Circumcision for teenagers: medical reasons, consent and NHS access

Foreskin development is gradual. The NHS says most boys' foreskins do not pull back before the age of 5, and sometimes it is not possible until they are 10 or older. A Sheffield children's emergency guideline says that phimosis continuing into adolescence will normally be managed in general practice with mild steroid creams, or later in the outpatient surgical clinic.

By the teenage years, a foreskin that still will not retract, or that has become tight after infection or skin disease, may cause problems with cleaning, pain, or difficulty with erections. The NHS lists painful erections, pain or a weak flow when peeing, blood in the urine, frequent urinary tract infections, swelling and tenderness, and bleeding or discharge among the symptoms that make a tight foreskin a problem rather than a normal finding.

Other medical reasons given in the sources include recurrent balanitis, recurrent paraphimosis, scarring from conditions such as lichen sclerosus or BXO, and abnormalities of the penis. BMA guidance lists phimosis (typically due to severe scarring of the opening or BXO), recurrent paraphimosis, recurrent balanitis and prevention of serious urinary infection (urosepsis) in people with underlying structural urinary tract abnormalities as clinical indications, and notes that normal anatomical characteristics of the infant foreskin have in the past been misinterpreted as abnormal.

The NHS lists steroid creams or gels to soften the foreskin, antibiotics if infected, and surgery. BAUS names topical creams and washes, a dorsal slit, frenuloplasty and preputioplasty as alternatives to circumcision, and says circumcision is usually necessary if topical agents fail.

For teenagers, creams and gentle hygiene are generally tried first. A GP referral guide from Coventry and Rugby says medical treatment is effective for more than half of patients and that phimosis may recur, and warns patients about paraphimosis. A teenager who has had a stuck foreskin even once should know that is an emergency, as the NHS instructs people to call 999 or go to A&E.

It is reasonable to ask a surgeon why a foreskin-preserving option is or is not suitable. BAUS notes the cosmetic appearance after dorsal slit is not as good as after circumcision and that circumcision may be needed later, so those are points to weigh.

BMA guidance, written for doctors, explains that consent may come from a competent child or young person, or, when the child lacks competence, from all parents with parental responsibility. It says a competent child may decide for himself, and that doctors assessing competence should be aware that parents can exert great influence on a child's view, so the decision has to be the young person's own independent choice.

The same guidance says it can envisage no situation in which it is ethically acceptable to circumcise a child or young person who refuses, irrespective of the parents' wishes. It also says that 16- and 17-year-olds are usually presumed competent. For a medically needed circumcision this means the young person should be given clear, age-appropriate information and the chance to ask questions, and parents should expect the surgeon to ask the young person what they want.

This section describes professional guidance, not legal advice. If parents disagree with each other or with the young person, the surgical team can explain what the guidance says in that situation.

The first step is a GP. The ICB male circumcision policy page lists the circumstances in which circumcision is funded: pathological phimosis, three documented episodes of balanoposthitis, preventing urinary tract infection in a patient with an abnormal urinary tract, recurrent paraphimosis, trauma such as a zip injury, a tight foreskin causing pain on arousal or interfering with sexual function, and abnormalities from birth.

The same page says the ICB does not commission male circumcision for cultural, social and religious reasons, and that a clinician can support an individual funding request where there is exceptional clinical need. The page uses the older term CCG in places, so check the current wording. BMA guidance adds that non-therapeutic circumcision is sometimes but rarely done on the NHS, and notes that just under 10,000 males under 18 had circumcision on the NHS in England in 2016 to 2017, without recorded indications.

Families who want a non-medical circumcision, for example for religious reasons, are in a different position from those with a medical need. The BMA says it takes no position on acceptability and asks that those authorising it for children demonstrate it is in the child's best interests; it also urges parents to make sure that whoever performs it has relevant training and proven experience and competence, and says doctors who perform it are expected to be registered with the CQC in England.

The NHS says circumcision is usually done in hospital, home the same day, usually under general anaesthetic but sometimes local anaesthetic or an epidural. The surgeon makes a circular cut just below the head of the penis, removes the foreskin and attaches the skin with dissolvable stitches that should dissolve after 2 to 6 weeks. It takes about 30 minutes and is the same for adults and children.

Recovery, from the NHS: healing takes 4 to 6 weeks, swelling, bruising and some minor bleeding for 1 to 2 weeks are normal, the head of the penis will be very sensitive, and tightness or discomfort with erections usually goes away within a few months. Keep children off school for a week, do not give aspirin to children under 16, avoid swimming, cycling, sport and heavy lifting for at least 2 weeks, and avoid sex or masturbation for at least 4 weeks or until healed.

BAUS lists swelling of the penis lasting up to 7 to 14 days in all patients, increased sensitivity of the glans for up to two weeks, permanent altered or reduced sensation in almost all patients, infection in 1 to 2% and bleeding needing a further procedure in 1 to 2%. The NHS adds that circumcision usually leads to loss of sensitivity of the head of the penis, which may be noticeable during sex, but should not have a major effect on sex life in the long term.

This guide does not recommend any provider and gives no prices. For a young person, useful questions include whether the surgeon regularly operates on under-18s, whether the provider is registered with the CQC and the surgeon with the GMC, what consent process is used for the young person and for parents, which anaesthetic is planned, what the written quote covers if a complication needs further treatment, and who to contact out of hours.

The NHS says to always call 111 for a child under 5 after circumcision, to ask for an urgent GP appointment or NHS 111 help for bleeding that does not stop, fever, a red or warm wound, very painful penis or blood in the pee, and to call 999 or go to A&E if the young person cannot pee at all.