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The Flip-flop over Foreskin

Asian_newborn_crying_BRAND_PHO_EN

This is a guest post by Elizabeth Reis, professor of women’s and gender studies at the University of Oregon. Professor Reis is the author of Bodies in Doubt: An American History of Intersex (Johns Hopkins University Press, 2009). This year (2012-2103) she is a visiting scholar in the History of Science Department at Harvard University.

The American Academy of Pediatricians recently released a statement saying that the health benefits of circumcision outweighed the risks. This pronouncement contradicts the Academy’s earlier ruling, just thirteen years ago in 1999, which stated unequivocally that the health benefits of the procedure were slim. The 1999 statement reversed a previous one made in 1989 that said there were good medical reasons for it; but a few years earlier, in 1971, the Academy had officially concluded that it was not a medical necessity. Clearly, circumcision is one of those surgeries about which opinion shifts back and forth over the years.

Medical concerns have changed frequently. In the 1840s many worried about phimosis, a condition in which the foreskin does not retract completely. To read some of the medical journal articles from the period, one might think this problem was nearly epidemic. Circumcision became one of the cures widely touted by physicians for this particular disorder. They also recommended circumcision as a remedy for masturbation and nervous conditions later in the century; in fact, some even endorsed the surgery for women suffering the same maladies.

Circumcision Set, 1870 

Unlike the nineteenth-century physicians who focused on individual ailments, today’s circumcision advocates turn to public health justifications. To be sure, even today there are some who argue for its benefits on an individual level: it might decrease the already low incidence of infant urinary tract infectionsand even rarer penile cancer in adults, but these studies are contested and are not so compelling to advocates as the possibility of stemming the rising numbers of HIV/AIDS infections, particularly in Africa. In each era, circumcision promoters have emphasized the particular health crisis most urgent at the time; syphilis during World War I, HIV/AIDS today.

Even if we agree that circumcision has some public health benefits, it is not the cure-all that we might imagine. The pediatricians’ report cited several studies done in Africa, where HIV is spread primarily among heterosexuals. This research found that it reduced transmission from infected women to men but had no effect on transmission between men. In addition, it ameliorated the spread of some sexually transmitted infections (HPV and herpes) but not gonorrhea, syphilis, or the most common STI, chlamydia. Is altering perfectly healthy bodies prophylactically really the best response, or might education campaigns about safe sex practices be more successful (and less invasive) for the prevention of all these diseases?

The public health crisis of HIV/AIDS should not be taken lightly, of course, but the endorsement of circumcision for newborns is a radical step, particularly when the surgery has its own complications; the New York Times noted that one in 500 infants suffer severe consequences (infection, excessive bleeding, and disfigurement of the penis), and some babies even die each year.

Anticircumcision proponents (known as intactivists) argue that it is unethical to make a decision that permanently alters another person’s body without that person’s informed consent. Babies cannot consent, obviously, and so intactivists deplore second party assent to unnecessary surgery. Though offering ethical arguments and critiques of procircumcision claims, those who question routine circumcision are too easily dismissed.

Pediatricians, like most other Americans, are accustomed to thinking of circumcision as natural, harmless, and beneficial. Indeed, popular perceptions of the surgery represent it as a mere “snip of skin.” So many men in this country have been circumcised as infants that the surgery can strike us as “normal,” and many (though not all) do not feel they have suffered from it. Paradigms are difficult to shift. But if we took a moment to put aside what we think we know, and to look carefully at the conflicting medical debates circumcision has inspired over the years, we might be persuaded to at least question the necessity and wisdom of the procedure, given its risks, its permanence, and the fact that its recipient might have chosen otherwise.

For some religious and cultural communities, of course, non-health reasons motivate circumcision. Jews and Muslims circumcise boys to fulfill religious covenants, and these rituals have recently come under scrutiny in Germany. Many there and in our own country as well are worried about pitting state power against religious freedom. By emphasizing parents’ rights to make informed decisions, the AAP statement speaks to those families for whom cultural or religious considerations might supersede all else. But most American families do not have these same concerns. Many parents are likely to simply ask their physicians what to do.

