Circumcision: Support or circumscription?

Middle ground is difficult to find

Would your ethics committee approve a request to perform nontherapeutic surgery that would permanently alter the body of a healthy patient without his or her consent? What if the patient was very young and the parents wanted the surgery for religious or cultural reasons? What if they argued the procedure was necessary to reduce a remote possibility of future illness?

You should weigh your answer carefully. Such surgeries are, in fact, very common.

Annually, more than 1 million infant males in the United States undergo circumcision surgery within a week of birth to remove the prepuce (or foreskin) of the penis.1 Approximately 60% of all American males are circumcised. Although the procedure is routine, it also is controversial.

"Perpetrating sexual surgery on healthy nonconsenting minors under the legal age of informed consent or refusal, to purportedly prevent an unlikely . . . future infection, is unacceptable," wrote Eileen Marie Wayne, MD, in a letter published in the journal Infectious Diseases in Children.2 "Intentionally amputating healthy erogenous genital tissue from tethered, protesting infants is a surgical act of sexual sadism."

Proponents of the procedure are equally vehement.

"The lifetime health benefits of neonatal circumcision — including the long-known benefits of genital-hygiene improvement and prevention of local infection and penile cancer — far exceed the risks of the procedure," counters pediatrician Edgar Schoen, MD, in an issue of the American Council on Science and Health’s Health Priorities.3 "Circumcision prevents serious kidney infections, especially in infancy; and there is strong evidence that it has a protective effect against some serious STDs, including HIV infection, syphilis, and chancroid. A 1-week-old circumcised boy has a significant health advantage over his uncircumcised contemporary."

Although it would seem an issue ripe for debate in the bioethics community, the procedure has received little attention, notes David Benatar, PhD, associate professor of philosophy at the University of Cape Town in South Africa.

Benatar and his brother, fellow researcher and pediatric neurologist Michael Benatar, MD, recently published a paper examining the practice in the spring issue of the American Journal of Bioethics (AJOB).4

"We are aware that people on both sides feel very strongly about the issue and that most people do not change their minds readily," David Benatar tells Medical Ethics Advisor. "We felt there was a need for a dispassionate analysis of both the evidence and of the arguments for and against."

Where are we now?

An ancient ritual practiced in numerous societies for thousands of years for both religious and cultural reasons, neonatal male circumcision became a commonly performed procedure in U.S. hospitals in the 1950s and 1960s because it was thought to prevent masturbation and make genital hygiene easier. By 1971, an estimated 90% of male infants in the United States were circumcised each year.5

In recent years, however, both parents and physicians have questioned the practice of removing part of a healthy person’s anatomy without a compelling medical reason.

In 1977, the American Academy of Pediatrics (AAP) changed the designation of the procedure from "routine" to "elective" and currently does not recommend routine neonatal circumcision, though its policy statement indicates there are potential medical benefits to be derived and that parents can legitimately choose to have the procedure performed.6

Following the AAP’s original decision not to recommend the practice, circumcision rates began declining. However, some researchers studying the incidence of sexually transmitted diseases, infections of the genitalia and urinary tracts in males, and penile cancer discovered a slightly higher incidence of such problems in uncircumcised men. Although the data are limited and only show a marginal possible benefit, some clinicians feel they provide sufficient justification for performing the operation.

Not a crime, not a cure-all

In the AJOB article, the Benatars examine the evidence presented in the medical literature purporting to support circumcision, as well as the ethical and medical arguments against the practice.

The evidence, they conclude, does not strongly support either side but instead supports allowing parents’ discretion in choosing what they believe is best for their child, David Benatar says.

Although there is some evidence of a small medical benefit, the data don’t provide a strong medical justification for the procedure, he notes. Neither, however, is there evidence that the procedure is harmful, he says. And, for families where there is a strong cultural or religious impetus to circumcise, the procedure could be considered to be in that child’s best interest.

"We went into this agnostic on the question of circumcision, and we didn’t know whether we would be in favor of or against. We really went in wanting to assess the evidence to the best of our ability and see where it fell," Benatar says. "The conclusion that we came to was that there is not a compelling medical argument for it, but neither is there a compelling medical argument against it. There are, however, some very strong religious and cultural arguments for it. Given that it is not clearly damaging to the child, and given that it may be beneficial — although that evidence is not clear — we concluded that it was a matter suitable for parental discretion."

A nonmedical medical procedure?

But the absence of a clear medical reason for performing circumcision is precisely the reason that the medical community should not be involved in the practice, says George C. Denniston, MD, MPH, a physician and president of Doctors Opposing Circumcision, a Seattle-based nonprofit group opposed to routine neonatal circumcision.

"The AAP policy statement of 1999 stated the committee searched the literature published over the past 40 years and the data were not sufficient to justify recommending routine infant circumcision," he says. "If the data are not sufficient, they are not sufficient. No one should be doing them."

The practice is not widespread in other areas of the world, Denniston adds. Eighty-five percent of the world’s men are intact and experience no detrimental effects.

Removing healthy genital tissue because of the remote chance it might one day become infected or contribute to an infection makes no more sense than removing a healthy earlobe or eyelid and can be much more damaging, he contends.

Only one in 100 uncircumcised infant males gets a urinary tract infection, and circumcised males get them too, albeit at a lower rate. Penile cancer occurs in one in 100,000 men and occurs mostly in men older than 50. Circumcising 100,000 infants to prevent one case of penile cancer is not justifiable from a risk-benefit perspective, especially considering that complications from circumcisions can also occur.

