Situation of religious circumcision in Spain

INTRODUCTION

The services included in the Spanish public health system are aimed at the prevention, diagnosis and treatment of disease. The performance of circumcision for religious reasons is a questionable practice whose indication is not well defined within the scope of medical practice.^1,2

The aim of our study was to illustrate the heterogeneity that exists in the practice of religious circumcision in Spain by physicians employed in the national health system in order to develop a general guideline in regard to this practice.

MATERIALS AND METHODS

We performed a nationwide survey in 49 public hospitals offering paediatric surgery services. We submitted a questionnaire for collection of epidemiological and descriptive data and to explore the opinions both overall and of paediatric surgeons to at least 2 surgeons per hospital.

Participation was anonymous, and the questionnaire consisted of a total of 20 items with a single-choice, multiple-choice or open-answer format (Table 1).

NHS: National Health System.

Table 1. Questionnaire on religious circumcision submitted to paediatric practitioners
1	How many circumcisions are performed in your hospital?
2	Are circumcisions performed due to religious reasons in your hospital?
3	Are patients referred to you by one or more of these reasons? Patient’s paediatrician / Other
4	Do you experience conflict with the family when you refuse to perform the intervention for this indication? Yes / No / Only in some cases
5	When you schedule a circumcision (without a medical reason for it), do you do it as a compassionate measure to prevent harm to the patient should he undergo the procedure under poorer conditions outside the public health system? Yes / No / Other
6	Has this issue been discussed in your surgical department to establish a uniform approach? Yes / No
7	Has this issue been brought up at the Ethics Committee of your hospital? Yes / No / Other
8	Is there any regulation in your autonomous community or your hospital as to how to approach this issue? Yes / No / I don’t know
9	Do you know whether this indication is covered in the services offered by the NHS? Yes / No / I don’t know
10	When you refuse to perform religious circumcision within the NHS it is because: Patient does not have phimosis / You do not consider any other clinical advantages other than resolving phimosis / You do not wish to add to the economic burden of the public health system / All of the above / Other
11	Do you think there can be other medical indications (other than cultural) to perform circumcision? Yes / No / Other
12	If performance of religious circumcision is rejected within the NHS, do you believe that the patient should be referred to private health care services? Yes / No / Other
13	Do you apply the same criteria for the indication of circumcision in your public (NHS) and private practices? Yes / No / Other
14	Is there a specific individual in the surgical department that performs these procedures? Yes / No / Other
15	In case you perform these procedures, have you found a higher incidence of complications or complaints about the aesthetic outcomes from the family? Yes / No / Other
16	Do you use a specific surgical technique in these cases? Yes / No / Other
17	These procedures are scheduled based on: Individual judgment / Collective criteria in the department / Other
18	Do you ever manage patients with complications of religious circumcisions performed outside the Spanish NHS? Yes / No / Other
19	Do you wish that a protocol, regulation or consensus guideline on this subject were available within the Sociedad Española de Cirugía Pediátrica? Yes / No
20	Do you believe that surgeons should have the right to declare conscientious objection in these cases? Yes / No / Other

RESULTS

We received 142 completed questionnaires, corresponding to a response rate of 71%. We found that 76.6% of paediatric surgeons did not perform circumcisions for religious reasons within the public health system and that 65% would refer these patients to private providers.

Of all the patients managed in these hospitals, 89% had been referred by their paediatrician, and a lower percentage by other specialists.

As many as 65% of respondents reported having had conflicts with families due to refusing to perform circumcision for a religious indication.

Of the professionals who reported considering religious reasons an indication, 39% stated they agreed to perform these surgeries to prevent their performance under poorer conditions outside a hospital.

Most surgery departments do not have a specific individual in charge of this type of procedure, and the indication for the surgery and the surgical approached are established based on the personal judgment of the surgeon.

