The law and ethics of medically unnecessary1 genital modification of pre-pubescent children is
increasingly debated (3–8). On the one hand, it is widely internationally accepted that such
modification, brought about by cutting or removing healthy tissue, is both ethically and legally
inappropriate in the case of roughly half of all such children: namely, those whose genitalia at the
time of birth are deemed to fall within normative standards for “binary” female classification (i.e.,
non-intersex2 females), virtually all of whom will be raised as girls. This international proscription
on surgical interference with non-intersex girls’ healthy genitalia applies no matter how slight the
intended cut and even when done in a medicalized fashion, that is, with sterile instruments and
anaesthesia by a skilled practitioner (16–18). In the United Kingdom (UK), the country on which we
focus in this paper, such medically unnecessary genital cutting is, in fact, a criminal offence
irrespective of the individual’s own consent even after the age of 18.3 Moreover, in the case of non-
intersex girls under the age of 18, parental “proxy” consent or permission for such cutting—based on
a sincere assessment of the child’s best interests, including interests related to ethnic identification or
cultural or religious belonging4—is considered to be categorically invalid...

Abstract.

The current legal status and medical ethics of routine or religious penile circumcision of minors is
a matter of ongoing controversy in many countries. We focus on the United Kingdom as an illustrative
example, giving a detailed analysis of the most recent guidance on the subject, from 2019, from the British
Medical Association (BMA). We argue that the guidance paints a confused and conflicting portrait of the law
and ethics of the procedure in the UK context, reflecting deeper, unresolved moral and legal tensions
surrounding child genital cutting practices more generally. Of particular note is a lack of clarity around how
to apply the “best interests” standard—ordinarily associated with time-sensitive proxy decision-making
regarding therapeutic options for a medically unwell but incompetent patient, such as a young child dealing
with disease or disability—to a parental request for a medically unnecessary surgery to be carried out on the
genitalia of a well child. Challenges arise in measuring and assigning weights to intended sociocultural or
religious/spiritual benefits, and even to health-related prophylactic benefits, and in balancing these against
potential physical, functional, and psychosexual risks or harms. Also of concern are apparently inconsistent
safeguarding standards applied to children based on their birth sex categorization or gender of rearing. We
identify and discuss recent trends in British and international medical ethics and law, finding gradual
movement toward a more unified standard for evaluating the permissibility of surgically modifying healthy
children’s genitals before they can meaningfully participate in the decision.

The genital prepuce or foreskin is a shared anatomical feature of both male and female members of
all human and non-human primate species (61). In humans, the penile and clitoral prepuces are
undifferentiated in early fetal development, emerging from an ambisexual genital tubercle that is
capable either of penile or clitoral development regardless of genotype (71). Even at birth – and
thereafter – the clitoral and penile prepuces may remain effectively indistinguishable in people who
have certain intersex traits or differences of sex development (28,72,73). The penile prepuce has a
mean reported surface area of between 30 and 50 square centimeters in adults (74,75) and is the most
sensitive part of the penis, both to light touch stimulation and sensations of warmth (76–78). The
clitoral prepuce, while smaller in absolute terms, is continuous with the sexually-sensitive labia
minora; it is also an important sensory platform in its own right, and one through which the clitoral
glans can be stimulated without direct contact (which can be unpleasant or even painful) (79).
Regardless of a person’s sex, the prepuce is ‘a specialized, junctional mucocutaneous tissue which
marks the boundary between mucosa and skin [similar to] the eyelids, labia minora, anus and lips ...
The unique innervation of the prepuce establishes its function as an erogenous tissue’ (61)(p. 34). It
has been argued that, insofar as one assigns a positive value to the penile or clitoral prepuce, or to the
ability to decide for oneself whether such delicate genital tissue should be cut or removed, its non-
consensual excision necessarily harms the person, to that extent, irrespective of medical risks or
complications