Non-therapeutic Male Circumcision: the “Competent Non‑Medical Circumciser” Safety Standard and Totality in Sentencing

1. Introduction

Alazawi v R [2026] EWCA Crim 947 is a significant Court of Appeal (Criminal Division) decision addressing when non-therapeutic male circumcision—lawful in principle even when performed by a non-medically qualified person—crosses the boundary into criminal assault, and how sentencing should reflect overlapping criminality (fraud, wounding, and medicines offences) without double-counting.

The appellant, a mobile circumciser serving largely Muslim families, performed circumcisions on babies and young children at home using a Plastibell technique and injected local anaesthetic. He was not medically qualified. The case engaged reporting restrictions under s.45 Youth Justice and Criminal Evidence Act 1999 protecting the identities of children.

The prosecution advanced two “routes” to liability for s.18 offences (wounding with intent): (i) Route one—parental consent was vitiated by fraud (misrepresenting he was a doctor/surgeon); and (ii) Route two—even if consent existed, the procedure was carried out so unsafely that it became an unlawful assault. The appeal also raised whether injecting anaesthetic was a separate assault and whether medical expert evidence was appropriately used to judge home-based non-medical circumcisions.

2. Summary of the Judgment

• Conviction appeal: Leave granted but dismissed. The Court held Route two liability exists in principle, criticised the jury direction for lacking a clear non-medical benchmark, and doubted the fairness of relying on hospital-based medical standards to assess a home, non-medical procedure. However, the convictions were safe because the appellant’s injection of local anaesthetic (unlawfully administered by an unqualified person) was sufficiently far outside what a competent non-medical circumciser would do that a jury would inevitably convict under a properly framed Route two test. Route one convictions were also safe.
• Procedure as a single act: The Court upheld the trial judge’s ruling that injection of anaesthetic formed part of a single continuing circumcision procedure, not a separate assault.
• Sentence appeal: Allowed. Total sentence reduced from 9 years to 6 years due to double-counting and excessive aggregation by consecutive terms for fraud and medicines offences that substantially overlapped with the s.18 offending.

3. Analysis

3.1 Precedents Cited and Their Role

Reg. v Coney (1866) 10 Cox CC 371

This early authority anchors the public policy limitation on consent: even if participants “consent”, activity that is dangerous in a way contrary to the public interest may remain criminal. The judgment in Alazawi uses Coney as part of the historical lineage for distinguishing lawful consensual harm (sports) from unlawful violence (prize-fighting).

Attorney General's Reference (No 6 of 1980) [1981] 715

The Court relied on Lord Lane’s formulation that it is not in the public interest for people to cause actual bodily harm “for no good reason”, while recognising “accepted” exceptions such as “properly conducted games and sports”, “reasonable surgical interference”, and “dangerous exhibitions”. In Alazawi, that structure (general rule + limited exceptions) frames the problem: ritual circumcision is an established exception, but what counts as “properly conducted” when the practice is largely unregulated?

R v. Brown [1994] 1 AC 212

Brown is the leading modern statement on consent and bodily harm. The Court in Alazawi extracted two key propositions:

• Consent is generally not a defence to wounding/ABH “for no good reason”;
• Some activities are nevertheless “lawful” by longstanding acceptance/public policy (including “Ritual circumcision”).

Alazawi treated “ritual circumcision” as a recognised lawful category, but emphasised that the authorities often qualify lawfulness by concepts like “properly conducted” activities or “reasonable” standards—even if those standards are not formally legislated.

R v BM [2019] 1 QB 1

BM is pivotal for two reasons. First, it underscores that the exceptions are historically “ad hoc” and reflect value judgments over time. Second, it shows the Court’s reluctance to create new exceptions for non-medical invasive procedures (body modification), particularly where the procedures resemble surgery without regulation. Alazawi used BM to highlight the regulatory contrast: in many exception categories there are rules or frameworks (sports rules, medical regulation, local authority controls for piercing/tattooing), whereas ritual circumcision lacks a comparable general statutory scheme—creating evidential and doctrinal difficulty when unsafe practice is alleged.

McCarthy [2019] EWCA Crim 2202

Cited in sentencing argument as a comparator to demonstrate how courts have sentenced serious, consensual body modification. While not directly determinative, it informed submissions about proportionality and the seriousness spectrum for non-therapeutic procedures.

3.2 Legal Reasoning

(A) Route two liability: a principled standard exists, but it must be framed correctly

The Court rejected the appellant’s primary argument that, because Parliament has not regulated non-medical religious circumcision, a court cannot criminalise “unsafe” practice absent gross error or injury. The Court held that a line must exist on the spectrum between acceptable religious practice and criminal assault.

However, the Court was “troubled” by the jury question used at trial—whether the circumcision was unsafe so as to expose the child to “a significant and unnecessary risk of additional harm”—because it did not specify what standard of safe practice applied to a non-medical circumciser.

The Court stated the correct formulation should have been:

“Are you sure that the circumcision was conducted in a manner so far from that which a competent and careful non-medical circumciser would have adopted that the child was exposed to a significant and unnecessary risk of additional harm?”

This is the key doctrinal clarification: Route two is assessed by reference to the benchmark of a competent and careful non-medical circumciser, not a medically qualified surgeon in a clinical setting.

(B) Expert evidence: hospital-based medical critique may be unfair without a non-medical comparator

The Court agreed that relying on expert evidence from a consultant surgeon and consultant paediatric anaesthetist to evaluate a home, non-medical religious circumcision risked holding the defendant to inappropriate standards, even with judicial caveats that non-medical circumcision can be lawful and need not meet surgical standards.

