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Thank you. Hello. Hello. Hello. Hello. Hello. Yeah. Yes. Hello. Hello. Hello. Yeah. Hello. Hello. Ok. Hello. Yeah. Ok. Mhm. The hello Q hi doctor. Um you? Ok. Yes, I am good. Um I'm just sharing my screen just to intro um uh the invited guest and immediately after that I will stop sharing so that you can share your screen. Ok. Pro um Del will be sharing her screen for me. Ok. She'll be my, she'll be my mouse. Ok. Ok. Ok. But the two of us, she will, she two of you will coordinate with each other. Huh? Yes. Ok. No problem. Ok. Thank you, Del. Are you set up to help you? Yes, bro, I'm ready. Ok, good. Ok. It, hello, good afternoon. Hi, Doctor. How are you? Good, good. And you? Good. Thank you. Uh Thank you for joining. Uh we'll start in a few minutes perfectly fine. I thought I'd go a bit earlier just to make sure that all the technology works. And yeah, tell me about it. New world we live in. Yeah. And um now we are also learn. Uh so we have had our fair share of difficulties over last few weeks. But, uh, yeah, we tried to adjust. Yeah, absolutely. So I'll just get it and then, um, I'll wait, I'll wait for you to, to tell me when. Yes. Um, as, as I wrote to you in my email, the format will be, I will intro you with, uh, with the bio sketch which you sent to me. Then I will invite Doctor Sally to, uh, to talk, which will be about 25 maximum, 30 minutes. After that, I will invite you to give your comments um on the topic which is quite, yeah, um quite an interesting topic to say. And uh yeah, after your comments, then I'll ask one by one, my other three consultant colleagues to comment and if then audience people have any questions, then we will answer that. So hopefully we shouldn't be longer than 1.5 hour, one hour, 20 minutes. Ok, perfect. Tell me, where are you best? Are you in Cape Town? Where are you Pretoria? Are you in Pretoria? Yes. Ok. Yeah. Ok. I mean, uh do, do you have a law practice in Pretoria as such? No, I'm the head of uh delivery services for M psi. So um that is my current role. Um But yes, I've been, I've been in uh in the medical legal field for many years. Yes. Yes, I saw, I saw that and it's very interesting I will control. So uh that uh you have worked in uh medical legal field in different spheres of our society. It's a very, very interesting journey. Indeed. You name it and you were there? Nursing Military Medical Association, MPA Ethical. So, I don't think there's any field of medical, legal significance. You have not been to, it will be interesting to, to actually assess that. Um, but yeah, I think I've seen it from all sides. That's right. Yeah, that's right. Yes. And, um, I mean, it was, it was uh it was good to know you uh from, from this meeting. And um yeah, we uh we have adjusted uh to the new normal and uh we are conducting our weekly academic meetings on Zoom and uh then slowly uh it so happened that we have started one expert invited guest for each meeting. And uh that's actually a blessing in disguise because now who could have imagined last year or beginning of this year that I would be inviting you and you would be participating in our academic meeting. Yeah, absolutely. Yes. No, thank you for inviting me. No, no, no problem. No, it's our, it's our pleasure. So I'm just waiting for a few more people to join in. Um It's two past five another minute or so and then we will start good. So uh Tony Bahman and you do you work um sort of together or you in the different departments? Um we work together but we are in different departments. So the delivery services um team is a new team that's in the process of being established. Um, in South Africa for mps, for MPS members. Yes. And then Tony is on, we're working with Gran Craig, um, on the, on the other part of the MPS business. Yes. So, in that respect, we are working together. Yes. Yes. Um, I think we can start, uh, Yoba and can we start now? Yeah. Show that. Yes. Yes. Let's start. It's now three past five and, uh, Miss is also here. So, so we'll start. Um, ok, good afternoon everyone. Um, it gives me a great pleasure to, uh, to welcome you all and also our special guest today, uh M Betel who has lots of credentials to her credit. And, um, I'm just going to quickly read through her bio sketch which uh she sent to me today. Sorry. Um Sorry. No. And she has vast legal background for almost three decades and she has worked in the medical legal field in various fears of our medical and nursing uh, fraternity in the country. Like, as you can see, she was part of the nursing council, then part of the Army state law adviser, also, um, uh, advisor to the Medical Association and currently working in the legal Department of the Medical Protection Society. So we couldn't have asked for a better, um, invited guest for our, uh, talk today which will be delivered by Doctor Corita si. And it is on a very common topic. But uh has very important legal and ethical considerations. It's the issue of circumcision in Children. So I welcome you Randi and I invite Doctor Sally to, to talk. I'll just stop sharing my screen in a second. Thank you. Ok. Ok. Q you can share your screen, please. Ok, good afternoon, everybody. Um As prof mentioned, the talk today will be on circumcision in Children within the context of South Africa. Next slide things me circumcision um is the surgical removal of the foreskin as we know it is the most common surgical procedure performed worldwide. And having said that there's a huge gap in ethical awareness surrounding this procedure. Hence the decision for the topic of today's talk, we are going to have a look at the Children's Act and we are going to define the requirements for cultural and religious circumcisions. We will also have a look at absolute and relative medical indications for this procedure. We will discuss the points for and against male circumcision as well as ethical considerations. And then lastly, we will review some takehome points on the topic neck. So with regards to the children's Act, um the minimum age for consent for treatment is 12 years of age for minor to consent to medical treatment. They require the maturity to understand the benefits, risks, social and other implications. And for surgical procedures, the minor needs to be assisted by his or her guardian or parent neck, slightness, minors who are 12 years of age and who are parents themselves may also consent to medical examinations and treatment for their child. They may also consent to surgical procedures for their child again with the assistance of the parent or guardian. Next like this, it is vital that when getting consent, one takes into consideration the maturity and intellectual capacity of the child. One also needs to consider the beliefs, wishes and opinions