Female genital mutilation (FGM) and male circumcision: should there be a separate ethical discourse?

Female genital mutilation (FGM) and male circumcision: should there be a separate ethical discourse?

This month, the Guardian launched a campaign in conjunction with (the petition is here) to end “female genital mutilation” (FGM) in the UK—see Dominic Wilkinson’s recent analysis on this blog. I support this campaign and I believe that FGM is impermissible. Indeed, I think that all children, whether female, intersex, or male, should be protected from having parts of their genitals removed unless there is a pressing medical indication; I think this is so regardless of the cultural or religious affiliations of the child’s parents; and I have given some arguments for this view herehereherehere, and here. But note that some commentators are loath to accept so broadly applied an ethical principle: to discuss FGM in the same breath as male circumcision (and perhaps intersex surgeries), they think, is to “trivialize” the former and to cause all manner of moral confusion.

Consider these recent tweets by Michael Shermer, the prominent American “skeptic” and promoter of science and rationalism:



This sort of view appears to be common. One frequent claim is that FGM is analogous to “castration” or a “total penectomy,” such that any sort of comparison between it and male circumcision is entirely inappropriate (see this paper for further discussion). Some other common arguments are these:

Female genital mutilation and male circumcision are totally different. FGM is necessarily barbaric and crippling (“always torture,” according to Tanya Gold), whereas male circumcision is no big deal. Male circumcision is a “minor” intervention that might even confer health benefits, whereas FGM is a drastic intervention with no health benefits, and only causes harm. The “prime motive” for FGM is to control women’s sexuality (cf. Shermer in the tweets above); it is inherently sexist and discriminatory and is an expression of male power and domination. Male circumcision, by contrast, has nothing to do with controlling male sexuality – it’s “just a snip” and in any case “men don’t complain.” FGM eliminates the enjoyment of sex, whereas male circumcision has no meaningful effects on sexual sensation or satisfaction. It is perfectly reasonable to oppose all forms of female genital cutting while at the same time accepting or even endorsing infant male circumcision.

Yet almost every one of these claims is untrue, or is severely misleading at best. Such views derive from a superficial understanding of both FGM and male circumcision; and they are inconsistent with the latest critical scholarship concerning these and related practices. Their constant repetition in popular discourse, therefore—including by those like Shermer with a large and loyal audience base—is unhelpful to advancing moral debate.

What is going on here?

To see the source of the problem, we need to begin by defining our terms—“FGM” and “male circumcision.” For FGM, The World Health Organization (WHO) gives us four major types, with multiple subdivisions:

  • Type I — Partial or total removal of the clitoris and/or the prepuce (clitoridectomy). Type Ia, removal of the clitoral hood or prepuce only; Type Ib, removal of the clitoris with the prepuce.
  • Type II — Partial or total removal of the clitoris and the labia minora, with or without excision of the labia majora (excision). Type IIa, removal of the labia minora only; Type IIb, partial or total removal of the clitoris and the labia minora; Type IIc, partial or total removal of the clitoris, the labia minora and the labia majora.
  • Type III — Narrowing of the vaginal orifice with creation of a covering seal by cutting and appositioning the labia minora and/or the labia majora, with or without excision of the clitoris (infibulation). Type IIIa, removal and apposition of the labia minora; Type IIIb, removal and apposition of the labia majora.
  • Type IV — All other harmful procedures to the female genitalia for non-medical purposes, for example: pricking, piercing, incising, scraping and cauterization.

The first thing to notice about this list is that “FGM” is not just one thing. Disturbingly, there are many different ways to nick, scratch, or cut off parts of a girl’s vulva, ranging from, at the lowest end of the “harm” spectrum, pricking the clitoral hood (under anesthesia, and with sterile surgical equipment, as was proposed in the “Seattle Compromise” — note that this would qualify under FGM Type IV), up through various types of ‘piercing’ that do not necessarily remove tissue (of course, such piercing is common in ‘Western’ countries as a form of perceived “cosmetic enhancement”*), to interventions that alter the labia, but not the clitoris (the clinical term is labiaplasty – note that this is also popular in ‘Western’ countries), to, at the highest end, excising the (external) clitoris with a shard of glass and stitching together the labia with thorns. It is important to point out that the most severe types of FGM (such as the form just mentioned) are comparatively rare, whereas it is the more minor and intermediate forms that are more common.

Nota bene, such “cosmetic enhancement” surgeries in ‘Western’ countries are typically carried out under conditions of informed consent (a point to which I will return, as I think the moral analysis turns on this factor), although there is an alarming trend among some teenage girls in these countries — some as young as 13 or 14 — of having their labia reduced (or undergoing other forms of “designer vagina” surgery), apparently with the permission of their parents. Global health agencies such as the WHO, however, have been strangely silent on this issue, preferring instead to focus their FGM-eradication efforts almost entirely on the continent of Africa.

In this African context, genital cutting (of whatever degree of severity) is most commonly performed around puberty, and is done to boys and girls alike. In most cases, the major social function of the cutting is to mark the transition from childhood to adulthood, and it is typically performed in the context an elaborate ceremony. Increasingly, however, African, Middle Eastern, Indonesian, and Malaysian genital alterations (again, of both boys and girls) are being carried out in hospital settings by trained medical professionals—and on infants as opposed to teenagers–on the model of male circumcision in the United States.

Understanding the harm

It should be clear that the different forms of cutting listed above are likely to result in different degrees of harm, with different effects on sexual function and satisfaction, and different chances of developing an infection, and so on. But as Obermeyer notes in her systematic analysis of health consequences for FGM:

It is rarely pointed out that the frequency and severity of complications are a function of the extent and circumstances of the operation, and it is not usually recognized that much of [our] information comes from studies of the Sudan, where most women are infibulated. The ill-health and death that these practices are thought to cause are difficult to reconcile with the reality of their persistence in so many societies, and raises the question of a possible discrepancy between our “knowledge” of their harmful effects and the behavior of millions of women and their families.

Notwithstanding these gradient differences for types FGM, as well as the gradient consequences that vary along with them, all forms of FGM—no matter how sterilized or minor—are deemed to be mutilations. All are prohibited in Western democracies. Again: I am in support of the motives behind such legislation. I do not think that a sharp object should be taken to any girl’s vulva unless it is to save her life or health, or unless she has given her fully-informed consent to undergo the procedure. In the latter case, of course, she wouldn’t be a “girl” anymore, but rather an adult woman, who can make a decision about her own body.

What about male circumcision?

The story is very different when it comes to male circumcision. In no jurisdiction is the practice prohibited, and in many it is not even restricted: in some countries, including in the United States, anyone, with any instrument, and any degree of medical training (including none) can attempt to perform a circumcision on a non-consenting child—sometimes with disastrous consequences. As Davis notes, “States currently regulate the hygienic practices of those who cut our hair and our fingernails … so why not a baby’s genitals?”

But just like FGM, circumcision is not a monolith; it isn’t just one kind of thing. The original Jewish form of circumcision (until about 150 AD) was comparatively minor: it involved cutting off the overhanging tip of the foreskin—whatever stretched over the end of the glans—thus preserving (most of) the foreskin’s protective and mechanical functions, as well as reducing the amount of erogenous tissue removed. The “modern” form is substantially more invasive: it removes one-third to one-half of the motile skin system of the penis (about 50 square centimeters of sensitive tissue in the adult organ), eliminates the gliding function of the foreskin (see here for a video demonstration), and exposes the head of the penis to environmental irritation.

