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Human rights and bodily integrity |
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National Human Rights Consultation: Submission
Human rights include the right to bodily integrity and to protection from unwanted surgical interventionsIn this submission it is argued that there is a glaring gap in the Australian human rights framework, namely, that boys are not given any protection against unwanted and unnecessary surgical interventions such as circumcision. It is suggested that boys are entitled to as much protection from circumcision (male genital mutilation) as girls from female genital mutilation (female circumcision). Since it is unlikely that any such protection will be provided by legislative measures, alternative means such as public education and the removal of financial incentives are proposed.
Contents
A Socratic dialogue
Introduction: Human rights
Relevant human rights instruments
Developments in bioethics and law
Circumcision in Australia
Policy statements of medical authorities
Circumcision and public health
Harm of circumcision
An anomaly in law and ethics: Boys need protection
Summary
Conclusion
Recommendation
A Socratic dialogueDiogenes: It seems to me that circumcision of girls is fundamentally wrong. Not only is it physically harmful, but it is a breach of a baby girl’s human rights.
Philo: If it is a breach of human rights, then, since boys are human, it would follow that circumcision of boys is a breach of human rights too.
Diogenes: That would appear to be the case.
Philo: Yet many authorities on medical ethics and human rights make no mention of boys when discussing genital mutilation or even argue that the bioethical or human rights principles applying to girls do not apply to boys.
Diogenes: If circumcision of girls is a violation of their human rights but circumcision of boys is not, there are two logical implications: either it is not a breach of their human rights to circumcise girls, or boys are not human.
Philo: Neither of those propositions seem reasonable or logical, so there must be a further possibility.
Diogenes: Which is?
Philo: That the ethical and human rights authorities are mistaken when they assert or imply by silence that the arguments against circumcision of girls do not apply to boys.
* * * * * * *
Importance of the individualThe only purpose for which power can be rightfully exercised over any member of a civilized community, against his will, is to prevent harm to others. His own good, either physical or moral, is not a sufficient warrant. He cannot rightfully be compelled to do or forbear because it will be better for him to do so, because it will make him happier, because, in the opinion of others, to do so would be wise, or even right. … The only part of the conduct of any one, for which he is amenable to society, is that which concerns others. In the part which merely concerns himself, his independence is, of right, absolute. Over himself, over his own body and mind, the individual is sovereign.
The only freedom which deserves the name, is that of pursuing our own good in our own way, so long as we do not attempt to deprive others of theirs, or impede their efforts to obtain it. Each is the proper guardian of his own health, whether bodily, or mental and spiritual.
— John Stuart Mill, On Liberty
Introduction: Human rightsAttempting to define human rights, the Australian Human Rights Commission website states:
Every person has inherent dignity and value. Human rights help us to recognise and respect that fundamental worth in ourselves and in each other. Human rights are the same for all people everywhere – male and female, young and old, rich and poor, regardless of our background, where we live, what we think or what we believe. This is what makes human rights “universal”.
Human rights are important. They recognise our freedom to make choices about our life and develop our potential as human beings. They ensure that we can live free from fear, harassment or discrimination.
The background paper to this consultation similarly states, “Human rights are about equality and fairness for everyone. A society that commits to human rights, commits to ensuring that everyone is treated with dignity and respect.” “Everyone” explicitly encompasses both males and females, boys and girls.
It would be hard to imagine a more gross violation of personal dignity than to restrain and forcibly subject a male infant or boy to surgery that excises a significant part of his penis. Any such procedure carried out on minors is necessarily performed without consent. It is not treating them with dignity and respect.
Human rights protect individualsThe key points about human rights are that they pertain to individuals, not to groups or collectivities, and that their purpose is to protect the dignity of the individual and the integrity of his or her body and personhood. The modern concept of human rights emerged in the eighteenth century as part of the European Enlightenment, expressed most vividly in the Declaration of the Rights of Man, but the modern concept of an individual right derives from John Locke’s arguments against the divine right of kings in his Treatise on Government, where he wrote that “every Man has a Property in his own Person. This no Body but himself has any Right to but himself. The Labour of his Body, and the work of his Hands, we may say, are properly his.” [1]
An important implication of this perspective is that a right is an assertion against power, something conferred by law or custom that those without power can deploy in their defence against those that do have power. In the relations between children and adults, it is the children who are powerless and the adults who hold the power, and it follows that the children are the party in need of the rights. It makes no sense to say that parents have the right to circumcise their children because parents already have vast power over them and can, in practice, do anything they like to them. Law, custom and (in recent times) human rights instruments attempt to even up this disparity in power by setting limits on what parents may do to their children.
Several of these instruments make direct or implied reference to circumcision.
Relevant human rights instrumentsUniversal Declaration of Human Rights
Composed in the shadow of the Second World War, this has nothing direct or indirect to say about genital or other bodily mutilations, but it is interesting to recall that the initial seed idea for a declaration of rights emerged from attempts by H.G. Wells to formulate some war aims in 1939, and that his first draft included a prohibition on bodily mutilation. The draft was included in a letter to the Times, Article 9 of which included the following words: “That no man shall be subjected to any sort of mutilation or sterilization except with his own deliberate consent, freely given, nor to bodily assault, except in restraint of his own violence, nor to torture, beating or any other bodily punishment.” [2] No statement as explicit as this was included in the declaration that emerged after the war, but some authorities have seen an implied criticism of mutilations in its provisions on self-determination, physical and moral integrity, and protection of children. [3]
United Nations Convention on the Rights of the Child, 1989
This contains two provisions relevant to circumcision, including one that has been interpreted as a specific prohibition of genital mutilation.
Article 19 (1)
States Parties shall take all appropriate legislative, administrative, social and educational measures to protect the child from all forms of physical or mental violence, injury or abuse, neglect or negligent treatment, maltreatment or exploitation, including sexual abuse, while in the care of parent(s), legal guardian(s) or any other person who has the care of the child.
Article 24 (3)
States Parties shall take all effective and appropriate measures with a view to abolishing traditional practices prejudicial to the health of children.
Circumcision "potentially illegal": Queensland Law Reform Commission
It is hard to know what Article 24 (3) could refer to unless it was genital mutilation of children, and it has generally been interpreted as having this intent. Following the adoption of the convention, many western countries and some Australian states introduced legislation criminalising any form of female genital mutilation, and in 1993 the Queensland Law Reform Commission looked into the possibility of a law along the same lines to protect boys. Its conclusion was that circumcision of minors was technically illegal on two grounds: first, on the common law ground that
if the young person is unable, through lack of maturity or other disability, to give effective consent to a proposed procedure and if the nature of the proposed treatment is invasive, irreversible and major surgery and for non-therapeutic purposes, then court approval is required before such treatment can proceed. The court will not approve the treatment unless it is necessary and in the young person’s best interests. The basis of this attitude is the respect which must be paid to an individual’s bodily integrity.
Secondly, circumcision of a minor could be regarded as an assault as defined by the Queensland Criminal Code:
On a strict interpretation of the assault provisions of the Queensland Criminal Code, routine circumcision of a male infant could be regarded as a criminal act. Further, consent by parents to the procedure being performed may be invalid in light of the common law’s restrictions on the ability of parents to consent to the non-therapeutic treatment of children.
In other words, the Commission concluded not merely that circumcision was a violation of a person’s bodily integrity, and thus of his human rights, but potentially a breach of the law. It suggested some remedies, but acknowledged that given wide community acceptance of circumcision as a legitimate intervention, the prospects for legislation were slim – and so it proved. While the Queensland Criminal Code (S323A) prohibits genital mutilation even on an adult female who desires and has consented to such a procedure, and recent legislation has restricted the right of minors to get themselves decorated with tattoos or piercings, boys remain without any protection against being circumcised at the request of somebody else. [4]
The reasons why the wording of the Convention on the Rights of the Child was so vague may be guessed, but that it was intended to refer to both male and female genital cutting was made clear in some of the subsequent consultations, such as in Lesotho, where a local committee reported:
Culture is a component of education. Cultural activities like circumcision are not to be a hindrance to a child’s right to education. It is proposed that proper medication be administered at circumcision schools. Children should be allowed to decide at 21 years of age whether or not they want to be circumcised. [5]
The reference here is to children’s right to decide, meaning both boys and girls. In Guinea-Bissau another report made clear that “traditional practices” were those affecting all children, not just girls:
The report states that traditional practices and customs are causing serious problems for children and women. The circumcision of boys aged 9 to 13 years and female genital mutilation in girls aged between 7 and 12 years among the Fula and Mandinga ethnic groups are the most cruel and harmful practices. There are no effective measures at the national level to eliminate them. [6]
Despite the reference to children, however, the rest of the report forgot about boys and went on to talk about the need for campaigns against female genital mutilation, and made no further mention of circumcision of males.
This tendency for “traditional practices prejudicial to … children” to be increasingly interpreted as applying to girls only was deplored in a report to the United Nations by the National Organization of Circumcision Information Resource Centers, which pointed out:
That international humanitarian law, insofar as it provides protection against rape and other sexual assaults, is applicable to men as well as women is beyond any doubt as the international human right not to be discriminated against (in this case on the basis of sex) does not allow derogation. Males may not be discriminated against in the application of human rights principles. United Nations experts have acknowledged that at least under certain circumstances male circumcision constitutes a human rights violation. [7]
The reference in the last sentence is to a UN report on the civil war in Yugoslavia, which states that as well as women suffering rape and other forms of sexual violence, “Men are also subject to sexual assault. … They have also been subjected to castration, circumcision or other sexual mutilation.” [8]
Other treaties: bioethicsThere are several further international conventions in the bioethics field that explicitly give children protection against unwanted or unnecessary medical procedures. These are the Council of Europe’s Convention on Human Rights and Biomedicine 1997, and the UNESCO Universal Declaration on Bioethics and Human Rights 2005.
1. Convention for the Protection of Human Rights and Dignity of the Human Being with regard to the Application of Biology and Medicine
Chapter II (Consent), Article 5, states as a general rule that
An intervention in the health field may only be carried out after the person concerned has given free and informed consent to it. This person shall beforehand be given appropriate information as to the purpose and nature of the intervention as well as on its consequences and risks. The person concerned may freely withdraw consent at any time.
Article 6, Protection of persons not able to consent, states that “an intervention may only be carried out on a person who does not have the capacity to consent, for his or her direct benefit.” [9]
Here the term “person” clearly refers to both males and females, both adults and children, and requires fully informed consent for any medical intervention. The provision amounts to an acknowledgement that people of any age or sex have the right to refuse unwanted medical or surgical interventions and to be protected from interventions they do not understand.
2. UNESCO, Universal Declaration on Bioethics and Human Rights
This includes a number of clauses that appear to protect individuals from unwanted medical interventions. These are quoted in full:
Article 3 – Human dignity and human rights
1. Human dignity, human rights and fundamental freedoms are to be fully respected.
2. The interests and welfare of the individual should have priority over the sole interest of science or society.
Article 6 – Consent
1. Any preventive, diagnostic and therapeutic medical intervention is only to be carried out with the prior, free and informed consent of the person concerned, based on adequate information. The consent should, where appropriate, be express and may be withdrawn by the person concerned at any time and for any reason without disadvantage or prejudice.
Article 7 – Persons without the capacity to consent
In accordance with domestic law, special protection is to be given to persons who do not have the capacity to consent.
Article 8 – Respect for human vulnerability and personal integrity
In applying and advancing scientific knowledge, medical practice and associated technologies, human vulnerability should be taken into account. Individuals and groups of special vulnerability should be protected and the personal integrity of such individuals respected. [10]
It is readily apparent that circumcision of a non-consenting minor, unless essential to correct a deformity, injury or disease that has not responded to conservative treatment after a fair trial, would breach every one of these provisions. In Article 3 (2), “interest” should be interpreted in a wide sense as including all the individual’s interests apart from “welfare”. These might include self-esteem, body image, aesthetic preferences, cultural allegiances, erotic practices and self-identification, all of which might be seriously affected by the presence or absence of the foreskin. Article 8 gives special protection to the personal integrity of those unable to protect themselves, that is, to infants and children.
Developments in bioethics and lawIn the decade that followed the passage and ratification of the United Nations Convention on the Rights of the Child there has been a proliferation of studies by legal scholars, human rights experts and bioethicists who have developed convincing arguments that medically unnecessary circumcision of non-consenting minors is a violation of accepted principles of medical ethics and human rights. Some commentators have even raised doubts as to the legality of the procedure. Important landmarks include essays showing that “informed consent” for such an intervention constitutes a “legal and ethical conundrum”; that the justifications for such an operation as a prophylactic measure cannot override the ethical objections; and that circumcision of boys is a violation of the rights of the child. [11] Other scholars have shown that the ethical and physical harm arguments against female genital mutilation apply just as strongly to circumcision of boys, that the physiological parallels of the two sets of procedures are very close, and that there is no justification for quarantining discussion of male circumcision from FGM. [12]
Australia’s obligations under the Sex Discrimination Act 1984 and as a signatory to the Convention on the Rights of the Child require the national and state governments to treat males and females equally and without discrimination on the basis of sex, and to take action to eradicate traditional practices harmful to children. Article 24 (3) of the Convention requires parties to take “all effective and appropriate measures with a view to abolishing traditional practices prejudicial to the health of children.” As noted above, in pursuance of this development several states passed laws to prohibit any form of female circumcision, and the Commonwealth specifically excluded such procedures from the Medical Benefits Schedule. Although there was nothing in the wording of the Convention to suggest that it did not include male children, no action has yet been taken to protect them. Although the Medicare guidelines state that payments are not available for cosmetic or clinically unnecessary procedures, a rebate for circumcision is still provided, thus subsidising and encouraging the procedure and sending a signal that it is socially and ethically acceptable. This failure to take any action to protect boys is increasingly recognised as constituting, as a recent article in the Australian Journal of Human Rights argued, “a hidden human rights violation”. [13]
Background: Circumcision in AustraliaCircumcision of normal male minors as a preventive health precaution became common during the late Victorian period in Britain and the United States and soon spread to other Anglophone communities. The practice was never adopted anywhere else, except in South Korea after 1953 as a consequence of the U.S. occupation following the Korean War. Although circumcision was abandoned in Britain in the 1950s, it remained common in New Zealand until the 1960s, in Australia until the 1970s and in Canada until the 1980s, and it is still widely practised, and obstinately defended, in the United States. [14] Over the past thirty years Australian medical authorities have consistently sought to discourage the procedure; in policy statements issued in 1971, 1983, 1996, 2002 and 2004 they have stressed that there is no medical indication or need for circumcision as a routine or precautionary procedure, and that serious legal, ethical and human rights concerns hang over the procedure when performed on minors.
The motivations for circumcision fall into four broad categories:
- religious or cultural (as in Judaism, Islam and a number of tribal societies);
- customary or social (to look like dad or the neighbours);
- therapeutic (to correct a deformity, injury or disease);
- prophylactic or precautionary (to reduce the supposed risk of potential health problems or disease in the future).
In addition, a very small number of adults seek circumcision for a variety of personal reasons
It is widely accepted that most circumcision procedures in Australia, especially on boys under the age of ten years, are not clinically necessary and are performed either because the parents prefer the boy to have a circumcised penis (“social circumcision”), or because there has been a false or premature diagnosis of phimosis or other foreskin problem and conservative measures have not been given a fair trial. [15] For this reason, public hospitals in most states have deleted circumcision from their schedule of free services. Unfortunately, this decision has opened the field for opportunistic GPs who ignore the recommendation against circumcision issued by the Royal Australasian College of Physicians and advertise themselves as “circumcision specialists”. Some even claim to provide a “bloodless and non-surgical procedure”, a false and misleading claim that should be investigated by the Australian Competition and Consumer Commission.
Policy statements by medical authoritiesAll the medical organizations that have issued a policy on routine circumcision of minors agree that the procedure is medically unnecessary and should not be performed unless there is a serious medical problem that cannot be resolved in any other way. These bodies include the British Medical Association, the Canadian Pediatric Association, the American Academy of Pediatrics and the Royal Australasian College of Physicians. In its most recent statement the RACP states there is “no medical indication for routine male circumcision” and that there is “no evidence of benefit outweighing harm for circumcision as a routine procedure”. Medical organizations in Scandinavia take an even stronger line against the operation. [16]
In Finland, the Central Union for Child Welfare has issued a policy which states that circumcision of boys violates their personal integrity and is not acceptable--
unless it is done for medical reasons to treat an illness. The basis for the measures of a society must be an unconditional respect for the bodily integrity of an under-aged person. … Circumcision can only be allowed to independent major persons, both women and men, after it has been ascertained that the person in question wants it of his or her own free will and he or she has not been subjected to pressure. [17]
In Denmark, an editorial in the principal medical journal, Today’s Medicine, affirmed that “is that no adult is entitled to carry out irreversible surgery on a child, unless it is for health reasons”, that is, to correct a problem that has not responded to conservative treatment. The editorial continued:
the operation is associated with a small but unnecessary risk of severe mutilation. Therefore circumcision and all other permanent body modifications should be deferred until the child has reached the age of majority. Only then can individuals choose to have themselves circumcised, tattooed or otherwise beautified, for religious, cultural or other reasons. However, prior to 18 years of age, Danish children have a right to be protected from ritual interventions which can cause pain or permanent damage. [18]
In Britain prophylactic circumcision is not practised at all, and therapeutic circumcision only rarely, and nearly all procedures are done for cultural or religious reasons (mainly at the desire of Muslim parents). Guidelines issued by the British Medical Association therefore place strict conditions on the operation, recognising that the rights of the child are paramount and that his wishes in the matter should be respected, as set out in the following principles:
- The welfare of child patients is paramount and doctors must act in the child’s best interests.
- Children who are able to express views about circumcision should be involved in the decision-making process.