of the parents or caregiver and the clinical circumstances as well. Considering all of these parameters may be quite conflictual. However, as healthcare providers looking after minors, we need to bear in mind that the child's interests are of paramount importance neck sls. Um So with regards to social and cultural circumcisions, uh male circumcisions are allowed provided that you have proof that the child is at least 16 years old and form two from HBC say being signed. So on the following slide, there is an example of form two. Um part one, I'm not sure if you guys can see. So I'll just quickly go through it. Part A of form two. has all the personal particulars of the child. Part B has the details of the medical practitioner or the person administering the circumcision and at the bottom of that page, um it also has tick boxes that basically it shows or indicates that you have explained to the child the following the nature of the circumcision, the different methods on how to perform the circumcision the method that you will follow any risks associated with the circumcision, any complications associated and also any other implications or possible consequences. And then you also need to allow the child the opportunity to ask any questions on the second part of that form part C um That is the consent that the child signs saying that um all of the above that I've just mentioned has been clarified with the child. And then lastly at the bottom part D um is signed by whoever the parent or guardian is, who is assisting the child in making the decision. Next slide, please. So with regards to religious circumcisions, again, male circumcisions under the, under this time, under the age of 16 is prohibited unless it is for medical reasons. Um It also conforms to prescribe religious practice. It also needs to conform to prescribe religious practice and for religious circumcisions form three needs to be signed. So we'll go to the next slide and just have a look at form three. Again, part A contains the particulars of the child. Part B contains the information from the medical practitioner or person administering the circumcision and again has tick boxes at the bottom ensuring that you have explained the following to the person consenting for the procedure. This again is the nature of the circumcision. The risks associated, any complications associated and any other implications or possible consequences of the circumcision. Again, there needs to be a platform for whoever is signing the consent to ask any questions for clarification. Part C is the consent by the parent or guardian when the child is under the age of 16 neck like this. So with regard to um absolute circumcisions, one, so sorry, absolute indications for circumcision, one needs to be aware that um there are very few absolute indications for male circumcision. These include the following type fois secondary to balanitis, cirrhotic obliterans, recurrent balanoposthitis, um smeg cysts or trauma that resulted in non retractile scarred foreskin. Next slide please. With regards to relative um indications. One would now consider the prevention of urinary tract infections in boys with urological abnormalities. So it has been reported that there's a 3 to 7 times higher risk of urinary tract infections in uncircumcised boys. The greatest risk here is when they are under the age of one year. This is um very popular indication for circumcision in healthy infants in the US. Um There is difference in the approach as there is for most things across the Atlantic and in Europe, the policy is actually much stricter. Next slide, please. Um Further relative indications are certain urological conditions that benefit from circumcisions. These include recurrent urinary tract infection and high grade vesicoureteric reflux. Next slide please. So points for circumcision include the following um easier hygiene, reduced risk of urinary tract infections. There is also reported reduced, reduced risk of some sexually transmitted infections in men, protect against penile cancer. Next slide please. It is also um it reduces the risk of cervical cancer in female partners prevents balanitis and balanoposthitis and prevents fibrosis and fimosis. Next slight points against circumcision. Um So obviously, it's the pain uh which will you'll be able to pick up on the baby crying, the facial expressions and also the torso rigidity when they the infants, um increased episodes of upset are reported with inadequate analgesia, which is also important to note neck like this. So, if pain and distress are significant enough, it may be classified as trauma. And if this distress lasts for more than one month, the diagnosis then progresses to posttraumatic stress disorder. It has also been noticed that some infants don't cry much at all and remain quiet following the procedure. This has been described as dissociation which is worrisome in its own right. There has also been some suggestion that such severe pain and distress may negatively impact the bond between mom and baby. Ultimately, it has been suggested that a male who has been circumcised um as a child is more likely to react with terror rage or dissociation when confronted with situations interpreted as threatening. Next large circumcision in male infants has been described by some as a neurological castration. Due to the sensory input loss, it reduces sexual gratification and may possibly also lead to sexual dysfunction. Next slide for you onto ethic ethical considerations, many debate as to whether the autonomy of the minor is actually safeguarded as circumcisions are often performed due to the cultural and religious requirements of the parents or guardians and not necessarily that of the infant or child. One can therefore argue that the child cannot effectively give informed consent for the procedure. Again, even though the age of surgical procedures is 12 years old, are we actually taking into account the psychological and not just the chronological age of the child when obtaining consent from them? Another ethical dilemma here is cost. Can South Africa as a developing country actually afford the hospital admissions and clear to time for elective circumcisions, let alone the complications and prolonged hospital stay. Should a complication then occur. Next slide please. Another interesting consideration is how female and male circumcisions are viewed. One can argue that the law may be sexist by protecting girls and not boys as female circumcision is by no means allowed under any circumstances. And so we pose the question. Can one justify circumcision for any reason other than absolute medical indication as the topic of circumcision is an ever evolving ethical dilemma. We as healthcare providers are required to keep our finger on