Fatwa Exempts Children, Men With Haemophilia From Circumcision

The 77th Muzakarah Jawatankuasa Fatwa Majlis Kebangsaan exempts children and men with haemophilia from circumcision, citing potential life-threatening complications.

PUTRAJAYA, March 22 – Concerns about the risk of circumcision complications have led experts in both the medical and religious communities to advise against the procedure for individuals with haemophilia or bleeding disorders.

While a 2007 fatwa exempts individuals with haemophilia from circumcision, some patients or parents still feel obligated to undergo the procedure for religious reasons.

Dr Mohamad Salleh Abd Aziz, director of MyMedikal Healthcare Sdn Bhd, recently spoke about an unexpected complication during a circumcision he performed on an eight-year-old boy who had a history of haemophilia – a condition the boy’s parents had not disclosed beforehand.

“The child also showed no signs of bruising or bleeding tendency, so the circumcision proceeded as usual. Immediately after circumcision, there was bleeding in the frenum.

“I managed to secure it with a suture (stitches), but it started bleeding again. So, I sutured it again, two times in total. After that, it was quite secure with no bleeding, and I compressed it with a crepe bandage and gauze. The patient was discharged in good condition.

“However, after one hour, the patient was brought back to the hospital/clinic due to bleeding at the circumcision site, despite compression. There was a lot of bleeding, and we tried to open it up and resuture, but it still failed to stop the bleeding.

“It was like paip air,” said Dr Mohamad Salleh, a consultant general surgeon at Hospital Islam Az-Zahrah in Bangi. “Banyak sangat bleeding. It was very scary.”

Dr Mohamad Salleh was speaking at the Malaysian International Circumcision Conference 2022 (MICC22), organised by MyMedikal Healthcare on February 25 and 26, 2023.

The patient was later referred to Tunku Azizah Hospital for further treatment after Dr Mohamad Salleh’s team suspected it to be a case of haemophilia.

According to the World Federation of Hemophilia (WFH), up to 35 per cent of mild to moderate haemophilia cases are diagnosed during circumcision after bleeding.

Dr Mohamad Salleh cautioned those who perform circumcisions that the more procedures they do, the higher their chances of encountering patients with haemophilia.

“I didn’t think I would encounter one, but I did. If you suspect the patient has a haemophilia history, please don’t do it,” the general surgeon said. “It’s very scary. Refer to paediatric surgery or the haematology team.”

While circumcision is not completely off the table for those with haemophilia, medical professionals urge caution and collaboration between surgeons and haematologists.

Haemophilia is a rare genetic bleeding disorder that affects around one in every 5,000 males worldwide. In Malaysia, the estimated total number of patients of all types of haemophilia in 2018 was 2,075, making the prevalence 3.4 per 100,000 population.

Dr Liana Yusof, a general paediatric at Tunku Azizah Hospital Kuala Lumpur, said haemophilia cases can be identified through further questioning or investigation of the patient’s bleeding history.

Symptoms that may indicate haemophilia include easy or spontaneous bruising, joint swelling, prolonged bleeding after surgery or injury, and severe bruising after vaccination. In addition, doctors can use the ISTH-SSC Bleeding Assessment Tool to determine if a patient has haemophilia.

Apart from the health risks associated with haemophilia, patients must also consider the high costs involved to prepare for circumcision.

Dr Liana said pre-procedure preparation can include putting patients on increased doses of prophylaxis or inhibitors over a period of a few days or a week, depending on the patient’s condition, to create blood clots and stop bleeding.

Proper treatment of haemophilia also involves replacement therapy, which involves replacing the missing or defective clotting factors in the blood. This can be done through intravenous infusion of clotting factor concentrates, which can further add to costs.

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