Circumcision—and other forms of male genital cutting—are performed at different ages, in different environments, with different tools, by different groups, for different reasons. Traditional Muslim circumcisions are done while the boy is fully conscious, between ages 5 and 8, or possibly later; American (non-religious) circumcisions are done in a hospital, in the first few days of life, with or without an anesthetic (usually without), and using a range of different clamps and cutting devices; metzitzah b’peh, done by some ultra-Orthodox Jews, involves the sucking of blood from the circumcision wound, and carries the risk of herpes infection and permanent brain damage; subincision, carried out in aboriginal Australia and elsewhere, involves slicing open the urethral passage on the underside of the penis from the scrotum to the glans, often affecting urination as well as sexual function; circumcision among the Xhosa in South Africa is done as a rite of passage, in the bush, with spearheads, dirty knives, and other non-sterile equipment, and frequently causes hemorrhage, infection, mangling, and loss of the penis—see here for some disturbing pictures—as well as a very high rate of death. But even “hospitalized” or “minor” circumcisions are not without their risks and complications: in 2011, nearly a dozen boys were treated for “life threatening haemorrhage, shock or sepsis” as a result of their non-therapeutic circumcisions at a single children’s hospital in Birmingham in England.

Here is the important point. When people speak of “FGM” they are (apparently) thinking of the most severe forms of female genital cutting, done in the least sterile environments, with the most drastic consequences likeliest to follow. This is so, notwithstanding the fact that such forms are the exception rather than the rule. When people speak of “male circumcision” (by contrast) they are (apparently) thinking of the least severe forms of male genital cutting, done in the most sterile environments, with the least drastic consequences likeliest to follow–because this is the form with which they are culturally familiar. This then leads to the impression that “FGM” and “male circumcision” are “totally different” with the first being barbaric and crippling, and the latter being benign or even health-conferring (on which more in just a moment). Yet as the anthropologist Zachary Androus has written:

The attitude that male circumcision is harmless [happens to be] consistent with Western cultural values and practices, while any such procedures performed on girls is totally alien to Western cultural values. [However] the fact of the matter is that what’s done to some girls [in some cultures] is worse than what’s done to some boys, and what’s done to some boys [in some cultures] is worse than what’s done to some girls. By collapsing all of the many different types of procedures performed into a single set for each sex, categories are created that do not accurately describe any situation that actually occurs anywhere in the world.

So it depends on what you’re talking about. Do those who oppose FGM (and that includes me) think (as I do) that even certain “minor” or “medicalized” forms of such cutting—done without consent, and without a medical indication—are inconsistent with medical ethics, deeply-rooted moral and legal ideals about bodily integrity, the principle of personal autonomy, and a child’s interest in an open future? Or is it only the wholesale removal of the clitoris – with a broken piece of glass – that inspires such condemnation? If the former is the case, then consistency would seem to require that one be opposed to the non-therapeutic, non-consensual circumcision of boys as well: not only is it much more invasive than several “minor” (yet prohibited) forms of FGM, but it is numerically a much greater problem, occurring several millions of times per year.

Cutting comes in degrees. Consequences vary. This is true for boys and for girls alike, and at some point the harms overlap. As a result of this realization, many scholars of ritual cutting are choosing to abandon the terms “FGM” and “male circumcision” (which presume a strict moral difference between them), and are using instead such terms as FGC, MGC, and IGC. These stand for female, male, and intersex genital cutting respectively; and they make no moral claims per se. Instead, the moral character of the genital cutting—regardless the person’s gender—can be assessed separately in terms of actual physical harms, as well with respect to such considerations as whether the cutting is therapeutic, consensual, or otherwise.

So let’s not be misled. There are many kinds of “FGM” as well as many kinds of “male circumcision” and the consequences vary for each one. But perhaps there are some other important differences between male and female forms of genital cutting – apart the sex or gender of the person being cut – that could serve to justify their strict separation in terms of ethical discussion. Let’s look at some further possibilities, from the set of common arguments I listed above.

Male circumcision … might … confer health benefits, whereas FGM [has] no health benefits, and only causes harm.

Both parts of this claim are misleading. First, how do we know that “FGM” (or FGC, as I’ll say from now on) does not confer health benefits? Certainly the most extreme types of FGC will not contribute to good health on balance, but neither will the spearheads-and-dirty-knives versions of genital cutting on boys. What about other forms of FGC? Defenders of FGC—including some medical professionals in countries where FGC is culturally normative—regularly cite such “health benefits” as improved genital hygiene as a reason to continue the practice, and at least one study has shown a link between FGC and reduced transmission of HIV! Indeed, the vulva has all sorts of warm, moist places where bacteria or viruses could get trapped, such as underneath the clitoral hood, or among the folds of the labia; so who is to say that removing some of that tissue (with a sterile surgical tool) might not reduce the risk of various diseases?

Fortunately, it’s impossible to perform this type of research in the West, because any scientist who tried to do so would be arrested under anti-FGM laws (and would never get approval from an ethics review board). So we simply do not know. As a consequence of this, every time you see the claim that “FGM has no health benefits”–a claim that has become something of a mantra for the WHO–you should read this as saying, “we actually don’t know if certain minor, sterilized forms of FGM have health benefits, because it is unethical, and would be illegal, to find out.”

Indeed, Western societies don’t seem to think that “health benefits” are particularly relevant to the question of whether we should be cutting off parts of the external genitalia of healthy girls. Without the girl’s consent, or a medical diagnosis, it’s seen as impermissible no matter what. By contrast, a small and insistent group of (mostly American) scientists have taken it upon themselves to promote infant male circumcision, by conducting study after well-funded study to determine just what kinds of “health benefits” might follow from cutting off parts of the penis. Why is there a double standard here? (Actually, there is an answer to this question; and it hinges on prejudicial cultural influences on what constitutes science and medicine—as well as on what sorts of research questions are deemed worthy of funding, among other problematic factors.)

Let’s look at one example of a “health benefit” that has been attributed to MGC: a lowered risk of acquiring a urinary tract infection. When it comes to girls, who get UTIs after the age of 1 fully 10 times more frequently than boys do, doctors prescribe antibiotics and try other conservative treatments; they also encourage girls to wash their genitals and practice decent hygiene. When it comes to boys, however, circumcision apologists tout the wisdom of performing non-therapeutic, non-consensual genital surgery, to the tune of 111 circumcisions to prevent a single case of UTI. Yet as Benatar and Benatar explain, “UTI does not occur in 99.85% of circumcised infant males and in 98.5% of un-circumcised infant boys.” And when it does occur, against those odds, it is both “easily diagnosed and treatable with low morbidity and [low] mortality.” So let’s review: washing the genitals for girls, foreskin amputation for boys?

With respect to reducing rates of HIV transmission in Africa—another health benefit that is frequently cited for MGC—remember that those studies were carried out on adult volunteers under conditions of informed consent, not on infants. I have no problem with a mature adult requesting surgery to remove a part of his own penis as a form of partial prophylaxis against HIV (in environments with very high base rates of such infection); that is certainly his right. Of course he would need to wear a condom either way to achieve any kind of reliable protection, but it’s his body, and it’s his decision to make. It’s quite a different matter, however, to circumcise an infant—who is not at risk of HIV or other STIs unless he is molested, who cannot consent to the procedure in the first place, and who might prefer to practice safe sex strategies when he does become sexually active, rather than forfeit a part of his penis. See herehereherehere, and here for further discussion of the “health benefits” arguments for MGC. The upshot is that they are not compelling, particularly in developed nations with functioning healthcare systems and access to soap and clean water.

