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Male Circumcision and the Enhancement Debate: Harm Reduction, Not Prohibition

This blog is a brief response to ‘Out of Step: Fatal Flaws in the Latest AAP Policy Report on Neonatal Circumcision’ by Steven Svoboda and Robert Van Howe, and the AAP Task Force on Circumcision’s ResponseThis is part of a special issue summarised by Brian Earp.


Around one third of men worldwide are circumcised. It is probably the most commonly performed surgical procedure. Circumcision is also one of the oldest forms of attempted human enhancement. It is and has been done for religious, social, aesthetic and health reasons.

Circumcision has a variety of benefits and risks, many of which are discussed in this issue.  There is some dispute about the magnitude and likelihood of these benefits and risks. Some argue that the risks outweigh the benefits and circumcision should not be performed on children who are not competent to make their own decisions.

If it were true that the risks of circumcision clearly outweighed the benefits, great harm has been done and is being done globally through this procedure. Around one third of men have been harmed. This is an extraordinary public health injury. Presumably, some would be entitled to compensation.

The fact that few people think that there is not such a bad situation affecting millions of men indicates that most people implicitly believe that circumcision is not a significant harm, if a harm at all. (This is an example of the kind of argument called modus tollens. If p, then q. Not-q, therefore not-p.)

It is reasonable to conclude either that:

1) It is not clear from existing evidence whether the risks of properly performed circumcision outweigh the benefits, or vice versa.


2) If circumcision is against the interests of an infant, it is only mildly so.

In general, people should make their own decisions about body modification and human enhancement when this is possible. Such an approach speaks in favour of waiting until a child is adult to make his or her own decision about circumcision. And procedures which are not clearly in a child’s interests should not be performed on that child. However, religious and other social exclusion may make delay in circumcision psychologically harmful.

It would be a mistake to ban circumcision, given its importance to many people. A dangerous “black market” would be created. As with other forms of potentially risky human enhancement, the best policy is one of harm reduction, not prohibition. Non-medical circumcision should be discouraged, but not prohibited(for further discussion see ‘Rational Non-Interventional Paternalism: Why Doctors Ought to Make Judgements of What Is Best for Their Patients’and ‘Liberal Rationalism and Medical Decision-Making’).

Many of the risks of circumcision, such penile injury, herpetic infection and pain are almost entirely avoidable with modern surgery. What seems ethically clear is that male circumcision in developed countries should only be performed by a properly qualified paediatric surgeon in a hospital setting, with appropriate analgesia. Where religion requires that circumcision be conducted by a religious official, that official should be surgically trained or participate in the surgical procedure in a way that does not compromise the interests of the infants.

Religious practices have been adapted in other cases. Circumcision is a challenge to modern religion to embrace modern medicine and surgery to protect the child.

There is one objection to circumcision which is common in folk debate but which should be dismissed.  Some people would object that the removal of the foreskin is “not natural” and so should not be performed on a child. This kind of naturalistic objection dominates discussion of enhancement in general.

Medicine, of course, is not natural. Vaccination is not natural. Pain relief is not natural. In both these cases, some religious fundamentalists objected on the grounds that vaccination and pain relief in labour thwarted God’s will. Thankfully, such arguments are no longer popular today. We have embraced many non-natural medical interventions which are not aimed at treating diseases, such as contraception, abortion and cosmetic surgery. The first two enhance reproductive freedom. Indeed, elective Caesarean section is not natural but an increasingly attractive option for some women as a way to maximize the outcome of pregnancy for their baby and themselves.

Imagine a child was undergoing an abdominal surgical procedure for some pain. The surgeon inspects the appendix and it is normal. However, the surgeon decides to remove the healthy appendix anyway to prevent future appendicitis and because the procedure was already in progress. Whether such a decision was right does not turn on whether natural bodily integrity is important to preserve, or whether there is some right to an appendix, but on the risks and benefits of removing a healthy appendix in this situation.

Circumcision is not natural. Whether it is an enhancement depends on the way it is performed and the situation in which it is performed. It is clear that the routine circumcision of male infants that was practiced in many parts of the developed world is no longer justified or necessary. However, the best practice should be for doctors to engage parents in dialogue about the risks and benefits of circumcision, perhaps attempting to discourage it. But if parents are adamant, frequently for religious reasons, then the procedure should be performed by a surgical professional in a hospital environment where the risks are minimized and hopefully removed entirely.

In cases of controversial contested enhancement, the best social policy is one of harm reduction, not prohibition.

Post script: sex, the foreskin and enhancement

Another objection stereotypical of the enhancement debate occurs in the male circumcision debate. Some claim that circumcision reduces sexual function, though others deny this. Thus some objectors claim that the foreskin is necessary for optimal sexual functioning.

Let’s assume for argument’s sake that circumcision does reduce sexual sensitivity (though the evidence on this appears conflicting). It does not follow that the male foreskin is necessary for optimal sexual functioning. The possibility of enhancement implies that we, at some point, may be able to do better than nature. That is, at some point in the future artificial foreskins may be available that surpass the natural variety in promoting sexual pleasure.

Bizarrely, there are already attempts to replicate nature – there are artificial foreskins (for example, the SenSlip). It is only a matter of time before these are better than what nature provided. The results of nature are not the result of design (even religious fundamentalists agree with this in the case of the foreskin), but of blind evolutionary processes which enable survival and reproduction in a particular evolutionary niche. It is possible, in principle, to do better than the foreskin.

Finally, if the foreskin is important to sexual functioning, there might be opportunity for further compromise. Circumcisions can be comparatively ‘tight’ or ‘loose’. Loose circumcisions preserve some of the rolling action in the prepuce that acts as a natural lubricant. One form of harm minimization that would respect religious liberties while reducing loss in sexual function would be to try to ensure all circumcisions are ‘loose’.*

Dialogue and compromise may be preferable to extremist positions such as zero-tolerance prohibition and laissez-faire.

*Thanks to Bennett Foddy for this point.





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52 Comment on this post

  1. Much of this blog entry is nonsense not backed up by evidence (very little is cited) and does not represent established fact. Male circumcision is harmful in all cases. Furthermore, should we aim for harm reduction, not prohibition in the fight against FGM? Male circumcision is genital mutilation, plain and simple. And it should be banned except for medical necessity and/or informed consent.

