Painful Cuts: The Case for Infant Circumcision Is Weakening

A popular U.S. tradition is becoming harder to justify.

Posted Dec 18, 2019

Male circumcision is the surgical removal of some or all of the foreskin (or prepuce) from the penis. The origins of circumcision are unknown, and probably predate written history, but the practice is incorporated into two major religious traditions.

Jews have been circumcising their infant sons for thousands of years, in a ceremony called Brit Milah. While circumcision is not mentioned in the Qur’an, the Prophet Muhammad recommended it, and most Muslim men today undergo circumcision in childhood. Currently, most male circumcisions around the world (roughly two-thirds of them) are performed in Muslim communities.

Circumcision rates vary widely around the world, and the data on them are merely estimates. The World Health Organization estimated that 30-33 percent of the world’s males aged 15 years or older are circumcised. Of these, approximately 69 percent are Muslim, 1 percent are Jewish, and 30 percent are circumcised for non-religious reasons. Of those in the latter category, 43 percent are in the U.S., while the rest are everywhere else combined.

Wikimedia Commons Public Domain
Rembrandt's The Circumcision in the Stable
Source: Wikimedia Commons Public Domain

The origins of non-religious circumcision of healthy newborn males in the U.S. probably trace back to the 1870s, when Dr. Lewis A. Sayre, an influential New York surgeon, developed a theory that circumcision could cure multiple diseases by “quieting the nervous system.” U.S. and British doctors who bought his claims helped spread the practice as a purported means of preventing many health problems, including impotence, sexually transmitted diseases, seizure disorders, bed-wetting, homosexuality, and paralysis. During the 19th century in the U.S.—a time when masturbation was (wrongly) purported to cause many illnesses—the practice of circumcision gained further hold as an anti-masturbation measure.

Contemporary parents who choose circumcision for non-religious reasons tend to cite either the health (easier hygiene, less cancer risk, etc.) or social (“I want him to look like his dad/other kids”) benefits of the procedure. The best predictor of whether a child is circumcised or not is the circumcision status of the father. Many parents may choose circumcision because health care providers in the U.S. routinely offer it to them.

The issue of circumcision stirs heated debate in part because it involves the volatile mix of religious, sexual, and parenting considerations, as well as residing on the short hyphen between the ethical and medical realms.

From a medical perspective, the debate has focused on the evidence regarding the procedure’s health implications. Circumcision has been shown in the literature to confer several health benefits. However, most of that literature is written by U.S. researchers, who tend to be circumcised males and culturally biased in favor of circumcision.

Thus, studies are often undertaken with the explicit goal of verifying the supposed benefits of male circumcision (U.S. researchers possess the opposite bias about female genital cutting, a topic for another day). Moreover, the benefits of circumcision are generally small and can usually be obtained by other, less invasive means, and without resorting to non-consensual surgery. For example:

Circumcision reduces the odds of penile cancer. However, penile cancer is one of the rarest forms of cancer, occurring in less than one man in every 100,000 (less than male breast cancer). Moreover, about one-third of penile cancers are caused by the human papillomavirus and can be prevented by the HPV vaccine

Due to this low base rate, approximately 300,000 circumcisions would need to be done to prevent one case of penile cancer, according to the American Academy of Family Physicians. Each circumcision carries risks of its own, thus further muddying the health equation. Moreover, circumcision reduces the odds of penile cancer indirectly by making good genital hygiene easier to maintain. When the general hygiene environment is good, the effects tend to disappear.   

Circumcision also reduces the occurrence of phimosis, a condition in which the foreskin can't be retracted from around the tip of the penis. Yet most early cases of phimosis resolve over time, and if foreskin retraction becomes a problem in childhood, non-invasive treatments such as topical creams and stretching will solve it in most cases. Moreover, phimosis due to a tightening of the circumcision scar tissue over the glans penis occurs in about 1 percent of boys, which is roughly the rate of persistent phimosis in intact adult males. Thus ironically, in the case of phimosis, circumcision creates the same problem it is said to prevent.

Circumcision has been shown to reduce men’s risk of contracting HIV. At the same time, male circumcision may actually increase the risk of HIV for female partners. Moreover, this evidence comes from studies of voluntarily circumcised adults in sub-Saharan Africa, where the base rate of HIV infection is high, and much of it is heterosexually transmitted. There is no evidence that circumcision protects against HIV in the U.S., and generalizing data from consenting adults in developing countries to non-consenting infants in developed ones is highly problematic.