So what other differences between FGC and MCG might justify their strict compartmentalization? Back to the arguments from above:

The “prime motive” of FGM is to control women’s sexualities – it is sexist and an expression of male power and domination. Male circumcision has nothing to do with controlling male sexuality.

There is a lot to say here. First, female genital cutting is performed for different reasons at different times in different cultures; likewise for male genital cutting. Contrary to common wisdom, however, it is not the case that FGC is uniformly “about” the control of female sexuality. For example, in Sierra Leone:

Among the Kono there is no cultural obsession with feminine chastity, virginity, or women’s sexual fidelity, perhaps because the role of the biological father is considered marginal and peripheral to the central ‘matricentric unit.’ … Kono culture promulgates a dual-sex ideology … [The] power of Bundu, the women’s secret sodality [i.e., initiation society that manages FGC ceremonies], suggest positive links between excision, women’s religious ideology, their power in domestic relations, and their high profile in the ‘public arena.’

In nearly every place that FGC is performed, it is carried out by women (rather than by men) who do not typically view it as an expression of patriarchy, but who instead believe that it is hygienic (see above), as well as beautifying, even empowering, and as an important rite of passage with high cultural value. (The claim that such women are simply “brainwashed” is a gross oversimplification.) At the same time, the “rite of passage” ceremonies for boys in these societies are carried out by men; these are done in parallel, under similar conditions, and for similar reasons–and often with similar (or even worse) consequences for health and sexuality: see this discussion by Ayaan Hirsi Ali.

Nevertheless, anthropological research does suggest that FGC is, in some cultures–especially in Northeast Africa and parts of the Middle East–intimately tied up with sexist expressions of patriarchal values; in these settings, the emphasis on female sexual ‘purity’ can more readily be discerned. As I have argued elsewhere, such an asymmetrical focus on female virginity in Islam (as expressed through genital cutting as well as through other practices) is extremely problematic and morally unjustifiable. However, it is important to note that, speaking generally:

The empirical association between patriarchy and genital surgeries is not well established. The vast majority of the world’s societies can be described as patriarchal, and most either do not modify the genitals of either sex or modify the genitals of males only. There are almost no patriarchal societies with customary genital surgeries for females only. Across human societies there is a broad range of cultural attitudes concerning female sexuality—from societies that press for temperance, restraint, and the control of sexuality to those that are more permissive and encouraging of sexual adventures and experimentation—but these differences do not correlate strongly with the presence or absence of female genital surgeries.

Indeed, in cultures where forms of FGC (and MGC) are culturally normative, many women regard the cutting as part of their cultural heritage and vigorously defend against the efforts of Western agencies, and sometimes the men in their own societies (see also here), who seek to wipe it out. Such a realization has led to the emergence of a counter-discourse among some Western feminists, who regard anti-FGC campaigns as a form of cultural imperialism. On this sort of view, the fight against FGC is inextricably bound up with a broader colonial and neo-colonial project of “white people saving brown women from brown men” (as well as from themselves). Thus as Nancy Ehrenreich writes in the Harvard Civil Rights-Civil Liberties Law Review:

 … the mainstream anti-FGC position is premised upon an orientalizing construction of FGC societies as primitive, patriarchal, and barbaric, and of female circumcision as a harmful, unnecessary cultural practice based on patriarchal gender norms and ritualistic beliefs. … Lambasting African societies and practices (while failing to critique similar practices in the United States) … essentially implies that North American understandings of the body are “scientific” (i.e., rational, civilized, and based on universally acknowledged expertise), while African understandings are “cultural” (i.e., superstitious, un-civilized, and based on false, socially constructed beliefs). [Yet] neither of these depictions is accurate. North American medicine is not free of cultural influence, and FGC practices are not bound by culture—at least not in the uniform way imagined by opponents.

Dustin Wax makes a similar argument:

In the case of anti-FGC advocacy, the voice of  “brown women” is almost entirely absent, literally silenced by an insistence that the horrendousness of the practice precludes any possible positive evaluation, and therefore the only valid voices are those that condemn FGC. All contradictory testimony is dismissed as the result of  “brainwashing,” “false consciousness,” “fear of male reprisal,” “anti-Westernism”, “ignorance,” or other forms of willful or unwillful complicity.

What about the other side of things? The usual claim is that male circumcision has “nothing to do” with controlling male sexuality. While it is probably true that most contemporary, Western parents who choose circumcision for their children do not do so out of a desire to “control” their sexuality (just as is true of most African parents who choose “circumcision” for their daughters), male genital cutting has been historically steeped in just such a desire, and it is implicated in problematic expressions of power to this day. Contrary to common wisdom, male genital cutting has indeed been used as a form of sexual control, and even punishment, for a very long time; the Jewish philosopher Maimonides argued that diminished sexual sensitivity was part of the point of doing circumcisions (to reduce excessive “lust” as well as “concupiscence”); circumcision was adopted into Western medicine in the Victorian period largely as a means to combat masturbation (as well as other expressions of juvenile sexuality); and forced circumcision of enemies has been used as a means of humiliation since time immemorial: this practice continues among the Luo of Kenya among numerous other groups. To return to the specific question of patriarchy, in Judaism, only the boys are allowed to “seal the divine covenant,” so the ritual is sexist on its face.

But it’s different in different communities. Moreover, the “reasons” given by most parents are not necessarily the same as the “reasons” the practice originally came about, nor the “reasons” for which it was consciously performed (i.e., as a “cure” for masturbation) in previous eras. As the renowned anti-FGC activist Hanny Lightfoot-Klein has stated: “The [main] reasons given for female circumcision in Africa and for routine male circumcision in the United States are essentially the same. Both promise cleanliness and the absence of odors as well as greater attractiveness and acceptability.”

So what are the implications here? Given that both male and female forms of genital cutting express different cultural norms depending upon the context, and are performed for different reasons in different cultures, and even in different communities or individual families, how are we meant to assess the permissibility of either one? Do we need to interview each set of parents to make sure that their proposed act of cutting is intended as an expression of acceptable norms? If they promise that it isn’t about “sexual control” in their specific case, but rather about “hygiene” or “aesthetics” or something less symbolically problematic, should they be permitted to go ahead? But this is bound to fail. Every parent who requests a genital-altering surgery for their child – for whatever reason under the sun – thinks that they are acting in the child’s best interests; no one thinks that they are “mutilating” their own offspring. Thus it is not the reason for the intervention that determines its permissibility, but rather the consequences of the intervention for the person whose genitals are actually on the line. So what kinds of consequences follow from FGC and MGC? Let us clear up one familiar legend:

Male circumcision is “just a snip” and in any case “men don’t complain.”

