Why we should not circumcise infant boys

Jun 17, 11 Why we should not circumcise infant boys

In response to Claire’s article on the San Francisco bill to ban infant male circumcision, I have decided to sketch what the case for banning really is. I’m going to structure this by reviewing the common (usually unarticulated) reasons for supporting circumcision, and then I’ll make the case against it.

Firstly, some disclaimers and terminology. This is an interest of mine, but I’m by no means the originator of most of what I’ll say here. It is most cogently put in the statement by the Royal Dutch Medical Association (KNMG) linked to at the end. In this article, as in that document, I will refer to the type of male circumcision under discussion as non-therapeutic circumcision (NTC) to distinguish it from the occasionally necessary medical procedure with the same effect. I’d like to keep this article readable and uncluttered, so I won’t reference in line, but will post some useful links in a short bibliography after the main text.

Secondly, the background (largely from the KNMG report). Approximately one-third of the world’s men are circumcised. It is estimated that 13 million boys around the world are circumcised each year. The increasing criticism of routine circumcision, also from doctors’ organisations, has led to a situation in which the incidence of circumcision is falling significantly in many countries and is less and less accepted as ‘normal’. In the United Kingdom, the number of circumcisions in newborns has fallen from 35% in the 1930s to 6.5% in the 1980s, to 3.8% in 2000. In the US, the incidence fell from 85% in 1965 to 56% in 2006. Canada saw a fall from 47.4% in 1973 to 31.9% in 2007, while Australia witnessed a fall from 90% in 1955 to 12% in 2000.

 

The case for NTC

There are two, often linked, arguments for infant NTC.

  1. Aesthetic: for a time NTC was on the rise as a social norm, leading to 70% of adult males in the US being circumcised. Thus, many parents believe that not circumcising their child would lead to social ridicule and ostracisation. This is in turn based on a perception that the foreskin is somehow dirty or ugly.
  2. Cultural: NTC has been part of many different cultures for thousands of years. NTC for infant males is an integral part of Judaism. It is also widely practiced by Muslims. In Africa NTC occurs at a range of stages, from neo-natal (as in Judaism) to adulthood (as part of a coming of age ceremony).
  3. Health: For a time there were touted health benefits to circumcision. It was believed to be more hygienic and to reduce the risk of both male and female contraction of HPV.

We are accustomed to a fourth argument being made, which we hear often because of our context: HIV: NTC reduces the risk of contracting HIV during unprotected sex.

I don’t believe this is an argument for infant NTC at all, but rather for adult NTC, prior to sexual activity. I still disagree with it then;  I merely offer this as a reason that I will not address it further.

Under the first two arguments, NTC is a sort of cosmetic surgery, thrust upon young boys before they could possibly consent. As a brief aside I want to point out that many countries prohibit tattooing or piercing newborns. I think this is right, for the same reasons I shall advance against NTC. The major argument that I plan to make is based on the right of the child to bodily integrity, and should this argument succeed, it should clearly trump both aesthetic and cultural concerns. Both of the above arguments are dealt with in the section below on female genital mutilation.

There is an implicit rebuttal advocated by many supporters of NTC which is roughly:

  • NTC goes on all the time (“I survived it”) and therefore there can’t possibly be manifest harms (“therefore my child will too”). This is not unlike a popular argument for beating your children as a component of instilling discipline.

This last argument establishes a weak demand on opponents of NTC to explain why we aren’t aware of the harms I shall outline. I think the answer is twofold: firstly, we often are. Many mothers report being traumatised by the process of circumcising their children. Secondly, new medical research constantly brings to light harms of which

So, having done that background and established what I hope is a fair sketch of the case for NTC, let me get onto my case opposing it.

 

Function of the foreskin

There is a common misconception that the foreskin is useless and therefore easily discarded. This is not the case. The foreskin performs a range of important physiological functions.

Protection: It keeps the glans soft, moist and sensitive. It maintains pH balance.

Defence: The glands in the foreskin are part of the body’s immunological defence system. The foreskin produces antiviral proteins like lysosome which are otherwise absent from the glans, reducing its defence.

Sensitivity: The foreskin itself is as sensitive as the fingertips or lips.