Of all respondents, 57% did not know whether this indication was included in the services offered by the National Health System or whether there are laws or regulations that could help clarify the approach to this issue. However, 88% agreed that they would like to have available a consensus guideline on the subject from the Sociedad Española de Cirugía Pediátrica (Spanish Society of Paediatric Surgery) (Figure 1).

Figure 1. Results of the survey (we only show a selection of the most relevant items )

DISCUSSION

Spain has a Muslim population of nearly 2 million inhabitants, making it the country with the fifth largest population with this religious affiliation in the European Union.³ Within Spain, Catalonia is the autonomous community with the largest Muslim population, followed by Andalusia, Madrid and the Community of Valencia, in addition to the cities of Ceuta and Melilla.³ Therefore, the practice of circumcision for religious reasons is an issue that is frequently faced and debated in medical practice in our country.^4,5

Various articles, both in the medical literature and the press, question the appropriateness of performing this service in the publicly funded National Health System.⁶ Its detractors, both in the public and private health systems, argue that the right of the minor to be able to make the decision himself once he comes of age has to be respected. Autonomous communities like the Basque Country or Catalonia have excluded this indication for circumcision from medical practice in the public health system.⁷

Several questions arise in this context, such as whether the presence of a medical problem like phimosis should be the sole indication for circumcision or the National Health System, in light of the growth of this subset of the population that demands this procedure on account of cultural or religious reasons, should adapt and include it in the services that it covers.⁸

Some paediatric surgeons advocate for offering religious circumcision in the public system to prevent complications derived from the practice of circumcision under poorer conditions, but should this be a personal decision of the surgeon or a rule established for the collective of surgeons, given that this practice has implications as regards the scope of services offered through the national health system?

On the other hand, should circumcision, which is a mutilating intervention, be deferred until the patient himself can make a choice about it?

All these concerns remain unsolved, calling for reflection and opening up different lines of debate for the future. For this reason, we conducted this study to explore the perspectives and attitudes of the paediatric surgeons that are frequently confronted with this dilemma with the aim of determining which is the best medical practice in this situation. We believe that the ideal situation would be to establish a homogeneous approach by having scientific societies develop a consensus protocol.

Since the response rate was less than 100%, our findings are only representative of 71% of the collective of paediatric surgeons in Spain.

CONCLUSION

The practice of circumcision for religious reasons within the public health system is controversial. In our survey, we found that most health providers did not know whether this practice is included in the scope of services offered, and agreed on the need of establishing a consensus protocol.

CONFLICTS OF INTEREST

The authors have no conflicts of interest to declare in relation to the preparation and publication of this article.

REFERENCES

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2. Aurenque D, Wiesing U. German law on circumcision and its debate: how an ethical and legal issue turned political. Bioethics. 2015;29:203-10.
3. Estudio demográfico de la población musulmana. Explotación estadística del censo de ciudadanos musulmanes en España referido a fecha 31/12/2017. In: Unión de Comunidades Islámicas de España [online] [accessed 10/06/2019]. Available at http://observatorio.hispanomuslim.es/estademograf.pdf
4. Banwari M. Dangerous to mix: culture and politics in a traditional circumcision in South Africa. Afr Health Sci. 2015;15:283-7.
5. Anwer AW, Samad L, Iftikhar S, Baig-Ansari N. Reported male circumcision practices in a muslim-majority setting. Biomed Res Int. 2017;2017:4957348.
6. Halioua B. Le xxie siècle sera religieux ou ne sera pas. Ann Dermatol Venereol. 2013;140:753-4.
7. Informe sobre gestión positiva de la diversidad religiosa en el País Vasco. Diciembre 2015. In: Secretaría General para la Paz y la Convivencia. Dirección de Víctimas y Derechos Humanos [online] [accessed 10/06/2019]. Available at www.pluralismoyconvivencia.es/upload/71/84/INFORME_diversidad_religiosa.pdf
8. Friedman B, Khoury J, Petersiel N, Yahalomi T, Paul M, Neuberger A. Pros and cons of circumcision: an evidence-based overview. Clin Microbiol Infect. 2016;22:768-74.

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