    1. Completely agree, the argument that we should aim for risk reduction, rather than outlawing – as this would create a black market – goes completely against the approach that has been taken with female circumcision. It that case a clear harm was identified, and legal processes initiated to ensure that people conducting such acts are punished. If male circumcision also causes harm, then the obvious conclusion which follows is that this should also be subject to legal restrictions and punishments – to not do so can only be the result of cultural or sex bias.

    2. I agree 100%. Populations that circumcise girls see no harm in that procedure, but that doesn’t mean there isn’t any. Slave owners, wife rapists and child beaters saw no harm in those practices either, in times past.

      Perhaps brit milah could be replaced by a pinprick, as sunna has been in many Islamic communities, although even a pinprick is a step too far in the zero tolerance campaign against FGM. If only boys were accorded that degree of consideration!

  2. Enhancement? What makes you think that ancients going at newborns’ genitals (boys, girls, intersex…) with flint knives and their fingernails, without asepsis, were aiming for, let alone achieved, enhancement? A bizarre assertion.

    ‘Penile injury’ is not a ‘risk’ of circumcision – it’s part of its definition; to argue otherwise is to do violence to language.

    Your argument of ‘tight’ versus ‘loose’ circumcisions is incoherent; you patently aren’t familiar with the anatomy you’re discussing. The ridged band, a specialised sensory structure described by Taylor in his papers (BJU, 1996 and 1999) sits at the very tip of the foreskin, and is ablated by circumcision, however ‘conservative’.

    “1) It is not clear from existing evidence whether the risks of properly performed circumcision outweigh the benefits, or vice versa.


    2) If circumcision is against the interests of an infant, it is only mildly so.”

    This is arrant nonsense. Girls’ genitals were being cut by physicians in the United States as late as the 1970s; many millions of girls, including a number in our own societies, are still being cut today. Why do you write as though the general public has perfect information? Organised consciousness-raising around the issue of genital cutting (of boys, girls, and the intersex) has only just begun.

    Which religious liberties ought we to respect? Those of Jews, apparently – and the nicer Muslims, I guess – you know, the ones who don’t think cutting girls is a religious obligation. Whatever will we do if people refuse to pay tax for ‘religious reasons’? There’s an idea…

    Ablating healthy, erogenous tissue from genitals other than your own, without pressing medical need (having exhausting all conservative treatment options), and/or in the absence of informed consent, is an assault, a disfiguring rape.

    Your article is f*cking terrible.

  3. Oh, and how would circumcision fail to diminish sensitivity? You’re circumcised, aren’t you? How am I always able to tell?

    What is circumcision? Circumcision is the excision of the foreskin. What is the foreskin? The foreskin is part of the penis. What is the effect of circumcision on foreskin sensitivity? Pretty devastating, I’d imagine. You see what I did there?

    Come on. Make an effort.

  4. What we call “male circumcision” amputates the mobile portion of the penis and thousands of the most specialized pressure-sensitive cells in the human body; Meissner’s corpuscles for light touch and fast touch, Merkel’s disc cells for light pressure and texture, Ruffini’s corpuscles for slow sustained pressure, skin tension, stretch, and slip, and Pacinian corpuscles for deep touch and vibration are found only in the tongue, lips, palms, nipples, fingertips, the clitoris, and the Ridged Band of the male foreskin. These remarkable cells process tens of thousands of information impulses per second! These are the cells that allow blind people to “see” Braille with their fingertips. Cut them off and it’s like trying to read Braille with your elbow. Information from tactile sensitivity gives humans environmental awareness and control. With lack of awareness comes lack of control. Luckily, for those who have them, Nature has mandated that these four types of mechanoreceptors do not age-degrade like the rest of the body’s cells. To say that amputation of the clitoris or the mobile roller-bearing-like portion of the natural penis and consequently thousands of these specialized nerve cell interfaces does not permanently sub-normalize one’s natural capabilities and partially devitalize one’s innate capacity for tactile pleasure is grossly illogical denial of the bio-mechanical and the somatosensory facts of human genital anatomy. The foreskin also forms an organic seal keeping natural lubricants inside the vagina during intercourse. Millions of years of trial and error evolutionary forces have synchronously engineered the human sex organs. The penis perfectly compliments the female body. Like other organs and limbs, a man can live without out it, but he’s certainly better off with it – all of it.

    1. “To say that amputation of the clitoris or the mobile roller-bearing-like portion of the natural penis and consequently thousands of these specialized nerve cell interfaces does not permanently sub-normalize one’s natural capabilities and partially devitalize one’s innate capacity for tactile pleasure is grossly illogical denial of the bio-mechanical and the somatosensory facts of human genital anatomy.”

      Well said.

      The Braille analogy is also very effective at conveying the point. People never seem to want to look at the neural workings of the penis and even more reluctant to admit the high sensory resolution of the the foreskin.

      I would like to see research into the brain to see what happens to the axonal connections that are not receiving impulse anymore due to the excision of the mechanoceptors. Could the young plastic brain forever lose its total pleasure deriving capacity once their brain solidifies into an adult one? My suspicions are demonstrated by circumcised men who race towards orgasm only, they cannot sense pre-orgasmic sensations very effectively.

      Its actually better to let the individual choose for himself. That way the patient can choose the conditions, especially after the foreskin has retracted. That said, no anomalies in adolescence can occur if too much skin is removed early in life. The patient can choose how much to remove and which structures. The frenulum is the most sensitive part of the penis, some anatomically aware men choose to leave this intact knowing just how much pleasure giving capacity it has. An infant cannot, he will lose it or get it partially compromised. Due to psychological harm so early in life, its best to leave the decision to the patient.

      Non-therapeutic infant circumcision is a human rights violation and Hippocratic one too. The religious argument is invalid as it violates a person’s right to self determination as circumcision is a mark and/or association of Christians/Jews/Muslims. As a secular Atheist for example, I find this against my interests, once again, it was forced on me just like everything else following religion. Human rights overrule religious interests that impede on one’s self determination.

      As for the “Senslip” this acts only to cover the mutilated penis and reduce the effects of cornification, it doesnt revive the the tens of thousands of nerve endings lost. All that remains primarily are nociceptors in the Glans. Nothing coming anytime soon can replicate the complexity of 12 sq inches of vascular and highly innervated tissue. Who knows if its even possible since after so many years the child’s brain adapts to having a deficit of the natural feed of neural impulses from the abscence of an area of high sensory resolution. Even if it were possible, the victim would still have to find a way to pay for such services, these may not be very affordable to all people who have had their genitalia removed.