- Consent for circumcision is valid only where the people (or person) giving consent have the authority to do so and understand the implications and risks.
- Both parents must give consent for non-therapeutic circumcision.
- Where people with parental responsibility for a child disagree about whether he should be circumcised, doctors should not circumcise the child without the leave of a court.
Much of the document refers to religiously-motivated circumcision, but of particular relevance to the Australian situation is the BMA’s advice that there is no consensus in the medical world as to the health benefits of circumcision and that parents should be warned against uncritical belief in the (often improbable) “health” claims of interested parties:
There is significant disagreement about whether circumcision is overall a beneficial, neutral or harmful procedure. At present, the medical literature on the health, including sexual health, implications of circumcision is contradictory, and often subject to claims of bias in research. Doctors performing circumcisions must ensure that those giving consent are aware of the issues, including the risks associated with any surgical procedure: pain, bleeding, surgical mishap and complications of anaesthesia. … Doctors should ensure that any parents seeking circumcision for their son in the belief that it confers health benefits are fully informed of the lack of consensus amongst the profession over such benefits, and how great any potential benefits and harms are. The BMA considers that the evidence concerning health benefit from non-therapeutic circumcision is insufficient for this alone to be a justification for doing it. [19]
Australian medical authorities have lagged behind in their recognition of the ethical and human rights questions surrounding circumcision, but in 1996 the Australian Association of Paediatric Surgeons issued a position statement in which it declared its opposition to routine circumcision of neonates: not only was their no medical justification for such an intervention, but there was the distinct possibility that the boy would regret losing his foreskin:
We do not support the removal of a normal part of the body, unless there are definite indications to justify the complications and risks which may arise. In particular, we are opposed to male children being subjected to a procedure, which had they been old enough to consider the advantages and disadvantages, may well have opted to reject the operation and retain their prepuce. [20]
In other words, in the absence of any urgent medical necessity, it was unethical and cruel to deprive a boy of a normal body part that he might later appreciate. The argument, it will be noted, was quite independent of any “health” considerations, since it assumed that an individual has the right to manage his own health and to make his own decisions about the appropriate balance of risks and pleasures.
Circumcision and public healthAlthough certain prominent circumcision evangelists have predicted dire health consequences as an effect of Australia’s abandonment of circumcision, a study by the Australian Institute of Health and Welfare in 2005 found that there had been a major improvement in child health outcomes between the early 1980s and 2000 – the very period when routine circumcision disappeared. [21] A recent cost utility analysis of neonatal circumcision found that even if the extreme claims of advocates were true, the associated complications and adverse outcomes would cancel out and exceed the benefit to health. [22]
In places such as Australia, with a past history of widespread circumcision, it is common to find misconceptions about the normal development of the penis and the correct care of the natural (uncut) penis, especially in rural areas. Many people, including doctors, continue to believe that the foreskin should be retractable soon after birth, or at 3 or 4 years at the latest, and that it should be forcibly retracted for cleaning purposes as soon as possible. These ideas are incorrect, since it is quite common for the foreskin not to become retractable until puberty; this rarely causes any problems, and no action is needed unless the boy is experiencing pain or discomfort. [23]
It is also often assumed that minor foreskin problems (discomfort arising from tightness, minor skin infections, minor UTIs, persistent phimosis etc) cannot be cured by conservative treatment but require amputation. The normal rule in modern medical practice is medical treatment first, followed by surgical intervention only if medical treatment fails; this rule has often not been, but should be, applied to the penis as much as to other parts of the body. There is, in fact, abundant evidence that most foreskin problems can be successfully treated with conservative measures; [24-28] since parents and even doctors are not always aware of them, this information should be publicised more widely.
HIV-AIDSWhile there is evidence from Africa that circumcised men who have frequent unprotected intercourse with infected female partners are less vulnerable to infection with HIV, and world health authorities have recommended circumcision of sexually active adult men as an adjunct to controlling the spread of AIDS in severely affected regions of Africa, there has been no suggestion from responsible authorities that such measures are appropriate in developed nations or in places with a low incidence of female to male transmission. The Australian Federation of AIDS organization has stated that circumcision has no role in the management of HIV in Australia, where the disease is largely confined to specific sub-cultures. [29] In any case, protection against HIV would not be a justification for circumcising infants or children, since they are not sexually active and thus not at any risk of contracting the disease (unless through surgery itself.)
Even in Africa the recommendations of the World Health Organisation have been contested, and its gung-ho approach to what it calls the circumcision roll-out has been attacked by the South African Medical Journal as costly, ineffective, a violation of accepted principles of bioethics and human rights, culturally insensitive and smacking of medical colonialism. [30] It has also been criticized by child health and human rights experts as neither medically necessary nor ethically permissible. [31] To cite the African data as an argument for circumcision of male infants and boys in Australia would be irresponsible and inappropriate.
Balancing public health and individual choiceIn this context it is useful to recall the framework proposed by Hodges et al for balancing the requirements of human rights with the those of public health. In an important article published in the Journal of Medical Ethics in 2002, they considered prophylactic interventions in children and how conflicts between the demands of public health and human rights might be resolved. Noting that such interventions were traditionally justified on the grounds of “best interests of the child” and/or “public health”, they proposed two sets of criteria which had to be met before an intervention could be accepted as ethical. The criteria for the “best interests of the child” argument were (1) presence of clinically verifiable disease, deformity or injury; (2) least invasive and most conservative treatment option; (3) net benefit to the patient and minimal negative impact on patient’s health; (4) competence to consent to the procedure; (5) standard practice; (6) individual at high risk of developing the disease. The criteria for the “public health benefit” argument were: (1) substantial danger to public health; (2) condition must have serious consequences if transmitted; (3) effectiveness of the intervention; (4) invasiveness of the intervention; (5) whether individual receives an appreciable benefit not dependent on speculation about future behaviour; (6) the health benefit to society must outweigh the human rights cost to the individual.
The authors evaluated several interventions against one or other of these sets of criteria, and neonatal circumcision against both of them. They concluded that while immunisation generally satisfied the “best interests” and “public health” justifications, circumcision failed to satisfy either of them. Such an intervention was thus impermissible because it was performed on a minor without consent; the human rights cost to the individual exceeded the proven public health benefit; and the disease could be avoided through appropriate behavioural choices. [32]
Harm of circumcisionThe risks and complications of circumcision are well known (see RACP policy for a summary), and the most common of these (bleeding) is so frequent that there is a MBS code dedicated to its treatment. [33] But even the most conscientious procedure causes bodily harm insofar as it removes an integral, functioning, visually prominent and emotionally significant part of the body. It is now known that the foreskin supports the main nerve centres of the penis, and that its removal significantly alters sexual sensation and response. Taylor et al found that circumcision excises highly innervated skin and mucosa from the penis, [34] while Cold and Taylor showed that the human foreskin has numerous physiological functions, including protective, immunological, mechanical, sensory, and sexual functions. [35] A Korean study found circumcised men significantly more dissatisfied with their condition following the procedure: “There was a decrease in masturbatory pleasure and sexual enjoyment after circumcision, indicating that adult circumcision adversely affects sexual function in many men”. [36] In the United States Sorrells et al found that the areas of the penis most sensitive to fine-touch are located on the foreskin. [37] Until the late nineteenth century it had been a truism of Western medical knowledge that the foreskin made a significant contribution to sexual sensation and that its loss was a misfortune to be regretted – so much so that in the eighteenth century men regarded it as “the best of your property.” [38]
There are particularly strong reasons for not performing circumcision procedures on very young boys, since the small size of the penis makes it difficult to operate on, and the need to tear the foreskin from the glans (since it is usually adherent at that age) adds a further dimension of both pain and injury.
- The Australasian Association of Paediatric Surgeons advised that if elective circumcision has to be performed, it should always be after 6 months of age. [39]
- A recent study in Saudi Arabia, where circumcision of young boys is common as a result of adherence to Muslim custom, concluded that neonatal circumcision should not be recommended and that circumcision at 5 months (if it must be done for social reasons) resulted in “significantly fewer serious complications than circumcision in the neonatal period, irrespective of the method used.” [40]
- It is not possible to give effective pain relief to very young children. While EMLA is frequently used as a pain relief for infants, [41] the manufacturers specifically state that “EMLA should not be used in children under 6 months of age. We do not have enough knowledge yet to be sure it is safe in very young babies.” [42] Yet circumcision without effective anaesthesia is extremely painful. Lander found “extreme distress” in babies circumcised without pain relief, [43] and Taddio found a stronger pain response when circumcised boys were vaccinated several months later. [44]
There is in fact abundant evidence that many men have bitterly resented having been circumcised, and that many have suffered serious emotional, psychological and physical harm as a result. [45] Agonising though it is, the pain of the operation is insignificant compared with the life-long harm of being deprived of an integral, visually prominent, aesthetically attractive and erotically significant component of the body.
An anomaly in law and ethics: Boys need protectionIn Australia it is evident that boys are in far greater need of protection from genital mutilation than girls. On a world scale it has been estimated that some 13 million boys are circumcised each year, compared with only two million girls subjected to FGM. [46] Societies that circumcise girls are found in Africa, the Middle East and parts of south-east Asia, but the practice is all but unknown elsewhere, except among immigrants from these regions. It might be argued that the laws against FGM that have been passed in many western countries are aimed at a problem that scarcely exists. In Australia, as in the United States, however, thousands of boys annually are the victims of circumcision procedures, the vast majority of which are not required for any health reason, are certainly not desired by the child, and are probably not in his best interests.
To give an example of how vulnerable boys are, consider a case in Bundaberg in 2002, when an estranged father who had been denied custody of the two boys (aged 5 and 9) from his former marriage took advantage of a regular visit to race the boys off to a surgeon and have them circumcised. Although the frantic mother made efforts to have him prosecuted, he was let off without even a slap on the wrist. The boys were traumatized and bitter. Even more shameful than the father’s conduct was that of the surgeon, who made no attempt to consult the views of the mother, the feelings of his two terrified and unwilling “patients”, or even if the father was entitled to authorise the operation (which he was not). [47] His motivation arose from his Turkish-Islamic background, but it could just as easily have been a young mother who had been alarmed by scaremongering assertions on talk-back radio, or the advertising of circumcision “experts”, or stories about the dreadful fate awaiting boys whose foreskins were not snipped off before it was too late, such as getting caught in their zipper, becoming infected and ultimately succumbing to gangrene and causing death. [48]
SummaryIn this submission I have attempted to show the following.
- International treaties in the human rights field give people the right to bodily integrity without discrimination as to gender.
- The Australian Sex Discrimination Act 1984 commits the Commonwealth to treating the sexes equally. While the legislation does not refer specifically to protection from bodily harm, it would be contrary to its spirit to deny boys protection given to girls.
- Many human rights authorities and bioethics experts consider circumcision of minors to be a human rights violation.
- Circumcision causes physical and psychological harm and is often resented by those who have been subjected to it.
- Medical authorities do not consider circumcision a desirable routine measure for child health and have raised serious doubts about the ethics and even the legality of the procedure.
- There are no “compelling” public health arguments that would justify circumcision of non-consenting minors in Australia.
- Boys in Australia are at far greater risk of genital mutilation than girls.
Conclusion: Balancing parental and child rights
It is, however, difficult to suggest an effective and widely acceptable means of protecting boys from adults (usually their parents) who want to get them circumcised. The issue is a contentious and highly emotional one, touching on both the relations between parents and their children and the sensibilities of ethnic/religious minorities who regard circumcision as a requirement of their faith or a necessary mark of their tribal identity. Previous attempts to take action have foundered on precisely this rock. When, in 1986, the Commonwealth government dropped circumcision from the Medical Benefits Schedule the decision aroused protests from Jewish religious leaders, who considered the reform discriminatory in that it applied to circumcision only of boys under six months. The decision was reversed without a fight. In the early 1990s the Queensland Law Reform Commission was considering the possibility of legislation that would give boys protection from genital mutilation similar to that already accorded to girls. It received such a flood of contradictory submissions that it was unable to reach a firm conclusion, and nothing was done. Many of the submissions were from Jewish and Muslim organisations which insisted that any restriction on their right to circumcise boys would be an infringement of their religious freedom and thus a breach of Australia’s human rights obligations.
Interestingly, however, most of the public submissions did not try to justify circumcision on the culturally relativist ground of ethnic/religious particularity, but in terms of an old fashioned set of health benefits, the validity of which had already been rejected by medical authorities. Nonetheless, the reliance on medico-scientific arguments to defend a traditional cultural practice was not a new strategy, and it would become more pronounced as the 1990s wore on. It has been argued that the revival of old claims for the “health benefits” of circumcision that became apparent in the mid-1990s is really a response by traditional circumcising cultures to developments in human rights, law and medical ethics that were threatening to outlaw their practices: the power of modern science and medicine was to be harnessed in defence of ancient customs. [49]
The problem for critics of circumcision was that any general ethical or human rights argument against circumcision could not avoid applying to the cultural and religious groups that were most committed to the practice, and most loath to give it up, who naturally reacted fiercely. They, in turn, formulated their arguments in favour of circumcision in terms that applied to all boys, not just their own sub-culture. The result has been that in order to preserve circumcision among the ethnic/religious groups that traditionally practise it, all other boys have been placed at risk of the operation, and many have, in consequence, been subjected to it.
Is there no way out of this dilemma? At least for the foreseeable future there is unlikely to be legislation similar to that criminalising FGM to protect boys from circumcision. In this environment, all we can hope for is better education of parents as to its non-necessity for health, and the cessation of signals that it is a medically-approved procedure. Notwithstanding the government’s failure in 1986, the simplest and least discriminatory way of achieving this is by dropping medically unnecessary circumcision from the Medical Benefits Schedule and deleting circumcision from the list of allowable childbirth expenses under the Medicare Safety Net.
RecommendationMedical Benefits Schedule
Items 30653, 30659, 30660, 30656
30653 – Circumcision of male under 6 months of age
30656 – Circumcision of male over 6 months and under 10 years
30659 – Circumcision of male 10 years of age and older by a GP
30660 – Circumcision of male 10 years or older by a specialist
ProposalConfine the Medical Benefits Schedule rebate for these procedures to cases of genuine medical need. This can be achieved quite simply by adding the words “where medically necessary” at the end of each item.
ExplanationThe Medicare guidelines state that a medical benefit is payable only for medical procedures that are clinically necessary and is not payable for cosmetic or other unnecessary surgery. [50] It is widely accepted that most circumcision procedures, especially on boys under the age of ten years, are not clinically necessary and are performed either because the parents prefer the boy to have a circumcised penis (“social circumcision”), or because there has been a false or premature diagnosis of phimosis or other foreskin problem and conservative measures have not been given a fair trial. It is, further, a sound principle of public finance that government programs should be directed strictly at areas of need and administered with economy and prudence; to use the health budget to subsidise procedures that are not clinically necessary is a violation of this principle.
Definition“Genuine medical need” means a case where (1) there is a medical problem that has not responded to conservative (non-surgical) treatment after reasonable efforts; and (2) this is certified by two qualified medical practitioners, one of whom must be an appropriate specialist, and neither of whom may be the surgeon who is to perform the surgery.
JustificationThe justifications for the policy reform proposed here may be considered under the headings of medical policy, consistency, human rights and economy. Since medical policy and human rights have already been covered, only consistency and economy are dealt with here.
Consistency
The Australian Government is the only national jurisdiction in the world that provides no-questions-asked coverage of circumcision of minors through the health budget. This policy is despite the fact that most State governments (Victoria, Western Australia, Tasmania, New South Wales and South Australia) do not provide free coverage of circumcision in public hospitals, and it is in sharp contrast with the practice of comparable developed nations.
- In Britain the National Health Service has never included circumcision among its free procedures, and covers it only as a therapeutic procedure in cases of medical necessity. The same is true of New Zealand.
- In Canada, where medical insurance is the responsibility of the provinces, the only province to include circumcision in its cover is Manitoba.
- In the United States, the central government provides the funds for public health insurance to the states, which make their own decisions as to which services they cover. When the program was introduced in the mid-1960s all states covered circumcision, but since the 1970s at least sixteen states have ceased to fund it, except in cases of genuine medical need; [51] in a country where circumcision is deeply entrenched as a social ritual, [52] this is a remarkable development.
- Circumcision is not funded by the governments of Israel or Turkey, countries where the procedure is widely practised as a cultural/religious ritual, not even when the operation is performed in hospitals rather than (as is traditional) in the boy’s home.
- The Dutch national health insurance service withdrew coverage of circumcision in 2004 when it was realised that 90 per cent of the procedures were done for religious/cultural rather than for health reasons (mainly by the Netherlands substantial Moslem population) [53].
The Commonwealth Sex Discrimination Act, Section 3 (b), states that the Act applies to the administration of Commonwealth laws and programs, while Section 22 (b) makes it illegal to discriminate on the basis of sex in the provision of goods, services and facilities. It could be argued that the exclusion of female circumcision from the MBS is a breach of this provision, since it denies to women a benefit given to men; [54] whether or not circumcision is regarded as a benefit or a deprivation, it is certainly anomalous that the MBS specifically denies coverage for cutting procedures on the female genitals while providing no-questions-asked coverage for comparable procedures on the genitals of boys.
The simplest way to remove this anomaly and restore the principle of equal treatment is to limit coverage of male circumcision to cases of proven medical necessity.
The policy issued in 1983 by the Australian College of Paediatrics led the National Health and Medical Research Council to recommend that circumcision be dropped from the Medical Benefits Schedule, and this recommendation was partly accepted by the Health Department and endorsed by the then Minister, Neal Blewett in 1985. The Department made the mistake, however, of limiting the withdrawal of benefits to circumcision below the age of 6 months and leaving it in place for circumcision above that age. This was seen as discriminatory by some members of the Jewish community (since Jews traditionally perform circumcision at 8 days), and they successfully lobbied the government to reverse the decision. Since that time the Health Department has replied to letters which urge the abolition of the circumcision subsidy that a previous attempt to do so aroused widespread protests and had to be abandoned.
