Neonatal fatal haemorrhage after a ritual circumcision: forensic and ethical considerations

Forensic Science, Medicine and Pathology https://doi.org/10.1007/s12024-025-01011-w CASE REPORT Neonatal fatal haemorrhage after a ritual circumcision: forensic and ethical considerations Pierluigi Passalacqua1 · Raimondo Vella2 Michele Treglia2 · Margherita Pallocci2,3 · Giorgio M. Coppola2 · Nazaria Lanzillo2 · Francesca Servadei2 · Accepted: 11 April 2025 © The Author(s) 2025 Abstract Neonatal circumcision is a common procedure worldwide, which may be performed for medical reasons and for cultural and religious motivations. Regarding ritual circumcision, there has been a wide-ranging debate in medical society about the level of acceptability of this practice. Even from a bioethical and legal point of view, the problem is approached differently in different contexts worldwide, especially given that, even if rare, complications can occur both during and after the procedure, and may result in infections, bleedings, hemorrhages and even death. Bleeding occurs most frequently after the fourth week of life and is related to the presence of an abundant venous vascularization of the penile shaft. Unlike adults, the blood loss rates suggestive for hemorrhagic shock are not defined in neonatal populations. Therefore, the diagnosis of the cause of death can be challenging for the forensic pathologist, especially if circumstantial information is missing. We report the case of a full-term infant boy born after a terminally complicated pregnancy. He underwent a “domestic” circumcision on 22nd day of life. The same day he was admitted to the emergency room in cardiac arrest and died despite resuscitation procedures. The autopsy findings revealed the presence of a large amount of blood in the diaper and a circumferential laceration of the penile shaft, consistent with a recent circumcision. Diffuse organ pallor was macroscopically and microscopically demonstrated, consistently with a hemorrhagic shock. To conclude, the diagnosis of hemorrhagic shock can be difficult in the newborn and requires the estimation of lost blood volume. Moreover, due to the possibility of rare fatal complications, neonatal circumcision should be performed only in a controlled, medical environment. Keywords Male circumcision · Hemorrhage · Fatal outcome · Forensic pathology · Ethics · Case reports Introduction “Circumcision”, is a very ancient practice that has been developed independently and simultaneously in different cultures. Evidence of this procedure has been found, e.g. in the earliest Egyptian mummies (around 2300 BCE), and it is Margherita Pallocci 1 Department of Public Health and Infectious Diseases, “Sapienza” University of Rome, Piazzale Aldo Moro, 5, Rome 00185, Italy 2 Department of Biomedicine and Prevention, University of Rome “Tor Vergata”, Via Montpellier, 1, Rome 00133, Italy 3 PhD Program in Applied Medical-Surgical Sciences, Department of Surgical Sciences, University of Rome “Tor Vergata”, Via Montpellier, 1, Rome 00133, Italy also attested by wall paintings that it was customary several thousand years earlier [1]. Nowadays, Male Circumcision (MC) is one of the most frequently performed operations worldwide, with a prevalence of 25–30% of the global male population [2], with higher rates in distinct geographical areas, such as North America, Australia and Africa [3, 4]. The reasons of MC are usually related to therapeutical, prophylactic or ritual purposes. Among the therapeutical indications, it is usually performed to treat preputial diseases, such as pathological phimosis or balanoposthitis [5]. Some authors have suggested that by improving penile hygiene, circumcision could represent a potential protective factor against infections of the urinary tract, sexually transmitted diseases, and inflammatory penile diseases [4]. In several cases, circumcision is also performed for religious and ritual aims, especially in newborns. Neonatal Male Circumcision (NMC) is required by several religions, 13 Forensic Science, Medicine and Pathology such as Judaism– according to which it’s performed on 8th day of life -, Islam, as well as in several cultures of Africa and Australia (and particularly in Aboriginal population). In such cases, NMC is not always performed by qualified and trained medical personnel, but also by relatives or representatives of their religious communities. In this regard, it is important to notice that, though NMC is a substantially safe procedure, it can lead to potentially hazardous and rarely fatal complications, that can occur either during or after the procedure, and may result in infections, bleedings, hemorrhages and even death or SIDS [6–8]. A recent literary review has highlighted that the most frequent complications of therapeutical circumcisions involve adhesions, meatal stenosis and infections, while in the case of non-therapeutical ones, bleeding, infections and problems related to the removed of the device are observed [9]. Age is a determinant risk factor for complications, with a proportional increase in frequence, also in pediatric population. Another condition that may have an impact is the presence of pre-existing penile pathologies: indeed, the risk of complications is higher in case of therapeutic circumcisions, as well as in the case of operations performed by operators with a low level of experience and training and working in non-sterile environments [10]. The most serious complications, including death, are rare events, although a reliable estimate of the true incidence at global level is not currently available: according to some authors, complication rates may range from 0.2 to 5% up to 55% [11]. A retrospective analysis has estimated a case fatality rate of 10.2 deaths per 500,000 circumcisions. The same study showed that the concomitant presence of cardiovascular diseases or coagulopathies represents an increased risk of occurrence of fatal events in infants undergoing circumcision [12]. According to other authors, the incidence of fatal events is approximately 0.0012%, in most cases related to massive bleeding or infections [13]. Bleeding occurs most frequently after the fourth week of life and is related to the presence of an abundant both arterial and venous vascularization of the penile shaft [14]. The case we present concerns the death of a 22-days-old infant which, based on the circumstantial and clinical data, as well as of the findings of the judicial autopsy, could be causally linked to the procedure the infant had undergone a few hours before his death. To the best of the authors’ knowledge, despite the extreme frequency NMC worldwide, the presented case is among the few described concerning the fatal consequences of hemorrhagic shock in an infant undergoing such a procedure. 13 Case description We report the case of a full-term infant boy born via an urgent caesarean section after a terminally complicated pregnancy. The delivery occurred at 40 weeks + 4 and the C-section was due to a persistent bradycardia at (...truncated)