      Hegemony is responsible for the deviations from what is current world wide, like the fact that most men do fine having foreskins. It only so appears that in America, men are allergic to their foreskins and a resistant to antibiotics.

      And why would this article say “Bizarrely,” when its natural to want to have the body you are born with. Theres more than enough studies to describe the nature of the prepuce. Reduction of tissue damage (in which circumcision is inherently tissue harm) is a good start, but due to its unnecessary nature, its best not to force it onto infants. Commonly the grounds at which its performed and justified, are very shaky at best, its history isnt very impressive either (especially with its overdrive during the anti-masturbatory campaigns in the late Victorian Era.) With all that said, its pretty much clear (atleast to those observing all the aspects of circumcision) that circumcision is something that should not be forced on infants, it should be elective to a consenting individual or with legitimate medical indication (no forced pre-mature retraction to fool parents.)

  5. Let’s compromise by only cutting off part of girls’ clitorises! That way we can reduce the loss of sexual pleasure while still making the parents happy.

    Can’t believe this guy is a professor of practical ethics. What a joke.

  6. Anthony Drinkwater

    You describe Julian, the case of the surgeon and the removal of a healthy appendix which you justify by the consequent positive balance between risk and benefit.

    I agree completely, but you do not go far enough in your argument.

    We should not only remove all appendices and foreskins, but we should also castrate all boys at an early age and thus hugely benefit humanity.
    As you state, the rightness of the decision does not turn on whether natural bodily integrity is important to preserve, or whether there is some right to natural sexual and hormonal characteristics, but on the risks and benefits of castration. There is not much doubt that we would at least eradicate AIDS, rape and war through this policy, and probably obtain a mass of secondary benefits (the voices of castrati are said to be angelically beautiful, for example). It is hard to see the risks (provided of course that the intervention was performed by a properly qualified paediatric surgeon in a hospital setting, with appropriate analgesia). Human reproduction can be assured by IVF and a few carefully chosen males with the best genetic material could be employed to fill the sperm banks…
    I look forward to your advocating it on Euhiro.

    1. Wow, really? Eugenics and castration, why not just suicide too while we are at it. Compromising the quality of life while creating a bunch submissive frail eunuchs as well as violating human rights on a daily basis on children. Its people like you Anthony who interests in extremism are responsible for mind sets that propel the very things you aim to stop. The HIV argument is invalid as described by the US, a country that has been circumcising for the last century, still the AIDS epidemic ensues unlike in intact Europe who reigns supreme in sexual health. War is caused by social disputes, not genitalia.

      Such sexual abuse you promote is unethical and is a characteristic of extremist views, eunuchs are no different than the people they try not to be. This is an example of a mindset that is involved in the genesis of such barbaric rituals like circumcision.

      1. Anthony Drinkwater

        I’m not the first, or only one, Justin. Dean Swift advocated eating babies to solve the question of the Irish famine : A Modest Proposal for Preventing the Children of Poor People From Being a Burden to Their Parents or Country, and for Making Them Beneficial to the Publick, in 1729. You might care to read it.

        1. Dean Swift’s “Modest Proposal” was a satire on the cruelties that resulted from British policy towards the Irish. It wasn’t meant to be taken literally.

          1. Anthony Drinkwater

            Thank you Michael, but I’m not sure that I believe you, as it is intellectually dishonest to write the opposite of what one really means to say.
            Personally, I’d never attempt to use such methods – especially on an Ethics blog.

      2. In New Zealand, non-therapeutic circumcision was reduced from near-universal to residual levels within one generation by a few actions that had nothing to do with the law. The chair of the Professorial Board of the newly opened National Women’s Hospital in Auckland ruled in 1962 that babies could only be circumcised there by private practitioners – they would be given a tray of instruments and a room and left to it, but the hospital’s doctors could not circumcise healthy babies. Other hospitals followed suit, and a “sleeping dogs” policy of not raising the subject became the norm. Some time after this, public funding (which covered birth) was cut. This was done so inconspicuously that we have been unable to find out the exact date. Now there are only a few large cities where any doctors will do it, and their clients are mainly the children of Muslims and non-Maori Polynesians.

        In countries such as the USA where circumcision has become a cultural norm and there is a financial incentive to do it, such tactics may not work, and a more deliberate approach may be necessary. I suspect that the consciousness-raising parades of the “Walking Wounded” men in white overalls with a bloodstain at the crotch will do much to make the point that this is an action that affects not just babies but men. In the last ten years the subject has become much more controversial, and this can only be a good thing when the arguments for it are so weak and those against it so strong. It is the irrational aspect that will be the hardest to counter.

  7. The alleged benefits are contrived by people trying to keep the practice going – they want to pass it on to the next generation.

    This person doesn’t understand the 20000 pleasure nerves because he has no reference? He does have nipples, fingertips and lips that have similar nerve endings. Would he also say that removing these will not lower sensation/pleasure? Does he think sensory input is optional. How can people think the everting parts of the penis are not important? Do they NOT have them?

    This would all be funny, but for the fact that people pay attention to this person. What would you think if a bunch of color blind people told you you need to shut off your child’s color sight? …or one eyed people saying 3D sight is of no purpose?

    How can people have an opinion on this when they think the THOUSANDS of specialized nerve endings and their connection to BRAIN is not meaningful? These are the most innervated parts of the penis. The parts cut off shut down a huge part of the kid’s/man’s sensory system.

    These parts can never be returned. They belong to the owner and should never be taken away without the owner requesting it.

  8. I know there are many religious reasons for circumcisions, but I think it should be based on medical reasons. I do not believe there is a sound reason to cut part of your body other than complications.

  9. It is odd that Savulescu sees male child circumcision as an enhancement without considering the possiblity that it might be a diminuition. Other “enhancments” might include piercings, scarification or tattooing. We recognise that these “enhancments” are to be elected by consenting adults, not imposed upon non-consenting children. The same should be true of circumcision, which brings us to the real issue: the child’s right to autonomy. Future enhancements might include the installation in the body of chips to provide additionall senses, but these too should respect the child’s right to autonomy and not be imposed before the child is old enough to give or withhold consent in his own right.