This claim is far from the truth, since the decision was in fact widely applauded; it was objected to only by the Jewish community, and even then mainly on account of the discrimination inherent in continuing the benefit for circumcision procedures on boys older than 6 months. Had the decision been to withdraw the subsidy for all circumcision procedures except in cases of genuine medical need there might have been some complaints, but there would have been no valid grounds for objection. [55] The way forward is to treat everybody equally and without discrimination by confining the rebate for circumcision to situations of genuine medical need as defined above.
Economy
All government welfare programs should be targeted at genuine need and be administered with prudence and economy. An open-slather approach to funding a medically unnecessary procedure is wasteful and invites over-servicing. It also acts as a signal that circumcision is a socially acceptable and even medically recommended operation, thus encouraging more parents to seek to have it done.
- Assuming 15,000 unnecessary circumcision procedures per year at a cost of between $100 and $1600 each, Spilsbury et al have estimated that the removal of medically unnecessary circumcision from the MBS would save between $1.5 million and $24 million per year. They state that “the potential savings to the public purse would be considerable if elective and discretionary circumcision was removed from the Medicare schedule in line with other cosmetic surgeries, leaving rebates for the genuine medically indicated circumcision.” [56]
- In the 2006-07 financial year, Medicare item 30653 alone cost $1,260,869 to circumcise 17,877 babies under 6 months of age [57]. This is more than a million dollars spent on a service that is not medically necessary and which is discouraged by the Australasian Association of Paediatric Surgeons and other responsible medical authorities.
- These figures do not include the cost of treating complications and long-term adverse effects, which may not become apparent until adolescence. An American cost utility analysis of neonatal circumcision found that even if the extreme claims of advocates were true, the associated complications and adverse outcomes would cancel out and exceed the benefit to health. [58]
- Now that public hospitals in most states do not include circumcision among their free services, the field is open for medical entrepreneurs and private clinics to exploit the situation through advertising that is likely to mislead the public as to the benefits and acceptability of the surgery. [59]
These might not seem substantial sums in the context of today’s billion-dollar budgets, but when every effort is being made to rein in public expenditure, especially the ever-expanding health budget, every million saved can make a difference. Not only this: given the irresponsible media commentary on the role of circumcision in HIV control and the efforts of scaremongering local evangelists to instil a mood of panic, the demand for circumcision is likely to increase as ignorant parents become fearful of the alleged risks of not taking action. The cost of the circumcision subsidy is thus likely to increase unless it is restricted. Removal of circumcision from the MBS will send a clear signal to Australian parents that routine circumcision is not a medically recommended procedure and is not necessary for the health and safety of their child.
Speaking of safety, some of the practitioners who perform many circumcision procedures are not necessarily the most competent, as suggested by the cases of Dr Aladdin Mattar and Dr Suman Sood, both of whom were deregistered (eventually) on account of the crudeness of their surgery and the high incidence of complications and severe disfigurement. [60]
Summary and conclusion
- It is both humane and good medical practice to discourage circumcisions in the newborn period and infancy, when the operation is both more risky and more damaging, and when safe, effective pain relief cannot be given.
- There is evidence that the younger a circumcision procedure is performed, the greater the risks. Abolishing the subsidy for neonatal circumcision would encourage parents and doctors to wait until the procedure is less risky and can be performed in a more humane manner.
- Confining the MBS subsidy for circumcision to cases of proven medical necessity would save public money by limiting unnecessary surgery. It would also discourage rogue practitioners, promote ethical medical practice by recognising the human rights of male children, restore the principle of equal treatment on the basis of sex, and bring Australia into line with best practice as seen in comparable developed nations.
- The sensibilities of the Moslem and Jewish communities would not be affronted by this reform, since the new rules would apply to everybody, without discrimination. The reform would not restrict the right of Jewish, Aboriginal or Muslim parents to circumcise their children in accordance with their respective traditions.
Appendix 1: Relevant MBS codes and payments30653: Circumcision of a male under 6 months of age
Scheduled fee: $42; Benefit: $31.50 (75%); $35.75 (85 %)
30656: Circumcision of a male under 10 years of age but not less than 6 months of age
Scheduled fee: $97.65; Benefit: $73.25 (75%); $83.05 (85%)
30659: Circumcision of a male 10 years of age or over by a GP
Scheduled fee: $135.20; Benefit $101.40 (75%); $114.95 (85%)
30660: Circumcision of a male 10 years of age or over by a specialist
Scheduled fee: $167.65; Benefit $125.75 (75%); $142.55 (85%)
30663: Haemorrhage, arrest of, following circumcision requiring general anaesthesia
Scheduled fee: $130.35; Benefit $97.80 (75%); $110.80 (85%)
Until 1995 these codes were unisex and read “circumcision of a person”, thus authorising a benefit for circumcision of females as well as of males. In order to protect girls from genital mutilation as part of the general development of laws and policies against FGM that followed the passage of the UN Convention on the Rights of the Child in 1989, “person” was changed to “male”, thus introducing two elements of discrimination: females were denied a service that remained available to males; but males were denied the protection that was accorded to females.
Appendix 2: Key articles in human rights and medical ethicsWilliam E. Brigman, “Circumcision as child abuse: The legal and constitutional issues”, Journal of Family Law, Vol. 23, 1985
Ross Povenmire, “Do parents have the legal authority to consent to the surgical amputation of normal, healthy tissue from their infant children? The practice of circumcision in the United States”, Journal of Gender, Social Policy & the Law, Vols. 8-7, 1998-1999
Gregory J. Boyle, J. Steven Svoboda, Christopher P. Price, J. Neville Turner, “Circumcision of healthy boys: Criminal assault?” Journal of Law and Medicine, Vol. 7, 2000
Arif Bhimji, Infant male circumcision: A violation of the Canadian charter of rights and freedoms”, Health Care Law (Toronto) 2000, January 1:1-33
J. Steven Svoboda, Robert Van Howe and James Dwyer, “Informed consent for neonatal circumcision: An ethical and legal conundrum”, Journal of Contemporary Health Law and Policy, Vol. 17, 2000, 61-133
Margaret Somerville, “Altering baby boys’ bodies: The ethics of infant male circumcision”, in The Ethical Canary: Science, Society and the Human Spirit (Toronto: Viking, 2000)
Frederick Hodges et al, “Prophylactic interventions on children: Balancing human rights with public health”, Journal of Medical Ethics, Vol. 28, 2002, 10-16
S.K. Hellsten, “Rationalising circumcision: From tradition to fashion, from public health to individual freedom – Critical notes on cultural persistence of the practice of genital mutilation”, Journal of Medical Ethics, Vol. 30, 2004, 248-53
Jacqueline Smith, “Male Circumcision and the Rights of the Child”, in Mielle Bulterman, Aart Hendriks and Jacqueline Smith (eds.). To Baehr in Our Minds: Essays in Human Rights from the Heart of the Netherlands. Utrecht: Netherlands Institute of Human Rights, 1998 (SIM Special No. 21): 465-498.
Marie Fox and Michael Thomson, “Short Changed? The Law and Ethics of Male Circumcision”. International Journal of Children’s Rights 2005;13:161–181
Clark P.A. ,“To circumcise or not to circumcise?: A Catholic ethicist argues that the practice is not in the best interest of male infants”. Health Prog 2006; 87(5): 30-9; “Is infant male circumcision an abuse of the rights of the child? Yes!”
Geoff Hinchley, British Medical Journal, Vol. 335, 8 Dec. 2007, p. 1180.
Doctors Opposing Circumcision, Genital Integrity Policy Statement, June 2008
Most of these articles are available through CIRP bioethics and human rights and legal resources.
References1. John Locke, An Essay Concerning the True, Original Extent and End of Civil Government (Second Treatise on Government), Book II, Chapter V
2. H.G. Wells, “The rights of man”, letter to Times, 25 October 1939, 6A; reprinted in The Rights of Man; or What Are We Fighting For? (Harmondsworth: Penguin Special, n.d. [1940]
3. For example, the United States group, Attorneys for the Rights of the Child.
4. Queensland Law Reform Commission, Circumcision of Male Infants Research Paper (Brisbane 1993).
5. Committee on the Rights of the Child, Initial reports of States parties due in 1994: Lesotho. 20/07/98. CRC/C/11/Add.20. (State Party Report), full text here.
6. Committee on the Rights of the Child Considers Initial Report of Guinea-Bissau, United Nations Press Release, 22 May 2002.
7. Submission by Nocirc to the U.N. Sub-Commission on the Promotion and Protection of Human Rights, 23 March 2002, Document E/CN.4/Sub.2/2002/NGO/1.
8. United Nations Security Council, Commission of Experts’ Final Report [on the former Yugoslavia], 27 May 1994, document S/1994/674, part IV, section F. Text available here.
9. Council of Europe, Convention for the Protection of Human Rights and Dignity of the Human Being with regard to the Application of Biology and Medicine.
10. UNESCO, Universal Declaration on Bioethics and Human Rights, 2005.
11. For a list of key articles, see Appendix 2
12. Christine Mason, “Exorcising excision: Medico-legal issues arising from male and female genital surgery in Australia”, Journal of Law and Medicine, Vol. 9, 2001; Kirsten Bell, “Genital Cutting and Western Discourses on Sexuality”. Medical Anthropology Quarterly 19(2):125–148; Robert Darby and J. Steven Svoboda, “A rose by any other name: Rethinking the differences/similarities between male and female genital cutting”, Medical Anthropology Quarterly, Vol. 21, September 2007
13. Ranipal Narulla, “Circumscribing circumcision: Traversing the moral and legal ground around a hidden human rights violation”, Australian Journal of Human Rights, Vol. 12, 2007, 89-118
14. David Gollaher, Circumcision: A History of the World’s Most Controversial Surgery (NewYork: Basic Books, 2000); Robert Darby, A Surgical Temptation: The Demonization of the Foreskin and the Rise of Circumcision in Britain (Chicago and London: University of Chicago Press, 2005)
15. Spilsbury K, Semmons JB, Wisniewski ZS, Holman CD. Routine circumcision practice in Western Australia 1981–1999. ANZ J Surg 2003;73(8):610-4; Spilsbury et al, Circumcision for phimosis and other medical indications in Western Australian boys, Medical Journal of Australia 2003;178 (4): 155-158
16. Statements from medical organizations are conveniently collected at www.cirp.org/library/statements
17. Finland, Central Union for Child Welfare, Position Statement of the Circumcision of Boys (Helsinki 2003).
18. Editorial, “Ban circumcision of boys”, Today’s Medicine, 19 December 2002.
19. British Medical Association, The Law and Ethics of Male Circumcision: Guidance for Doctors, November 2007.
20. The Australasian Association of Paediatric Surgeons, Guidelines for Circumcision (1996).
21. Australian Institute of Health and Welfare, A Picture of Australia’s Children (Canberra: AIHW 2005). Summary at circinfo.org-news.
22. Van Howe RS. A cost-utility analysis of neonatal circumcision. Medical Decision Making 2004;24:584-601
23. Dan Bollinger, “The penis-care information gap: Preventing improper care of intact boys”, THYMOS: Journal of Boyhood Studies, Vol. 1, Fall 2007, 205-219.
24. Concern at unnecessary circumcision. The Age, Melbourne, Sunday, 16 February 2003. Seen at cirp-news
25. Rickwood AMK, Walker J. Is phimosis overdiagnosed in boys and are too many circumcisions performed in consequence? Ann R Coll Surg Engl 1989; 71(5):275-7.
26. Griffiths D, Frank JD. Inappropriate circumcision referrals by GPs. Journal of the Royal Society of Medicine 1992; 85:324-325.
27. Robert S. Van Howe, Cost-effective Treatment of Phimosis, Pediatrics Vol. 102 No. 4 October 1998, p. e43
28. Rickwood AMK, Kenny SE and Donnell SC, Towards evidence based circumcision of English boys: Survey of trends in practice, British Medical Journal 2000; 321:792-793. See also Spilsbury K, Semmons JB, Wisniewski ZS, Holman CD. Routine circumcision practice in Western Australia 1981–1999. ANZ J Surg 2003;73(8):610-4; Spilsbury et al, Circumcision for phimosis and other medical indications in Western Australian boys, Medical Journal of Australia 2003;178 (4): 155-158
29. Australian Federation of AIDS Organisations, Briefing Paper, 23 July 2007, Male circumcision has no role in the Australian AIDS epidemic.
30. D. Sidler, J. Smith, H. Rode, “Neonatal circumcision does not reduce HIV/AIDS infection rates”; A. and J. Myers, “Editorial: Rolling out male circumcision as a mass HIV/AIDS intervention seems neither justified nor practicable”, both in South African Medical Journal, Vol. 98, No. 10, October 2008. Both available at http://www.cirp.org/library/disease/HIV/
31. Robert Van Howe and J. Steven Svoboda, “Neonatal circumcision is neither medically necessary nor ethically permissible: A reply to Clark et al”, Medical Science Monitor, Vol. 14, 2008.
32. Hodges FM, Svoboda JS, Van Howe RS. Prophylactic interventions on children: balancing human rights with public health. J Med Ethics 2002;28: 10-16
33. Infection and haemorrhage are the most common causes of death following circumcision, especially in infants. For an account of the inquiry into the death of a child following hospital circumcision in Canada in 2002, see www.circinfo.org/account.html#ryleigh
34. Taylor JR, Lockwood AP, Taylor AJ. The prepuce: specialized mucosa of the penis and its loss to circumcision. Br J Urol 1996; 77:291-5.
35. Cold CJ, Taylor JR., The prepuce. BJU Int 1999;83 Suppl. 1:34-44. Available at www.cirp.org/library/anatomy/cold-taylor
36. Kim DS and Pang M-G. The effect of male circumcision on sexuality, BJU International 2006;99:619-622.
37. Sorrells ML, Snyder JL, Reiss MD, et al. Fine-touch pressure thresholds in the adult penis. BJU Int 2007;99:864-9. This has the text but not the illustrations. For a clearer presentation of the data and illustrations, see www.circumstitions.com/Sexuality. See also H.S. Meislahn and J.R. Taylor, “The importance of the foreskin to male sexual reflexes”, in George Denniston, Frederick Hodges and Marilyn Milos (eds), Flesh and Blood: Perspectives on the Problem of Circumcision in Contemporary Society (New York and London: Kluwer Academic and Plenum Publishers, 2004)
38. Surgical Temptation, chap 2; Darby Svoboda, “A rose by any other name”
39. J. Fred Leditshke, Guidelines for Circumcision. Australasian Association of Paediatric Surgeons, Herston, QLD: 1996.
40. M. Machmouchi, A. Alkhotani, Is Neonatal Circumcision Judicious? Eur J Pediatr Surg 2007; 17: 266-269.
41. Despite such warnings, Australia’s most vigorous champion of circumcision, Dr Terry Russell, uses EMLA cream, claiming that it is both totally effective and completely safe. One mother on a discussion forum said that he used EMLA cream on a 5-week-old baby, “We had our son circumcised at 5 weeks. We saw Dr Terry Russell at Mt Gravatt in Brisbane. Dr Russell makes two appointments with you. The first is to discuss the circumcision with you and to give you the EMLA cream (anaesthetic) for the procedure”.
42. EMLA Consumer Medicine Information available here. See also the warnings collected at www.cirp.org/library/complications/EMLA/
43. Lander J, Brady-Freyer B, Metcalfe JB, et al. Comparison of ring block, dorsal penile nerve block, and topical anesthesia for neonatal circumcision. Journal of the American Medical Association 1997; 278:2158-62. “Although our physicians were highly experienced in performing circumcision and had excellent surgical technique, every newborn in the placebo group exhibited extreme distress during and following circumcision.”
44. Taddio A, Goldbach M, Ipp E, et al. Effect of neonatal circumcision on pain responses during vaccination in boys. Lancet 1995;345:291-2.
45. John Warren et al. Circumcision of children. British Medical Journal 1996;312;377; Hammond T. A preliminary poll of men circumcised in infancy or childhood. BJU International 1999; 83 (Supplement 1):85-92; Robert Darby and Laurence Cox, “Objections of a sentimental character: The subjective dimension of foreskin loss”, in Chantal Zabus (ed.), Fearful Symmetries: Essays and Testimonies around Excision and Circumcision (Amsterdam and New York: Rodopi, forthcoming); Shane Peterson, Assaulted and mutilated: A personal account of circumcision trauma, in George C. Denniston, Frederick Hodges and Marilyn Milos (eds), Understanding circumcision: A Multi-disciplinary Approach to a Multi-dimensional Problem (London and New York, Kluwer Academic and Plenum Press, 2001)
46. George C. Denniston, Frederick Hodges and Marilyn Milos (eds), Understanding Circumcision: A Multi-disciplinary Approach to a Multi-dimensional Problem (London: Kluwer Academic-Plenum Press, 2001), v
47. Details of the case here.
48. As Brian Morris solemnly warns parents: In Favour of Circumcision (Sydney: New South Wales University Press, 1999), 27
49. See Robert Darby and J. Steven Svoboda, “A rose by any other name: Symmetry and asymmetry in male and female genital cutting”, in Chantal Zabus (ed.), Fearful Symmetries: Essays and Testimonies around Excision and Circumcision (Amsterdam and New York: Rodopi, forthcoming)
50. “What Medicare covers”.
51. Amber Craig and Dan Bollinger, “Of waste and want: A nationwide survey of Medicaid funding for medically unnecessary, non-therapeutic circumcision”, in George C. Denniston et al (eds), Bodily Integrity and the Politics of Circumcision: Culture, Controversy and Change (New York: Springer, 2006), p. 234.