the pulse. Of importance is the counseling for all parties involved, the parents, the caregivers and also the child. In addition, we need proper documentation prior to the procedure to protect ourselves from unforeseen legal challenges. And lastly, we need to remember and take into consideration what is best for the child at all times. Thank you kita. That was an excellent presentation, very short and to the point and you have raised those pertinent questions for which we are looking for answers. And um I will invite now Ml Burs to give her thoughts about legal things, legal issues, ethical issues as related to circumcision in Children in our country today. Thank you, Flo is yours? Thank you very much. That was, um that was very uh really a very good presentation. I was um before the presentation, I was actually very interested to see if you pick up on um the points that that is usually problematic in in circumcision. I think maybe just to um set the scene. I'm just gonna share some slides that now I do apologize. They are, they are, I tried to get them in the right mps format, but unfortunately, II came up with a hybrid type of slide that um so it's apologies for that. So I'm just gonna share my screen and just take you through um some aspects that I want to highlight that you have touched on. But I do think that we um maybe need to discuss in a, in a wider context uh when it comes to ethical and legal considerations. So let me just find the right um stream. Yes, apologies. My OK. OK. Let me just try and see if I can go into presentation mode. Um Actually, OK, it, it doesn't matter. I think it will, it will be fine the way, the way that we do it now. So the first thing that I want to point out is that it's, it's, it's, it was very good to start, you know, to look at the children's act. But one must always remember that um the constitution is actually where most of the rights that we see and that we uh address in, in any medical legal um dilemma actually stems from the constitution. So the Bill of Rights is usually the starting point. The starting point because that is the the document that informs all the rights in the bill of rights are what informs um like for example, the Children's Act P Poppy, um the National Health Act, et cetera. So, so they are all what we call constitutional laws or constitutional legislation because they are the result of rights that have been um included in the Bill of Rights. Now, I've listed a number of rights there. The first one is um section 12 which deals with the right to bodily and psychological integrity. That is typically the human right that underpins um informed consent. So it links up with both a constitutional right, a legal right, as well as an ethical right. Um when it, when it comes to interventions or medical interventions, we also another right that is relevant for, for the topic under discussion is um section 15 which relates to the freedom of religion, belief and opinion. Very importantly, section 27 which deals with the right of access to healthcare and it especially you will all be familiar with the right of um emergency healthcare and section 27 3, which says that in an emergency, you may not refuse medical um treatment. Then probably the most important one which is the right um to the the of protection of Children, the rights of Children in terms of section 28. And that is the right on which the Children's Act is founded. Um So the Children's Act gives effect to the rights of Children in terms of section 28. So I'll, I'll, I'll um address that in a little while also the right to language and culture in terms of sections that we and then sections that we want cultural, cultural, religious and linguistic communities, the right to protection of those. So you can see that from a constitutional perspective, you often have more than one right, or several rights that can apply. And very often it can happen that these rights are actually conflicting and that makes it even more difficult to um to make it, you know, to decide when it comes to justification and whether interventions are, are justified um in particular circumstances because there could be more than one right that you need to consider for. Now. Um I'm gonna focus on section 28 which is the rights of Children. And in terms of section 28 Children have the right to basic healthcare services um and uh and must be protected from maltreatment, neglect, abuse or Degra uh degradation. What I want to emphasize here and this is in future. And I always say this when I do CPD talks or when I do, um if I write an article or anything like that around Children is this is the most important right to know when it comes to Children. So whether it relates to circumcision or whether it's any other treatment involving a child. Section 28 2 of the constitution says, and our constitutional court has confirmed this on numerous times in various judgments that a child's best interest are of paramount importance in every matter concerning the child. So that is the mantra that I that I install on healthcare practitioners that at all times it is the best interest um in that matter. And, and you did touch on, you did bring that out in, in the presentation, but it's not always clear as to in a particular situation, what is actually what is the best interests of a child mean? Um And I will, I think that's a, that's an aspect we can discuss um a bit later perhaps. So in respect of the Children's Act, as I, as I mentioned, section 28 is the Bill of Rights and the Children, the Children's Act gives effect to section 28 of the Bill of Rights. So that, that is the, the law that explains and sets out what the constitution means with best interest of the child. Now, there's another thing that I aspect that I want to highlight and point out because II I've realized over the years that very often healthcare practitioners do not know that there are actually two effective dates for the Children's Act. And the f the first date is the first of July um 2007 when the first part of the act came into being. And then the first of April um 2010 when the second part of or the ba the remaining part of the act came into operation. And that was when the regulations were finalized. Now, that is important because um in our courts have decided that an act without regulations is actually uh you know, it's, it's almost impossible to enforce. And that is why it's important to note that most of the provisions are, are actually came into effect or um from the first of April 2010, I just wanna explain. And this, this is an aspect that you would have seen from the forms that you, that you um went through is that it's very important to understand that there are always three elements to informed consent. So information um or knowledge, capacity, or