Circumcision has been shown to reduce the rates of UTIs in infants. Yet this evidence base is problematic since it's based mostly on cohort and observational studies, as randomized clinical trials on the topic are rare. Infant UTIs, moreover, tend to decrease over time, regardless of circumcision status.

UTIs affect about 1-2 percent of boys in the first two years of life. This base rate means that multiple infants need to be circumcised to prevent one UTI case. This is problematic since circumcision, like any surgery, carries risk, and other less invasive and risky procedures are readily available (such as antibiotics, the standard of care for girls, in whom UTIs are much more common).

Balanitis (inflammation of the glans penis) also appears less commonly in circumcised males. Yet again, this issue is usually easily treated with good hygiene and ointments, which are much less invasive and problematic than non-consensually (and permanently) severing functional genital tissue from healthy infants.

From a medical perspective, the cumulative evidence appears to arrive at somewhat of a stalemate. Summarized crudely, circumcision's health benefits are too small to recommend, mandate, or routinize the procedure, yet the medical risks are too small to forbid it. Thus, The American Academy of Pediatrics’ official policy states: “Although health benefits are not great enough to recommend routine circumcision for all male newborns, the benefits of circumcision are sufficient to justify access to this procedure for families choosing it.” Families, for their part, are choosing it less often, particularly in the industrial world.

The ethical argument for circumcision is even more difficult to sustain than the medical one, since removing a healthy, functional bodily tissue surgically without consent or medical necessity is quite intuitively seen as a violation of basic individual rights.

Recently, a team of more than 90 medicine, law, ethics, and human rights scholars with expertise in genital cutting authored an international consensus statement on the ethical issues related to circumcision. They write:

“Under most conditions, cutting any person’s genitals without their informed consent is a serious violation of their right to bodily integrity. As such, it is morally impermissible unless the person is nonautonomous (incapable of the consent), and the cutting is medically necessary … a common understanding is that an intervention to alter a bodily state is medically necessary when (1) the bodily state poses a serious, time-sensitive threat to the person’s well-being, typically due to a functional impairment in an associated somatic process, and (2) the intervention, as performed without delay, is the least harmful feasible means of changing the bodily state to one that alleviates the threat."

Clearly, neonatal circumcision fails to satisfy either criterion.

Brian Earp, Associate Director of the Yale-Hastings Program in Ethics and Health Policy at Yale University (full disclosure: he’s a Facebook friend) and a leading scholar on this topic, offers the following analogy: Consider labiaplasty (surgical cutting of the labia). It is similar to circumcision in that it removes genital tissue that is involved in yet not necessary for sexual enjoyment, and in that the genital tissue in question requires good regular hygiene, can become infected or even cancerous, and is involved in people's assessment of genital aesthetics. Given these similarities, Earp proposes, we can assume that removing the labia will produce both health and psychosocial benefits for some women.

Would we approve of non-voluntary neonatal labiaplasty in the U.S. under these conditions? Unlikely. This is because there is quite a broad agreement in our culture that:

1. Healthy, functional bodily tissue is valuable in and of itself, and removing such tissue permanently without consent is wrong if other means exist to prevent and treat rare potential problems associated with maintaining it.

2. Girls have rights, including the right to genital integrity, the right to grow up with their genitals intact and decide for themselves, when they are properly able, whether and which parts they would like to keep, alter, or chop off.

Why would the same arguments not apply to male circumcision?

In sum, the best evidence suggests that in most cases in the U.S., the potential health benefits gained from neonatal circumcision can be achieved through non-surgical means or through performing the procedure, consensually, later. Neonatal circumcision involves the permanent removal of a healthy, functional bodily tissue without consent or medical necessity, which leaves the procedure standing on thin and slippery (and rapidly melting) ethical ice. No wonder that, increasingly, parents of boys are thinking twice before they choose to cut once. 

References

Selected References (available for free online)

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Auvert, B., Taljaard, D., Lagarde, E., et al. (2005) Randomized, controlled intervention trial of male circumcision for reduction of HIV infection risk: The ANRS 1265 trial. PLoS Med 2(11): e298. 

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Boyle, G. J. and Hill, G. (2011). Sub-Saharan African randomised clinical trial in male circumcision and HIV transmission: methodological, ethical and legal concerns. J Law Med, 19: 316-34. 

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