52. Geoffrey Miller, “Circumcision: Cultural-legal analysis”, Virginia Journal of Social Policy and the Law, Vol. 9, 2002, 497-585; Sarah Waldeck, “Using circumcision to understand social norms as multipliers”, University of Cincinnati Law Review, Vol. 72, 2003, 455-526
53. www.cirp.org/news/canadianpress12-17-04
54. In June 1995 sub-regulation 4.24 of the Health Insurance (General Medical Services Table) Regulations was amended to change “circumcision of a person” to “circumcision of a male”. The explanatory memorandum stated that the change reflected “government policy that this procedure should be restricted to males”. The amendment was in response to the UN Convention on the Rights of the Child and was aimed at protecting girls and women from genital mutilation. Whether this qualification contravenes the Sex Discrimination Act has not yet been tested.
55. “Medical advice and the politics of healthcare: Public funding of routine circumcision, and the Australian debate over Medicare in 1986”, unpublished research paper by Dr Robert Darby, Canberra, 2005.
56. Spilsbury, Routine circumcision practice, 613
57. Medicare statistics calculated from http://www.medicareaustralia.gov.au
58. Van Howe RS. A cost-utility analysis of neonatal circumcision. Med Decis Making 2004;24:584-601
59. Both Terry Russell and “Dr Snip” advertise extensively on Google. Contrary to RACP guidelines, “Dr Snip” states that he confines his services to babies of less than 6 months. Dr Russell was caught taking advantage of babies brought into be circumcised to perform another unnecessary cutting operation, this time of the tongue web after a diagnosis of “tongue-tie”. The Professional Services Review of 5 October 2004 found this service to be “inappropriate” and ordered him to be reprimanded and to refund the sums charged to Medicare.
60. Dr Aladdin Mattar, a Sydney GP, was deregistered for a minimum of three years in 2000 after ignoring conditions imposed on him in 1996 and continuing to perform circumcisions on young babies. Six counts of “grossly unethical” and serious misconduct were proved against him. Medical Tribunal, New South Wales, Determination 40021 of 1999, 3 August 2000. See also “Circumcised baby almost died”, Daily Telegraph, 14 June 2000. In 2006 Dr Suman Sood was deregistered for 10 years for misconduct in relation to both abortion and circumcision. NSW Medical Tribunal, Determination 774 of 2005, 6 October 2006.
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Assaulted and mutilated: Aussie boy’s circumcision nightmare |
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Excessive removal of skin and mucosa is one of the most common results of neonatal circumcision, yet the true frequency of this injury and its adverse effects on physical and psychological development have never been adequately documented. In this account, Shane Peterson tells his own story of the lifelong trauma he has suffered as a result of the “routine neonatal circumcision” to which he was subjected soon after birth – an operation in which nearly all the skin of the penis shaft was removed in addition to the skin and mucosa of the foreskin.
The horrific results and damaging long term sequelae of this iatrogenic injury distorted Shane’s physical and psychological development, his sexuality, his perceived place in society, and his career. Doctors and psychiatrists were unsympathetic when he complained of pain and disfigurement. Reconstructive surgery to resolve the physical injury yielded such disappointing results that he attempted suicide. Eventually, Shane was able to achieve partial resolution of the psychological trauma through a combination of ongoing counselling, successful litigation against the operator, and an active commitment to public education about the detrimental effects of circumcision.
Shane Peterson's storyThe following account was written in 2000, when the author was 27 years old and studying for a PhD at the Australian National University.
IntroductionI am a 27-year-old postgraduate student (doing PhD) who was badly injured by a routine neonatal circumcision performed within days of my birth. For the last nine years, I have struggled to cope with this injury and to seek legal redress for my suffering, while at the same time I have successfully pursued a career in medical science. I recently achieved a precedent-setting legal victory in Australia with an admission of liability and AU $360,000 in damages for my injury. I view routine circumcision as an act of assault and a breach of human rights, and I am dedicated to the eradication of this unnecessary and potentially disastrous procedure.
OverviewThis article is an account of my experience of the possible, and largely unpublicized, complications that can arise from routine neonatal circumcision. Circumcision and other forms of male and female genital mutilation originated in primitive societies and have been practiced for several thousand years. Despite this long tradition of mutilation, the resulting complications, injuries and deaths have been consistently unreported.
Ironically, many contemporary advocates of male circumcision claim that the historic development of this practice in primitive societies is evidence that male circumcision is beneficial to health. For example, circumcision advocates Szabo and Short [1] claim that male circumcision is depicted in a controversial relief from the Old Kingdom tomb of Ankhmahor at Saqqara, Egypt. This relief may be one of the oldest records of male genital mutilation in the ancient world, and dates from around 2400 BC. [2-3] A number of trained Egyptologists, however, doubt this claim. A number of alternative interpretations have been offered by experts in the field. Some Egyptologists argue that this is a scene of a ritual shaving, [4]while others suggest that it might be a scene of emergency dorsal slit surgery to relieve a case of paraphimosis. [5] Even if genital mutilation is depicted in this relief, controversy exists over the similarity of this practice to circumcision, and its cultural significance to the Ancient Egyptians. [6]
Regardless of the type of genital mutilation depicted in the Ankhmahor tomb relief, it is apparent that one man has been forcibly restrained. This can be interpreted as involuntary genital mutilation. The relief provides evidence that, since ancient times, it has been normal for individuals to be very unhappy and distressed when forcibly subjected to an act of mutilation. All forms and degrees of genital alteration, including circumcision, have always been a phenomenon that should be a matter of personal choice.
Major life eventsI was born and circumcised in Western Australia in 1973, but was unaware of any genital abnormality as a young child. Because I was circumcised as an infant and not informed of this fact, I was not aware that my body had undergone any surgery. I had no reason to suspect that I had a penile problem until puberty. At the age of 18, in 1992, I underwent reconstructive surgery. The outcome of this surgery was exceedingly disappointing, and I attempted suicide six months later. In 1993, six months after the suicide attempt, I underwent further surgery.
Between 1993 and 1997, I concentrated on pursuing my academic career and resolving the emotional and ethical issues associated with my injury. I first sought legal advice in 1994, then commenced a legal claim for medical negligence with a Writ of Summons issued in October of 1997. This claim was finalized in 1999 with an admission of liability and payment of damages. I have since had several interviews with the media and am now dedicated to promoting public awareness of the detrimental affects of routine circumcision.
Birth and circumcisionMy early childhood was happy. I had many interests, most especially in science. I was unaware of any complications with my circumcision. The circumcision scar was at the extremity of the penis, just below the corona glandis. Having no conception of what my penis looked like prior to circumcision, I was completely unaware that the family doctor who circumcised me had removed not only the foreskin but also most of the penile shaft skin. He then pulled up the scrotal skin and stitched it just under the corona. As an infant and young child, the excessive removal of skin was less obvious because of the lack of pubic hair.
There were two reasons why my parents decided to have me circumcised. First, my father had been circumcised shortly after birth, and was unaware he had lost tissue of any value. Second, my father’s younger brother was spared circumcised as an infant but was subsequently circumcised at the age of eight, allegedly due to painful adhesions, bleeding, and repeated infections. My father remembered how traumatic this experience was, and my parents wanted to spare me from suffering similar problems. From information provided later by my grandmother, it appears likely that my uncle’s “problems” were actually the result of repeated, forcible premature retraction of the foreskin for cleaning during infancy.
My mother had concerns about circumcision. She was a young mother of 17 years and knew nothing about how circumcision was performed, what risks were involved, and what the expected result should be. When family members suggested that she should have her unborn child circumcised if it was a boy, she sought advice from her family doctor during a prenatal check up. She was advised not to worry: “Just one little snip and it would all be over.” The doctor assured her there were no risks and that it was such a simple procedure that Jewish mohels, with no medical qualifications, could perform circumcisions. Consequently, I was circumcised by this family doctor. My parents did not notice that anything was amiss during my early childhood. My mother does recall the penile skin appearing very tight during erections when I was a baby. She thought little of this, as my father’s penile skin was similar.
Adolescent years (1986-1990)With the onset of puberty between the ages of 12 and 13, I became aware of pubic hair growth and penile erections. These erections were very tight and painful, with the hair-bearing scrotal skin pulled up onto the penile shaft. With the onset of this pain, I suspected that my penis might be abnormal. There was, and still is, however, a lack of available, accurate information about the normal anatomy and function of the penis. Instructors for the sex education classes at school advised that it was normal for adolescents to feel concerned that the changes taking place in their bodies during puberty might not be normal. We were taught that these doubts are a normal part of growing up and there was no need for concern.
Although I took this advice and tried not to worry, I still suspected that I had been born deformed. The severity of the problems increased as I progressed through my teenage years at high school. As the penis grew, the skin became tighter and more painful, and the bending of the penis to the left became more apparent. This physical deformity had a major impact on my confidence and self esteem. I was reluctant to use public change rooms after physical recreation classes and tried to avoid sporting activities. I became very shy, self-conscious, and found it difficult to interact spontaneously with other teenagers my age. Because of these difficulties, I withdrew socially and made less of an effort to make friends. Because I often appeared quiet and shy, I was susceptible to victimization. I was bullied and bashed on a regular basis. Because I did not make my interest in the opposite sex obvious in a chauvinist manner, I was, occasionally, labelled as ‘gay.’ This experience indicates to me that I live in a prudish society that is unable to deal competently with sexual issues.
Young adult yearsIn 1991, at the age of 17, I was relieved to escape the bullying environment of high school and commence university studies. At that time, I believed I could achieve my life ambitions by succeeding at university. Unfortunately, by this time, the severity of the erectile deformity, tightness, and pain had increased to the extent that I could no longer achieve a full erection. As a university student, I was exposed to relationship and sexual issues. Although I met people I felt attracted too, I was unable to deal with these issues because of my belief that I had been born deformed and would be rejected. At this time, I was still unaware that my deformity was due to a circumcision injury.
I felt very ashamed of my deformity and was unable to seek help. This situation led to anxiety and depression, and I failed courses at university. The depression and anxiety, combined with the lack of success at university, eventually overwhelmed me. I did not know what do and regularly contemplated suicide. Although I had previously been sexually attracted to the opposite sex, at this point in my life I began to consider alternative options. During my second year at university, in 1992, I reached a crisis point. I felt compelled to confide in someone, so I told my mother. My mother was shocked and immediately suspected the deformity could be related to my circumcision. This was the first occasion that either one of my parents had ever mentioned that I had been circumcised.
I made an appointment with my family doctor on 11 April 1992. This appointment was not with the doctor who had delivered and circumcised me. I had seen my family doctor regularly from the age of six months. During the examination, the physician took one look at my penis and said that whoever circumcised me had not known what he was doing. The doctor informed me that I had suffered an aggressive circumcision, and that far too much skin had been amputated. He then referred me to a urological surgeon, whom I saw on 23 April.
The urological surgeon examined me more closely, but appeared reluctant to admit that my penis had been damaged. He commented that if anything was wrong, it was not obvious. After I insisted that a problem definitely existed, the urologist conceded that any potential problems would be more apparent upon an artificial erection. When I asked if the problem could be repaired, the urologist informed me that the tissue removed by the circumcision could never be replaced. I was told that I might just have to put up with the situation. This scenario was intolerable to me, so the urologist referred me to a plastic and reconstructive surgeon. I was examined by the plastic surgeon on 7 May 1992. This surgeon specialized in the treatment of severe burn victims, especially small children. Upon examination, the plastic surgeon advised that my injury would be very difficult to treat, but she believed that she might be able to improve my situation.
My reactionIt was difficult for me to cope with the above events, all of which took place within the space of only one month during the first university semester of 1992. I was shocked and angered to learn that I had not been born deformed, but was injured because my body had been interfered with by another person. I hated the family doctor who circumcised me, and I hated my parents for allowing it to be done. I began to feel disgust towards Australian society, which has historically maintained that routine neonatal circumcision is a beneficial practice. I also resented members of my extended family who were reluctant to believe that I was seriously injured by a simple procedure that, in their minds, removed only “the useless piece of skin on the end of a man’s dick.”
Research findingsAs a university student, I was trained in research skills and had access to medical libraries. I began to research the topic of circumcision intensively in order to explore possible treatment options. The results of my research were dismaying. I was angered to find that my circumcision had been completely unnecessary from a medical standpoint. [7] I was horrified to find that, in addition to excessive skin removal, circumcision results in a range of injuries referred to as “complications.” [8-11] I suspect that this sort of ruse serves to dissociate the blame of the injuries from the surgery that caused them. Such injuries include:
1. Haemorrhage [12]
2. Urinary retention [13]
3. Meatitis, meatal ulcer and meatal stenosis [14]
4. Adhesions or skin bridges [15-16]
5. Infection: including gangrene, [17] septicemia and meningitis [18]
6. Chordee [19]
7. Cysts [20]
8. Urethral injury and fistula [21-23]
9. Hypospadias and epispadias [24-25]
10. Impotence [26-27]
11. Psycho-social issues, such as schizophrenia [28-29]
12. Amputation or necrosis of the glans [30-32]
13. Total necrosis, ablation or amputation of the penis [33-35]
14. Death [36-37]
I was stunned to learn that in cases of penile amputation during routine neonatal circumcision, infants have been surgically reassigned to the female gender. [38-40] There are many ways by which an unnecessary routine circumcision can destroy a man’s life, and not all of them are listed as complications. Many of the most frequent complications, as in my case, are seldom listed as such. All complications, both major and minor, can exert a negative impact on the quality of a man’s life. This is especially true when circumcision is imposed on an individual without his permission, as is always the case with routine neonatal circumcision.
I also learned from my research that the quantity of skin removed during neonatal circumcision is highly variable between patients. [41] It is evident that excessive skin removal is one of the most common injuries. [42] Indeed, one contemporary urological textbook includes a subheading under circumcision:
Disasters: Too much skin removed
Take the excised foreskin (pick it up off the floor, if necessary!) and stitch it back in place. Often, it will take as a free graft. If it does not, graft the penis with skin taken from a hairless area. [43]
If a victim’s skin is not picked up off the floor and reattached, a far less satisfactory option is reconstructive surgery involving skin grafts to the penis in an attempt to replace the excess removed during circumcision. I also learned that the penile skin, mucosa, and nerves that are removed by circumcision can never be replaced, [44] and skin-graft recipients can be very dissatisfied with the results of such surgery. Grafted skin is not a satisfactory surrogate for the penile skin and mucosa and lacks the necessary innervation, elasticity, and suppleness. It is interesting that the highly unique characteristics of preputial tissue make it an excellent candidate for grafting to repair dermal trauma of other areas of the body, such as severe lacerations or burn injuries. [45]
Life optionsMy options in early 1992 were to endure my circumcision injury for the rest of my life, commit suicide, or try surgery. By this time, I had seriously considered suicide for more than a year. Rather than enduring the circumcision injury for the rest of my life, suicide represented an attractive option, as it would free me from my physical pain and psychological trauma. First, however, I chose reconstructive surgery as the only available option before the final resort of suicide. While reviewing the medical literature, I was interested in function more than cosmetics, and took an evidence-based approach. If a sex-change operation would yield the most functional end result, I might even have pursued that option. After assessing the medical literature, however, I was satisfied that penile reconstruction with skin grafts was more likely to achieve a functional result than a gender reassignment.
The option of non-surgical skin stretching requires special consideration. Although it is likely that I lacked sufficient remaining skin to stretch, I am disappointed that I was not made aware of this alternative in 1992. Unfortunately, non-surgical options were not presented in the literature that I surveyed nor offered by my surgeons. I have observed that medical practitioners are generally immersed in a surgical paradigm and often fail to advise patients of less invasive alternatives to surgery. Surgery is one of the most invasive and high-risk forms of medical intervention. As such, surgery should always be the absolute last resort for the treatment of a condition, to be employed only after all other less invasive options have failed.
Reconstructive surgeryI underwent reconstructive surgery on 30 June 1992. A full-thickness skin autograft of 12 cm by 14 cm was harvested from my left thigh for grafting to the penis. The thigh was the only prospective donor site that was large enough to supply a graft of the appropriate dimensions. A split-thickness graft was then harvested from my right thigh and applied to cover the exposed subcutaneous tissue at the left thigh donor site. Overall, the reconstructive procedure resulted in two large wounds to my thighs.
A full-thickness skin graft is composed of the full thickness of skin (dermis and epidermis), with the dermal surface of the graft trimmed of the underlying fat or subcutaneous tissues. [46] A split-thickness graft contains only the epidermis and a portion of the dermis. Although a split-thickness skin graft involves less trauma to the donor site, these grafts tend to be brittle and often contract when placed on unsupported tissue. My surgeons grafted a full-thickness of skin to the penis out of concern that a split-thickness graft might contract and erectile function would again be restricted.
Description of penis before reconstructionPrior to reconstruction, the circumcision scar was very prominent and had migrated towards the base of the penis, due to the tethering and tension. The remnant inner preputial mucosa was stretched and distorted, with pitting and scarring evident. The shape of the glans was also distorted by the tension. The circumcision scar was highly irregular, as excision of the preputial tissue was asymmetrical, with more skin removed from the left side of the penis, than the right side. This created tethering and deviation of the penis towards the left upon erection. During erection, due to the extreme skin deficit and tension, the scrotal skin migrated more than two thirds of the distance along the penile shaft towards the glans.
A damaged remnant of the frenulum remained, which was particularly sensitive. As occurs in all circumcisions, the normally moist glans mucosa underwent keratinization and has been covered by a dry layer of dead epithelium. This represents a further reduction in sexual sensitivity of the penis, in addition to that caused by excision of the preputial mucosa and erogenous nerve endings.