appreciation of uh the child or the, or the patient or the user in terms of the National Health Act. And then also the acquiescence or the voluntariness or the agreeing of the procedure. So, those are are very important to, to consider when it comes to treatment, the treatment of any child. Now, you correctly pointed out that section 129 deals with consent to medical treatment and consent to surgical uh procedures and what the requirements are in respect of age and capacity and maturity. Um The important thing here is that with surgical procedures, the the child must be as oops sorry about that must be assisted by a parent or a guardian. Hence, the forms that you um refer to requires um that assistance. What I do want to correct um In, in your presentation is that the forms are not HBC SA forms, they are actually the prescribed forms in terms of the regulations. Um As I said to you, the regulations that were finalized on the first of April 2010 and there are other forms that actually needs to be taken into or take a note of as well. Um Form 34 and 35 deals with uh medical treatment and surgical procedures and particularly when it's minors under the age of 12 or when it's child parents with minors and they themselves are Children. I'm not gonna go into that. Um There's also forms for virility testing and then correctly the forms for circumcision that you um that you discussed the, the key to circumcision that is often a um a debate or leads to a debate is the age of consent because while section 100 and 29 of the children's act says there's the age of 12. Um The for circumcision, the Act actually prescribes that the age of consent is 16. So this is a very important distinction to take note of because in terms of the children's act, circumcision of boys below the age of 16 is prohibited except when these conditions are, are met. And that is the incision is performed for religious purposes in accordance with the practice of that religion or it's for medical reasons on the recommendation of a medical practitioner. So, unless those two requirements are met, you circumcision is, is actually not allowed by law the requirements. I'm not gonna go through everything all of what's written there. Um There are specific requirements in terms of the children's act as to who can actually conduct circumcisions on, on uh boy Children. And what I, what I need to point out at the bottom there is the last bullet point is that the, the the child can actually refuse the circumcision, taking into consideration the age maturity and the state of development. And that links up with what the requirements are that we see in section 100 and 29 of the act, the general, the general um consent requirements, if I can put it that way. So what we need to uh you correctly pointed out that there are two forms specifically dealing with the consent to social cultural circumcision in terms of form two or religious circumcision, in terms of form three, um when boys are over the age of 16, these are the requirements, it may only be performed if the child has given consent in the prescribed manner. And that is now in terms of the forms that I that I that you uh mentioned or that you uh described forms two and forms three. So form three when they are um over the age of 16, after proper counseling and again, in the prescribed manner, as prescribed by the regulations, the following requirements must be met if the boy is older than, than 16 years. Is that um the parents or the guardian must assist the child? So that is similar to what we see in section 100 and 29. Um and the boy's age must be verified. So you've touched on all the important aspects um in respect of the children's act, I think what often I'm gonna stop sharing my screen now because that was basically what I wanted to capture. The important thing that we often see or aspect is when we have conflict between the law. Um the, the ethics, you know, is it ethically correct? And is it constitutionally um sound in terms of the, the bill of rights? So I'll, I'll leave the topic there for, for some discussion or some views as to how you, how you see it when you are confronted with these conflicts between law and ethics. Thank you very, very much for, for that uh legal background um To us, um I will just mention um a couple of important practical uh scenarios we face with um for medically indicated circumcision. Uh There is no issue at all. It's the local colored community. It's a culture to get their boys circumcised. So that's number one because father is circumcised. Big brother is circumcised. The boy needs to be circumcised into inverted comma. That's number one. Yeah. And I'm sure you are well aware of the, is it sa uh culture of circumcision beyond 16. But with the known morbidity and even mortality of traditional circumcision, some parents including grandparents are bringing their young almost toddler boys to our hospital services for circumcision to prevent um mortality or morbidity in future. And, and we are in ethical dilemma um for both of these situations, are we doing the right thing? Um Are we protecting the interest of the child? Are we legally correct? So I think that's where this discussion keeps coming back time and again. So, so I don't know whether you want to comment now and then I'll invite my other consultant colleagues to, to come in. Yes, you're absolutely correct. And that is a question that I've on numerous times over the years have been asked to comment on, you know, what do we do? Um as um healthcare practitioners, as doctors when parents bring in um a a young child that's that they want to, that they want you to do or they request a circumcision because they don't necessarily want to risk the child going to a traditional um you know, to, to, to um for initiation to, to be done um by the traditional um healers. Um And that becomes very problematic. The reason being is that what constitutes the best interest of the child? Because do you then consider, well, how are you going to say? Well, if, if, because that is often the question that doctors battle with is, well, if I don't do it, they go, they go off to initiation school and something goes wrong. Is it on me or do I have the duty to even though it's not medically specific that in order or um rather do it now? And I would like to get the views of um some of the other colleagues as to what they think and now they suggest that ethical then it might be addressed. Yes, thank you. Just one last comment. Uh We also faced with the, the same problem. Uh We are the only service provider for more than 85% of the population in the central one third region of the Eastern Cape province. So, and we have the capacity to do circumcision safely in the two hospitals where we work. And if we don't offer this