Rethinking Circumcision: Medical Intervention, Religious Ceremony, or Genital Mutilation?

EDITORIAL

Alexander and Cheng's interesting and thoughtful discussion of female genital mutilation (FGM) in this issue's Law, Ethics, and Gender in Medicine column¹ made me think about the other side of the coin. What's morally and medically different between female genital mutilation and male genital mutilation (circumcision)? While most of us abhor the former, we freely practice the latter, and even surround it with celebration as a rite of passage here in the United States. Often, this surgical procedure is not even performed with the benefit of an anesthetic. (The custom of having the infant suck on a corner of a napkin dipped in wine or sugar water does not guarantee anesthesia.) And, like FGM, circumcision is often performed by laypersons and not physicians. When condemning mutilations endorsed by a particular society (that seem incomprehensible to us), it behooves us to take a good look at ourselves. It's quite likely that we countenance things we've accepted as harmless and even salubrious that might be interpreted quite differently by other cultures---and that we should rethink. In spite of the fact that the devastation incurred by the more extensive forms of FGM is usually (but not always) greater than that of most circumcisions, there are striking and absolute parallels between the two procedures.

Certainly humans have been performing male circumcision for awhile; reports indicate that the Egyptians practiced it as early as 4000 years before the birth of Christ.² It has been perpetuated throughout the ages for various reasons, ranging from a Victorian notion that it would prevent masturbation, to the modern idea that the procedure improves hygiene and prevents disease in both the male and his sexual partners.

While opinions differ about whether circumcision should be a routine procedure, prestigious medical organizations have come down firmly against routine circumcision of the newborn. The Royal College of Surgeons of England released a statement on March 6, 2001, that represented not only their own opinion, but also that of the British Association of Paediatric Surgeons and the Royal Colleges of Nursing, of Paediatrics and Child Health, and of Anaesthetists. These groups oppose the procedure, except in the case of scarring at the opening of the foreskin, which makes it nonretractable, an unusual condition that occurs before age five. The skin of the penis grows forward from the eighth week of gestation and eventually covers the glans; there is no separation between the two, and, in fact, the foreskin is often nonretractable until the age of three. The prepuce continues to develop after birth and spontaneously separates from the glans around the third year of life; by the time they are three, 90% of boys will have a retractable foreskin. The statement also points out that circumcision is a surgical procedure like any other, and must be performed with adequate pain control, and be surrounded by the same precautions as any other surgical procedure (including that it should be done in an operating theater). Finally, as with any other operation, the infant should have postprocedural care, including pain control by medical professionals.

Circumcision is much more common in the United States than in other parts of the world; 1.2 million newborn males undergo the procedure annually in this country. This is in spite of the fact that the American Academy of Pediatrics began publishing statements on neonatal circumcision in 1971, and until its last revision was published in 1983, concluded that there was no absolute medical indication for performing the procedure routinely.³ The Academy's 1999 position paper reviewed the evidence-based medical data concerning circumcision and pointed out that a review of the literature suggested (but did not prove) that there is an increased risk for urinary tract infection (UTI) in uncircumcised babies under one year of age.⁴ Based on their review, the Academy speculated that seven to 14 out of 1000 uncircumcised male infants will develop a UTI during the first 12 months of life, compared with one to two out of 1000 circumcised babies. However, the studies that were cited differed in methodology (methods of urine collection varied; suprapubic aspiration, catheterization, and collection by bag were all used), in the number of confounding variables (eg, prematurity), and even in the definition of a UTI. The putative protective effect of circumcision on the incidence of penile cancer was also difficult to demonstrate; penile cancer itself is a very rare disease, and there are only nine to 10 cases a year per one million men. The best estimate of risk in the uncircumcised male is that it may be increased threefold over the circumcised man, but the absolute incidence is still low. Finally, although some data suggest that circumcision offers protection from HIV, the Academy believes not only that the data on the co-incidence of HIV and circumcision are conflicting and complex but also that behavioral factors are much more immediately and significantly important in contracting HIV infection. The statement concludes that there are no compelling medical data to support a recommendation for routine neonatal circumcision.