    Savulescu asserts: “It is not clear from existing evidence whether the risks of properly performed circumcision outweigh the benefits, or vice versa [or if] circumcision is against the interests of an infant, it is only mildly so”. For the men who resent the fact that circumcision was imposed on them in childhood without the opportunity to refuse, the alteration of their body can be a cause of lifelong suffering. For these men the harm is real and they must not be ignored.

    Children must be protected from circumcision not because it is “unnatural”, but because it denies their right to autonomy. As such the practice must be consigned to the dustbin of history along with slavery and foot binding.

  10. As the author of this blog has talked about harm minimisation, I will take him at his word and propose some changes in the law to achieve that aim. It is based on certain premises:
    * That circumcision is a controversial operation where people hold passionate but quite incompatible views both for and against.
    * That because people’s views about circumcision are so polarised, at least some disputes between parents about circumcision are inevitable.
    * That circumcision carries risks, that can be greatly reduced but not completely eliminated by proper medical practices.
    * That no responsible person could or would countenance the forced circumcision of adult men.

    First, the forced circumcision of men has been documented in many contexts, including Ambon, Indonesia in 2001, South Africa, Kenya and other places. See , and i believe that the best way to stop forced circumcision is to treat it as a sexual assault, and brand the assailants as sexual offenders. This is a powerful way of stigmatising the aggressors.

    Secondly, circumcision is very risky if it is done by incompetent surgeons, or if it is done in unhygienic surroundings or by unqualified people. Despite this, there appear to be no laws that would prohibit unqualified people from circumcising others. Take the case of Omunnakwe Amechi in London. He successfully argued that there were no formal rules governing circumcision and it was not regulated by the General Medical Council or anyone else. It is outrageous that someone can walk in off the street and circumcise people without any qualifications. Circumcision by unqualified operators should be illegal.

    Thirdly, not all parents agree on circumcision. Take this recommendation that circumcision “should not be performed in the face of parental disagreement” This should be enacted into law.

    Fourthly, thee should be firm rules to ensure that every baby to be circumcised must be medically examined by an independent doctor and a circumcision must not go ahead unless the doctor has given written advice that the child was strong enough to withstand the surgery and is free of any contra-indications like haemophilia or a genital anomaly that would make the procedure inadvisable.

    Fifthly, if a circumciser does the job badly, he or she should be prohibited from doing circumcisions. See the cases of Drs Aladdin Mattar (1997) and Suman Sood (2006) in Australia a New Zealand case a recent British case

    These and other rules won’t stop circumcisions from being performed but will help to minimise the harm that is done.

    1. The whole point of this post was to argue that it would be a mistake to ban circumcision because it would still be done and cause great harm. In fact, I said it should be discouraged. The facts are well described in the special issue of the Journal of Medical Ethics to which this blog relates.

      Thanks Michael Glass for engaging with the actual proposal and for these very helpful suggestions. I will link to your blog in the eventual editorial to the special issue in the JME. The first thing we ought to be doing is ensuring that any circumcisions that are going to be done are done properly.

      By all means go ahead and try to ban it. You will fail to prevent it, as the recent episode in Germany shows.

      1. I agree that the practice should be discouraged, and that trying to “ban” it is not the best way forward.

        That said, we need to recognise that it is n ot a victimless crime. It does infringe boys’ right to autonomy and we do have a right and a duty to try to protect that.

        What the German experience shows is that circumcision is a crime under existing laws, and that politicians will bend over backwards to protect the practice rather than respect the principle that human beings have a basid right to autonomy and human dignity.

        Ending the practice will be difficult, but end it we must just as we did with slavery and footbinding.

      2. Anthony Drinkwater

        I understand your “gradualist” argument Julian, although I do not agree with it.
        I wonder whether you would use the same argument concerning female genital mutilation? And if not, why not?

      3. As others have noted, FGM should no be banned by the logic you are using. Your point of view is absurd, and your blog entry fails to reflect the ethical, medical, and legal issues regarding male circumcision. I believe that you should consider educating yourself on this issue before continuing further down this path. Male circumcision is not parental choice. It’s the choice of the owner of the penis. It should be banned just as FGM should be banned except in medical necessity or as cosmetic surgery in which the patient is old enough to consent.

      4. Chiming in here to salute Michael Glass for these very specific proposals, as Julian rightly notes. I have come to the view that outright prohibition of all non-medically indicated circumcisions would certainly be premature at this point, and might only become plausible or advisable at a future point if the culture has changed sufficiently. In the short-term, therefore, harm reduction becomes the paramount aim (along with medium- and long-term efforts to nudge the culture toward clearer and more consistent thinking on this issue, which in my view would put it on par with female genital cutting, all forms of which are federally prohibited in the U.S. no matter how slight, and no matter for what reason); and it seems to me that some of Mr. Glass’s recommendations might well be on the right track toward this end. Looking forward to seeing some of these concrete suggestions raised in Julian’s editorial with credit to Mr. Glass.

      5. It is a mistake to abolish slavery, instead let’s just whip then less often.
        It is a mistake to allow women the vote, instead we’ll just count every tenth vote.
        It is a mistake to prevent children working in factories, instead we’ll just make sure they take a midday nap.
        It is a mistake to outlaw female mutilation, instead let’s make sure they are cut with clean knives.

        It is a good thing those activists didn’t take your advice.

  11. This is indeed a polarised and divisive debate, and there is no doubt which camp Mr Savulescu is in. He says: “It would be a mistake to ban circumcision, given its importance to many people.” I presume that he is referring to the forced circumcision of infants and minors. As far as I am aware most of those who feel strongly about this issue do not give a tuppenny damn about what consenting informed adults do with their penis. However, I wonder how many infants and minors feel it is important to have a functional and perfectly natural part of their body forcibly amputated? This same body part is possessed by all mammals and yet we smart humans do not forcibly circumcise all the animals that we exploit for our own gratification and benefit. If it is so beneficial and harmless for us humans then why not for livestock as well? Are not dumb animals that do not have the sanitary conditions that we enjoy, suffering from all the problems that circumcision is purported to spare us humans from?