Before addressing these oft-repeated claims about male genital cutting, let us reflect on the analogous female forms that tend to dominate popular discussions. The interventions associated with extreme forms of FGC are gut-wrenching to think about. Many people find FGC to be “barbaric” and “inhumane” in part because they can call to mind grotesque and vivid images of slicing and cutting—perhaps with a shard of glass—and they react with a mix of sadness, horror, and disgust. Much less disturbing, however, are the images apparently called to mind by male circumcision, as evidenced by the widely repeated (but false) declaration that circumcision is “just a snip.”

Male circumcision is never “just a snip.” It is a frequently traumatic intervention; it is usually extremely painful, even in hospital settings, since adequate analgesia is rarely given; the same is true in ritual settings; and indeed sometimes the excruciating pain of circumcision is used as a test of masculinity. As Nelson Mandela reported about his own (tribal) circumcision:

Flinching or crying out was a sign of weakness and stigmatized one’s manhood. I was determined not to disgrace myself, the group or my guardian. Circumcision is a trial of bravery and stoicism; no anaesthetic is used; a man must suffer in silence. [Before] I knew it, the old man was kneeling in front of me. … Without a word, he took my foreskin, pulled it forward, and then, in a single motion, brought down his assegai [knife]. I felt as if fire was shooting through my veins; the pain was so intense that I buried my chin in my chest. Many seconds seemed to pass before I remembered the cry, and then I recovered and called out, ‘Ndiyindoda!’ [‘I am a man!’]

In infant circumcision, the “snip”—if there is one—only comes at the end: the foreskin must first be separated from the head of the penis, to which it is adhered throughout much of childhood, then it is either stretched out and sliced, or crushed, or torn, or even strangled to the point of necrosis. When any of these things is done with unsterilized equipment, by a medically untrained practitioner, in environments with limited access to healthcare, the risk of serious infection, loss of the penis, and death is dramatically increased. I suggest that readers of this blog watch this video (of a hospitalized, American circumcision) or this one (of a traditional Muslim circumcision) or this one (of a Jewish circumcision), or this one (of a circumcision in Uganda) so that they can permanently lay to rest the idea that circumcision is “just a snip.” It is time to retire this phrase; it should not be used any more.

As to the notion that “men don’t complain” – that is simply false. Just as some women who have undergone forms of FGC complain passionately about what was done to them without their consent, so too do some men who have undergone forms of MGC. Here are some examples of thoughtful and articulate complaints about MGC by resentful, circumcised men: here, herehere, and hereThis man lost his penis. Several thousands of men are attempting “foreskin restoration,” which is an arduous process of stretching skin from the shaft of the penis using weights, tapes, and other materials, in an attempt to “restore” some semblance of their pre-circumcised state. This is not an insignificant number. Of course, when men do complain, their feelings are often trivialized; but they continue to complain nevertheless – in increasing numbers, and ever more vocally as they find the courage to speak out.

Many men do not complain, of course; but then many women who have undergone various forms of FGC do not complain either: in a survey of 3,805 Sudanese women, of whom 89% had experienced FGC, 96% said they would do it to their daughters and 90% favored the continuation of the practice generally. Yet it is enough that some men do complain, and that some women do as well: in both cases a healthy part of their body was removed, and without their informed permission. In Western societies, we teach our citizens that they have a right to bodily integrity: we forbid the tattooing of children, for example, and we tell them that adults should not so much as touch them inappropriately. In this sort of social and legal environment, complaints about having a part of one’s genitals removed without one’s own consent should be treated with serious concern. Finally:

FGM eliminates the enjoyment of sex, whereas male circumcision has no meaningful effects on sexual sensation or satisfaction.

Again, this depends. Obviously more minor forms of FGC – such as ritual ‘pricking,’ some kinds of piercing, or even removal of the vaginal lips – will not eliminate erogenous sensation; however, does this make any of these interventions permissible, if they are done without consent? The answer, in my opinion, is “no.” Even the risk of damaging sensitive nerve tissue with a ‘prick’ should be avoided unless the person taking on the risk is acting freely as an informed adult. Or what about removing “just” the clitoral hood? The clitoris might lose some sensitivity over time, as it rubs against environmental factors (just as the penile glans seems to do after male circumcision; in fact the clitoral hood and the foreskin are anatomically analogous structures), but perhaps some sensation would be preserved, and in any case sexual enjoyment cannot be reduced to stimulation of the clitoris or even ability-to-orgasm. Does that make ”clitoral unhooding” OK?

Not if it’s done without consent.

Finally, what about one of the most invasive forms of FGC – the excision of the external clitoris? According to a recent review published by the reputable Hastings Center, “Research by gynecologists and others has demonstrated that a high percentage of women who have had genital surgery [including excision] have rich sexual lives, including desire, arousal, orgasm, and satisfaction, and their frequency of sexual activity is not reduced.” Indeed, in one study, up to 86% of women who had undergone even “extreme” forms of FGC reported the ability to orgasm, and “the majority of the interviewed women (90.51%) reported that sex gives them pleasure.” These counterintuitive findings might be explained by the fact that much of the clitoris (including most of its erectile tissue) is actually underneath the skin and is therefore not removed by even the most invasive types of FGC: only the glans of the clitoris (the “part that sticks out”) can be excised. But this does not make the surgery somehow “OK.” Every girl’s body is different, and the value she will end up placing on having an intact clitoral glans cannot be known in advance–even in cultures in which the glans is socially stigmatized. At the end of the day, if a fully-informed adult woman chooses genital surgery for herself, it may be permissible on some analyses. However, it is not permissible on children.

What about male circumcision? The same sort of reasoning applies. While the majority of circumcised men (whose circumcisions were not seriously “botched”) report that they experience sexual pleasure during intercourse, and even enjoy sex quite a lot: (a) they do not have a point of comparison, unless they were circumcised in adulthood, so they cannot know what sex would feel like had they not been circumcised (the same point applies to FGC done early enough in childhood) (b) the risk that a “botch” might in fact occur means that the surgery should be undertaken voluntarily, insofar as it is non-therapeutic in nature, (c) some men whose circumcisions did not result in “botches” may nevertheless experience adverse sexual outcomes, simply through the loss of erogenous tissue, and (d) some men’s sexual experiences are hampered via psychological mechanisms, including through the resentment they may feel at having been circumcised before they could object.

Scientists are divided over the “average” effect of (expertly performed, perfectly executed) circumcision on key sexual outcome variables. What is not controversial, however, is that any sensation in the foreskin itself is guaranteed to be eliminated by circumcision (just as any sensation in the labia or the clitoral glans will be eliminated by labiaplasty or excision, respectively), as are “any sexually-relevant functions associated with [the foreskin’s] manipulation. In other words, a man without a foreskin cannot ‘play’ with his foreskin, nor can he glide it back and forth during sex. That these can be pleasurable activities, with great subjective value to genitally intact men and their partners, is uncontroversial.” Finally, the most extreme forms of male genital cutting (e.g., when it leads to penile amputation) eliminate sexual capacity altogether.

As Sara Johnsdotter has pointed out, there is no 1:1 relationship between the amount of genital tissue removed (in either males or females), and subjective satisfaction while having sex, so “FGM” (and male “circumcision”)—of whatever degree of severity—will affect different people differently. Each individual’s relationship to their own body is unique, including what they find aesthetically appealing, what degree of risk they feel comfortable taking on when it comes to elective surgeries on their “private parts,” and even what degree of sexual sensitivity they prefer (for personal or cultural reasons). Thus each individual should be left to decide what to do with his or her own genitals when it comes to irreversible surgery.