By affirming that medical benefits outweigh the risks, the AAP makes the health card difficult to trump. For those parents who rest their case on the most recent health claims, it would be worth keeping in mind that medical opinions have consistently flip-flopped over circumcision. The AAP’s decision is reversible. Is the parents’?

This article is reprinted with permission from  The Hasting’s Center Bioethics Forum. 

9 Comments Post a comment
  1. Michael Steane #

    Pediatricians know perfectly well that infant circumcision is not natural. They hear the screams of the restrained baby loudly enough. They are one of the three groups that are supporting this bizarre and unethical lobby: profiteers, puritans and perverts.

    August 30, 2012
  2. Amy #

    We don’t cut off body parts for health reasons, we promote good hygiene, educate and use anti-biotics.

    August 30, 2012
  3. Yvonne Brown #

    The issue of pain has also concerned me. As far as I know unless practices have changed, the infant receives no anesthesia for this painful procedure. Does this not seem barbaric for this day and age? Also I think people still underestimate the huge influence doctors and medical professionals have on people. When the man/woman in the “white coat” tells you something is perfectly “safe” and “necessary” for good health, it is next to impossible for most people to question. The only thing a parent hears is the “safe” and “necessary” part–words–not the risks, although the risks are seldom mentioned. I believe the medical culture has only gotten more intimidating with the advent of super technology and pharmacology!

    August 30, 2012
  4. Jay S. #

    http://www.iasociety.org/Default.aspx?pageId=11&abstractId=2177677

    Here’s a study showing that female circumcision reduces AIDS significantly. But we don’t advocate this because cutting away erogenous tissue for the purpose of reducing the likelihood of STD transmission during unprotected sex is an unnecessary surgical procedure on a non-consenting individual.

    August 30, 2012
  5. Warren C. Wood #

    I have witnessed more than a half-dozen circumcisions (two of them on my own sons). The babies I saw did not cry until they were strapped on the circumcision board and stopped the moment they were back in the arms of their mother or father. The cry did not intensify during the surgery. I know that there are studies that claim to prove that the procedure is extremely painful for the infants who undergo it, but the samples in the ones I have seen are small, and the interpretation of the data is open to some alternative analyses (i.e. the levels of stress suffered by the child from which the studies derive evidence of pain might not be attributable to the surgery but other factors). Today most doctors who perform circumcisions, even moehels, use anesthetic and prescribe children’s Tylenol if the boy seems uncomfortable after the procedure. I don’t think any child should have to be circumcised, nor do I think parents who want their boys circumcised, especially if it is for religious reasons, are being cruel or immoral. The image of the rusty old circumcision set above is a bit of melodrama worthy of Belasco (who, like me, was Jewish and probably circumcised). I am neither a profiteer, a puritan, or a pervert. And here is another challenge: If we presume that “babies cannot consent” and therefore circumcision is unethical, what are those of us who support abortion rights to say to the anti-abortion activists who claim they are speaking for unborn babies who cannot speak for themselves? I think the choice to circumcise your child or not is like the choice to terminate a pregnancy or not. The decision inevitably is complex and it should be left to those it effects most. It is a private decision that should be made by informed parents of the children involved. It is not a matter for public extortion or moralizing.

    September 2, 2012
  6. Meghan #

    One thing to consider is that a neonatal response to pain is often to “shut down”. The infants may still have physiologic pain markers (changes in respiratory rate, changes in heart rate, visual pain markers) but do not cry. This is interpreted by the parents and others as “Oh, they didn’t even feel it and slept right through it!” when in fact it is a developmentally appropriate response to significant pain.

    I have been present at more circumcisions that I want to count, and although a penile nerve block is almost always used, the injection itself is painful. When the foreskin is removed, it essentially exposes the same amount and kind of nerves that would be exposed by removing one’s fingernails, and then that tissue is exposed regularly to acidic urine. There is no way, physiologically, to call circumcision a painless procedure.