service, then as you said, um they might go to traditional surgeons later. They will the CSA. But the boys from the colored community, where will they go? They may either go to a general practitioner who may or may not have the necessary skills and may try and do it in an unsafe manner in his or her own surgery again, where the wellbeing of the child may be at risk. And uh the private health care is exorbitantly prohibitively expensive. So people who are not on medical aid, my last understanding say last year it would have costed more than 30,000 rand for a little boy to get circumcision in the local private hospital. So those are the problems we face with. I think maybe if I can get some comments from some other consultants. Yes. Um Yeah, I it is high time for me to invite one after the other consultants. Um So yeah, sure that can you please uh comment and, and uh give, give your advice, please. Ok. Uh Thanks doc. Uh And thank you. Thank you. So just, just give me one second just to introduce you. Uh Doctor Ya Man is our consultant, pediatric surgeon. Uh She originally comes from Durban but has been with us for last three years. Uh So I just invite her to now give her comments, please. Yes, sure that. Ok, thanks, bro. Uh Thanks Lily and thanks Kisha for that very informative talk. I think I learned a lot about the medical legal considerations even having been doing this procedure for a while now. Um, I don't think I have answers for all your questions. Um, I think it is still an ethical dilemma and it's, it's, uh, it's an, uh, a choice that we all have to make on an individual basis with the patient and with the parents. And, uh, I think we've highlighted already how important the consent is, especially in these cases. What I do want to say is that for the cultural and traditional ones or religious rather. Um Yes, I get that it is legal and I still would encourage the parents, which I do um you know, in our clinic to wait till the child is at least six months old because they come with neonates and infants. And in my opinion, um an elective surgery, even a circumcision at that age is too much of a risk under six months of age. So I would still encourage even though it's legal um to wait more than six months to, to do the elective operation, the circumcision. And just to highlight that we choose to do the circumcision with a general anesthetic under a general anesthetic. So, Juanita rightly brought up the issues about analgesia and the model and ethical considerations of doing these um doing these procedures with inadequate analgesia because people assume that neonates and premature neonates can't feel anything whe when because they can't say anything. So, uh I think we have to advocate for them in that um in that setting because uh we should be advocate, advocates for the child and for his wellbeing and she rightly brought up the trauma that is associated with pain at, at that level of pain at that age. So I just wanted to bring up those points for, you know, the religious circumcisions and maybe even more cultural now, like pro you rightly brought up that it's becoming more of a cultural rather than religious request from the parents. Um whether it is ethically correct and whether the child should have more autonomy when they are older, I think we're gonna have to like, like we, we, I mean, like the the rights were brought up and how they can, you know, be on, on other sides of the scale. Um Unfortunately, with these religious um indications, uh sometimes it is better to, to follow that religion, uh the religious indication for the wellbeing of the child. So it is uh difficult. But at the moment, I think medical legally, we should offer the circumcision for religious purposes or cultural purposes and of course medical purposes. Um Yeah, so that's my comment. Th thank you that these are very pertinent and practical points. Uh Shall I invite the other two consultants to make their comments, please? Yes. Uh The next I invite Doctor Sello Mataya. Doctor Mataya is our homegrown consultant. He uh completed his full training of pediatric surgery in East London from 2015 onwards and he has been consultant in our department of pediatric surgery um, for over almost a year. Uh, so sell, please give your comments. Uh, hi. Thanks for the wonderful introduction. Um, and thank you for keeping it nice and short and sweet. Um, I think I II think the issue that we have has to do with, um, deciding, is it religious or customary? Because I might be mistaken, I may not have picked it up thoroughly, but the law says religion and kind of highlights religion and doesn't necessarily consider your customs and your own family belief. And I think it's pertinent prof that you had actually mentioned, like in a colored community, you can't say um it's religious because that's what happens in the family, in the community at large. So in a sense, it would be cultural um reason um as to why they're getting the circumcision. Um So that's, that's always a dilemma because everyone always looks only at religion and doesn't follow uh customs of that specific family. And as much as we try not to do any harm. Um And we definitely, that's not the point of what we're doing. It's to definitely be of benefit to the child and to the family. And the way we're trying to be of benefit um to the child for the family is by offering a circumcision, a child in certain certain situations. If they're not circumcised, they're not considered part of the family, they get ostracized. So it's one of a vicious, vicious cycle where, um, luckily not as much for circumcisions where, um, what I'll give a, it might be, uh, going at a tangent but a child who may need blood, who's a job weakness and should the child receive the blood, the family would kind of cut the child out. So, it's one of those things where it's, you want to help the child, you want to make sure that the child, um, benefits from your treatment and does not actually get repercussions from the family or from the society at large. So everyone in the community has a, is circumcised. We are not intentionally going to harm the child. We're trying to actually follow the wishes and the practices of that community and the family. So hence why we offer circumcision and the law um kind of doesn't say that you can go ahead. It says religiously, yes. So if you're a Jew Muslim, good for you. But if you're a colored um person who might not necessarily be following any religious uh antic um shame, it's good luck for you. So that's, it's, it's unfortunate shame for that. The one nice thing that our anesthetist kind of enforced um for us, which makes it easier for us to delay um offering circumcision unless, unless if, if it's mandatory is they've um kind of pushed us to only doing circumcisions once