To summarize, if “FGM” is wrong because it “destroys sexual pleasure” – then forms of “FGM” that do not destroy sexual pleasure must (on this logic) be considered permissible, or else they should be given a different name. But if “FGM” is wrong because it involves cutting into the genitals of a vulnerable child, without a medical indication and without consent, thereby exposing the child to surgical risk (without the presence of any disease), and (in some cases) removing a healthy part of her body that she might later wish she could have experienced intact, then male circumcision is equally wrong on those grounds. This is true whether sexual pleasure is “destroyed” or whether it isn’t, and whether a complaint is made later or not.

Explaining the double standard

Given everything that has been said so far about the relevant objective “overlaps” between male and female genital cutting, why exactly have they become so compartmentalized? Rebecca Steinfeld, a political scientist at Stanford who studies ritual cutting, has speculated as follows:

Alongside the differences in harm and misperceptions about the contrasting settings and ages at which the procedures take place, the double standard stems from two further factors: sexism and ethnocentrism. Male bodies are constructed as resistant to harm or even in need of being tested by painful ordeals, whereas female bodies are seen as highly vulnerable and in need of protection. In other words, vulnerability is gendered. And little girls are more readily seen as victims than little boys. The consequence of this … is that patriarchy often allows men’s experiences to remain unquestioned.

Familiarity also creates comfort, and since MGC has been practised in the West for millennia and been routine in English-speaking countries for a century, we’re desensitised. By contrast, since FGC is geographically or culturally remote, it’s more liable to be seen as barbaric.

On this last point, Andrew DeLaney (unpublished manuscript) gives a similar analysis:

It is safe to say that [male genital cutting] is a norm in the United States, despite any activists’ efforts to raise awareness about it. In the words of one law professor describing her generation, “Everyone was circumcised.” … FGM, on the other hand, is likely a completely foreign idea to the vast majority of people living in the United States or the rest of the western world, with the only exposure to it being horrific reports that are presented based on cases or reports out of Africa. With this being the case, moral objection to the practice of FGM is taken as self-evident, with research and activism being conflated and data on FGM that is sometimes not actually investigated taken as true. All the while, [male genital cutting] occurs as a completely normalized practice.

To return to the Guardian and the petition, it is of course to be welcomed that a prominent global newspaper is campaigning to protect the rights of girls to be free from non-therapeutic, nonconsensual cutting into their genital organs. I cannot state enough that I am in support of such efforts (although I do not favor the use of the term “FGM” for the reasons I have already given). My argument has been that they should not be stopping there. Female, male, and intersex genital cutting should be done exclusively with a medical indication or with the informed consent of the individual. Children of whatever gender should not have healthy parts of their most intimate sexual organs removed, before such a time as they can understand what is at stake in such a surgery and agree to it themselves. It is time to stop the compartmentalization exhibited by Shermer and others and recognize that there is “1 cause” here: respecting children’s rights and protecting them from harm.


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The AAP report on circumcision: Bad science + bad ethics = bad medicine

By Brian D. Earp

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UPDATED as of 27 May, 2013. See the bottom of the post.

The AAP report on circumcision: Bad science + bad ethics = bad medicine

For the first time in over a decade, the American Academy of Pediatrics (AAP) has revised its policy position on infant male circumcision. They now state that the probabilistic health benefits conferred by the procedure outweigh the known risks and harms. Not enough to positively recommend circumcision (as some media outlets are erroneously reporting), but just enough to suggest that whenever it is performed—for cultural or religious reasons, or sheer parental preference, as the case may be—it should be covered by government health insurance.

That turns out to be a very fine line to dance on. The AAP position statement is characterized by equivocations, hedging, and uncertainty; and the longer report upon which it is based includes a number of non-sequiturs, instances of self-contradiction, and cherry-picking of essential evidence (see analysis below).

The AAP appears to be out of tune with world opinion on this issue. On a global scale, medical authorities remain skeptical about whether circumcision of male minors confers any – let alone significant – net health benefits. Indeed, child health experts in Britain, Germany, Scandinavia, Australia, New Zealand, Canada, and elsewhere are predominately of the view that non-therapeutic circumcision (NTC) confers no meaningful health benefits on balance (considered against drawbacks, harms, and risks), and that it should be neither recommended to parents nor funded by health insurance systems.

Nota bene: these cosmopolitan physicians and the medical boards on which they sit have access to the very same data as the AAP. They just don’t draw the same conclusions.

In view of this empirical uncertainty on the medical question, it is problematic to assert, as the AAP does in its new report, that a person does not retain the right to decide whether he wishes to keep his own healthy foreskin–and thus preserve his genitals intact–and that the right belongs instead to his parents.

Parental rights

On the question of parental rights, a point of comparison is frequently raised, including the example of ear-piercing for little girls. Don’t parents have a right to do that? And how is circumcision any different?

There are two ways to respond to the ear-piercing example (and these responses may serve as templates for other comparable interventions). The first way is to suggest that perhaps ear-piercing, too, should not be permitted before the child herself can weigh in on whether or not she would like to have her own ears pierced. If she understands that it will be painful, that there are certain risks involved, and so on, and yet it’s still something she’d like to undertake, then so be it.

The second, stronger way, is to point out that the two practices—ear-piercing and infant male circumcision—are not remotely commensurate, neither in terms of the interventions themselves, nor their effects. Ear-piercing removes no tissue, does not threaten any bodily function, can be tolerated without anesthesia, and is reversible: the hole will close up over time if the child decides later on that she would like to have her earlobes hole-free.

By contrast, male circumcision removes up to half of the skin system of the penis, eliminates the motile and protective functions of the foreskin, cannot be tolerated without anesthesia, and is irreversible: anyone who resents having had his foreskin removed can never get it back.

Given, then, the substantial differences between ear-piercing and male circumcision—in terms of both the interventions themselves and their necessary (i.e., not just accidental or probabilistic) effects—that are directly relevant to the moral calculus involved in assessing their respective permissibility, much more work would be needed to establish that there is any kind of parity of reasoning between them.

Indeed, those who are skeptical about the ethical soundness of ablating the foreskin in infancy are not typically suggesting that any intervention that breaks the skin of any child at any age—regardless of the level of risk involved, and regardless of the diminishing effects on function, and regardless of the reversibility of the procedure, and regardless of the child’s having had an opportunity to give some input as to the desirability of the intervention—should be considered ethically dubious. Rather, it is precisely the level of harm involved, the degree of functional diminishment, the irreversibility, the impossibility of attaining any input from the person whose body (indeed whose penis) is to be permanently surgically altered, and so on, that mark out infant male circumcision as a specially problematic practice.

Parents can of course give proxy consent for needful therapeutic procedures aimed at treating a known pathology. That is, if the pathology presents a genuine threat to the child, and if the intervention cannot be delayed until the child understands what is at stake, and if there are not safer, more reliable, more effective alternative treatments. A healthy foreskin, however, is not a pathology. It needs no treatment at all. To remove it, therefore, on grounds of “proxy consent” is to misunderstand—quite egregiously—the ethical limits of  parental authority.

A more reasonable conclusion than the AAP’s, then, is that the person whose penis it is should be allowed to consider, for himself, the available evidence (in all its chaotic murkiness) when he is mentally competent to do so—and make a personal decision about what is, after all, a functional bit of his own sexual anatomy and one enjoyed without issue by the vast majority of the world’s males.

