition known as phimosis, which is where the foreskin is too tight and cannot be pulled back.
This is normal in a newborn baby, but over time the foreskin loosens and can be pulled down more easily.
This why doctors say that circumcision should, in most cases, not be offered to under-fives.
But for some children the process can take longer and, according to NHS figures, half of all children under ten have phimosis.
By the age of 17, 99 per cent of phimosis cases will have resolved themselves, some studies suggest.
In almost all cases where phimosis continues past this age it is linked to an inflammatory skin condition called lichen sclerosus.
This can cause scar tissue to build up within the foreskin, making it shrink – and leading to phimosis.
While there are treatments that can help relieve lichen sclerosus, the scarring is irreversible, meaning circumcision is the only real option for patients.
‘Most men still suffering from phimosis in adulthood have lichen sclerosus, and it is one of the only reasons you should perform a medical circumcision,’ says Vaibhav Modgil, a urologist at Manchester University NHS Foundation Trust.
In younger men and boys who do not have lichen sclerosis, treatments for phimosis include steroid creams, which given over several months can help soften the skin, and an operation known as a penile preputioplasty, in which only part of the foreskin is removed.
‘There are many boys who do not suffer from lichen sclerosis who are having circumcisions,’ says Ms Harwood.
‘By comparison, very few are having a penile preputioplasty, so we know there are surgeons who aren’t exploring the other options properly.’
Some doctors, however, believe that in many cases circumcision can be the only feasible option for children suffering from phimosis.
One reason is that steroid creams can be ineffective – an American study found a third of phimosis patients do not respond to them.
They also argue that penile preputioplasty is a complex operation and can cause further issues.
While this ‘partial circumcision’ procedure can fix the phimosis, patients often report dissatisfaction at how their penis looks afterwards.
‘Penile preputioplasty can be difficult to get right and it’s challenging to get an acceptable cosmetic result,’ says Dr Marc Lucky, a urologist at Liverpool University Hospitals NHS Foundation Trust.
And while many children’s phimosis will naturally resolve itself, doctors say teenagers who are in pain due to the condition should be considered for circumcision.
Phimosis can cause problems with hygiene, increasing the risk of a condition called balanitis in which the foreskin becomes inflamed, and other infections.
Ideal way to tackle a burn? Cold water for 20 minutes
It’s a mainstay of first aid advice for treating burns – run the affected skin under cold water.
Now scientists have discovered precisely how long you need to do it for and why the remedy is so effective.
According to research by leading skin specialists, 20 minutes is the optimum time spent under the tap.
Doing so led to a 56 per cent reduction in the depth of the burn – which is how damage to the skin is measured.
This time protocol is longer than that recommended by some NHS hospitals, which advise just ten minutes.
Professor Hugh Wright, a consultant hand surgeon at Leeds General Infirmary who led the study, experimented on 30 pieces of tissue donated from patients who’d undergone breast reconstruction.
The breast tissue was burned to the same severity as the skin of a hand touching a gas hob.
This created so-called ‘mid-thickness burns’, where the damage penetrates only the upper layer of the skin.
This is the most common form of burn.
The tissue was then run under water cooled to 16 C – the average temperature of tap water – for different 20 minutes, and compared with burnt skin that had not been cooled.
Prof Wright explains that the cooling effect interferes with the bodily process that triggers skin damage after a burn.
When the skin is injured, the immune system releases proteins called cytokines which protect against infection in the wound.
But often, too many cytokines are released in response to a burn, leading to prolonged inflammation in the area and increased damage to the tissue as a result.
Prof Wright’s study, entitled Putting Out The Fire Of The Burn, argues that cooling the wound shuts off the release of cytokines, limiting the tissue damage.
He said the findings, presented at the British Association of Plastic, Reconstructive and Aesthetic Surgeons in December, show that, if more injured people run burns under cold water for 20 minutes, there would be fewer severe burns treated on the NHS every year.
Roughly 250,000 Britons experience burn injuries every year, with 175,000 attending hospital for treatment, according to the National Institute For Health and Care Excellence.
The most common type is a scald – caused by hot water or steam.
Prof Wright said: ‘If we can teach people why it is so important to cool skin after a burn and how to go about it, we can save many people skin grafts, infections and ongoing burns treatment.’
Paraphimosis, in which the foreskin gets retracted and cannot be returned to its original position, can also occur.
This can cut off blood supply to the penis and is considered serious if not remedied.
‘If a child has these issues, particularly in their teenage years, then there’s a good argument that they might need circumcision,’ says Dr Lucky.
Nevertheless, doctors agree that circumcision is not a risk-free procedure. According to the British Association of Urological Surgeons, ‘almost all patients’ will experience some permanent reduction in sensation in the penis.