the child is above two years of age, which um they based based it on the onus that um uh the child's brain is still growing and at two years of age, it's more um safe for a safe anesthetic um for a developing brain. But obviously, there's lots of um research that came out that showed that um that's not true but to keep peace with the anesthetist, we kind of have also adopted um that trend and actually tried to uh prolong um or delay the intervention of doing a, a circumcision um unless we are forced to do it obviously. Um So yeah, that's my feeling about it. I actually find it interesting what he was mentioning about female circumcision, which um I've, I've never been part of it. I've never witnessed one but I know in certain parts of Central Africa, it's one of those, also one of those customary or traditional um things that they do. I'm not sure of what benefit it would be for a female because it's been proven to have quite a lot of benefits during a circumcision in a male. Um as Q highlighted. Um But in a female, I II personally don't know what benefit that would be as much as they say, it might heighten sexual um arousal or so forth. I I'm not sure if it's of benefit. So that on its own is I think it's a discussion. Yes, it's because that's what I'm, I gathered that that's a separate issue. I go c yeah, I just, you know, with the kind of then it is. I just found it interesting and yeah, because I had never even witnessed one. So that's why. Yes. Yeah. But, but I II think um yeah, for, for us, um definitely, we always try to, we always rather not try. We always um go ahead if it's a religious or if there is a proven medical um indication for during your circumcision. And um it's only when um we have circumcisions where there's no actual medical indication for that, um specifically in the colored community where we kind of prolong it after two years of age and um try to accommodate them at that at that time and being in the Eastern Cape and lots of kids having to go to the mountain for traditional circumcision and seeing the adverse effects of um, of uh what unregulated uh circumcisions. We've, we've see, we've actually opted to try and encourage to have as many circumcisions as possible because we're kind of avoiding that because as much as traditionally as well, it's, it's one of those play because traditionally they, they want to go to the mountain, they need to get that done as to prove their manhood. But we know the risks um involved with um going that path versus the hospital, which may also have its own complications. We are not without complications, but it's lots, it's 10 or maybe even more at times, um, cleaner or even safer and we can definitely deal with the complications earlier if um they do occur. So II II still don't know to this day. Um as to what Trump's, what does religion, Trump culture or the law kind of says, OK, you must listen to us and only do uh what we tell you and whatever the family thinks is not necessarily so important because that's kind of what is happening um where certain individuals or certain family members um before even coming to us, they're kind of encouraged to tell us that um the child has recurrent uh infections of the foreskin. And as the child comes into the hospital, the child is healthy, there's no issue we're seeing with the foreskin, but obviously, the family is telling us that the child keeps having these recurrent problems. Um Should we just sit around and wait to see the problem or should we act and try to prevent the problem from happening, which is where you would kind of have a situation where you're doing a circumcision on a healthy child with a relatively um normal penis at that time without any complications. And would we have adverse effects in the future legally? Um of saying we did a circumcision which was unwarranted at that point in time. Yeah, I think I've said enough shame for today. Thanks, Bob. Yes. Sell. Thank you. Uh Thank you for touching various aspects which had not been touched. I just want to make just one comment. I think that sense of belonging uh to a community is extremely critical which Yoda also touched on it. And, and I think that has a lot of significance um not only for the family but for the proper growth of that boy and, and uh identity of that boy when he grows and becomes a man. And uh to me, actually, the law is unfair because it favors as CEO said and also said, two communities that is Muslims and Jews. And um uh what happens for the other communities? Why doesn't the law not respect Kosa culture uh for boys younger than 16 co com co culture of the colored community or any other family where parents say that. No, I was circumcised and I want my boy to be circumcised. So that is the problem. So I think uh ya do you want to make any additional comment? You sure that um uh no pro I think uh I think important for us to just understand the law. Yes, so that we can make a policy for ourselves because II said six months, which is what I tell the parents. Uh for me that's a safer anesthetic but is saying two years. Oh no, that I think those two are different uh indications. Yeah, soda. Uh what you say is also correct for the religious circumcisions. And I also fully agree with you that we should not and we don't entertain religious circumcisions before six months of age. But yeah, so has said it more pertains to the cultural circumcision of the colored community, boys and maybe even the cosa boys who were brought to us early. OK. OK. So, so um do you want to make an because consultant I would like to invite, but you can make a comment? I think that is exactly the dilemma that, that um the law has created and, and you know, II think when the, when the law was written, when the Children's Act was written, um I don't think all the aspects necessarily were considered, that's my personal view because even if we look at the headings of the different forms and forms two and form three, now form two, reads consent to social and cultural circumcision and form three, reads consent to religious circumcision. So that in itself is already confusing um in just in, in the the headings of, of the forms themselves. So what has happened and what I know other um practitioners do is that they, they, they basically apply the form um be it social, be it cultural, be it religious. So, so they, they actually go a bit beyond the, the strict boundary of the law um to still comply with the requirements of the law if that, if that makes sense to rather have a proper consent form and make sure that the, the process was followed um than, than saying, well, there's a gap. Um So I'm just gonna leave it or I'm, I'm, I'm not going to um to, to, to, you know, I'm strictly going to follow the letter of the law because I think this is a