Health benefits and medical ethics

According to the Seattle-based physicians group Doctors Opposing Circumcision, there is neither a medical nor an ethical case for removing healthy genital tissue from baby boys. They can’t consent to the procedure in the first place, and the bulk of the claimed—yet heavily disputed—health benefits don’t actually apply to them: babies are not sexually active, yet circumcision is supposed to protect chiefly against sexually-transmitted infections and related diseases. In any case, these are afflictions whose prevention is much more soundly assured by the use of a condom (and other safe sex practices) in adulthood than by genital surgery in infancy. With respect to the issue of urinary tract infections in early childhood, remember that these are rare for boys (about 1%), and can be easily treated with antibiotics if and when they do occur—no surgery required. A recent Cochrane Review—the highest standard of medical analysis—found no reliable evidence that circumcision does in fact protect against UTIs, and even studies that do find a link report that 111 circumcisions would have to be performed to prevent a single case of UTI.

So how did the AAP reach its much-hyped, yet ultimately fallacious, and as I will argue, ethically unjustified conclusion?

* * *

First, let us be clear about what their position is. “This is not really pro-circumcision,” explains one of the authors of the technical report behind the new analysis. You wouldn’t know that from reading the week’s headlines, which have taken the “health benefits” narrative and gone running impetuously on to town, but there it is from the horse’s mouth. Instead, the AAP believes that the purported benefits of circumcision are merely “sufficient” to “justify access to this procedure for families choosing it” and to “warrant third-party payment for circumcision of male newborns” if and when it does occur.

Here they depart from their 1999 statement in asserting that (1) the benefits of the surgery definitively outweigh the risks and costs and (2) that it is therefore justifiable to perform the operation without the informed consent of the patient. This does not follow. Just as with the parental “proxy” rule discussed above, in medical ethics, the risk/benefit rule was devised for therapeutic procedures aimed at treating an extant pathological condition, and for minor prophylactic interventions such as vaccination (interventions that, notably, most rational adults would choose for themselves, and that are rarely or never a source of later resentment). It has no relevance to nonessential amputative surgery, especially when it involves the removal of healthy, functional erogenous tissue from the genitals, and when (once again) safer, more effective substitute strategies exist for achieving the same ends.

One might be surprised to learn that the word “condom” does not appear even once in the 28 page AAP report.

In making their risk/benefit calculations, then, the AAP simply leaves out a critical bulk of factors relevant to the equation, including the existence of a range of proven healthcare strategies like condom-use or the administration of vaccines (including an effective HPV vaccine) and antibiotics. If they had taken the time to consider human rights and bodily integrity issues, the function of the foreskin, its value to the individual, and his possible wishes in later life, as well, their computations would arguably yield a different answer.

Some readers will be unaware that the AAP is not a dispassionate scientific research body, but rather a trade association for pediatricians. Those among its members and stakeholders who perform NTCs stand to profit from the procedure, to the collective annual tune of $1.25 billion according to one (albeit not impartial) estimate. Given the yawning potential for a financial conflict of interest, then, there needs to be a very strong, independent medical case for circumcision; and the AAP had better be able to show that it is both the safest and most cost effective means of promoting infant health. Both of these propositions fail, however, as I will continue to show in what follows.

* * *

The AAP has been tossing and turning on the question of circumcision since 1971, when it announced that “There are no valid medical indications for circumcision in the neonatal period.” Emphasis mine. From 1999 until August 27th of this year, the AAP had maintained that the “health benefits” of circumcision were perhaps neck-and-neck with the costs, at best, so that it could not recommend the procedure from a therapeutic perspective. This policy was in line with the still-current official position of every other major medical association in the world. Except, actually, those that now actively campaign against circumcision, such as the Royal Dutch Medical Association in Holland.

For the AAP to revise its stance, then, it stands to reason that something must have changed—either human biology has altered, or some new evidence must have cropped up—to justify tipping the cost-benefit scales away from their recently prior equilibrium. Indeed, the AAP circumcision task force makes much ado of a collection of studies conducted in Africa between 2005 and 2007 purporting to show a link between circumcision and a reduced risk of becoming infected with HIV.

According to the New York Times, these studies include 14 publications “that provide what the [AAP] characterizes as ‘fair’ evidence that circumcision in adulthood protects men from HIV transmission from a female partner.” Notice the phrase in adulthood. The AAP policy, by contrast, is concerned with circumcision in infancy, a procedure for which there is literally no evidence of a protective effect against HIV. Notice also “fair” rather than “good” evidence and that the findings apply exclusively to (heterosexual) (African) (adult) males. This is in contrast to females, for whom circumcision of the male partner is apparently a risk factor for becoming infected with HIV. The New York Times continues:

“Three of the studies were large randomized controlled trials of the kind considered the gold standard in medicine, but they were carried out in Africa, where H.I.V. — the virus the causes AIDS — is spread primarily among heterosexuals.”

There are a number of things to say about these “randomized controlled trials.” First, the trials appear to have been “controlled” in name only, as this exhaustive analysis demonstrates. Clinically relevant flaws included “problematic randomization and selection bias, inadequate blinding, lack of placebo-control … inadequate equipoise, experimenter bias, attrition …  not investigating male circumcision as a vector for HIV transmission, not investigating non-sexual HIV transmission, as well as lead-time bias, supportive bias … participant expectation bias, and time-out discrepancy (restraint from sexual activity only by circumcised men).” Hence, as I explained in this earlier post, the “Africa studies” may not have been a clear-cut example of “gold standard” medical research (but see the counterarguments cited in that commentary).

Critics have also pointed out that the “60%” figure that is typically offered as the relationship between circumcision and reduction of HIV infections is the output of a potentially misleading statistical sleight-of-hand: the absolute reduction between the circumcised and intact groups in these studies was just 1.3%. Whether such a reduction will have meaningful ramifications at the population level is the subject of ongoing dispute.

The next thing to highlight is the part of the quote that comes after the “but” – a very important “but” – namely that “[the trials] were carried out in Africa” where, as the article goes on to explain, HIV is mainly a heterosexual phenomenon. Outside of Africa, it is mainly not—it is largely transmitted among injecting drug users and gay men, at least in the United States—which means that even if we were to accept the data from the “randomized controlled” studies, we would have very little evidence that circumcision could be useful in the country that is actually the subject of the AAP’s analysis. The same holds for countries such as Australia, and New Zealand, and indeed most anywhere else in the developed world. The epidemiological and social environments are just flatly non-analogous — as this study shows.

Hence, as even the authors of the AAP report acknowledge, “the degree of benefit, or degree of impact [of circumcision], in a place like the U.S. will clearly be smaller than in a place like Africa.” Of course, we already knew that circumcision does not present a serious obstacle to heterosexual HIV-transmission in the U.S., since the U.S. has both the highest rates of infant circumcision and the highest rates of heterosexually transmitted HIV among industrialized nations. (Obviously there are innumerable confounding factors that can mediate the relationship between HIV rates and circumcision rates in different cultural contexts; the point here is that those factors play a bigger role than the percentage of excised foreskins in a country’s male population.)