    As we know, but so many will not admit, circumcision is important to those men who had it forcibly imposed on them as infants and persist in denying that they have suffered any harm as a result. They thus feel it appropriate to force it upon their young as a form of affirmation for themselves that it is harmless and even beneficial to save their male offspring from the psychological trauma of having been left intact as nature intended.

    I and I know many others are firmly of the belief that great harm has been caused to society by circumcision. The main reason that it has not been obvious to millions of men who have suffered this great harm, is that they have never known what their life would have been like if they had been allowed to remain whole as they were at birth. You don’t miss what you never had, but that doesn’t mean that you are not the poorer man without it!

  12. It is up to parents to determine whether their boys should be circumcised. This is a decision that is to be made between a boy’s parents and their doctor. It also appears to be the emerging consensus in North America as to where the medical community is moving on this issue. When it comes to the medical policy on circumcision for boys, it has recently been reported that the Canadian Pediatric Society will now be following the lead of the American Academy of Pediatrics by dropping its previous opposition to male circumcision. The new Canadian policy will recommend that parents be informed of both the benefits and risks of circumcision for boys and leave the decision up to the parents.

    1. Actually, both American and worldwide medical opinion is swinging the other way. Circumcision is a money-making institution for American doctors and that’s why they don’t want to see it go. You fail to consider the decision of the child to keep his own penis intact. Please explain why it is not the owner of the penis’s choice. By your logic, FGM such as Sunat would be acceptable.

  13. Any individual or organization that claims infant circumcision is harmless, or that the benefits outweigh the risks, is either incredibly ignorant about the many functions of the intact (uncircumcised) penis or is deliberately being intellectually and morally dishonest. The medical community has NEVER investigated the long-term adverse physical, sexual, psychological or emotional consequences to men circumcised in infancy.

    The Global Survey of Circumcision Harm was a 14-month online survey that gave men the opportunity to document their circumcision harm through a survey and the ability to upload photos of their harm and video testimonies.

    This is the second such grassroots survey, the first being a “Preliminary Poll of Men Circumcised in Infancy or Childhood” published in 1999 by BJU International.

    Men’s voices against this practice are increasingly being raised. It’s high time the medical community made an effort to investigate this harm before they issue any further policies on this social custom.

  14. Proposing a “harm reduction” approach to infant circumcision – rather than an outright ban – is ludicrous. The very term itself admits that harm is being done, which begs the question “Why should any society that claims to care about children tolerate any child being even ‘minimally harmed’, regardless of the child’s gender or the religious/cultural background of the child’s parents?”

    In most countries non-medically indicated circumcision of male infants exists in a legal gray area; it is neither illegal nor is it explicitly legal.

    However, every non-medically indicated circumcision of an otherwise healthy child, even when performed by skilled surgeons or religious/tribal elders, inflicts harm by altering the design, form and functions of the human genitals and infringes upon the child’s eventual right to an open future regarding this most intimate part of his body.

    Yes, an outright ban will encourage “back alley” circumcisions, just as happens with female circumcision in many Western and African nations where the practice is banned. After an initial outcry, however, most parents, doctors and ritual circumcisers develop a new-found understanding of children’s rights, they conform to the law and they develop alternative non-cutting rituals. Yes, a small percentage of the public might try to circumvent the law by engaging in “illegal” circumcisions, and they should be dealt with accordingly by the justice system. Even with “back alley” circumcisions, the number of children exposed to “severe” harm will be much smaller than the much larger number of boys currently exposed to “minimal-to-moderate” harm by the practice in its current state of legal limbo.

    1. I would like to point out that many thoughtful individuals who are invested in the ultimate abolition of involuntary circumcision of males — who see it as a form of assault, on par with analogous interventions on female minors — are in agreement that an across-the-board ban might be counterproductive at this particular point in the social and cultural conversation. These people might be persuaded that a ban is indeed the best strategy, given decent counterarguments and the proffering of real evidence in favor of that view. But they aren’t simply nuts. Lots of things are harmful, and banning them is not always the best way to eliminate the harm, as it can sometimes lead to greater harm on the side. Whether that would be the case for male circumcision, if a law were suddenly passed in every Western culture prohibiting the practice outright, is not clear, and is certainly not definitively knowable given current evidence. Female genital cutting has indeed been banned in Western societies, no matter how slight the intervention, and regardless of the motivating reason. This seems to me a good target for males as well, who should be protected as much as their sisters. But in the United States, at any rate, it might very well be the case that such a ban would lead to MORE harm of boys through the black market Julian predicts. Hence anyone who is concerned with protecting boys from needless genital interference, from injury, infection, and even from death, must be willing to consider possible side-effects of a prohibition strategy. At the very least, to suggest that ANY position other than a full-on and immediate legal ban on male circumcision is “ludicrous” is to close oneself off to productive discourse, not only with those who would passionately oppose such a ban, but even with those who are interested in eliminating involuntary circumcision via any other mode than immediate prohibition. Prohibitions that are put in place before the culture is ready for them have been tried many times throughout history, and they have a pretty bad track record. Therefore a chief aim must be in changing the cultural conversation, and getting people to see that male and female forms of genital cutting done at the whim of the parents’ culture are equally outmoded, and equally hard to square with contemporary notions of medical ethics and human rights. If this change in cultural conversation is to have any chance of happening, then those who are invested in such an outcome must, in my view, take care not to label any viewpoint other than their own as “ludicrous.” As I say, this is to alienate not only those who wish to defend circumcision, but even those who seek a gradual solution that minimizes harm over the short-, medium-, AND long-term, including many passionate anti-circumcision advocates. Thinking of the baby who dies, or of the infant who loses his penis outright in a “back-alley” circumcision done by an incompetent practitioner should give pause to the person who would scoff at any intermediate strategy of reducing harm on a gradualist framework. Should that baby die, or lose his penis to a scalpel-slip, as the price to pay for some other counterfactual baby losing his foreskin with anaesthesia administered at the hand of a skilled surgeon — who has back-up measures available in case something goes horribly wrong — in the medium term? Are you willing to sacrifice that baby, or that baby’s penis, on the alter of an immediate righteous ban? Or could we at least discuss intermediate strategies that begin with harm reduction, that aim to change the cultural conversation, and that lead, with minimal collateral damage, to the ultimate abandonment of this pre-Enlightenment rite?