Operative procedureAn artificial erection was produced by placement of a tourniquet around the base of the penis and injection of normal saline solution into the left corpus cavernosum. The chordee (deviation) of the penis to the left was made quite evident through this procedure. Next, an incision was made along the circumcision scar. Upon release of the tension, the hair-bearing scrotal skin retreated to the base of the penis. The underlying connective tissue (Buck’s fascia) was completely exposed, illustrating the severe skin deficit due to the removal of almost all the shaft skin by the neonatal circumcision.
Another critical observation made at this stage of the operation was the complete absence of the dartos fascia. This abnormal situation, caused by the original circumcision, was not detected until this stage of the surgery. The dartos fascia is a delicate layer of areolar tissue that assists with the mobility of preputial tissue over the penis. [47] It should not be completely removed during circumcision, and its removal in my case resulted in painful adhesions between the remnant preputial mucosa and underlying Buck’s fascia. These adhesions caused further tethering of the penis. In conjunction with the excessive and asymmetrical excision of preputial tissue, the absence of the dartos fascia and resultant adhesions would have rendered non-surgical techniques of skin stretching ineffective.
The remnant preputial mucosa was subsequently excised due to adhesions to the Buck’s fascia. With excision and the release of tension, the preputial mucosa contracted to one fifth of its pre-operative size. Post-operatively, I discovered that removal of this mucosa had resulted in a dramatic loss of sexual sensitivity. I could not have appreciated the significance of this loss had I not experienced it myself. This loss is made all the more significant when combined with the sensitivity lost as a result of the large amount of preputial tissue removed during the original circumcision. Therefore, having experienced a “second circumcision”, I can attest from experience that circumcision dramatically reduces sexual sensation.
The full thickness skin graft from the left thigh was placed around the penis. The skin graft was attached to the penis with Histoacryl tissue adhesive (Braun) with the suture line along the underside of penis in the position of the raphe. Surgery concluded with the application of a compression bandage to secure the skin graft to the penis and facilitate the establishment of a blood supply. The thigh donor sites were also bandaged. Postoperative pain was acute, and pethidine injections were given at the base of the penis at two or three hourly intervals for one week. Similar pain was also experienced in the donor sites.
Short-term resultsThe end result of the surgery was more aesthetically pleasing than the appearance when the bandages were removed, one week post-operatively. A large amount of swelling was evident, and I was surprised that any part of my body could swell to such a large size. The skin graft had an unpleasant consistency of thick, dried leather. With the topical application of vitamin E oil twice daily, the graft gradually became more supple over a period of several weeks, and the swelling subsided. Unfortunately, as the suppleness and elasticity of the graft increased, the graft contracted as it does not express the genes and hormones that instruct natural penile skin to remain loose. A series of ridges formed, which later developed into red hypertrophic scarring. The graft also developed hair due to follicles inadvertently transplanted with the graft from the thigh.
The donor site wounds were very similar to burn injuries, and were treated as such. DuoDERM E, a semi-permeable polyurethane wound dressing, was worn for several weeks post-operatively to facilitate re-epithelialization and reduce pain. [48] After wound closure was complete, the thigh donor sites also developed prominent red hypertrophic scarring during the healing process over subsequent weeks.
To reduce the hypertrophic scarring of the penile graft and thigh donor sites, I was advised by the surgeon to massage twice daily with vitamin E oil, and wear compression bandages on the donor sites as much as possible. Although very inconvenient and uncomfortable, I disciplined myself to massage with vitamin E oil and wear the compression bandages as directed. Although not directed to do so, I also wore condoms to compress and assist in scar reduction of the penile skin graft. Compression bandages and condoms were worn for over two years postoperatively.
ElectrolysisIn June 1993, electrolysis was performed to destroy the hair follicles transferred with the graft from the thigh to the penis. A steroid injection was also given to assist in scar reduction for the penile skin graft. Unfortunately, the outcome of electrolysis was horrific, with extreme swelling and pain. Due to the fragility of the penile skin graft, necrosis and atrophy of tissue occurred in a radius of several millimeters around each electrolyzed hair follicle. Although these wounds have healed, dark scars and pitting remain.
Long-term resultsThe penile skin graft reduced tethering and enabled fuller erections. Upon erection, the penis became longer and the deviation to the left less severe. The remaining deviation is due to the restricted growth of the left corpus cavernosum - a permanent result of the tethering during puberty. This deformity demonstrates that penile growth and development are severely restricted when the penis is denuded by circumcision. The prominent scarring of the thigh donor sites is an unpleasant outcome of the surgery, as the damage caused by the neonatal circumcision has disfigured other areas of my body. These bright red scars were prominent while I was naked in change rooms or wearing shorts in summer. The scars have attracted attention and caused embarrassment on a number of occasions, including in the workplace.
The prominent redness of the donor sites faded after approximately three years, and the raised edges of the scars were reduced by the bandages and vitamin E massage oil. The graft sites, however, are now conspicuously pale, with ridging of the skin and an absence of hair. They still attract unwelcome curiosity. Despite the application of vitamin E oil and compression with condoms, the reduction of the scarring on the penis has been much less successful than for the donor sites.
Pain persisted in the graft and donor sites for many years after the surgery, but the intensity and frequency subsided with time. I now experience aches and pains only occasionally. However, since the surgery I have also experienced unpleasant or altered sensations, such as itching or tingling, and numbness. These still persist. Apart from this sensory disturbance in the underlying tissue, I have no sensation in the penile skin graft and also large areas of the donor sites. Due to the absence of the dartos fascia, the graft has adhered to the underlying buck’s fascia and is not mobile like natural penile skin. The graft has also contracted and is approximately six to eight times thicker than normal penile skin.
Suicide attemptThere was no way that I could have been psychologically prepared for the highly invasive and extreme nature of the reconstructive surgery, and the resulting pain, trauma, and embarrassment. Members of my extended family were still reluctant to believe that I had been injured, as were a number of psychiatrists whom I consulted. A number of these professionals appeared to be biased in favour of circumcision due to their medical training, and told me that my problems were “all in my head.” They advised that I should “just get over” my perceived problems and get on with my life. I felt alone and isolated. I also began to view my injury as a result of assault, and I felt that I had been mutilated. These feelings first emerged before the reconstructive surgery, and increased in intensity with the trauma of surgery.
Six months after the surgery, I attempted suicide on 7 January 1993. I had concluded that the impact of the circumcision injury on my life was insoluble. With the exception of my parents and close friends, few people were willing to acknowledge the severity of my injury and trauma, and even fewer people wanted to help. I felt as though I was living in a society where circumcision was still beyond criticism and few people were willing to accept the reality that routine circumcision is a harmful and destructive practice. I could not allow myself to be a hypocrite and live silently in a society where unnecessary circumcision was still condoned and practiced.
Legal actionAfter surviving a suicide attempt, I experienced a fuller appreciation that the cause of my horrendous experiences is unethical and completely unacceptable. I realized that I could not live with myself if I did nothing to prevent the practice of unnecessary circumcision and spare others from enduring what I had suffered. I decided that I was unwilling to remain yet another victim whose silence was taken by society as an affirmation that circumcision is harmless.
For several subsequent years, I concentrated on my university studies and tried to resolve the psychological trauma. This was most difficult. Overall, my Bachelor degree was delayed by four years due to the reconstructive surgery and associated trauma. During this time, I also considered the possibility of taking legal action to gain recognition of my injury and provide proof to Australian society that male circumcision is a highly destructive practice. I first sought legal advice from Dwyer Durack in 1994, but felt overwhelmed by the potential emotional trauma and financial expense of my case. Consequently, I did not proceed with an action at that time.
In October of 1997, I was finally approaching the final examinations for my degree. Unfortunately, I was also approaching my 24th birthday. This birthday represented the expiry date for the Statute of Limitations for issue of a Writ of Summons against the doctor who circumcised me. I was not psychologically prepared to commence legal action in 1997, but I was determined not to miss any potential opportunity for justice with expiry of the Statute of Limitations. A writ was issued against Dr. Michael Morley in October 1997, based on the failure of Morley to fulfil his duty of care. The Statement of Claim included loss of quality of life, pain and suffering, and special damages that included a psychological component. My solicitor at Slater and Gordon estimated that I might receive between AU $50,000 to $100,000 in compensation. I replied that, after my horrendous experiences, I would accept no less than AU $500,000 and would prefer in excess of AU $1,000,000.
The legal action was difficult due to a lack of similar claims and precedents in Australia. An additional disadvantage was that civil cases in Western Australia are determined by a judge only, in contrast to a judge and jury in other Australian states. Western Australia is also the most conservative state with respect to the treatment of sexual issues by the judicial system. For these reasons, I tried to avoid proceeding to trial. My solicitors found my case difficult to research, prepare, and discuss. It was necessary for me to maintain constant communication and an assertive attitude to ensure the progress of my case. I also completed as much of the research and photocopying as possible to assist my solicitors and to minimize costs.
In August 1999, my claim proceeded to a pre-trial conference. I interrupted my doctoral studies at Australian National University and returned to Perth for the first conference on 30 August. As the solicitors for the Defendant requested further evidence, two more pre-trial conference sessions were held on 27 September and 2 November. My psychological health and studies suffered due to the time required for gathering additional evidence, the financial cost, emotional drain, and the associated stress and depression. I felt that I was in danger of losing my PhD candidature.
A settlement was still not reached at the final pre-trial conference. Not satisfied that the Defendant’s solicitors gave my injury due recognition, I directed my solicitor to issue a 24A offer. This offer gave the Defendant one final opportunity to settle before the claim proceeded directly to trial. The terms of my offer were:
1. The Defendant pay the Plaintiff the sum of AU$360,000 plus repayment to the Health Insurance Commission of AU$5,070.40.
2. The Defendant pay the Plaintiff’s costs and disbursements of the action up to and including the date of acceptance of this offer, to be taxed if not agreed.
3. The Defendant admit liability.
The Defendant accepted this offer in late November 1999. Although my private health insurance fund paid approximately AU$5,000 of my medical expenses, the Defendant refused to recognize or refund this money. Despite the Defendant’s agreement to pay costs, I was required to pay approximately half of the legal costs involved.
The admission of liability was vital to my sense of victory and vindication. I wanted public acknowledgement that I had been injured by routine neonatal circumcision. This injury was inflicted on me and has deprived me of freedom, liberty, and a normal life. For this reason, I refused to forego my freedom of speech and would not agree to a settlement that included a confidentiality clause, or a clause denying the medical practitioner’s responsibility for my injury.
Current statusI am still in a state of shock from my experiences. I am unhappy to have endured such severe injury and trauma due to a surgical procedure that was completely unnecessary. I would never have consented to circumcision if I had received an opportunity to make the choice that was rightfully mine. Since 1999, I have focused on public awareness to help prospective parents be aware that routine circumcision is completely unnecessary and very destructive. My parents would never have consented to my circumcision if this information had been made available to them. Public awareness was most successfully achieved by an article published in Woman’s Day, which included an interview with Dr David Brand, the current head of the Australian Medical Association. Woman’s Day obtained an unprecedented statement:
The Australian Medical Association doesn’t advise circumcision for many reasons. They claim the practice can lead to scarring, deformity, severe blood loss, as well as infection. [49]
The Australian Medical Association had never previously acknowledged to the public that circumcision could lead to scarring and deformity.
What I would like to see happen in AustraliaRoutine circumcision is a controversial issue, with no easy solution. I believe that no person has the right to surgically inflict their religious, sexual, or cosmetic preferences on another person. I contend that no parent or adult has the right to inflict medically unnecessary and irreversible surgery on a child. The Australian legal system must address this issue, as it has done for the issue of sterilization of intellectually disabled females (Family Law Council, 1994), for which Court permission is now required by a new division in the Family Law Act. [50] Likewise, Court permission should be required to perform circumcision on a child under the age of 18, or an adult incapable of giving informed consent, unless there is documented proof of the absolute medical necessity for the health of the individual to support the decision to operate without consent.
Many people respect an individual’s right to engage in unprotected sex with multiple sexual partners, yet maintain a mistaken belief that the risk of disease transmission may be reduced through the forcible removal of a normal and healthy body part from non-consenting babies. This view fails to recognize or acknowledge that it is solely my right to choose the sexual practices that I will engage in, and solely my right to choose which body parts I will retain or discard.
It is also solely my right to choose the religious beliefs and cultural traditions I will subscribe to, and again, solely my right to choose which body parts I will retain or discard. Members of some ethnic groups claim that they have a right to dictate the cultural and religious beliefs that their children will adopt. Such views fail to recognize that children are not the property or the chattel of their parents. I contend that children require an opportunity to learn about their cultural heritage and exercise freedom of choice over the beliefs and traditional practices they will adopt. Parents have a duty to protect their children from harmful practices, and no tradition should be enforced by the permanent alteration or disfigurement of the body of an individual who is legally incapable of providing informed consent.
As with many issues concerning human rights, it is difficult to convey these messages to society. The public needs to be accurately informed and educated about circumcision and its associated risks and disadvantages. My mother was shocked to learn that the “useless bit of skin” removed from me was actually rich in sensory nerve endings. [51] She now considers male circumcision the equivalent of female circumcision - a cultural practice that the majority of parents in western societies would never contemplate inflicting on their daughters. It would be beneficial to promote public awareness of the similarities in cultural origins and destructive consequences of male and female genital mutilation.
I would like also like to see it become unlawful for family doctors and other inadequately qualified individuals to perform circumcision. Only a pediatric surgeon has the necessary expertise and experience to perform surgery on small children and deal with the possible injuries and complications that circumcision can cause. A step in this direction was recently taken in Israel, following the heavily publicized case of glans amputation during a ritual circumcision. [52] The Israeli Health Ministry has agreed to issue a directive to Israeli hospitals, for the first time allowing them to certify doctors to perform circumcisions. [53]
It should also be unlawful for surgery of any kind to be practiced without adequate pain relief. Several ethnic groups and a number of medical practitioners have disseminated a primitive, self-serving belief that infants do not experience pain when subjected to circumcision. [54] The extreme pain and distress experienced by infants who undergo circumcision, however, is well documented. [55-56] For the less than 1% of the male population who may require circumcision for genuine medical reasons, [57] adequate pain relief should be provided, both during the procedure and postoperatively. As a means of discouraging the current widespread practice of circumcision without adequate pain relief, laws should be passed to imprison any individual who is guilty of such conduct for inflicting torture and grievous bodily harm.
Rebates for circumcision should be limited on the Medicare Benefits Schedule. Rebates should not be given for routine circumcision or any other unnecessary medical intervention. The Australian public health system is currently in financial crisis. Patients with life-threatening conditions are being denied prompt and essential treatment. Public awareness of the human and economic costs of medically unwarranted circumcision, and the resulting injuries and trauma, may assist in changing attitudes towards this unnecessary and harmful practice.
AcknowledgementsI thank Mrs. Kerry Peterson and Dr. George Williams for their assistance with the preparation of my symposium presentation and this manuscript. I also thank all those who were present at the Sixth International Symposium on Genital Integrity (Sydney 2000), where this paper was first given . Their encouragement and support helped me to deliver this most difficult account of my experiences.
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17. Sussman SJ, Schiller RP, Shashikumar VL. Fournier’s syndrome. Report of three cases and review of the literature. Am J Dis Child 1978;132(12):1189-91.
18. Menahem S. Complications arising from ritual circumcision: pathogenesis and possible prevention. Isr J Med Sci 1981;17(1):45-8.
19. Kaplan GW. Circumcision - an overview. Curr Probl Pediatr 1977;7(5):1-33.
20. Kaplan GW. Circumcision - an overview. Curr Probl Pediatr 1977;7(5):1-33.
21. Lackey JT, Mannion RA, Kerr JE. Urethral fistula following circumcision. Jama 1968;206(10):2318.
22. Limaye RD, Hancock RA. Penile urethral fistula as a complication of circumcision. J Pediatr 1968;72(1):105-6.
23. Redman JF. Rare penile anomalies presenting with complication of circumcision. Urology 1988;32(2):130-2.
24. McGowan AJ. A complication of circumcision. JAMA 1969;207(11):2104-5.
25. Vyas PR, Roth DR, Perlmutter AD. Experience with free grafts in urethral reconstruction. J Urol 1987;137(3):471-4.
26. Hanash KA. Plastic reconstruction of partially amputated penis at circumcision. Urology 1981;18(3):291-3.
27. Palmer JM, Link D. Impotence following anesthesia for elective circumcision. JAMA 1979;241(24):2635-6.
28. Ball JR, Grounds AD. Head injury, hypopituitarism and paranoid psychosis: Circumcision for the “Singapore virus”. Med J Aust 1974;2(11):403-5.
29. Flaherty JA. Circumcision and schizophrenia. J Clin Psychiatry 1980;41(3):96-8.
30. Rosefsky JB. Glans necrosis as a complication of circumcision. Pediatrics 1967;39(5):774-6.
31. Sterenberg N, Golan J, Ben-Hur N. Necrosis of the glans penis following neonatal circumcision. Plast Reconstr Surg 1981;68(2):237-9.
32. St Margaret’s Hospital for Women (Sydney) vs McKibben. Hearing before the Supreme Court of New South Wales, Court of Appeal. BC8701368. 14 May 1987.
33. Gearhart JP, Rock JA. Total ablation of the penis after circumcision with electrocautery: a method of management and long-term followup. J Urol 1989;142(3):799-801.
34. Hanash KA. Plastic reconstruction of partially amputated penis at circumcision. Urology 1981;18(3):291-3.
35. Izzidien AY. Successful replantation of a traumatically amputated penis in a neonate. J Pediatr Surg 1981;16(2):202-3.