Male sexual function: The foreskin has a wide range of motion; it can retract almost to the base of the penis and slip forward over the glans. This is a stimulus mechanism for orgasm.

Female sexual function: During intercourse, the foreskin acts as a self-lubricating, mobile sheath. This allows for a different form of female stimulation than friction alone: pressure movement in the absence of friction. This is absent sans foreskin.

Furthermore, a recent Danish study on the effect of circumcision on sexual function concluded:

Circumcision [circumcised status] was associated with frequent orgasm difficulties in Danish men and with a range of frequent sexual difficulties in women, notably orgasm difficulties, dyspareunia and a sense of incomplete sexual needs fulfilment.”

In light of the above, it seems strange that the foreskin could be unhygienic, or that its removal could protect one from infections like HPV. Indeed, such claims have since been debunked, with the most recent meta-analyses showing that there is no statistically significant relationship between circumcision and a reduction in the incidence of HPV.

 

Harms

There is a contingent fact about NTC that features in many cases against it which I’ll mention for the sake of completeness. NTC is incredibly painful. (Circumcision.org calls it “the most  painful procedure in neonatal medicine” and states that “adult patients would not tolerate this level of pain”.) 50% of NTCs are performed without anaesthetic in the US. The 50% that do use is often use a topical cream which is slow to act and ineffective. Thus, the majority of babies undergoing NTC experience excruciating pain. Obviously this could be corrected, but it is something to keep in mind about the practice as it exists.

Now for the inherent harms. Firstly, there are structural harms.

  1. Circumcision removes as much as 80% of the penile skin, making the penis up to 25% shorter.
  2. Circumcision permanently immobilises the remaining penile skin, preventing its movement over the shaft. This removes the natural stimulus mechanism for the glans.
  3. Circumcision externalises the glans, usually an internal organ. The skin of the glans hardens and desensitizes in response.
  4. Circumcision can twist or bow the penis, due to the tension introduced by the stretched remaining skin.
  5. Circumcision is unhygienic. Artificially externalising the glans exposes it to dirt and abrasion. The loss of the foreskin makes men more susceptible to urinary tract infections. Circumcising a baby requires tearing the foreskin from the glans, leaving it bleeding and exposed. This entire area is then susceptible to infection.

Secondly, contrary to popular belief, there are documented physical harms to the surgery we term NTC. Some of these are harms associated with all surgery: bleeding (which is often copious and hard to stop due to the large blood supply to the foreskin) and infection. Others are particular to this surgery: meatus stenosis (narrowing of the urethra) occurs in up to 10% of all circumcisions and can lead to increased vulnerability to UTIs.

Thirdly, there is evidence to suggest associated psychological trauma. Infant trauma can be difficult to track, and the evidence is mixed. However, the British Medical Association states that they believe psychological harms exist. NTCs are often conducted without anaesthetic (especially when performed for cultural reasons) and there is a mass of evidence to suggest that extreme pain can cause ‘infant medical trauma’ which causes behavioural shifts and has been correlated with increased PTSD later in life.

 

Medical best practice

There is a strong principle of medical best practice with regards to minors which states that minors should only be exposed to medical treatments (especially invasive/harmful ones) if illness or dangerous abnormalities are present, or if there is manifest benefit to the child. The case of vaccinations is an excellent example of such a justified medical procedure: it is demonstrably in the best interests of the child to make them suffer the unpleasantness of a series of injections, because they are protected from otherwise life-threatening diseases.

Note that I am not ignoring the HIV argument here. I am merely arguing in the context in which most infant NTCs occur, a context which has nothing to do with HIV prevention. There is a strong burden on the NTC-as-HIV-prevention lobby to tell us why this circumcision should be done to infants, and why it is necessary (given the harms) when other options (condoms) seem to do much better.

 

Rights of the child

The relevant rights of the child are those to autonomy and bodily integrity.

Autonomy is clearly violated in that the child has no control in the matter. As the procedure is irreversible, it removes the possibility of a choice being made by the child later in life. The parents (in fact, often just doctors) decide on his behalf. The common argument at this point is that parents are empowered to do this all the time. While this is true, it is always constrained by their acting in the best interests of the child. Considering the above, I think this is clearly not happening.