typical situation where the letter of the law is not clear. Um And you have conflicting, you have conflicting situations. Um The one thing that I want to emphasize because one, you know, I was listening with interest with the six, the six months versus the two years. And the one aspect that I think is very critical to this discussion is evidence based medicine. So evidence based, what is the best at the time for the child, for that particular child in that particular situation? And I'm, I mean, you, I'm, I'm you will, you are the experts, you, you know what that will mean. Um But the important thing is just to say, well, you know, if it's if and, and I like the idea of the guidelines because we often find that where there is this gap um between law and ethics. Um And we don't, we don't really have clear guideline or clear direction from the law is that the best way to actually deal with it is to develop guidelines on institutional level or um practice level. And to say, well, this is, this is how we approach it. This is the criteria that um we apply. Um This is the reason, these are the reasons for the criteria because that forms part of the consent process in any event So when you have that discussion in the counseling session with patients, then at least you have objective criteria that you can rely on to inform your decision. And because what we, what I tend in the past to see is, is, and I II no particular practice we happened in, in Lipo where the parents um would go to say one GP and that, that GP would refuse the circumcision and then they will just go to the next door GP until they find somebody who actually does it. And that is, that's the other risk that we have is that, you know, if they, if they are adamant, if parents are adamant that they wanted to get it done, they will get it done. It doesn't make, you know, it doesn't make, you know, it doesn't, they, they're not too, you know, it doesn't matter who does it because at the end of the day that is, um, that's what they want. And I think, I think that is where the advocate, you know, the, the, the advocating for the child is so important. Um I'm not sure and I'd be interested to know how often have you experienced in practice where you've been able to convince parents not to have a circumcision or not to get the child circumcised where they, you are able to talk them out of it. I mean, just out of interest. How often do you encounter that? Um, if I can answer that. Uh I don't think I personally have tried to uh um uh reason out any parent from getting circumcision done. Obviously, there are medical contraindications for circumcision and we don't do circumcision in certain uh congenital abnormalities. So that is clear, but um II can invite other consultants. Uh Doctor Yoda. Doctor Sello or Professor Lazarus is also here if the, when I request him to comment, whether they have managed to um to, to sort of get AAA group of parents, uh to accept, uh, to convince them not to get uh, their child circumcised. Uh Yes. Uh So, uh uh in my experience, II haven't convinced them not to, to get the circumcision, but I've convinced them to wait um, until it was a safer, uh, safer operation in a bigger child. So that I've had very, I've, I've had a lot of success convincing them that of that, even though, you know, they're religious um beliefs is that it should be done as early as possible. Um We, we still manage to convince them that it is safer than later. Uh, but I haven't convinced him now. No, no, th thank you, soda. And, uh, if I can just sort of um, highlight or clarify, uh with respect to the adult urologist, um I know for certain in town, uh, very senior urologist, I think they still tend to do circumcision in newborns. And I knew of some gynecologist who used to do them. Um, a as soon after birth as possible. Uh They do it in the emergency unit under local anesthesia, which is completely no, no for us pediatric surgeons. And um next, when I invite Professor Lazarus, he can comment. But it is my understanding even though I don't have facts. A almost like the association of pediatric surgeons of South Africa have decided that it is not um not safe to do circumcision immediately after birth. But Professor Lazarus can correct me if I'm wrong, at least in my personal practice. Uh as Doctor Yoda said, I get plenty of request at least once every month, uh mainly from Muslim community that they want their little boy to be circumcised within seven days after uh birth. And I give them the exactly same advice as doctor said, at least wait until six months of age when it is safer to do an anesthetic. So I will now invite Professor Colin Lazarus uh to give his thoughts. Um just a very brief intro because his intro can be very long. He is one of the most senior pediatric surgeons in the country, not only in town and he was our ex boss and mentor to most of us. And um he's involved in academics and college of Medicine and association activities, et cetera. So Colin, please give your thoughts. Excellent. All right. For the introduction, I just wanna say that by way of introduction, I couldn't have been in a more contrasting environment than this discussion with the excellent contributions from Q and Ulundi your introduction. So your shower, I mean, I mean that quite seriously because about six years ago, I think it was, I chaired the meeting at the Sharps conference that's our pediatric Surgical Society. Um an hour was given to the discussion uh which is exceptional for any conference. And I can only say that it was filled with acrimony, the folk who are present from the pediatric Association and the Pediatric Surgical Association came from their own points of view and they expressed them vigorously and somewhat emotionally. And in fact, there was only heat and no light which I'd hoped would come at the end of the of the wait. So this con this discussion now with this introduction uh has been so uh different. I don't think I have a lot to add to all that has been said. The thing is that with regard to our local community. Um It's, it's so evident that the medical indications which we have and which you had given us of one of the inverted commas absolute indications being recurrent balanoposthitis. Well, it's very, very difficult not to make that a very gray area. OK. So inevitably with a little bit of urine under the foreskin, there will be itchiness and irritability and that can be produced at one end of the spectrum. And of course, there can be severe fibrosis at the other end. So it's not difficult for an indication to be found. Mm But as I at the nature of the community which has outlined that which we serve, it seems to me to be a cultural requirement, a com a requirement of the community. And I think that unless you are within that