36. Gairdner DM. The fate of the foreskin: A study of circumcision. BMJ 1949;2:1433-7.
37. Gee WF, Ansell JS. Neonatal circumcision: a ten-year overview: with comparison of the Gomco clamp and the Plastibell device. Pediatrics 1976;58(6):824-7.
38. Gearhart JP, Rock JA. Total ablation of the penis after circumcision with electrocautery: a method of management and long-term followup. J Urol 1989;142(3):799-801.
39. Money J. Ablatio penis: normal male infant sex-reassigned as a girl. Arch Sex Behav 1975;4(1):65-71.
40. Diamond M, Sigmundson K. Sex Reassignment at Birth: Long-term Review and Clinical Implications. Arch Pediatr Adolesc Med 1997;151(3):298-304.
41. Patel H. The problem of routine circumcision. Can Med Assoc J 1966;95(11):576-81.
42. Gee WF, Ansell JS. Neonatal circumcision: a ten-year overview: with comparison of the Gomco clamp and the Plastibell device. Pediatrics 1976;58(6):824-7.
43. Clark P. On the penis. In: Operations in Urology. New York. Churchill Livingstone; 1985. pp. 107-112. [here, p. 111.]
44. Taylor JR, Lockwood AP, Taylor AJ. The prepuce: specialized mucosa of the penis and its loss to circumcision. Br J Urol 1996;77(2):291-5.
45. Jordan GH. Grafts and flaps in urology. In: Glen JE, Graham SD, Boyce WH, Turner-Warnick R, Brendler CB, et al., editors. Urologic Surgery. Philadelphia. Lippincott; 1991. pp. 1085-97.
46. Jordan GH, Schlossberg SM, Devine CJ. Surgery of the penis and urethra. In: Walsh PC, Retick AB, Vaughan ED, Wein AJ. Campbell’s Urology, 4 vols., 7th ed. Philadelphia: W.B. Saunders; 1998. vol. 2. pp. 3316-33.
47. Jordan GH, Schlossberg SM, Devine CJ. Surgery of the penis and urethra. In: Walsh PC, Retick AB, Vaughan ED, Wein AJ. Campbell’s Urology, 4 vols., 7th ed. Philadelphia: W.B. Saunders; 1998. vol. 2. pp. 3316-33.
48. Hermans MH. Duoderm E in the treatment of donor sites: a report. Annals of the MBC 1990;3(3):166-9. [September 1990]
49. Stanley D. Shane’s circumcision nightmare: I wish I’d never been born. Woman’s Day (Sydney, Australia), (1 May 2000): pp. 24-5.
50. A report to the Attorney-General prepared by the Family Law Council. Sterilisation and Other Medical Procedures on Children. Commonwealth of Australia 1994.
51. Taylor JR, Lockwood AP, Taylor AJ. The prepuce: specialized mucosa of the penis and its loss to circumcision. Br J Urol 1996;77(2):291-5.
52. Siegel-Itzkovich J. Baby’s penis reattached after botched circumcision. BMJ 2000;321(7260):529. [2 September 2000]
53. Siegel-Itzkovich J. Israel’s health ministry ends circumcisers’ monopoly. BMJ 2001;322(7277):10. [6 January 2001]
54. Weiss GN, Weiss EB. A perspective on controversies over neonatal circumcision. Clin Pediatr (Phila) 1994;33(12):726-30.
55. Taddio A, Pollock N, Gilbert-MacLeond C, Ohlsson K, et al. Combined analgesia and local anesthesia to minimize pain during circumcision. Arch Pediatr Adolesc Med 2000;154(6):620-3.
56. Anand KJ, Hickey PR. Pain and its effects in the human neonate and fetus. N Engl J Med 1987;317(21):1321-9. [19 November 1987]
57. Rickwood AM, Kenny SE, Donnell SC. Towards evidence based circumcision of English boys: survey of trends in practice. BMJ 2000;321(7264):792-3. [30 September 2000]
Further information
Complications and injury
Deaths
Pain
Phimosis
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Review: Marked in your flesh |
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Leonard B. Glick. Marked in Your Flesh: Circumcision from Ancient Judea to Modern America. New York: Oxford University Press, 2005. xiv + 370 pp. $30.00 (cloth), ISBN 978-0-19-517674-2.
Reviewed by Emily Wentzell (Department of Anthropology, University of Michigan)
Published on H-Histsex (June, 2006)
A Genealogy of Male Infant Circumcision
In his wide-ranging exploration of the religious history, medicalization, and current North American practice of infant male circumcision, Leonard Glick, a retired professor of anthropology, makes a case against the practice by denaturalizing it. While Glick briefly argues directly against infant circumcision at the beginning and end of the book, his central goal is to cause readers to question the unquestioning acceptance of circumcision as a medically advisable act, and, for Jewish readers, to problematize the practice as a straightforward and harmless marker of religious identity.
Tracing a path from the original Jewish circumcision, the Biblical story of God's covenant with Abraham, to portrayals of circumcision as recent as Seinfeld, Glick explores the historically shifting social meanings and material consequences of circumcision as a Jewish ritual practice; turns to medical literature to discuss the clinical adoption of circumcision as a secular surgery; and provides an overview of current American debates about the medical value and religious meanings of the practice. Glick argues that this focus on Jewish circumcision is a prerequisite for a study of modern American circumcision, since the doctors who promoted medical circumcision deliberately borrowed the Jewish ritual practice, and the Jewish religious discourse about circumcision continues to coexist with the medical dialogue. Since this work covers so much ground and thus could be useful as a reference for scholars interested in a variety of time periods and topics, I shall provide an overview of the contents of each chapter as well as a discussion of the work as a whole.
The first portion of the book deals with the history of infant male circumcision from its Biblical inception to modernity. Chapter 1 covers the religious and social meanings of circumcision from the advent of Temple Judaism around 500 B.C.E. to the Hellenic world of the first century C.E. Here, Glick first discusses the earliest ritual significance of circumcision in Judea, relying on a rich variety of early religious texts and secondary sources to map the web of meanings that the practice may have held, in order to explain why the ritual removal of infant male foreskins developed. Glick then addresses the social consequences of circumcision in the Greco-Roman world (using examples such as excerpts from Roman satire and historical accounts of the attempts by Jewish gymnasium-goers to re-stretch their foreskins) to argue that circumcision functioned as an often-derided ethnic marker. Finally, Glick discusses Gentile attitudes toward circumcision as a religious act, as shown in the rhetorical efforts by Philo (first century) to link Jewish circumcision with fertility, physical and spiritual cleanliness, and the diminishment of sexual pleasure.
Greeks, Romans and EuropeansThis chapter exemplifies the way that each portion of the book addresses broad temporal, topical, and geographical spans. This breadth enables Glick to cover a specific genealogy of circumcision in its entirety, flexibly moving throughout space and time to pause at points of particular significance or for which there is especially rich historical information. While this technique enables a great breadth of information to be brought into the history of circumcision, at times it may cause readers to lose their bearings or to feel that, while they have been given the information necessary to understand an event or actor's role in the history of circumcision, they cannot understand it in its own specific context. At points in this wide-ranging history, the reader may therefore feel that depth is sacrificed for breadth. However, Glick employs this strategy in order to present a particular history that will enable him to make a statement about modern circumcision that can have real-world consequences, and the decision to seek historical breadth is thus appropriate for his goals.
Chapter 2 covers the Christian rejection of circumcision, focusing on the ways in which debates about the practice were implicated in larger disagreements among early Christian theologians about the relationship of Christianity to Judaism. Separation of the two was achieved in part by the eventual Christian rejection of physical circumcision in favor of a concept of spiritual circumcision and derision of ritual focus on the flesh. Glick then discusses Roman opposition to politically threatening Jewish proselytism in the second to fourth centuries C.E., and the resulting juridical sanctions placed on the act of circumcision. Next, he outlines the rise of Rabbinic Judaism, focusing on the codification of circumcision in the Mishnah and Talmud, to show how the creation of these texts altered the physical practice of circumcision (calling for the removal of significantly more penile tissue), and cast the rite as central to the very idea of humanity in Rabbinical thought.
Addressing the practice and public perception of circumcision in Europe, chapters 3 and 4 cover the development and significance of European circumcision rituals and Gentile reactions to the practice. Glick argues that circumcision became a key marker of Jewishness in medieval Europe, and he discusses the social significance of various aspects of the circumcision rite, many of which persist today. In the context of increasing stigmatization of Jews due to economic changes in the eleventh and twelfth centuries, Glick analyzes the writings of figures such as Peter Abelard, Martin Luther, and Benedictus de Spinoza on circumcision as emblematic of differing ways of thinking about Jewishness in their particular historical and social locations. Glick then discusses the social and sometimes juridical impact of popular stories told in twelfth-through-fifteenth-century Europe about Jewish kidnapping, circumcision, and murder of Christian boys, and their supposed use of Gentile blood in religious practice, including circumcision. Chapter 4 concludes with a discussion of the discourse on the barbarity of circumcision that was employed to overturn an Act enabling the naturalization (and thus economic advancement) of British Jews in 1753.
Jewish critics of circumcisionGlick separates the book into two sections, stating that the work's "pivot" point occurs in chapter 5, with the advent of modernity in the mid-nineteenth century, and a reform movement within Judaism that enabled some revaluation of circumcision as a necessary and appropriately modern practice. Here, Glick seeks to show both how circumcision persisted, and how the persistence of circumcision was remarkable in the face of such change. The latter is a difficult point to argue, as it requires a demonstration that circumcision was and is counterintuitive in its social and historical contexts. While this argument gives the story of circumcision a political framing appropriate to Glick's project of questioning the modern necessity of the practice, his historical analysis of the specific ways in which circumcision did persist, both as a religious and then as a secularized medical procedure, is much stronger than his discussion of the strangeness of this occurrence. Glick effectively shows that circumcision remained a marker of Jewish identity that even the most radical reformers were loath to challenge, and he traces the complex links between religious ritual and medical circumcision that enabled popularizing of the practice as a secularized medical procedure in North America and Britain. There were several outspoken critics of circumcision among nineteenth-century German Jews, including the remarkable Abraham Geiger and Samuel Holdheim, who argued that the practice should be entirely dropped, but they did not succeed in convincing more than a few individuals in their community. Glick demonstrates that religious and medical reforms, such as early state public health activities, combined not to eliminate, but to medicalize circumcision--for example, by calling for the medical training or licensing of practitioners of the rite.
Chapter 6 details the pro-circumcision bent of doctors in Victorian and early-twentieth-century America, as an astonishing range of maladies, from chronic masturbation to paralysis, were attributed to the sexual stimulation and supposed dirtiness of the foreskin. Glick writes that doctors took up circumcision as a weapon against both disease and immorality, and that Jewish doctors further supported the medicalization of the practice by arguing that doctors, not mohels (ritual circumcisers), should perform the operation.
Medicalization of ritual circumcisionGlick further discusses the medicalization of circumcision in chapter 7, presenting medical discourse about the health benefits of the procedure from 1910 to the present. He argues that during this period circumcision became viewed as a preventative health procedure, thought to ward off the most feared diseases of the early and late twentieth century--cancer, syphilis and HIV/AIDS. Glick focuses on discussions of the health benefits of circumcision in the medical literature, detailing the arguments of the highest profile participants in this discourse, evaluating the legitimacy of their case, and contexualizing them with biographical information about their popularizers, including consideration of the effect of their religious beliefs on their advocacy for or rejection of circumcision. Glick also discusses the often-fraught statements that medical governing bodies, such as the American Academy of Pediatrics, have made about the validity of the practice, and he grounds this discussion in material medical practice with a brief history of the development and use of the clamps now commonly employed in medical circumcision procedures. This chapter provides an excellent topography of the key figures in twentieth-century American debates about the medical value of circumcision, and demonstrates that their arguments continue to shape medical ideas about, and the practice of, this surgery.
In the final chapters of the book, Glick addresses modern American discussions and representations of circumcision. Seeking again to show the persistence of circumcision as counterintuitive, he presents a somewhat paradoxical argument--that circumcision, through medicalization, has lost its meaning as a Jewish practice, and that this loss of meaning makes it anachronistic for secular Jews to continue viewing the practice as central to Jewish identity. However, the evidence he presents in chapter 8--accounts from Orthodox, Reform, and Humanistic Jews about their struggles with certain ethical aspects of circumcision that usually conclude by reaffirming that the practice is the key to Jewish identity, as well as Jewish books on baby care and text from Mohels's web sites--tends rather to demonstrate that circumcision has retained strong meaning for Jews, despite its medicalization and its adoption by non-Jews.
The American mediaChapter 9 provides an overview of representations of circumcision in American popular media, discussing selected texts from Jewish periodicals, children's books dealing with the circumcision of a sibling, feminist discussions of circumcision as a patriarchal practice, fiction by Jewish authors, sitcoms such as Seinfeld and Sex in the City, and jokes. While all the chapters move selectively between key texts, events, and actors over a broad spatial and temporal range to provide a wider picture of the genealogy of circumcision, this chapter is the least successful, as it seems to cover texts chosen for their accessibility rather than their cultural significance, while the discussion of the texts is sometimes more descriptive than analytic.
In the epilogue, Glick lays out his political stance against circumcision. He argues that the validity of circumcision boils down to two questions: whether the practice is medically effective, and whether parents have the right to alter a child's healthy body so significantly without the child's consent. Glick's previous argument about the medicalization of circumcision sheds ample light on his first question; his historicization of medical discourse of circumcision frames it as social text rather than presentation of biological fact, making his historically grounded discussions of the invalidation of claims for the health benefits of medical circumcision very convincing. However, the second question is hurriedly contextualized in a discussion of human rights that ignores long-standing critiques of the concept as inherently Western and individualistic.[1]
While Glick makes passing references to discussions about female circumcision (in this case, unproblematically discussing activist critiques without noting that some feminists have argued that this type of activism is culturally imperialistic) and to male circumcision rites in religions like Islam, he does not fully develop these links.[2] Further developing these connections would have enriched the analysis of modern portrayals of and discussions about circumcision practices. Glick also uses his case that circumcision has lost religious significance to argue against the necessity for Jews to circumcise their male infants; but again, this argument is muddied by the evidence he has presented that circumcision remains a culturally salient practice.
If elements of Glick's final argument against circumcision are not fully developed, however, it is because in large part his project is an historical one, geared toward detailing the development of Jewish and then medical circumcision in order to present it as a historically and socially located practice that can be questioned by modern practitioners. The great strength of the book is its thorough yet wide-ranging genealogy of infant male circumcision. While other in-depth scholarship has increased our knowledge of the medicalization of circumcision, Glick's work sets this phase of circumcision's history into a broader historical and social context; further, his rich discussion of the original meanings of the Jewish practice fills a gap in the literature on circumcision.[3] In short, Glick's project is to provide a complete history of circumcision, ranging across place, time, and the divide between religion and medicine, in order to enable individuals to make better-informed choices about whether they will participate in the practice, and this he ably achieves.
Notes[1]. For a discussion of this and the opposing point of view in relation to female circumcision, see Alison T. Slack, "Female Circumcision: A Critical Appraisal," Human Rights Quarterly 10 (1988): pp. 437-486.
[2]. Ellen Gruenbaum, The Female Circumcision Controversy: An Anthropological Perspective (Philadelphia: University of Pennsylvania Press, 2001).
[3]. For discussions of the medicalization of circumcision, see Frederick Hodges, "A Short History of the Institutionalization of Involuntary Sexual Mutilation in the United States," in Sexual Mutilations: A Human Tragedy, ed. George C. Denniston and Marilyn Milos (New York: Plenum Press, 1997); David L. Gollaher, Circumcision: A History of the World's Most Controversial Surgery (New York: Basic Books, 2000); and Robert Darby, A Surgical Temptation: The Demonization of the Foreskin and the Rise of Circumcision in Britain (Chicago: University of Chicago Press, 2005).
Response by Leonard GlickThe following response by Leonard Glick was posted to the H-Histsex discussion list on 13 July 2006
I thank Emily Wentzell for the most generous and informative review that my book, Marked in Your Flesh has yet received. In fact, her critique of one major argument provides an opportunity for what might be helpful amplification. Although appreciating my “historical analysis” of Jewish circumcision, she found unpersuasive my argument that the practice “was and is counterintuitive in its social and historical contexts.” The paradoxical quality of that unterintuitive behavior is especially evident in the contemporary American context, and it is to that point in particular that I want to address this reply.
Continuing not only to accept but even to vigorously defend circumcision is indeed counterintuitive for most Jewish Americans, since its original religious significance--as the legacy of an immutable covenant between God and Abraham--has little or no valence for those who do not accept myth as history or biblical texts as obligatory guides for contemporary life. That is indeed a puzzling feature of the modern history of this supremely puzzling practice.
I think we can begin to untangle the knot by recognizing that Judaism is what I call a “localized religion” (in this case localized to a single people, not to a single place)--fundamentally different from the two definitively world or “universalist” religions, Christianity and Islam, but akin (perhaps surprisingly) to those of Native American peoples or distinct ethnic groups of Asia and Africa, whose religions are inseparable from specific localized identities. For example, just as one could not convert to the Hopi religion without somehow becoming a Hopi, one cannot convert to Judaism without becoming a Jew. This conflation between religious and ethnic identity is a source of confusion for non-Jews, some of whom cannot understand how a person who does not practice Judaism (the religion) can still claim to be Jewish. The answer is that in modern Western culture, with its emphasis on individual choice and responsibility, abandonment of the formal ritual requirements of traditional Judaism need not constitute denial of Jewish ethnic identity. (Note that many now identify themselves as “secular Jews,” but no one can be a “secular Christian.”)