The irrevocability of the act makes the burden on parents incredibly high in this case. I have a strong intuition that parents should avoid making irrevocable decisions unnecessarily. The fact that there exists a wide variety of opinion on NTC is itself suggestive of the fact that boys may grow to regret their parents decision. This is further supported by men who seek medical assistance in reversing circumcision later in life. Parents should therefore delay this choice until it can be made by the boy in question.

It appears to me that bodily integrity is violated ipso facto in NTC, but apparently this view is not universal. The implicit argument seems to be that the foreskin is no loss. I think the evidence of foreskin restoration is a telling piece of evidence that something is lost, and many of the victims would rather it had not been. As I stated above, the foreskin does perform important functions. The intersection of this aesthetic disagreement and medical evidence suggesting the change is not merely cosmetic makes NTC an assault on the body of the child.

 

FGM: Useful comparison or not?

(This section comes largely from the KNMG opinion)

There is some controversy over whether it is useful (or even acceptable) to make a comparison between NTC and female genital mutilation (FGM) sometimes erroneously called ‘female circumcision’. I think there is something to this comparison, given certain parameters. At base, both are modifications of the body, in particular sexual organs, without the consent of the person concerned. Both are culturally embedded behaviours, with supporters who are strongly opposed to outside intervention.

Obviously, the comparison must be a careful one. FGM is a generic term which covers all manner of crimes. All forms are rightly rejected by virtually everyone, including the WHO. The useful comparator here is the most minimal form of FGM (mFGM), descriptively called ‘ritual nicking’.

This practice is far less invasive than NTC – no tissue is removed at all. Yet, NTC is accepted while mFGM is rejected. The WHO says: ‘Female genital mutilation of any type has been recognized as a harmful practice and a violation of the human rights of girls and women’. I agree. Girls are fine as they are. Any assault on their genitalia should be seen as child abuse.  The same should go for boys.

There are a few arguments people use to distinguish between FGM and NTC. The first is sexual function: the damage to sexual function is much higher in FGM than in NTC. This is wrong for two reasons. Firstly, as seen above, the foreskin plays an important physiological and sexual role. Secondly, different varieties of FGM have different effects on female sexual function, yet all are rejected.

There is another argument used to differentiate between FGM and NTC. FGM is an expression of oppression of women, and nothing comparable exists for men. I agree with this, to an extent. My purpose in highlighting the similarities between FGM and NTC is not to equate them, but merely to provoke a reconsideration of the status of NTC.

However, the reason that FGM is an effective mechanism of female oppression is because it violates bodily integrity and controls sexuality. This is exactly what NTC does. There is evidence to suggest infant NTC was introduced by some cultures to suppress infant masturbation. Furthermore, the existence of an aesthetic argument for NTC is itself evidence of societal control of male sexuality.

 

Conclusion

Infant NTC causes physiological harms and the surgery by which it is accomplished causes both physical and psychological harm. It therefore represents an assault on the rights of the child, an abrogation of the parental duty to protect and nurture infants. Prioritising the right of parents to practice their religion/culture above the physical and psychological integrity of their child is abhorrent; a fact we recognise in the discussion of female genital mutilation. Parents should therefore cease to voluntarily and unnecessarily circumcise their male children, and we as a society should confront the cultural practice as well. At the very least, religious practitioners need to engage in the debate on NTC rather than cry religious persecution. Should they prove intractable, secular states may need to consider revoking their right to religious freedom in the interests of their children.

 

Further reading:

KNMG opinion: http://knmg.artsennet.nl/Diensten/knmgpublicaties/KNMGpublicatie/Nontherapeutic-circumcision-of-male-minors-2010.htm

Uncircumcision: http://www.ncbi.nlm.nih.gov/pubmed/9623850

Danish study: http://ije.oxfordjournals.org/content/early/2011/06/13/ije.dyr104.abstract

The case against circumcision: http://www.luckystiff.org/circumcision/information/The_Case_Against_Circumcision-4.pdf

Circumcision and HPV: http://intactipedia.org/index.php?title=Circumcision_and_HPV

Image by Aesop

  • Sydney Moganedi

    a very informative and well written arguement Joe!
    i too think a person should be entitled to decide on all things that yield irreversible results especially on one’s body!