Infants who die of infection after being circumcised typically are not reported, and some estimates have estimated that as many as 200 deaths per year in the United States can be attributed to complications from circumcision, he argues.

"No one, especially not a doctor, has the right to remove normal body parts from another human being. In so doing, he or she is violating the fundamental human right of every individual to an intact body," Denniston says.

Weighing cultural needs, values

Given that the United States outlawed female genital mutilation (FGM) in 1997, it seems obvious that continuing to perform male neonatal circumcision is unethical and harmful, Denniston adds. "Congressmen and women want to protect little girls from having their genitals mutilated, while leaving the field open to continue the mutilation of little boys."

Benatar agrees that many people appalled by accounts of FGM consent to male circumcision without giving it a second thought. However, comparing the two situations is not necessarily appropriate.

"People are much less critical of practices that are culturally familiar," he acknowledges. "They are much more critical of practices which are culturally strange. Of course, it doesn’t follow that our more ready acceptance of our cultural practices is mistaken, just as it doesn’t follow from our criticism of other cultures that they are mistaken. One of the things we are trying to do is alert our readers to these potential biases."

The procedure normally considered to be "female circumcision" is a much more radical procedure than removal of the male foreskin, and it is incorrect to directly compare the two, Benatar says.

It would be instructional to compare male circumcision with similar female procedures, he adds. Not all societies that perform alterations of female genitalia conduct procedures that remove all of the clitoris or outer labia. In some cultures, the prepuce of the clitoris is removed — a procedure similar to the practice of male circumcision.

However, when immigrants to the United States have attempted to bring these same practices to the United States or have requested modified versions of genital-modifying procedures on female babies, these attempts often have met with complete rejection.

In the journal article, Benatar relates the failure of what is known as the "Seattle Compromise." The Haborview Medical Center in Seattle was faced with repeated requests from immigrant Somali mothers to have their daughters circumcised, with the mothers indicating the babies would be circumcised with or without the doctors’ involvement. Some hospital personnel suggested a compromise procedure whereby the clitoral prepuce would be nicked to draw blood. Though some of the mothers indicated agreement with the compromise, the plan was quashed by others opposed to any nontherapeutic alteration on a girl’s genitalia.

Such a decision seems to reflect a cultural bias in favor of practices that are familiar to our society and a rejection of a similar procedure because it is strange, rather than due to its perceived harm.

"If the procedures you are comparing are analogous, then it is very likely that cultural bias is causing one to too quickly condemn another culture’s practice or forcing one to too readily endorse one’s own culture," Benatar explains.

Opponents of all FGM should give careful consideration to whether or not they should be comfortable supporting or ignoring similar practices on male children, he says.

However, given the available evidence, both pro and con, on neonatal male circumcision performed with analgesia, Benatar does feel that cultural considerations can support the practice.

"Not being circumcised can spell exclusion from some religious or cultural activities and this could be detrimental, given one’s environment," he says. "We don’t think cultural considerations should be overriding. If a culture required the amputation of both a child’s ears or something, or its nose, we would not endorse that. Where the medical evidence is evenly balanced, then we think cultural considerations can tip the scales."

References

1. National Center for Health Statistics. Trends in circumcisions among newboards. National Hospital Discharge Survey. 1999. Accessed on the web at: www.cdc.gov/nchs.

2. Wayne EM. Letters: Circumcision — sexual sadism? Infect Dis Child 1998; 11(2).

3. Schoen E. Is circumcision healthy? — Yes. American Council on Science and Health. Health Priorities 1998:9(4). Accessed on the web at: www.acsh.org/publications/priorities/0904/circyes.html.

4. Benatar M, Benatar D. Between prophylaxis and child abuse: The ethics of neonatal male circumcision. Am J Bioethics 2003; 3(2):35-48.

5. Committee On Fetus and Newborn. Standards and Recommendations for Hospital Care of Newborn Infants, Fifth edition. Evanston, IL: American Academy of Pediatrics; 1971, p. 110.

6. Task Force on Circumcision. American Academy of Pediatrics. Circumcision Policy Statement (RE9850). Pediatrics 1999; 103:686-693.

Sources

  • David Benatar, PhD, Associate Professor of Philosophy, Robert Leslie Social Science Building, Room 6.34, Faculty of Humanities, University of Cape Town, Private Bag, 7701 Rondebosch, Cape Town, South Africa.
  • George Denniston, MD, MPH, President, Doctors Opposing Circumcision, 2442 N.W. Market St., Suite 42, Seattle, WA 98107.

Additional info on the ethics of circumcision

Other related articles about the ethics of male circumcision:

  • Jones CM. Neonatal male circumcision: Ethical issues and physician responsibility. Am J Bio-ethics 2003; 3:59-60.
  • Mullen MA. Who speaks for sons? Am J Bio-ethics 2003; 3:49-50.
  • Benatar D, Benatar M. How not to argue about circumcision. Am J Bioethics 2003; 3(2). Correspon-dence. Accessible on-line at: www.bioethics.net/journal/correspondence.php?vol=3&issue=2&articleID=106.

Information on-line:

  • American Academy of Pediatrics (www.aap.org): This web site contains a fact sheet on circumcision.
  • Circumcision Resource Center (www.circumcision.org): This is an informational web site for health care professionals that contains information and advocacy against the practice of circumcision.
  • CircumcisionInfo.com. The site contains information and articles from physicians and health care personnel in support of neonatal male circumcision.