community, it's very difficult to seek to change the community's view on whether this is appropriate or not appropriate because as man is indicated, it's about that sense of belonging to a community. And um that's certainly not one of the indications that the law has given us. So it pro it continues to be a difficult ethical dilemma, particularly if as Lindi, you indicated some of the indications given to us and some of the ethical things uh given to us by the HPCS A, et cetera. Don't altogether make sense. I don't think I've added much to the conversation except to say it's not clear and I appreciate being part of this one today. Thank you. Thank you very much, Colin, thank you. Um uh I think uh I would request you to summarize, but I'll also ask her registers to ask questions, but just one thing uh Q we call her QA and I were, we were surprised that none of us was aware of form two and form three. I mean, do Lazarus and I have been working here together uh more than 25 years and all these consultants they add on to the expertise and the medical officers and registrars, but none of us so far, uh, because we probably didn't look, uh, and we didn't know where to look for. So our eyes didn't see what our minds didn't know, but Q actually found those. And as you correctly advised now we will have a discussion and um, somebody will be given the responsibility to formulate a policy for the department of pediatric surgery and it may be revised from time to time. So we will have a document to refer to um if it needs to be to be referred to. So, so uh please make some comments and then I'll invite our registers or medical officers if they have any questions. Um No, absolutely. Um You know, I often find even with forms 34 and 35 which is, which is consent to surgical procedures by minors and minor parents with, with minor Children. They a lot, there are very few um practitioners that actually are aware of these uh pre and they are prescribed. So they are, they are required by law um in terms of the Children's act. So it, it was definitely very, very well picked up um by, by Doctor Sally to, to uh to find that because I mean, if we say it's 10 years after they came, the, the regulations came into operation. Um and um there are still, there are still many prac practices or practitioners that are, that are not aware of the forms. So I do think though that the forms is, is a, a very useful guide, but it needs to be um supported by proper guidelines. Um And I do think that the policy is, is a very, is a very right way to do. And because the one thing that because it's such a gray area, the one and I, and I think that that is extremely important is the recording of the justification for whatever the decision is that is being made. So if the decision is being made to, for instance, postpone or to wait, um that proper, proper records are kept um in those instances or later, when a decision is made to do a circumcision where it's not really, you know, you're not comfortable that it's medically indicated, but it um as you said, the sense of belonging, which is actually also right in terms of the bill of rights itself that where you can actually, if ever asked in future, justify why at that particular time, you, you made that decision to either do the circumcision or postpone the circumcision um for that particular child. Um And I think that is that is the most important thing to, I almost want to say that is it take away from a discussion like this is so what, how does, how, how would, how will you implement this in practice? Because ultimately, you know, it is around the best interest of the child. Um It is weighing up risk versus benefit, um you know, doing harm versus not causing any harm and what that harm can mean not only physical harm, emotional harm, you know, pressure from society or acceptance in society. Um Do you, do you just a question for my own interest? Uh Do you ever involve cultural or societal leaders, community leaders in um you know, when, when you are dealing with a community issue like this, for example, do you think there would be any benefit of involving community leaders in saying, well, you know, as a as a community, when, when you are approached by the community, what, what sort of advice or assistance can the community leaders in that particular community? Give? Uh No, only we have never thought about that. I think um I will have to discuss it with my consultant colleagues and we will also take uh input and, and opinion from Professor Lazarus. And uh then, then we will proceed further because we'll just have to trade very carefully. Um uh Once uh we start inviting nonmedical people uh to participate in medical decision making. Uh then, then we have to now because we are all employees of the state, then we have to not only take permission from our own clinical director, chief superintendent. Uh It comes to the provincial department and all then then it starts the the ball snowballing. And yeah, I know, I know, I know because we ask for one document. And then we may not get a reply for next five years. So I think we will consider it amongst consultants and, and see maybe we can just tap the community leaders without officially inviting them or have some, some informal conversations and, and then see how we go about it. But that's a good suggestion. We'll have to just take it very carefully. Um I will just invite uh Neha or one of our registers. Anybody can just raise a hand and make a comment or ask questions. One delay. I see anyone. Ok, I see a couple of uh visitors from other departments. There is little time if you want to ask any questions. Otherwise I'm just going to conclude this excellent meeting. No hands up. Ok. So without keeping you waiting, I really, really want to thank you for the time and the advice and q excellent presentation. Thank you very much. It was really nice and I said short, so we could have enough discussion, but you stirred the pot very nicely and brought out pertinent questions and thank you very much and uh we will remember to call you next time. We have an ethical topic. Absolutely. And thank you for the invitation. Sorry that I couldn't provide you an answer. But II think it, it's so providing no. But see, in ethics, I don't think there is right or wrong. And uh I think that was the part of the discussion. My last request to you is uh do you think I can share your powerpoint presentation with my colleagues and the attendees? Ok. I will just get it in the correct MP. If that that's email it to you. No problem. Thank you very much. Thank you. Ok. Thank you, everyone. Have a good evening and wonderful to have you all and for, for the participation. Thank you, Lundy. Thanks. Thanks everybody. Have a good evening. Ok. Bye bye bye. Thank you, Meland. Bye-bye.