  • Toby_d_bennett

    I’m convinced, scary how peoploe use culture or asthetics as an excuse for this kind of abuse of their fellow human beings.

  • It feels like you’ve neatly side-stepped the most important issue (HIV prevention) and focused on the peripheral aspects instead.

    For example, I would give very little weighting to things such as penis length and pleasure during sex, because one can still experience great pleasure even with a circumcised penis. It isn’t as if the function of a penis has been so severely disrupted that you can’t procreate afterward.

    And if infant trauma is so difficult to track, how exactly did they come to the conclusion that links psychological trauma to infant circumcision? I mean, I doubt anybody who’d had the procedure as an infant actually remembered having it done to them – It just doesn’t make sense that people would suddenly start having nightmares because they were circumcised as a baby. I don’t think the “trauma” defense is a strong one.

    The rights of the child is something worth discussing, and I think Clair’s response (point 4) addresses it quite well. Parents have been known and tasked with the duty of acting as their children’s proxy. Is it really an “assault” on the child’s rights when the decision is made purely for the child’s future benefit? Even if the “reason” is based on religion, we can’t ignore the benefits that arise as a consequence. So I don’t think it matters whether it’s done because the parents were Jewish or because of the HIV thing… end result is still the same.

    You say circumcision should be done prior to sexual activity – Well, sexual activity starts at a pretty young age… would a 12 or 13 year old boy be able to make an informative decision? Probably not.

    Of course, if everybody had the foresight to use a condom, we wouldn’t be having this discussion. Fact is, most people don’t – and that’s why HIV is so prevalent. If we’ve already established that a circumcised penis is less likely to contract HIV, I don’t see why we should wait until a certain age when the procedure is so much more risky/painful/etc.

    • Joe Roussos

      Amy, I don’t feel like you’ve really engaged with my
      argument.

      Firstly, these issues aren’t peripheral. In many places,
      they are THE arguments on which this issue will be decided. In San Francisco,
      the debate isn’t about HIV, it is about these issues. More to the point, you
      can’t simply dismiss qualitative differences in sexual pleasure, as if such
      issues are negligible. No matter how hard-headed and sensible you may sound to
      yourself, the fact is that sex matters and sexual experience is an important
      part of the human experience. We should carefully consider any activity which
      reduces the ability of people to enjoy sex to the fullest. In short: sex isn’t
      just for procreation, dontcha know.  

      Secondly, the fact that infant trauma is difficult to track
      doesn’t make it impossible. If it were, the term wouldn’t exist. I don’t think
      it’s a definitive defence either, which is why I qualified my statement. If you’re
      interested, I can direct you to some actual studies on the matter (you can find
      them through the links in my main article). Science is hard, but that doesn’t
      make it not worth doing.

      Thirdly, if we can show that parents are systematically
      making the wrong decision, in the face of good evidence to the contrary,
      shouldn’t we step in? Isn’t this what we do when parents get it badly wrong on
      education and health (think of religios who refuse treatment). If it turns out
      that there are physiological harms, then the future benefit argument falls and
      we must consider this. Since I believe there are such harms, it is completely
      reasonable for me to argue that parents shouldn’t be allowed to do this.

      Fourthly, your comment on 12-13 year old males misses the
      point. There are real issues here about autonomy. You can’t circumvent them
      because of paternalistic (if you will) talk about how people will make the
      wrong decision. I’m quite happy to point out that we don’t allow people to make
      even important decisions for people just because they might get it wrong. We
      have a burden upon us to engage with such people and convince them of our
      position. Even 13 year olds, if that’s what it takes. So IF I believed
      circumcision were a good idea (which I’m not sure I do) then yes, obviously I
      would say you have to do the hard work and convince 12/13 year olds to do it
      your way. Far better that than assault their bodies for your convenience.

      Fifthly and finally, the benefits are contested. This is the
      core of what you think is the major issue. In SA we get told that the benefits
      are manifest and certain. This isn’t true, though I appreciate the political
      reasons for delivering a firm line. Both the KNMG and the Royal Australian
      College of Physicians contest the studies linking circumcision to HIV
      prevention. Furthermore, the benefit is incredibly marginal, so touting it as a
      stopgap for condoms is incredibly wrongheaded.