The Court observed it was “hard to understand” why neither party adduced expert evidence from a non-medically qualified religious circumciser, given the established nature of the practice in multiple faith communities.

(C) Despite misdirection concerns, the convictions were safe on the facts: anaesthetic use crossed the line

The Court nonetheless upheld the convictions because the appellant’s injection of local anaesthetic—which he had admitted by guilty pleas to offences under the Human Medicines Regulations 2012—was sufficiently outside the scope of what a competent non-medical circumciser would do. On the Court’s analysis, even under the corrected Route two test, a jury would inevitably conclude that injecting babies with anaesthetic as an unqualified person exposed them to significant and unnecessary risk (dose calculation, need to weigh the child, allergies, side effects, sterility).

Importantly, the Court suggested that if the case had depended only on other features (e.g. environment, assistants, hygiene), the combination of (i) misframed jury test and (ii) reliance on hospital-based medical standards could have rendered convictions unsafe. The convictions survived because the anaesthetic feature provided a decisive, non-medical benchmark breach.

(D) One continuous act: anaesthetic injection is part of the circumcision procedure

The Court upheld the trial judge’s approach that the circumcision was a single continuing procedure beginning with injection and culminating in cutting/removal of the foreskin. The appellant’s attempt to separate injection (as a different assault, undermining s.18 intent) was rejected as an artificial disaggregation of one course of conduct.

3.3 Sentencing: totality and avoiding double-counting where fraud and medicines offences overlap with unlawful wounding

The Court reduced the overall sentence from 9 to 6 years, identifying three linked errors of approach:

• Fraud as both mechanism and aggravation: Fraud was central to Route one (vitiating consent) and also treated as separate consecutive criminality. The Court accepted deception aggravates seriousness, but making fraud consecutive created overlap and an excessive uplift.
• Medicines offences as part and parcel of the procedure: The unauthorised administration/supply of medicines was integral to the circumcision episodes and overlapped with the risk-based seriousness of the s.18 counts. A further consecutive uplift risked double-counting.
• Focus on offences proved, not broader activity: The Court was concerned the judge may have been influenced by the total number of circumcisions suggested by diaries (hundreds), rather than anchoring proportionality primarily to the counts of conviction.

The Court’s remedy was structural: treat the s.18 offences as lead, impose 6 years for each s.18 count concurrent, and make all other sentences concurrent—arriving at a proportionate total for the proved criminality.

4. Impact

• Clarified Route two test: Future prosecutions alleging “unsafe” non-therapeutic circumcision should frame liability by asking how far the conduct departs from what a competent and careful non-medical circumciser would do, and whether that departure created a significant and unnecessary risk.
• Evidential consequences: The judgment strongly signals that courts should be cautious about using purely hospital-based medical benchmarks to judge home, non-medical circumcision. Parties should consider calling appropriate comparator expert evidence (e.g. experienced non-medical religious circumcisers, or evidence of established non-medical community standards/practices), particularly where the alleged unsafety does not hinge on inherently medical acts.
• Anaesthetic as a liability pivot: The decision indicates that unqualified parenteral administration of anaesthetic may itself be capable of moving a procedure beyond the lawful “ritual circumcision” exception because it is outside what a careful non-medical circumciser would do—especially where it imports clinical risks requiring medical safeguards.
• Sentencing guidance in overlapping criminality: Where fraud vitiates consent and medicines offences are integral to the same episodes, courts must avoid consecutive stacking that effectively counts the same seriousness multiple times. The fraud and medicines elements may be better treated as aggravating features of the primary violence-based offending when the narrative and harm/risk are tightly interwoven.
• Policy pressure point: While the Court declined to treat lack of regulation as immunising unsafe practice, the judgment exposes the practical difficulty of defining “proper” non-medical standards without a statutory framework—potentially encouraging future legislative or regulatory attention.

5. Complex Concepts Simplified

• Consent and assault: Consent is not a universal defence. The law allows certain socially accepted activities (sports, surgery, tattooing, ritual circumcision) even though they cause injury. Outside those exceptions, consent usually cannot legalise ABH/wounding.
• “Public policy exceptions”: These are judge-recognised categories where society accepts the activity as beneficial or longstanding. They are narrow and courts are reluctant to expand them (as emphasised in R v BM [2019] 1 QB 1).
• Fraud vitiating consent (Route one): If consent is obtained by a material deception (here, claims of being a doctor) and relied on, the law treats the consent as ineffective for the purpose of justifying what would otherwise be an assault.
• Unsafe practice converting a lawful act into an unlawful one (Route two): Even where the category of act can be lawful (ritual circumcision), the way it is carried out may be so far below acceptable non-medical practice that it becomes criminal.
• Totality and double-counting in sentencing: Courts must ensure the overall sentence matches overall criminality. If separate offences describe the same essential wrongdoing, consecutive sentences can punish the same feature twice.

6. Conclusion

Alazawi v R [2026] EWCA Crim 947 affirms that ritual circumcision remains a lawful exception in principle, but clarifies that “unsafe” non-medical practice can still found criminal liability. Crucially, the Court articulated the proper benchmark for Route two as departure from the standard of a competent and careful non-medical circumciser, while warning against unfair reliance on hospital-based medical standards in the absence of an appropriate non-medical comparator.

On sentence, the Court provided a practical application of totality: where fraud and medicines offences overlap substantially with the primary violence-based offending, consecutive uplifts risk double-counting. The result—a six-year concurrent-led structure—highlights the appellate court’s insistence that overall punishment must be proportionate to the proved counts rather than the broader alleged scale of activity.