  15. It’s unethical to cut off infants and childrens prepuces because it may or may not prevent them from possibly being cut off later. That’s like OCD crossed with schizophrenia. Proper education on the physiological functions and development of the male and female prepuces, from infancy through adulthood, and the safe and proper care, use, and hygiene of each can prevent circumcisions and excisions, along with all the long term risks and harms, physical and psychological, caused from excessive, botched, traumatic and unwanted forced circumcisions and excisions. The neurological functions of both sexes prepuces are to cause sexual arousal when physically stimulated. The amounts and effects of the nerve damage depends on how much the circumcisor chooses to remove. It is too easy for this power over sexual development to be abused and used as a form of eugenics by one ethnic group over another race or religion. This ancient superstitious witchdoctor medicine of ritual, routine, and religious infant circumcision should be kept outlawed like routine lobotomies. Only necessary prepucectomies should be allowed, not preventative sacrificings. That’s unethical. More than 70% of the worlds parents have been able to raise their children intact, and most all our ancesters. Having lips on our sex parts is as natural as lips on our faces. I had an excessive infant circumcision and I am restoring.

  16. Autonomy in medical practice is widely agreed to be just about the most fundamental principle when viewed from the perspective of the patient. Of course, some people without capacity (to make their own autonomous decision) must necessarily rely on others for decisions that can’t wait- usually at times of medical emergency. The extraordinary suggestion that we must now extend this to times of perceived religious or cultural emergency to operate on normal baby boys bears closer scrutiny.

    Ordinarily, doctors must bear in mind the following self-evident principles when considering treating a person without capacity:
    -Consider whether lack of capacity is temporary or permanent
    -Always take the least restrictive action
    -Always act in the best interests of the person

    In the context of ritual childhood circumcision, what are the best interests of the person in question?
    There is a very large body of respected medical opinion (forcibly and uniquely challenged by the AAP) supported by the evidence that it is a harmful procedure when performed on an intact, normal child. Increasingly, adult men are complaining that this non-emergency procedure was forced on them as infants before they had the opportunity to form their own views or cultural affiliations. The AAP position that cultural considerations should be added in to the mix is a good starting point but since we don’t know what the views of the child will later be, there can be no justification for performing an irreversible, invasive operation on the most intimate parts of a person’s body on a hunch. Were we to assume a child’s opinion or views, me might tattoo the name of the parents’ political party or football club on the child’s body at birth- after all, in the majority of cases the ‘hunch’ would probably be correct if equally unacceptable.

    Over and above purely medical considerations, in the UK, we have a guide to answer the cultural ‘best interests’ question by way of the 2003 FGM (female genital mutilation) legislation. Section 1(5) is unequivocal: ‘it is irrelevant whether or not a person believed the operation to be necessary in the child’s best interests as a matter of custom or ritual’. There is no coherent ethical or legal framework that would afford this protection only to children of one gender. And the law on FGM applies, as it should, to all forms of FGM including the minor ritual nick.

    The pragmatic argument in the article above that it would be a mistake to ban circumcision because experience has shown us that banning things doesn’t always work is flawed. It really depends what you’re proposing to ban.
    There is a huge difference between banning things that autonomous adults (essentially) do to themselves such as smoking, drinking, abortion, taking one’s own life, taking drugs and banning things that cause harm to non-autonomous people such as murder, robbery, rape, forced infant genital cutting. The former is a nuanced debate the latter is, or should be, covered by basic inalienable human rights. Damage limitation is a fine argument when we’re trying to limit the harm that people will do to themselves such as providing clean needles for drug addicts but is misplaced when the consideration is how best to protect vulnerable people from forced surgical excision of some of the most intimate parts of their own body.

    In practice, even the harm reduction argument is moot. In the UK many ritual circumcisions are performed on the NHS. In Birmingham such a putative harm-reduction strategy was set up about 4-5 years ago. And in 2011 alone, eleven baby boys were admitted to the paediatric intensive care unit of Birmingham Children’s Hospital with ‘life-threatening complications’ from an operation that they almost certainly didn’t need for any medical problem and that was likely carried out by registered medical practitioners.
    And if forced genital cutting to satisfy parental cultural demands were to be placed squarely, as suggested, in the sanitised domain of registered medical practitioners, what about the practicalities of which registered medical practitioner would participate? Would paediatric surgeons be obliged to perform this unnecessary operation as part of their contract? Would the health service be contractually obliged to provide a ritual cutting service or itself take the blame for backstreet operations?

    It is true that banning things doesn’t always achieve an immediate end to practices- (there are still murders, rapes and burglaries) but it helps to shift culture. As an educated guess, (for it’s notoriously difficult to collect reliable evidence in this area), it is likely that FGM legislation has reduced the numbers of girls subjected to this assault because some people will have taken heed of the law. Many religious and cultural traditions have adapted over the years to the environment in which they have found themselves.

    The best method of harm reduction is not to institutionalise the harm (even as a temporary measure) but to reduce the number of people subject to assault on their bodies. Backstreet ritual circumcision is already widespread in the UK, and many other countries. Banning the practice would likely increase the proportion performed by non-medics but would also likely reduce the total number performed as some people would opt to obey the laws of the land in which they find themselves. The end result would be less harm rather than more and would be more of an ethically acceptable approach than wilfully causing some harm purportedly to reduce a greater harm.

    In fact there is no need for a specific ban on non-therapeutic infant male genital cutting. The need is for time to be called on religious and cultural exceptions to the existing basic laws against cutting and wounding vulnerable people who have nothing wrong with them but who have happened to be born into an environment where a lot of people regard cutting children’s normal genitals for no medical reason as somehow normal and acceptable.

    That ‘most people implicitly believe’ something, (the argument from numbers) is hardly a good guide. 2 or 3 hundred years ago most white people used to ‘implicitly believe’ that black slaves were a lesser breed of human. And the fact that many slaves themselves didn’t have an experience of not being a slave, just as many men cut as infants have no experience of being intact, is not an argument for the safety or continuation of such practices.

    In the meantime I would wholeheartedly agree with Julian that: ‘the best practice should be for doctors to engage parents in dialogue about the risks and benefits of circumcision, perhaps attempting to discourage it.’ with the caveat that the word ‘perhaps’ is redundant.

  17. The risk-reduction measures suggested by Savalescu are theoretical, but not efficacious, practicable or justifiable from an ethical perspective.