But let’s put all that to the side. For even if it were true that circumcision offered a partially protective effect against heterosexually-transmitted, female-to-male HIV/AIDS (in epidemiological environments with very high base rates of such transmission) or other STIs such as HPV (for which, as I stated before, there is an effective vaccine), it would still not follow that the procedure could be ethically performed on infants, much less on infants in the developed world. Given that there is a cheaper, more effective, less invasive, less coercive alternative—namely condom-use and other safe sex strategies in adulthood—it is inconsistent with biomedical ethics to endorse the risky genital cutting of a young child toward the same ostensible end.

As pediatrician, statistician, and professor of clinical medicine Robert Van Howe showed in this recent cost-benefit analysis, infant circumcision is more costly and does more harm than leaving the baby alone, even based on models that start from very generous premises about the potential health benefits of foreskin-removal. If the AAP wants to justify “third party payments” it cannot plausibly claim them for a procure that is more perilous, more ethically problematic, less effective and less cost effective than available alternatives. The government dime is clearly better spent elsewhere.

So let’s review:

  1. The AAP used to say that circumcision could not be recommended on health grounds, which was, and as I have argued, remains, the only scientifically and ethically credible position for it to maintain.
  2. In 2012, the AAP revised its position (while stopping short of a recommendation) in light of “new evidence” suggesting that the health benefits could now be said to “outweigh” the harms and risks of the procedure.
  3. The “new evidence” consists almost entirely of data collected in Africa between 2005 and 2007 suggesting that circumcision in adulthood, in environments suffering from an epidemic of HIV/AIDS, may reduce the risk of contracting HIV through unprotected, female-to-male, heterosexual intercourse (although it may increase the risk of HIV transmission from males to females).
  4. These data, however, are of “fair” quality (according to the AAP), and show an absolute risk reduction for HIV of only 1.3% between the treatment and control groups. Yet even if these data were taken seriously on their own terms, they would only apply to adult heterosexual males in Africa – not to infants in the United States.

Indeed, the AAP report itself makes essentially this same last point: “… the task force recommends additional studies to better understand the impact of male circumcision on transmission of HIV and other STIs in the United States because key studies to date have been performed in African populations with HIV burdens that are epidemiologically different from HIV in the United States.” Emphasis mine.

Yes, and until those studies are run – and run properly, with consenting populations, under strict ethical controls – it would be prudent for the AAP to abstain from making unsubstantiated claims about the benefits of circumcising infants in the United States. Especially since, as they concede on page 772 of their report “the true incidence of complications after newborn circumcision is unknown.” It should go without saying that if one doesn’t know how often complications occur, then one is ill-equipped to assert that the benefits outweigh them. One wonders how they ran these calculations.

* * *

It took the AAP circumcision “task force” several years to choreograph its latest tap-dance routine. Why it has produced a document that is out of line with both world opinion and the most basic of bioethical principles is a fascinating—and troubling—question, but one which I cannot hope to answer in a single post. Whatever the reason, however, one can be sure that it has more to do with culture than with science. As medical historians and cultural analysts have meticulously documented, circumcision as a birth ritual remains deeply, and uniquely, embedded in American medical culture and in the naïve expectations of doctors and parents alike. This sets the U.S. apart from everywhere else in the developed world—certainly outside of religious communities for whom the ritual is still self-consciously sacramental, and by whom it is performed without needing the rationalization of “health benefits.” Like any ritual, American proponents of circumcision are loath to give it up, for dread of the unknown consequences.

* * *

UPDATE – as of 27 May, 2013

Since this post was first published in August of 2012, some interesting developments have come about. To begin with, two major critiques of the AAP documents were published in leading international journals, one in the Journal of Medical Ethics, and a second in the AAP’s very own PediatricsThis second critique was penned by 38 distinguished pediatricians, pediatric surgeons, urologists, medical ethicists, and heads of hospital boards and children’s health societies throughout Europe and Canada. These authors stated unequivocally:

Only one of the arguments put forward by the American Academy of Pediatrics has some theoretical relevance in relation to infant male circumcision; namely, the possible protection against urinary tract infections in infant boys, which can easily be treated with antibiotics without tissue loss. The other claimed health benefits, including protection against HIV/AIDS, genital herpes, genital warts, and penile cancer, are questionable, weak, and likely to have little public health relevance in a Western context, and they do not represent compelling reasons for surgery before boys are old enough to decide for themselves.

So how did the eight members of the AAP special Task Force on circumcision reach a set of conclusions that are in direct contradiction to those reached by the majority of their peers in the developed world? As I speculated in my original post, and as the title of the critique I just quoted from makes clear, one plausible explanation is that there is: “Cultural Bias in the AAP’s 2012 Technical Report and Policy Statement on Male Circumcision.” In other words, the AAP members come from an unusually pro-circumcision culture, such that their ability to evaluate the practice dispassionately may have been at least partially compromised.

Intriguingly, the AAP took the time to respond to this possibility in a formal reply, also published in Pediatrics earlier this year. Rather than thoughtfully addressing the specific charge of cultural bias, however, the AAP elected to boomerang the criticism, implying that their critics were themselves biased, only against circumcision. They write:

The central claim of these authors is that the conclusions of the task force report are culturally biased, leading the task force to a flawed understanding of what constitutes trustworthy evidence and to conclusions that are far from those reached by physicians in most other Western countries. The “obvious” cultural bias to which they refer apparently has its genesis in “the normality of non-therapeutic male circumcision in the US.” All of the commentary authors hail from Europe, where the vast majority of men are uncircumcised and the cultural norm clearly favors the uncircumcised penis. In contrast, approximately half of US males are circumcised, and half are not. Although that heterogeneity may lead to a more tolerant view toward circumcision in the United States than in Europe, the cultural “bias” in the United States is much more likely to be a neutral one than that found in Europe, where there is a clear bias against circumcision.

Let me take this one step at a time. First, the AAP states that “All of the commentary authors hail from Europe.” This is not true. Indeed, this factual error is emblematic of the committee’s lack of attention to detail as displayed in their earlier reports. Instead, the distinguished Canadian pediatrician Noni McDonald, the first woman to become a dean of medicine in Canada, was one of the authors of the commentary in question, and Canada is not in Europe. But perhaps the AAP was close enough. The other 37 authors do indeed hail from various European countries including several from England.

Notice, too, the AAP’s use of the term “uncircumcised penis” — as though it were a penis just waiting to be circumcised. They might also have called it an “intact”, “whole,” or “normal” penis, but their pro-surgery bias colors even their basic terminology. For a comparison, we would not ordinarily refer to a woman’s breasts as “un-mastectomized” in a report about breast cancer.

The AAP’s point about Europe, of course, is that it is a land “where the vast majority of men are uncircumcised and the cultural norm clearly favors the uncircumcised penis.” Perhaps the AAP would like us to believe, then, that it’s really just one regional cultural norm versus another. But in fact the vast majority of cultures worldwide happen to ‘favor’ the ‘uncircumcised’ penis (and indeed most living men possess one), as it is the default, healthy condition for male human beings as well as other animals. By contrast, non-therapeutic genital surgery performed on children is non-normative globally. In the case of female children, it is almost universally condemned.

(I am not arguing, of course, that mere global popularity is evidence in itself for the greater soundness of the dominant norm. There are a number of other reasons to favor the mis-identified “European” perspective, as I will explain in a moment.)