Here, I suggest, is the source of what Wentzell identified as “counterintuitive”: If circumcision (like many other ritual practices) no longer has its original symbolic power as a religious act, why do so many Jews insist that if they abandon it, the result will be disappearance of the Jewish people? To phrase this differently, if the more rigorous ritual requirements of the Jewish religion (kosher food regulations, strict Sabbath observance, and much more) are no longer essential components of modern Jewish life, why has circumcision, the most anachronistic of ritual practices, been elevated to the role of single, indispensable guarantor of ethnic survival?
The mystery deepens when we recognize two additional complications. First, infant circumcision is still widely accepted as an American medical practice, and even today more than 55 per cent of all American male infants are circumcised at or soon after birth. Moreover, since hospital operations are essentially identical in result to those performed by mohels (i.e., radical removal of the entire foreskin), ritually circumcised Jewish American males have penises altered in a manner indistinguishable from those of their Gentile neighbors. Second, according to religious doctrine the only valid circumcision is a ritual operation performed by a mohel on the eighth postnatal day. But many, possibly most, Jewish parents now choose hospital circumcision by a physician--a practice having no religious significance whatever--partly because other American infants are being circumcised in the hospitals, but also in the paradoxically contradictory belief that foreskin removal in itself distinguishes the boy as Jewish. The bottom line: in America circumcised genitals do not mark Jewish identity.
So one major question--why, then, does circumcision still receive such resolute endorsement by Jewish Americans?--is more readily asked than answered, and much of the argument in my book implicitly acknowledges that. One can only speculate: Is this because circumcision is a single day’s act performed on an uncomprehending infant, while other ritual regulations require a lifetime of burdensome daily observance by adults? Or is it perhaps because the dramatic, primordial quality of the event--a sacrificial blood offering, if one accepts the obligatory texts accompanying the rite--distinguishes circumcision from such comparatively mundane practices as dietary observances? Or is it simply that, with so much else abandoned, most Jews (even the “secular” nonbelievers) are unwilling to relinquish this beleaguered relic of pre-modern Judaism--even when performed in a manner contradictory to religious law?
One of my goals in Marked in Your Flesh was to show that even those Jews who are most determined to defend circumcision are troubled by a remarkable degree of anxiety, ambivalence, and even downright confusion. My purpose in quoting various contemporary texts--books for prospective Jewish parents, books for girls who ask why there is a rite of initiation for boys alone, fiction, television sitcoms, and so on--was to convey the floundering quality of many conventional explanations and justifications. Nearly all the quoted selections are by Jewish authors--not by my intention, but determined by the fact that, despite the controversial nature of all circumcision, it is Jewish Americans who are by far the most sensitive to any challenge to the practice.
Will infant circumcision maintain its hold on Jewish Americans as the overall American circumcision rate continues to decline? Until now it has been relatively easy to accept foreskin removal as a widely approved American custom--avoiding the obvious question of how this practice can guarantee the survival of a specifically Jewish identity in a nation of circumcised men! But as more and more Americans come to understand that infant circumcision is medically unjustifiable and indeed harmful, the general rate will continue its downward slide; and as that happens, more and more Jewish American parents will have to ask themselves whether circumcising their sons is wise or necessary. When that time comes, Ms. Wentzell and I may both be able to answer the ultimate question: Why must genitals be cut to define anyone¹s social identity?
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A short history of circumcision in the United States: Part 2 |
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6. Corporate institutionalisation of circumcision in the Cold War eraIn the United States, however, Gairdner’s paper was ignored, and the old myths repackaged by doctors such as Guttmacher held sway instead. Medical textbooks became even more insistent that obstetricians should examine every newborn boy to check whether his foreskin was adherent, unretractible or too long , and to perform an immediate circumcision if such symptoms of “phimosis” were present – as they nearly always were. In 1953 obstetricians Richard L. Miller and Donald C. Snyder published an influential paper in the American Journal of Obstetrics and Gynecology, calling for the immediate circumcision of all males straight after birth. Ignoring Gairdner and relying heavily on the writings of Wolbarst, they insisted that “phimosis” required immediate surgical correction, and asserted that circumcision would “reduce the incidence of onanism”, heighten male libido and “increase longevity and immunity to nearly all physical and mental illness.” They also stated that circumcision immediately after birth was convenient for the doctor and in the financial best interests of the hospital. Leading obstetrical textbooks were soon rewritten to include Miller and Snyder’s recommendations. [65, 66]
6.1 The new cancer scareDuring the 1950s, with syphilis under control thanks to penicillin, cancer regained its position as the most feared disease. Between 1943 and 1951 the number of articles on cancer in popular magazines increased by 182 per cent, a further 32 per cent between 1951 and 1955, and another 72 per cent from 1955 to 1957. In keeping with this renewed and increased alarm, Ravich published a new paper, “Prophylaxis of cancer of the prostate, penis and cervix by circumcision”, in which he alleged that 25,000 deaths annually from cancer were really caused by the foreskin, and that between 3 and 8 million American men then living had contracted prostate cancer through the influence of their foreskin. Ravich concluded that a program of mass compulsory circumcision was necessary as an “important public health measure”. [67] Ravich’s theory of cervical cancer was taken up by Dr Ernest Wynder at the Manhattan Memorial Centre for Cancer and Allied Diseases, and in 1954 he published a lengthy paper that purported to show that universal neonatal circumcision of males could eliminate cervical cancer in women. [68} Again, a popular news magazine (in this case, Time) gave warm coverage to Wynder’s claims, thus giving them both publicity and credibility, and encouraging public support for the burgeoning circumcision industry. [69]
Meanwhile, there were also a few calls for circumcision of girls and women. During the 1950s some American physicians stepped up their efforts to popularise circumcision of adult females – here meaning excision of the clitoral hood as a hygiene measure. In 1959 Dr W.G. Rathmann published an article in which he promoted the idea of female circumcision as a cure for psychosomatic illness and marital problems. He also took the opportunity to tout his newly-patented female circumcision clamp. [70]
6.2 Kaiser, Gomco and EuropeIn the 1950s an increasing number of corporation-managed hospitals and insurance companies entered the now profitable business of routine neonatal circumcision. Private hospitals instituted policies of immediate and automatic circumcision of all male neonates, often in the delivery room. At the Kaiser Foundation Hospital in 1950, out of 889 live male births, 812 (92 per cent) were circumcised immediately after birth. [71] Likewise, many urban hospitals adopted the policy of circumcising any boys who missed out at birth when they were brought in for other common procedures, such as having their tonsils removed.
In the late 1950s the American circumcision industry sought to spread the practice to Europe, with a particular focus in east and west Germany, the latter under extensive American influence as a result of the post-war occupation. Around 1957 the Gomco corporation established a distribution network in Ulm [72], and in the same year Kaiser worked with Otto Dietz, a minor official in the East Berlin secret police, to introduce circumcision in east Germany [73]. In 1959 150 babies born in a state-run clinic in Darmstadt, west Germany, were experimentally circumcised without anaesthesia a publicity stunt for the Gomco clamp [74], and in1963 Dr H. Koester arranged for the maternity clinic at the University of Giessen to adopt a policy of automatically circumcising all boys born there, again using the Gomco clamp. In 1968 a further demonstration of its speed and efficiency was arranged in east Germany [ 76].
By the early 1970s, however, the experiments had aroused the disfavour of both east and west German authorities, and the experiments came to an end. Gomco promptly turned its attention to Denmark and in 1973 arranged for 18 Danish newborns to be cut. [77]. Along with publicity photos of the clamp, the results were praised by the Danish medical press. The Danish public, however, were less impressed and strenuously resisted the idea of allowing their children’s sexual organs to be surgically altered for any reason, and the campaign faded away.
It is easy to see that Gomco’s attempted push into Europe had nothing to do with health, but was entirely a commercial venture.
6.3 Professional opposition to circumcisionThere was some opposition to forcible circumcision. In 1956 and 1959 Dr Richard K. Winkelmann, a fellow in dermatology at the Mayo Clinic, published two studies which documented the intense innervation of the foreskin and identified it as specific erogenous zone. [78, 79] In a period that was intensely hostile to sexual enjoyment, however, his studies were ignored. In 1954 Ravich’s theory that the foreskin caused cancer of the prostate was disproved [80], and in 1962 the hypothesis that it caused cervical cancer in women was falsified [81]. In 1963 a further study invalidated Wolbarst’s contention that smegma was carcinogenic. [82] In 1965 the trend towards scepticism was boosted when the Journal of the American Medical Association published Dr William Morgan’s provocatively titled paper, “The rape of the phallus”. In this article Morgan debunked all the then current arguments used by hospitals to justify involuntary circumcision and initiated a controversy within the American medical profession that continues to this day. [83]
An even more significant article, on the nature of the juvenile foreskin, was published in 1968. The British pediatric journal, Archives of Diseases of Childhood, carried an account of the exhaustive research of the Danish pediatrician Jakob Oster, who had examined the incidence of preputial adhesions in 9,545 Danish schoolboys aged 6 to 17 years. [84] Like Gairdner, Oster’s findings disproved the phimosis myth and demonstrated that adhesions between the foreskin and glans were not a birth defect, but a perfectly normal stage of penis development. He further showed that separation between glans and foreskin was a gradual biological process that often took ten years or more to complete. His research revealed that no interventions were needed in normal cases and, more importantly, that inappropriate attempts to hasten development (e.g. by tearing the foreskin from the glans) could damage both structures and actually bring about the phimosis it was supposed to fix. Oster’s study significantly advanced scientific understanding of the foreskin was widely read by the British and European medical community; in the United States it was pretty much ignored.
In 1970, however, the spark ignited by Morgan was fanned into flame in an article by Noel Preston, “Whither the foreskin?”, in JAMA. [85] The paper debunked all the reigning circumcision myths and influenced the American Academy of Pediatrics to publish the following revolutionary statement in the fifth edition (1971) of its Standards and Recommendations for Hospital Care of Newborn Infants: “There is no valid medical indications for circumcision in the neonatal period.” [86]
In the late 1970s, as Americans became increasingly aware of the abuses of power rampant in the nation’s social institutions, grass roots movements against the forced circumcision of American children began to emerge. In the face of ridicule and hostility from health care professionals, many American parents began to refused to allow their sons to be circumcised. At the same time, developments in medical ethics that brought the concept of informed consent into the surgical arena required doctors to explain the probable outcome of any surgery, state the known risks, offer alternative treatments for the problem and obtain written consent from the patient. Circumcision, too, now required a consent form, but since the person being operated on was not capable of giving informed consent, spokesmen for the circumcision industry claimed that parents could give consent by proxy. By presenting involuntary circumcision the parents’ choice, circumcision advocates obscured the vital fact that the person who ran the risks and had to bear the lifelong consequences of the surgery was still not permitted a choice in the matter. Critics countered that doctors had no legal power to concede control of the baby’s genitals to the parents because doctors had no legal power over his genitals in the first place.
6.4 Backlash from the circumcision industryThe high-water mark of involuntary circumcision was reached in the 1970s. With or without parental consent, hospital practice raised the incidence of neonatal circumcision to 90 per cent in the late 1970s and early 1980s. Circumcision advocates from urban areas took positions in small rural hospitals in America’s heartlands and instituted new circumcision programs in regions of the country where it had not been known.
At the same time, baby care guides, popular medical magazines and health texts circulated myths to the effect that a boy not circumcised in infancy would suffer terrible psychological damage if he ever saw that his father’s circumcised penis differed from his own. [87-89] (Oddly enough, this had not been raised as a problem when the father was uncircumcised and the boy cut, though you would think that a person would be more upset at lacking something his father possessed than possessing something his father lacked.) Another myth that was particularly effective in exploiting middle class anxieties about conformity and social status was that an uncut boy would be made to feel weird and inferior to his circumcised classmates in school locker-rooms. [90]
Accurate information on the anatomy and physiology of the foreskin was omitted from American textbooks and replaced with the pseudo-science of the circumcision lobby. [91, 92] Even anatomical representations of the penis in standard urology texts silently omitted the foreskin and showed the penis as circumcised, as though it were that way by nature [93]. The few drawings of the anatomy of the natural penis that could be found generally represented the foreskin incorrectly. The normal human penis became a strange and alien anomaly to the new generation of Americans – physicians and laymen alike – most of whom had never seen one. As an example of the outdated information being given to American medical students, here is a quote from the 1970 edition of Campbell’s Urology, the standard urology textbook:
Phimotic stenosis causes extreme difficulty of urination, with straining and crying; hernia or rectal prolapse may be secondary end results. Urinary infection is a frequent complication, and is often directly predisposed to by the preputial obstruction. Malnutrition, epistaxis, convulsions, night terrors, chorea and epilepsy have all been reflexly attributed to phimosis.
Consistent with these Edwardian notions, it also advised circumcision as a precaution against masturbation:
Parents readily recognise the importance of local cleanliness and genital hygiene in their children and are usually ready to adopt measures which may avert masturbation. Circumcision is usually advised on these grounds. [94, 95]
The Victorian masturbation hysteria was apparently still alive and well in American medical textbooks in the scientific seventies.
In October 1972 the American Academy of Pediatrics appointed a committee to discuss circumcision in order to provide guidance to health insurers who had been asking whether neonatal circumcision should be covered in their insurance policies. The outcome was never officially released, but the conclusion was unofficially presented by Dr Thomas Guthrie to an AMA conference in June 1973. He argued for even more widespread neonatal circumcision and the continuation of insurance coverage. [96]
Female circumcision had not entirely disappeared from American medical practice. In 1973 Dr Leo Wollman, a gynaecological surgeon at Maimonides Hospital, Brooklyn, published an article in which he argued for female circumcision (meaning excision of the clitoral hood) as a cure for frigidity. [97] Wollman’s appeal was geared to the ethos of the sexual revolution of the 1970s, when sexual pleasure was at last becoming recognised as a legitimate part of life and even the responsibility of the medical profession. Surgical modifications of the male and female genitalia, it was argued, would improve the quality of orgasm. This was the exact opposite of the message communicated a century before, when one of the chief virtues of circumcision was (correctly) held to be its effect in reducing sexual sensation. The sudden reversal of argument convinced critics that American circumcision advocates were willing to say anything in order to push circumcision onto a gullible but increasingly suspicious public.
To make matters worse for the circumcision lobby, in 1975 the American Academy of Pediatrics issued a further policy on circumcision that concluded:
There is no absolute medical indication for routine circumcision of the newborn. … A program of education leading to continuing good personal hygiene would offer all the advantages of circumcision without the attendant surgical risk. Therefore, circumcision of the male neonate cannot be considered an essential component of adequate total health care. [98]
6.5 Legal action for children’s rightsIn the 1980s men finally began to wake up to what had been done to them as infants, and several lawsuits against doctors and hospitals in California were filed, charging that hey had violated the constitutional rights of the plaintiffs by circumcising them without consent. [99, 100] The cases were filed in order to establish that parents do not have the right to consent by proxy to medically unnecessary surgery on their children, basing their claim on the 1975 AAP policy that circumcision was not medically necessary. The acknowledged lack of medical justification for circumcision put circumcisers at risk of litigation, but more importantly the constitutional challenge to the legality of subjecting children to involuntary circumcision threatened to dismantle a lucrative medical sideline – which in 1986 was estimated to generate some $200 million annually. [101] If neonatal circumcision were to survive, new medical excuses would have to be found.
6.6 The urinary tract infection scareIn the mid-1980s the new excuse was provided by urinary tract infections (UTIs). Although nothing on this rare condition had ever appeared in a popular magazine, the medical literature reflected a surge of research interest. A search of Medline uncovered only four publications on UTIs for the period 1966 to 1974; 65 from 1975 to 1979; and 350 from 1980 to 1984. While the national incidence of UTIs had not altered from 1966 to 1989, the astounding 8,650 per cent increase increase in the number of published studies showed clearly that UTIs were the next big thing, and it was not long before the foreskin was being blamed as a risk factor. In 1982 Drs Charles Ginsburg and George McCracken published a report of a study of 100 infants with acute UTIs. Because only 3 of the 62 males were circumcised, the authors speculated that lack of circumcision might increase susceptibility, though they admitted that “perineal hygiene was inadequate in many patients”. [102]
In 1985, evidently intrigued by this lead, Dr Thomas Wiswell, then a neonatologist at Brooke Army Medical Centre, Texas, sought to verify it with his own studies, and soon published in Pediatrics the first of many studies promoting the theory that the foreskin increased the risk of UTIs and that circumcision was therefore a valuable prophylactic. [103] Wiswell’s first review of hospital charts implied a UTI incidence of 1.4 per cent in uncircumcised boys and 0.14 per cent in circumcised boys, though he did not take into account such relevant factors as whether the babies were breast-fed (breast milk carries powerful antibodies) or the fact that many of the uncircumcised boys had been subjected to premature retraction of their foreskin, thus making it likely that the infection had been communicated by the doctor or nurse. Such questions were simply not asked. Although the difference between the two groups was very small (1.2 percentage points), it was made to appear much larger by being described as a 10 per cent increase. Circumcision enthusiasts hailed the results of Wiswell’s research as a new indication for circumcision and just what they needed to defeat the emerging legal and human rights challenges.