    Furthermore, routine infant circumcision is cosmetic surgery, being performed on a minor. Should we remove our daughters’ breast buds at birth? Should we remove their clitoral hoods (the physiologic equivalent of circumcision)? Religious circumcision is a tiny percentage of the million or more performed each year, and not the topic of this AAP statement at any rate. What this statement will do is financially encourage more routine infant circumcision, despite the fact that countries that do not circumcise and are otherwise comparable to the US do not have skyrocketing rates of STI, nor do states in the US where circumcision is relatively rare.

    September 4, 2012
  7. David Harley #

    There are often circumstances that shape the research and activism on this issue. Looking into this, some years ago, I was struck by just how many of those working on the AIDS and circumcision enquiry, or summarizing the research of others, appeared to have religious interests in justifying routine circumcision. There has been a long tradition of reinterpreting biblical and Quranic taboos, taken out of context, as prescient health regulations.

    On the other hand, European campaigns against religious circumcision often have a xenophobic undercurrent and have been supported by members of ultra-right parties. The same has occurred with humanitarian campaigns against kosher and halal butchery.

    For myself, I would not want to see any restriction on a religious ritual that has been so central to identity, except to ensure that no diseases are transmitted to the child, by an infected mohel, for example. It should be noted that Muslims are not of one mind on the subject.

    However, secular circumcision is surely a separate issue. Leaving aside the ethical questions, one really does need to ask why the US and Australia are the only developed countries where non-religious infant circumcision is a majority practice. What is it about these two countries? They are not generally compared with one another or with Europe. Like the incidence of hysterectomy, this is surely a topic that calls for cross-cultural ethnography.

    In the UK, before the introduction of the NHS, there was a strong class distinction, noticed by all at shower time during World War Two. Cavaliers and Roundheads were the terms used. Presumably, the various forms of health insurance used by working-class families would not cover elective operations, but perhaps the middle class was more readily persuaded by “expert opinion”, as on so many other matters.. After the war, there was a generational shift, as medical opinion changed, following cost-benefit research. Circumcision was no longer advised, and not likely to be covered by the NHS. The influence of the NHS’s foundation was not as sudden as it was in the case of spa medicine, but it was powerful over time.

    The interest of the CDC in cost-effectiveness is surely not what has kept circumcision alive in the US and Australia throughout the 20th century. Is it still the moral, even anti-sex, concerns of Kellogg and his colleagues?

    December 31, 2012
  8. AngelXY #

    Arguing back and forth about medical risks and benefits while stuck in a labyrinth of “research” means you can’t even see the wood for the trees. This habit is driven by cultural traditions and social norms, it has NOTHING to do with health or medicine.

    Removing genital parts means you no longer have to clean it and it also cant present any future problems. This curious principle is practiced on genitals only and not on any other body part which should be your first clue that something is very wrong here. Medicine normally treats any existing issues conservatively first, while aiming to preserve healthy tissue and nothing ever gets removed as a matter of “prevention” without the personal consent of the owner. Especially not when all these so called benefits can also be easily achieved without surgery, regardless of what is between your legs.

    They are just ways to gift wrap the ugly truth and sugar coat the reality – your society practices genital cutting just like many others around the world that believe it has health, hygiene, aesthetic, sexual or social benefits. The “studies” that try to justify it are heavily influenced by these beliefs. Those you trust have simply hijacked this bad habit after it was established to ensure their continued profits. You are just too blinded by the “science” to see the ugly truth clearly… So please continue to debate the “science” while I sit here laughing at you.

    How much “scientific evidence” do people evaluate before they decide whether to remove genital parts from infant girls or not? How much “research” do they need before even a pin prick to female genitals is considered harmful?

    Or is common sense enough to protect their physical integrity. Curious double standard…

    Its a boy – Harmless, beneficial, legal, ethical, medical, parental choice
    Its a girl – Harmful, violation, illegal, unethical, mutilation, abuse

    April 8, 2014

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