An article published in the British Medical Journal in 2000 contending that male circumcision protects against HIV infection⁵ was met with a storm of protests from readers. One of the more trenchant comments came from American physicians:

HIV transmission is heavily dependent on certain sexual behaviours, not anatomy. The authors have not provided any new information to alter this fact but have taken the discussion off on a needless tangent. Indiscriminate mass circumcision, which is currently popularized by some Western researchers... does not address the core behavioural issues that have fueled this pandemic. Therefore, it will not alter the course of AIDS in Africa.⁶

More recent data about the possible health benefits of circumcision include a meta-analysis of seven studies from five countries exploring its impact on the incidence of either human papillomavirus (HPV) infections in the male or cervical cancer in the female. Not only were circumcised men less likely to have HPV infection than their uncircumcised counterparts (odds ratio, 0.37; 95% confidence interval; 0.16-0.85), but women who had intercourse with men with a history of six or more sexual partners were less likely to have cervical cancer if their partners were circumcised.⁷ Even if one argues that circumcision lowers the incidence of HPV infection in the male and cervical cancer in his partner, and/or makes the male genitals easier to keep clean, these points of view fail to address the unfortunate and virtually universal assumption of most people, until quite recently, that it is fine to administer the procedure without the benefit of an anesthetic. Many people assume that, because a child is small, he feels no significant degree of pain. Yet, we know that this is not a fact and that even a fetus can experience discomfort.⁸ The outraged (read anguished) cry of the baby being circumcised is generally laughed off by those who surround it with the panoply of ritual and celebration; not unlike what our law column authors describe in some African societies when performing FGM. The situation is not as benign as it may seem; the babies' responses to circumcision without analgesia include well-documented changes in heart rate, blood pressure, oxygen saturation, and serum cortisol levels.^9-12

A fascinating document by researcher Jacqueline Smith, at the Netherlands Institute of Human Rights, addresses the contention of many that to compare FGM to circumcision is to trivialize FGM.¹³ On the contrary, although the former is a more extensive procedure, both surgeries involve genital mutilation. Ms. Smith comments on the decision of the  Netherlands Institute of Human Rights to address, study, and make recommendations only on the subject of FGM, and not to consider a statement on male genital mutilation (MGM) or circumcision because, as she states:

The choice to make a dissociation between the two practices was at that time a pragmatic, political decision, related to the vehement discussion in the Netherlands and because the fight against female genital mutilation would be more difficult if male circumcision were also to be challenged.

She points out that male circumcision, as fully as FGM, is a breach of the universally accepted human rights and rights of the child, citing the Convention on the Rights of the Child, which prohibits torture or other cruel, inhuman or degrading treatment or punishment, and urges in Article 24 that governments take all effective and appropriate measures with a view of abolishing traditional practices prejudicial to the health of children.

Enlarging on the legal and moral issues that surround circumcision, Australian David Richards comments on the fact that all humans have a right to bodily integrity and that parental permission for medical treatment must be grounded in the assumption that the treatment will result in a benefit that supercedes the negative of invading a child's personal integrity. Richards comments that female circumcision is likely to be prohibited in Australia in the near future and that it is illogical that male circumcision has not been considered with this prohibition. Surgical cutting and disfiguring of a healthy genital organ is consistent with both male and female circumcision.¹⁴

Whatever the benefits of male circumcision may turn out to be---none, some, or significant---they seem so far only to involve adult sexual behavior. A decision by an adult male to be circumcised might be quite appropriate once he has considered his own individual circumstances and the risks and benefits of the procedure. But that is quite different than subjecting a neonate to the procedure, where no clear health benefit has been established.

My favorite pediatrician and a Partnership scholar, George Lazarus, MD, does not agree that circumcision is without health benefits to the male and even to his female partners, but commented that the most frequent reason babies are circumcised is to look like Dad. Surely we can do better than that. The unquestioning acceptance of routine circumcision of a newborn, including religious purposes, deservesa hard look and wide-ranging debate.

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