    Savalescu says: “Many of the risks of circumcision, such (sic) penile injury, herpetic infection and pain are almost entirely avoidable with modern surgery. What seems ethically clear is that male circumcision in developed countries should only be performed by a properly qualified paediatric surgeon in a hospital setting, with appropriate analgesia. Where religion requires that circumcision be conducted by a religious official, that official should be surgically trained or participate in the surgical procedure in a way that does not compromise the interests of the infants.”

    The first sentence is entirely untrue (and the last sentence rather mystifying). There is simply no evidence at all that in the U.S., a developed country where hospital-based, physician-driven circumcision is the rule, complications only occur when the practitioner is untrained or incompetent? Will meatal stenosis, one of the most common complications of infant cutting, cease to occur if only “properly qualified pediatric surgeons” are allowed to perform circumcisions? I haven’t followed every lawsuit for botches or amputated glans penises, but nothing I have seen suggests that bad outcomes are mostly due to run-amok, untrained doctors. On the contrary, infant circumcision is an easy, mundane, ho-hum procedure; but the tiniest miscalculation or malfunction of equipment, or a doctor’s ignorance of an infant’s blood disorder can render the child a sexual cripple or send him into a death spiral. Just two weeks ago, a California newborn died from organ failure, following a hemorrhage induced by his circumcision in a California hospital. In 2011, 2 yr-old Jamaal Coleson died following his in-hospital circumcision in one of NYC’s most prestigious hospitals; news reports indicate the death was anesthesia-related.

    Similarly, Savalescu’s suggestion to “reduce harm” by seeing to it that all circumcisions are “loose” can strains credulity. Shall we start a vast training program for pediatricians, OBs and pediatric surgeons on how to perform loose circumcisions? Shall we ask the American Academy of Pediatrics or other physician associations to release a guideline saying, “Doctors, keep those circumcisions loose.” While a “loose” (and un-botched) circumcision may make it easier for an adult male to restore his foreskin (unless he’d rather buy a Senslip – another one of Savalescu’s rationalizations – you can buy something even BETTER than your own foreskin!), and may allow for more sexual sensation, the violation of unconsented-to assault is not mitigated in the least. Babies are still being tied down, their foreskins are being pried away from their glans penises and then clamped and cut, they still go into shock and disassociation, there’s an interruption in their ability to breastfeed and bond with their mothers…. How can a bit more foreskin be said to reduce this trauma, this violation?

    Finally, Savalescu’s comments that circumcision is important “to many people,” and thus that an outright ban is not a good idea. His harm-reduction solution here is to limit circumcision to those people, to certain babies. But whose babies, which babies, are we willing to sell out? The children of Jews and Muslims? Of all Jews and Muslims, or only those who prove their religiosity by following other religious practices? What about the children of Christians who claim that “circumcision is in the Bible,” and that’s why they want to do it? Allowing a “religious exception” might reduce the harm from a statistical standpoint (fewer circumcisions = fewer circumcision disasters), but it doesn’t lessen the chance of harm to a given child. Also, it’s impracticable; as an attorney, I cannot even imagine writing the rules for who will be alowed to cut, and which babies’ rights are waiveable.

    If the principal argument against infant circumcision were that it is medically dangerous, then a harm-reduction approach might be acceptable. But Savalescu is writing in a journal dedicated to medical ethics. The principal argument – indeed, the only unequivocal, consistent, irrefutable argument in the contemporary medical ethics and human rights context – is that circumcising a non-consenting child is flatly unethical and violates his (or her) rights. If that is true, then the concept of harm reduction is fallacious, and Savalescu’s efforts to show that “[if] circumcision is against the interests of an infant, it is only mildly so,” cannot be taken seriously.

    Western countries — even those where infant circumcision is rare — may not be ready for laws prohibiting circumcision; it is possible that society has to utterly abhor the practice before legislatures will ban it. However, that just means that whether those who consider the practice ethically unacceptable should push for a ban or not is simply a question of tactics, not a litmus test of their tolerance for “other cultures.”

  18. Savulescu’s reductio ad absurdum argument boils down to cultural relativism as it applies to genital mutilation, but with an ethics side-step. A person’s right to their own body is universally acknowledged as an inalienable or natural right. Glossing over this right, no matter how cute or urbane your prose, does not negate it. After all the lamentations, reasons, and rationales are history and the deed is done, the result is always the same: a person who, against their will, is permanently sexually altered.

    Let’s ratchet the argument back one notch. If strapping down a child and cutting off an organ is acceptable [sic], then it follows that it would also be ethically acceptable to do this to an adult. In fact, it might even be a moral imperative; what is good for the gosling is good for the gander (and goose).

    Of course that’s absurd, too, so we are left with only one conclusion; Savulescu is generating yet another anti-foreskin smokescreen to hide what he really wants: perpetuation of a human rights violation on a global scale that belies any notion of cultural relativism.

  19. Julian Savulescu’s examination of circumcision gives the impression of a powerful intellect struggling to make sense of a bizarre social custom that’s likely affected him personally and/or those close to him.

    From a bioethical perspective, the question is simply this; how much healthy, living tissue can one sever from a forcibly restrained child’s body before it becomes wrong? Should the gender of the child influence the answer? Is whether or not the tissue is erogenous influence the answer?

  20. Just want to remind people to please try and address arguments rather than attacking authors. If you shout people into silence, it just makes public discussion that much harder. When people see insults and profanity, it is likely they will simply tune out in the future when they hear the word circumcision. Being loud and confrontational may be appropriate in a demonstration, but not in forum such as this. Silence is the worst obstacle facing those opposing circumcision, so please try and keep the discussion going rather than trying to ridicule and dismiss opposing viewpoints.

  21. It can be tempting to make the perfect the enemy of the good. My proposals for reducing the harm of circumcision are designed to find something that reasonable people can agree on. Branding those who forcibly circumcise men as sexual offenders is something that is so important, especially as circumcision is being so aggressively promoted in Africa as a way of reducing the spread of HIV. The branding of forced circumcision of adults as a sexual assault sends a very strong message, just as the ban on female genital mutilation sent an important message world-wide. Ditto with my other proposals.