The AAP then states, “In contrast, approximately half of US males are circumcised, and half are not.” But note that this is a recent development. Rates in the US were as high as 80 percent in the late 1980s, and even higher in the 1960s when routine circumcision was at its peak. Note, too, that a recently-achieved 50% circumcision rate does not entail that the American norm regarding circumcision is only 50% favorable. Instead, attitudes toward circumcision in the US remain overwhelmingly positive, and uncircumcised men are frequently subjected to ridicule as well as to ignorant accusations of being “less clean.”

Furthermore, assuming pre-1980 dates-of-birth, and given the very high base rate of circumcision from that earlier period, it is more than likely that 100% of the male Task Force members are, themselves, circumcised. In addition, both the Chair of the committee, Dr. Susan Blank, and one of its members, Dr. Andrew Freedman, have a documented religio-cultural bias in favor of circumcision on top of any baseline “American” one: Dr. Freedman has admitted to ritually circumcising his own son on his parents’ kitchen table. Not only is this in violation of the AAP’s own code of bioethics prohibiting physicians from conducting surgery on family members (let alone in non-sterile environments), it also provides additional evidence of a pro-circumcision bias among the AAP Task Force members.

What does the AAP mean to demonstrate, then, with its reference to the 50% circumcision rate among American males post 1990? That they are “neutral” on the issue? Given that (evidently) not one of the American males actually sitting on the AAP circumcision committee has an intact penis, this citation is somewhat misleading. The strength of the “50/50″ defense is further diluted by the fact that fully 25% of the committee’s members, including its Chair, have reasons to support circumcision that are quite independent from any medical considerations. As Freedman stated in a recent interview, “I [circumcised my son] for religious, not medical reasons. I did it because I had 3,000 years of ancestors looking over my shoulder.”

This is not even to raise the specter of the committee’s bioethicist, Dr. Douglas Diekema. Diekema, too, gives a dangerously wide leeway for parental cultural motivations when it comes to healthcare decisions that may be harmful to children or that may violate children’s rights. Most notably, he has “testified on behalf of parents convicted of child neglect who failed, on religious grounds, to seek medical care for their seriously ill child.” He has also written in favor of certain forms of female circumcision, such as nicking girls’ clitorises with a razor if requested by their parents.

To imply, then, that the AAP committee was simply evaluating the evidence regarding circumcision from a “neutral” or “50/50″ position of normative equipoise is not only misleading, it is literally unbelievable.

But let us go along with the AAP and consider their argument a bit more. Let us even concede that the mainly European authors of the “Cultural Bias” commentary are, themselves, biased—only against circumcision rather than for it. Well … of course they are! Being biased against unnecessary surgeries performed on nonconsenting patients should be the default position of any healthcare professional worthy of the title. Such a position follows naturally from the principles of biomedical ethics that doctors become obliged to uphold upon receiving their medical degrees. The doctors’ country of origin should be of no consequence.

Let me summarize. By suggesting that a cultural norm favoring the non-therapeutic, non-consensual surgical modification of a child’s penis is somehow on par with, or just as reasonable as, a medical-ethical norm favoring the avoidance of such surgery unless it is absolutely required, the AAP committee simply reveals its cultural hand.

The “European” commentators, by contrast: “have ‘a clear bias against circumcision’ the same way they have a clear bias against parentally-elective infant toe amputation.” They should be biased against needless surgical risk, especially when the patient cannot consent. They don’t even need a special “Task Force on Leaving Boys’ Genitals Alone” to prove it.

I will close with an honest suggestion. Perhaps the next time the AAP convenes a committee to consider the prudence of cutting off people’s foreskins, they should think about appointing at least one member who actually has one.


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A fatal irony: Why the “circumcision solution” to the AIDS epidemic in Africa may increase transmission of HIV

By Brian D. Earp 

* Note: this article has been re-posted at various other sites, sometimes with minor edits. This is the original and should be referred to in case of any discrepancies.


A fatal irony: Why the “circumcision solution” to the AIDS epidemic in Africa may increase transmission of HIV

1. Experimental doubts 

A handful of circumcision advocates have recently begun haranguing the global health community to adopt widespread foreskin-removal as a way to fight AIDS. Their recommendations follow the publication of three [1] randomized controlled trials (RCTs) conducted in Africa between 2005 and 2007.

These studies have generated a lot of media attention. In part this is because they claim to show that circumcision reduces HIV transmission by about 60%, a figure that (interpreted out of context) is ripe for misunderstanding, as we’ll see. Nevertheless, as one editorial [2] concluded: “The proven efficacy of MC [male circumcision] and its high cost-effectiveness in the face of a persistent heterosexual HIV epidemic argues overwhelmingly for its immediate and rapid adoption.”

Well, hold your horses. The “randomized controlled trials” upon which these recommendations are based are not without their flaws. Their data have been harnessed to support public health recommendations on a massive scale whose implementation, it has been argued, may have the opposite of the claimed effect, with fatal consequences. As Gregory Boyle and George Hill explain in their extensive analysis of the RCTs:

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Is the non-therapeutic circumcision of infant boys morally permissible?

On the ethics of non-therapeutic circumcision of minors, with a pre-script on the law

By Brian D. Earp (Follow Brian on Twitter by clicking here.)

PRE-SCRIPT AS OF 25 SEPTEMBER 2012: The following blog post includes material from an informal article I wrote many years ago, in high school, in fact, for a college essay competition. I would like to think that my views have gained some nuance since that time, and indeed with increasing speed, as I have researched the topic in more detail over the past several months–specifically during the period of a little over a year since the blog post first appeared online. Since quite a few (truthfully: many thousands of) people have come across my writings in this area, and since I am now being asked to speak about circumcision ethics in more formal academic company, I feel it is necessary to bring up some of the ways in which my thinking has evolved over those many months.

The most significant evolution is away from my original emphasis on banning circumcision. I do maintain that it is morally wrong to remove healthy tissue from another person’s genitals without first asking for, and then actually receiving, that person’s informed permission; but I also recognize that bringing in the heavy hand of the law to stamp out morally problematic practices is not always the best idea. It is a long road indeed from getting one’s ethical principles in order, to determining which social and legal changes might most sensibly and effectively bring about the outcome one hopes for, with minimal collateral damage incurred along the way. Until enough hearts and minds are shifted on this issue, any strong-armed ban would be a mistake.

In the long term, however, I think the goal remains: that each child should have the same moral, legal, and policy protections regardless of sex or gender, designed to preserve their sexual anatomy in their healthy, intact form until such time as they are mentally competent to make a decision about altering them, surgically or otherwise.

The project for the meantime is to work on hearts and minds.

I am grateful to the many hundreds of individuals who have left thoughtful comments on my sequence of posts on the ethics of circumcision, and I look forward to developing my arguments in ever more sophisticated ways in the coming months and years as this important debate continues. I am especially grateful to those of my interlocutors who have disagreed with me on various points, but who have done so in a thoughtful and productive manner. May we all aim at mutual understanding, so that the best arguments may emerge from both sides, and so that the underlying points of genuine disagreement may be most clearly identified. — B.D.E.

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Routine neonatal circumcision in boys is unethical, unnecessary, and should be made illegal in the United States. Or so I argue in this post.

Yet lawmakers in California, it is now being reported, have introduced a bill with the opposite end in mind. They wish to ban legislation that could forbid circumcision-without-consent. What could be going on?

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