AACU: Circumcision controversy could hike urologists' liability premiums

This article is part of an ongoing series from the American Association of Clinical Urologists (AACU), based on a partnership between the AACU and Urology Times. Articles are designed to provide updates on legislative processes and issues affecting urologists. We welcome your comments and suggestions about topics for future articles. Contact the AACU government affairs office at 847-517-1050 or info@aacuweb.org for more information.

Male circumcision has recently been the focus of intense debate by policy makers and religious leaders. The sensitivity of this issue mandates a serious and unbiased review of legislative and religious activities across the U.S. and elsewhere to determine its impact on the practice of urology.

Legislators, researchers, imams, and rabbis argue whether male circumcision decreases certain diseases, whether a child can or should give consent, or whether religious freedom should trump all of this. Public policy discussions that are taking place throughout the Western world-specifically, the U.S.-have implications for urologists.

Americans are mostly insulated from horror stories around the globe, such as in Indonesia, where religious extremists who practice forced circumcision on men, children, and even pregnant women in attempts at forced religious conversion; or in South Africa, where certain cultures allow for the forced circumcision of boys deemed to be “past the age of initiation.” Female circumcision is now called “female genital mutilation” and is illegal in most of the Western world.

In the U.S., legal disputes about circumcision are settled in the courts. Most often, these cases involve parents who have differing opinions about having the procedure performed on their child, hospitals that mistakenly circumcise infants, or liability suits when a procedure leads to complications.

A few relatively recent events could have the potential to ignite the debate between those who hold that circumcision is part of religious freedom and those who say it’s a violation of a child’s right to bodily integrity, thereby placing doctors in the spotlight.

Rabbis in New York have stated that they will defy that city’s ban on a ritual form of circumcision after 11 infants allegedly contracted herpes during religious ceremonies. And after a ballot measure in San Francisco outlawing circumcision appeared to be headed for a vote, the California state government passed a bill banning local prohibitions on circumcision.

In Sweden, circumcision has been required to be performed under anesthesia with a doctor or nurse present since 2001. While religious figures who perform the procedure may be licensed, the law led to a number of legal disputes over allegations of circumcisions being performed without proper licensing or medical personnel present.

In May of this year, an appellate court in Cologne, Germany said, "A child's right to physical integrity trumps religious and parental rights." The decision only applies to the Cologne region and finds that the procedure isn’t illegal if medically necessary. Following the regional court’s decision, the city of Berlin declared that circumcision is legal but only if performed by a doctor, not as a ritual.

I highlight these examples not to show that one side of the debate is right or wrong, but to simply inform urologists that this debate appears to be heating up and, as with most questions that involve religion and public health, widespread agreement and resolution aren’t imminent. What’s more, what happened in Sweden, Germany, and San Francisco could be replicated in your backyard.

While action by the federal government on circumcision is unlikely, municipalities and states will be the test markets for new laws and regulations. And with uniformity or strict enforcement lacking, like in Germany and Sweden, confusion will ensue. And with confusion comes the potential for lawsuits.

Complications stemming from circumcision may have lifelong implications for the individual at the other end of the knife, no matter their age. A Jewish mohel or Muslim leader may not be sued, but should the law relegate this practice to your procedure room, urologists can expect a rise in medical liability insurance premiums akin to those paid by OB/GYNs.

Should physicians become the only game in town for circumcisions, it behooves urologists in particular to be prepared for potential pitfalls. After all, this is America. While our laws and court system won’t tolerate the barbaric and criminal acts perpetrated in South Africa or Indonesia, the right to an attorney and civil and criminal trial aren’t topics of debate.

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