  22. The comment by Anthony Lempert really put to task the idea ‘damage limitation’ proposals. If I had been born to parents who thought and reasoned like Dr. Lempert I might have been spared unnecessary suffering from what is nothing more than, in my case, an American cultural ritual.
    Guaranteeing that only ‘medically qualified’ personnel carry out circumcisions puts, as Anthony highlights, an unethical burden on medical professionals to become cultural and/or religious brokers. That’s not modern ethics that I can recognise.

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  24. While a lot of the arguments in the comments are quite convincing in a purely ethical sense, this is not a purely ethical blog. This is a blog of practical ethics, which I believe (though i may be mistaken, as this is just my limited understanding) is why the original post was against banning circumcision outright. Not because of the pure ethics, but the practicality. The true way to win the debate put forward by the author would therefore be not to attack his stance of the ethics of circumcision, but to provide arguments that would show that in the real world, a total ban on circumcision would cause less harm than the harm reduction strategy posed by Julian. That is my opinion on the matter at least.

    Also, while it is easy to cite the outright ban on FGM and its success, I do not think that was ever a practice that was so widely accepted in the West as circumcision. I do not think it can act as a good test of how the public would react to the ban. This is not a comment on which religion is more correct, but more one on which is more prevalent in the relevant society. If you are proposing a total ban, you must either be prepared to deal with the massive fallout, or be willing to massively change public perception first. I believe the majority view of the West was that FGM was very bad, while the majority view on circumcision appears to be that it is unnecessary at worst (though I would be interested to see the stats on this). I unfortunately do not have evidence to support these comments, they are meant purely as opinions.

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  26. Apologies. Where I wrote: ‘Guaranteeing that only ‘medically qualified’ personnel carry out circumcisions puts,…’ I meant ‘carry out ritual or non-thereapeutic circumcisions puts,…’. Qualified medical interventions are exempt, which fortunately are rare in children.
    Thank you, Georganne, for your reasoned arguments.
    To call sexual assault- and cutting healthy children’s genitals is exactly this- by another name is nothing more than lying. We already have laws covering assault. We just need to enforce them when it happens in hosptials/surgeries/temples/homes.
    A concerted effort of public education, funded by the federal government, about the functions of the foreskin, harms from circumcision and historical background as to why it has come to be considered a ‘normal’ choice- needs to happen.
    However we implement it, we need to have mandatory health screening- physicals- for children to be able to catch when violations of childrens’ rights occur. If, when a health condition absolutely mandates it, a boy needs a circ- the parents should have to produce the clinical evidence for the surgery. Otherwise the child’s rights were transgressed. Children’s rights need to taken seriously.
    Is this unreasonable?

    1. Nothing is unreasonable in what you argue for. However, the reasonable is not always attainable. Concentrating on what is achievable may be more successful. It is hard to argue against a ban on the forced circumcision of an adult. It is hard to argue against a law to ban unqualified people from circumcising others. There is a legal precedent for insisting that both parents agree before a child is circumcised. These and other changes in the law may bring improvements.

      1. In a financial crisis it helps to not cover cosmetic and non-therapeutic surgery especially on an unconsenting minor. Making parents think about their actions with the event of contemplation about unnecessary expenses could extend the chances of a child having his/her bodily rights respected because of second sight into budgeting and awareness of its implications on the child’s well being.

        No one is trying to ban adult circumcision, its infant circumcision, its about protecting children from religious marks that compromise a person’s human right of self determination as well as autonomy. Where as something as simple as a pin prick of the genitals of girls is prohibited even bypassing religious tradition, whereas over 12 square inches is removed from baby boys and its legal that that occurs with no protection from the ideology that perpetrates its rituals onto them.

  27. I think your opinions seem fear-based and cynical , Michael. There hasn’t been a single argument put forward in favour of mgm that hasn’t been soundly rebuked. A growing number of medical associations would be willing to back protection in law for children as well as Jews and Muslims who obey the laws against mgm. It is said, after all, that the vast majority of religious people are peaceful and law-abiding. Well then none of this should discourage us from insisting, in law, in equal protection for all children. Unless, of course, this was nonsense. But I don’t think so. I think religiously motivated parents just might sigh in relief at having this ‘choice’ denied them.

  28. Seamus, it’s tempting to believe that reform is easy, simple and straightforward. It’s not. The campaign for the abolition of slavery in England started in the 1780s. The reformers’ first target was the slave trade. Only later did they campaign for the abolition os slavery itself. Asking for the abolition of obvious circumcision abuses does not negate or undermine a principled stand for the equal protection of the law for all children. The slave trade was abolished in 1807, but slavery was not abolished in England until 1834 and in the United States until 1865.

    Seamus, if you agree that forcibly circumcising adult men is wrong, then support this reform.
    If you agree that unqualified operators should be banned from circumcising others, then don’t oppose moves to prohibit it.

    These reforms cannot and will not prohibit infant circumcision, but they will help to create a climate where human rights are better respected and protected. And that is all to the good.

  29. It may be that individual, conscientious parents will be ahead of the fearful political curve when it comes to establishing in law equal protection. Not sure. But I think equality legislation- or enforcing existing law- will change society. Yes, the abolition of slavery took decades to achieve, women the right to vote, too. But information and argument and debate is far more extensive and faster that it was even 50 years ago. People have access to so much information now- at our fingertips, at home- so people can be educated in anatomy, ethical viewpoints beyond their own and ideas challenged and debates witnessed. Culture can change quicker than in the past and all it takes is one generation, that majority, of intact young males to shape our (American) culture into one where it is normal, natural and wonderful to be genitally intact: like the rest of the (healthy)world majority. One generation. Cultures change every generation, whether a little or a lot. For Americans and the genital cutting of our boys- I think it will be a swift transition.

    1. Its on its way to becoming an intact and sexually healthy country but the only thing slowing it down are the desperate entities that wish to propagate the circumcision agenda such as the AAP and groups of pro-circumcision advocates. Now we are seeing more aggressive and coercive behavior from those entities just by their publications and endorsement in direct response to the falling circumcision rates.

      They are directing their circumcision “services” and coercing the lesser educated inhabitants of third-world Africa and cherry picking only those studies that fit their bias out of the pool of mixed results for a campaign to market it back to the naive American lay public. Its an infiltration into science which leaks back to medical texts therefore corrupting professional education. That phenomenon needs to be explained more in depth to prevent anymore of the like occurring if we want to see a foundational difference and help extinguish the misinformation machine.

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