This is because the skin that is removed, either using a scalpel or surgical scissors, contains several thousand nerve endings that transmit physical sensation to the brain.
A smaller number of men who undergo the procedure, which usually takes place under general anaesthetic, can experience more severe complications.
One in 50 will develop an infection or bleeding in the area.
While rare, oedema – a build-up of fluid in the skin – can occur, leading to dramatic swelling and deformity that can take many months to resolve.
In some cases, doctors say surgeons can remove too much foreskin, or not enough, which can lead to discomfort and pain later in life.
‘Circumcision gets trivialised, but it’s only trivial when it goes well,’ says Mr Modgil.
He says he often sees men who underwent a medical circumcision at a young age, who complain of issues in the area as a result of the surgery.
‘The foreskin grows and changes with age, so if you operate on it at a young age it’s hard to know what will happen to the skin later in life.
‘It’s common for us to see men who’ve been circumcised for medical reasons at a young age who are in discomfort by their 20s or 30s.’
Ms Harwood says these issues can also affect boys mentally as they grow older.
‘Some patients report a lack of sensation during sex, others experience mental health issues because they feel the decision to have surgery was taken away from them.’
In the UK, fewer than nine per cent of British males are circumcised, and the majority of these are either Muslim or Jewish, who are circumcised for religious reasons.
These operations are not typically carried out on the NHS.
Surveys suggest two per cent of men in the UK have been circumcised for medical reasons.
In America, however, more than three-quarters of men are circumcised, usually in infancy, and while rates have been falling in recent decades – currently fewer than 60 per cent of baby boys in the US undergo the surgery compared with nearly 80 per cent in the 1990s – it remains a much debated topic.
The American Academy of Pediatrics maintains that circumcision is beneficial, on medical grounds, because some studies suggest it reduces the risk of HIV infection, urinary tract infection and penile cancer.
But activist groups such as Intact America have called for an end to all but the most necessary medical circumcisions and a ban on religious circumcisions.
These activists, who often refer to themselves as ‘intactivists’, argue that children are too young to consent to the procedure.
Medical circumcisions were, historically, more common in the UK than they are now, too. In 2000, more than 15 per cent of Britons were circumcised, according to the British National Survey of Sexual Attitudes and Lifestyles.
This means the number of circumcised men in the UK has fallen by more than 40 per cent in 20 years, despite a continued increase in the proportion of the British population who are non-white and so are more likely to be circumcised for religious and cultural reasons.
Doctors say this is in large part due to the growing awareness of the risks of the procedure, as well as greater understanding of alternative treatments.
‘Circumcision was a relatively normal intervention one or two generations ago,’ says Dr Driver. ‘It’s declining, but there are still too many being done.’
Nonetheless, UK groups such as 15 Square, which has similar aims to Intact America, have repeatedly called on the NHS to address the number of medical circumcisions taking place.
They argue that men can often suffer serious mental health issues like anxiety and depression as a result of being circumcised.
Jim Pollard, one of the founders of the Men’s Health Forum, an online community devoted to men’s health issues, says the group believes too many circumcisions are carried out in the UK.
‘Circumcision is a big deal. It’s surgery on a very delicate part of the body. We don’t think doctors need to intervene so drastically because tight foreskins are very, very common.
‘There are plenty of options for boys before circumcision is even discussed.’
David Harding, 37, from Doune in Perthshire, underwent a circumcision aged four and says he has suffered sexual and mental health issues as a result.
He adds: ‘I became acutely aware that I lacked sensitivity. Climaxing during sex was almost impossible, and it could often be painful.’
However, doctors say it is important to remember that the majority of circumcisions happen without complications, and, crucially, can relieve intense suffering.
John, 30, from London, who didn’t want his full identity revealed, underwent a circumcision at 18 after suffering recurring bouts of balanitis, which is similar to lichen sclerosis but less severe and often temporary.
‘It was constantly red and itchy, and this went on for years,’ says John, who works in finance.
Eventually, doctors recommended a circumcision.
‘It was painful, to say the least. I couldn’t wear proper underwear or trousers for weeks because these would rub against the wound,’ he says.
‘Overall it wasn’t as bad an experience as I thought it would be, and thankfully my sex life hasn’t been affected and I haven’t had any issues with balanitis since.’
Mr Harding hopes in future NHS hospitals will provide parents with alternatives and offer circumcision only as a last resort.
He adds: ‘Circumcision is viewed as a routine practice procedure when it shouldn’t be. You’re dealing with someone’s most intimate parts.’
For more information on circumcision and other phimosis treatments, you can visit: 4skin-health.alderhey.nhs.uk/