Indeed, a letter in response to Wiswell’s study addressed the lawsuits directly. The author, Dr Aaron Fink (1926-1994) was a urologist in the mould of Wolbarst and Ravich and a long-time agitator for universal neonatal circumcision. He was clearly disturbed at the possibility that circumcisers might face the risk of legal action from their victims and ridiculed the idea that circumcision required the consent of the person on whom it was performed. [104] In his reply, Wiswell agreed that the medical indication he had discovered removed the need to obtain consent before operating. [105] McCracken was less convinced, however, and commented that “because the long-term outcome of UTI in uncircumcised male infants is unknown, it is inappropriate at this time to recommend circumcision as a routine medically indicated procedure.” [106]
Nonetheless, medical texts and popular magazines quickly incorporated UTIs into their list of why the baby should be circumcised [107-109]. Magazines such as Newsweek and US News and World Report ran feature stories on Wiswell’s discoveries and hailed them as the answer to those who were trying to stop circumcision. [110, 111] Since few males ever experience a UTI the UTI myth had little power to influence fathers, but research had shown that it was the mother, more often than the father, who signed the circumcision consent form. [112-114] Among girls, however, unpleasant and painful bouts of UTI are relatively common [115, 116], and the new UTI scare proved quite effective in frightening young mothers into agreeing to the circumcision of their sons. Unlike STDs and cancer, which did not affect men until they were sexually active adults and old men, UTIs could affect infants. Wiswell’s warning that the foreskin posed a serious threat to the baby’s health, and even his life, in the first few weeks, and that it could increase the risk of complications such as kidney failure, meningitis and death, naturally alarmed many parents and convinced them that they had better get the baby done “just to be on the safe side”. [117-118]
At this point Wiswell tried to turn the legal tables by suggesting that if insurers did not cover circumcision they might be held legally liable if a baby contracted UTIs. “If ten years from now there are uncircumcised children on dialysis with kidney damage associated with UTI , insurers who would not pay for circumcision might be held liable,” he wrote [119]. At the same time, oddly enough, he stated that “I tell them [parents] that I personally don’t like the procedure and don’t recommend it, but if they want it performed I will do it.”
A further effect of the UTI scare was to persuade pro-circumcision forces in the AAP to agitate for a new circumcision policy. In 1989 a new task force was established under the chairmanship of Dr Edgar Schoen (b. 1925), a pediatrician at the Kaiser Foundation Hospital, Oakland, since 1954, and a fanatical advocate of universal circumcision. (Kaiser, it will be recalled, was the commercial medical services company that tried to sell Gomco circumcision clamps to Germany and Denmark in the 1960s.) After intense debate the Task Force produced a new and highly equivocal statement that took Wiswell’s UTI hypothesis into account but stopped short of recommending a return to routine circumcision:
Newborn circumcision has potential medical benefits and advantages as well as disadvantages and risks. When circumcision is being considered, the benefits and risks should be explained to the parents and informed consent obtained. [120]
By closing the legal loophole in the 1975 statement, the new policy protected circumcisers from legal action while avoiding any overtly unscientific or unverifiable claims. Sensitive to the awkward fact that European countries had steadfastly rejected American attempt to export circumcision, Schoen (from his office in the Kaiser Permanente Medical Centre) made another attempt to badger northern European countries into adopting programs of routine circumcision on the United States model. [121] The terse reply to his overtures, written by two of Sweden’s most eminent physicians and published in a leading Swedish medical journal, invoked a number of critical issues that he had never considered: fairness, human rights and medical ethics. Pointing out that it was a violation of a person’s human rights to be subjected to such a procedure without informed consent, the authors observed that it was only fair to postpone a decision on the matter until the boy was old enough to make his own decision. The authors explained that since an ethics committee on experimental animals would never accept clinical trials involving circumcision without anaesthetic on laboratory animals, Europe could hardly justify subjecting its own children to such pain and suffering. [122]
* * * * * * * * * * *
NOTEIn relation to the following two sections it should be noted that this study was written in 1995-96 when the notion that the foreskin was a major risk factor for HIV-AIDS, and that circumcision was therefore an important part of any anti-HIV strategy, was no more than the speculation of cranks. At that time there was no predicting that the idea would be seized upon by the international AIDS industry, given massive funding, and presented to the world as the definitive solution to the AIDS problem in Africa, and probably in other underdeveloped regions as well. What we can observe is the consistency of the historical pattern: as soon as a new disease leaps to the forefront of public anxiety, circumcision enthusiasts suggest that the foreskin has something to do with it and yet more circumcision is the answer. In fact, the claim that mass circumcision is necessary to control AIDS is largely a re-run of the nineteenth century conviction that mass circumcision was necessary to control syphilis; in each case, an incurable disease had so terrified the public that they were ready to accept almost anything if it offered the possibility of increasing their safety without the need to change their habits.
What gets forgotten is that AIDS is not a particularly contagious disease and that you have to go to some trouble to contract it; apart from blood transfusions, tattoos, surgery and intravenous drug use (where circumcision would obviously make no difference), the only way you can get AIDS is through unprotected intercourse with an infected partner. The simplest way to run no risk of HIV infection, therefore, is not to be promiscuous and to practise safe sex. This policy has successfully kept HIV infection at a low level in countries such as Australia, Germany and Britain, but western health agencies seem to have much the same attitude towards Africans as Eugene Hand exhibited towards American Blacks: because they are too stupid to use condoms and too sex crazed not to be promiscuous, the only thing that can be done is to circumcise them in the hope of slightly reducing the risk. The foreskin is targeted not because it is a particularly useful point of intervention, but because it is an easy target for surgical removal and a once-off procedure, after which the agencies can congratulate themselves that they have done all they can.
It should also be remembered that there are strong cultural pressures to use the AIDS scare as the latest means of preserving circumcision as a routine procedure among the cultures that traditionally practise it. The billions poured into the World Health Organisation and UNAIDS represent a bizarre alliance between American medical research money, African tribalism and Muslim religiosity, all of which forces have an emotional commitment to finding new and “scientific” justifications for continuing their traditional practices.
* * * * * * * * * * *
6.7 The HIV scareIn the early 1980s the arrival of a new and terrifying infection in the form of HIV-AIDS (as it later became known) gave the circumcision lobby a juicy new opportunity to incriminate the foreskin in the generation of disease. First to capitalise on the opportunity, as early as 1986, was the egregious Aaron Fink, who was able to persuade the New England Journal of Medicine to publish his speculation that the presence of the foreskin made men more susceptible to infection. [123] On the basis of this theory, throughout 1987 and 1988 Fink lobbied the California Medical Association to adopt a resolution endorsing routine neonatal circumcision as “an effective public health measure”. His efforts were rejected by the Scientific Committee of the CMA in 1987, but in 1988 he managed to get his resolution passed on the voices at a CMA meeting. This attracted some national attention, unlike his other new reasons for circumcision – group B-streptococcal disease and “sand balanitis” [124, 125] These connections were evidently too far out even for the gullible American media.
Fink’s theory about the foreskin and AIDS, however, was eagerly taken up by other American circumcisionists, such as Francis Plummer and Stephen Moses, who have campaigned tirelessly for new programs of neonatal circumcision as a precaution against HIV acquisition in later life.
6.8 The future of involuntary circumcisionSince the 1980s private hospitals have been in the business of supplying the foreskins they harvest to private biological research laboratories and pharmaceutical companies that require human tissue as raw research material, as well as manufacturers of cosmetics and artificial skin. They have also supplied foreskins to transnational corporations such as Advances Tissue Sciences (San Diego), Organogenesis and BioSurface Technology, companies that have recently emerged to reap profits from the sale of products made form harvested human tissues. [126-129]
Despite the efforts of Schoen, Fink, Wiswell etc, the incidence of circumcision in the United States began to fall in the early 1980s, and the downward trend accelerated in the 1990s. The fall was not due so much to the policies of the AAP, which most doctors ignored, but to the educational efforts of popular and professional anti-circumcision groups. Official figures show that the incidence of neonatal circumcision in the western states, where such groups were most active, fell from 64 per cent in 1979 to 34 per cent in 1994. As a result of an increase in the rate in the Midwest, however, the national figures fell much less – from 64 per cent to 62 per cent over the same period.
In February 1996 a research team at the University of Manitoba led by Dr John Taylor published the results of the most significant investigation of the anatomy and physiology of the foreskin since Winkelmann. Their paper, “The prepuce: Specialized mucosa of the penis and its loss to circumcision”, described the structural and functional components of the foreskin and established its rich innervation and vascularisation, clearly evolved to constitute an erogenous zone and to enhance erotic experience. Since circumcision had originally been instituted precisely for the purpose of destroying these very features, it is not surprising that the medical establishment was reluctant to acknowledge Taylor’s work, let alone face the obvious implications. Other bodies, however, have paid attention, including the Australian College of Paediatrics and the Canadian Pediatric Society, both of which published policies on circumcision in 1996. Each recommended that circumcision of newborns be not performed, and pointed out that circumcision without informed consent was a violation of accepted principles of both medical ethics and human rights. [131, 132]
Around this time, too, prominent figures from the world medical community condemned the American practice of routine circumcision of infants as both medically unnecessary and morally wrong. The consensus among critics was that irrespective of the validity of the health arguments for circumcision, the fact that it was done without consent made it an unacceptable intrusion into the personal lives of individuals and an unwarranted deprivation of their private property. [133-138] The constitutional conflict between human rights and the American medical establishment’s assumption that it knows best what’s good for boys may be settled in the courts.
7. ConclusionThe historical record makes it clear that in the late nineteenth century American physicians sought to institutionalise genital mutilation of both boys and girls as a means of eliminating childhood sexuality, and that their efforts were successful in the case of boys, unsuccessful in the case of girls. Doctors circumcised boys to denude, desensitise and disable the penis to such an extent as to make masturbation impossible, or at least not worth the effort. Clitoridectomy of girls was introduced for the same reason. While the medical establishment’s use of popular fears about masturbation to justify mass circumcision has remained pretty constant since Victorian times, the subsequent supplementary excuses offered to justify circumcision follow a clearly defined pattern: whatever incurable disease happens to be the focus of national attention at any given time will be the disease that circumcision advocates will cite as a reason for circumcision. In the 1870s, when epilepsy was the disease of the moment, circumcision advocates claimed that circumcision could cure and prevent epilepsy. In the 1940s, when STDs were the focus of national health fears, they claimed that circumcision could prevent the spread of STDs. In the 1950s, when everybody was obsessed with cancer, circumcision advocates claimed that circumcision could prevent all sorts of cancers – of the penis, of the tongue of the prostate and of the cervix. Since the late 1980s, when HIV-AIDS became the greatest health scare since the Black Death, circumcision advocates have predictably claimed that circumcision is the answer to AIDS control.
Ironically, and despite these claims, the United States, for all that most of the men are circumcised, does not have a particularly good health record, and on most indicators is well behind places such as Japan and Scandinavia, where circumcision is practically unknown. Today the USA has both the highest percentage of sexually active, circumcised men and one of the highest rates of genital cancers and STDs in the western world. The paradox implicit in this history is that even though mass circumcision has been ineffective as a public health measure, and has done little to control either cancers or STDs, the American medical establishment has clung to its faith in circumcision and consistently sought to find new justifications for it. Their priority does not seem to have been maximising public health, but maximising their foreskin harvest. Such unscientific allegiance to an ineffective and harmful surgical procedure, when good sense would suggest the adoption of more conservative and more effective strategies, suggests that there may be a deeper, non-rational dynamic behind circumcision advocacy, and that it is not just matter of simply applying, as they so often claim, the discoveries of medical science to public health policy. [139]
The history of the institutionalisation of involuntary circumcision in the United States demonstrates that American society has been willing to apply what it takes to be scientific measures at the expense of personal liberty. It is tempting to dismiss circumcision as merely a quaint example of medical quackery pursued by a handful of zealous doctors. We would do better to remember that in the name of scientific progress, millions of American citizens have been subjected to genital mutilation and deprived of an integral, functional and beautiful part of their body. In the face of increasing international criticism and constitutional challenges we must wonder how much longer the medical establishment will be able to continue to indulge in the kinds of illogical thinking and disregard for human rights that underpin their commitment to circumcision as prophylaxis and therapy.
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84. J. Oster, Further fate of the foreskin: Incidence of preputial adhesions, phimosis and smegma among Danish schoolboys, Archives of Diseases of Childhood 43, 1968, 200
85. E.N. Preston, Whither the foreskin? A consideration of routine neonatal circumcision, Journal of the American Medical Association 213, 1970, 1853
86. American Academy of Pediatrics, Hospital Care of Newborn Infants, 5th edn, Evanston 1971, 110
87. Boston Children’s Medical Centre, Pregnancy, Birth and the Newborn Baby, Boston 1971, 285
88. V.E. Pomeranz and D. Schultz, The Mothers and Fathers Medical Encyclopedia, Boston 1977, 109
89. B. Livermore, Like father, like son, Health 19, 1987, 15
90. S. Barton, Your Child’s Health, New York 1991, 113
91. W.H. Masters et al, Human Sexuality, 4th edn, New York 1992, 58
92. M.A. Miller et al (eds), Kimber-Gray-Stackpole’s Anatomy and Physiology, 17th edn, New York 1977, 577
93. R.S. Snell, Atlas of Clinical Anatomy, Boston 1978, 136
94. M.F. Campbell, The male genital tract and the female urethra, in M.F. Campbell and J.H. Harrison (eds), Urology, 3rd edn Philadelphia 1970, Vol. 2, 1836
95. ibid
96. R. Burger and T.H. Guthrie, Why circumcision?, Pediatrics 54, 1974, 362
97. L. Wollman, Female circumcision, Journal of the American Society of Psychosomatic Dentistry and Medicine 20, 1973, 130
98. Report of the ad hoc task force on circumcision, Pediatrics 56, 1975, 610
99. Two suits charge circumcision malpractice, Contemporary Ob/Gyn 28, 1986, 150
100. Calif suit raises liability questions in circumcision, ObGyn News 21, 1986, 1
101. Two suits
102. C.M. Ginsburg and G.H. McCracken, Urinary tract infections in young infants, Pediatrics 69, 1982, 409
103. T.E. Wiswell and J.W. Bass, Decreased incidence of UTIs in circumcised male infants, Pediatrics 75, 1985, 901
104. A.J. Fink, In defence of circumcision, Pediatrics 77, 1986, 265
105. T.E. Wiswell, Reply, Pediatrics 77, 1986, 266
106. G.H. McCracken, Options in antimicrobial management of UTIs in infants and children, Pediatric Infectious Diseases Journal 8, 1989, 552
107. F.W. Burch, Baby Sense, New York 1991, 226
108. A. Santesteban, Child Care for the 90s, Bedford 1993, 18
109. D. Dollemore et al, Symptoms: Their Causes and Cures, Emmaus 1994, 199
110. Doubts about circumcision: Fewer boys are now cut, Newsweek 109, 1987, 74
111. J. Silberener, Circumcision, US News and World Report 104, 1988, 68
112. C.S. Rand et al, The effect of an educational intervention on the rate of neonatal circumcision, Obstetrics and Gynecology 62, 1983, 64
113. G.O. Bean and C. Egelhoff, Neonatal circumcision: When is the decision made?, Journal of Family Practice 18, 1984, 883
114. J.E. Lovell and J. Cox, Maternal attitudes towards circumcision, Journal of Family Practice 9, 1979, 811
115. N.H. Eriksen et al, UTIs infection, etiology, diagnosis and treatment with effective antibiotics, Nordisk Medicin 104, 1989, 35
116. A.L. Shabad et al, The pathogenesis and treatment of UTIs in women, Urologiia I Nefrologiia 4, 1995, 8
117. T.E. Wiswell, Risks from circumcision during the first month of life, Pediatrics 83, 1989, 1011
118. T.E. Wiswell, Routine neonatal circumcision: A reappraisal, American Family Physician 41, 1991, 859
119. S. Ahman, Academy holds fast to position on circumcision, Pediatric News 20, 1986, 38; more recent studies of UTIs can be found here.
120. Report of the task force on circumcision, Pediatrics 84, 1989, 388
121. E.J. Schoen, Is it time for Europe to reconsider newborn circumcision?, Acta Paedatrica Scandinavica 80, 1991, 573
122. I. Bollgren and J. Winberg, Reply to Schoen, Acta Paedatrica Scandinavica 80, 1991, 575
123. A.J. Fink, A possible explanation for heterosexual male infection with AIDS, New England Journal of Medicine 315, 1986, 1167
124. A.J. Fink, Is hygiene enough? Circumcision as a possible strategy to prevent group B streptococcal disease, American Journal of Obstetrics and Gynecology 159, 1988, 534
125. A.J. Fink, Circumcision and sand, Journal of the Royal Society of Medicine 84, 1991, 696
126. B. Manson, Forget pork bellies, now its foreskins, San Diego Reader, 4 May 1995, 12
127. S. Brewer, New skin twin life, Longevity, September 1992, 18
128. R. Rosenberg, Companies see $1.5b market in replacement skin products, Boston Globe, 19 October 1992, 22
129. C.T. Hall, Biotech’s big discovery, San Francisco Chronicle, 25 October 1996
130. J.R. Taylor et al, The prepuce: Specialized mucosa of the penis and its loss to circumcision, British Journal of Urology 77, 1996, 291
131. Position statement on routine circumcision, Australian College of Paediatrics, Parkville, Vic, 1996
132. Canadian Pediatric Society, Clinical practice guidelines: Neonatal circumcision revisited, Canadian Medical Association Journal 307, 1996, 769
133. J. Menage, Male genital mutilation, British Medical Journal 307, 1993, 686
134. L. Sorger, To ACOG: Stop circumcisions, ObGyn News 1 November 1994, 8
135. P.M. Fleiss, Female circumcision, New England Journal of Medicine 322, 1995, 189
136. S. Mullick, Circumcision, British Medical Journal 310, 1995, 259
137. J.P. Warren et al, Circumcision of children, British Medical Journal 312, 1996, 377
138. P.M. Fleiss, More on circumcision, Clinical Pediatrics 34, 1995, 623; a more recent statement by Paul Fleiss available here.
139. J. Bigelow, The Joy of Uncircumcising, Aptos 1995, 89
SourceOriginally published as “A short history of the institutionalization of involuntary sexual mutilation in the United States”, in George C. Denniston and Marilyn Milos (eds), Sexual Mutilations: A Human Tragedy (New York: Plenum Press, 1997). The paper has been slightly edited in places for brevity and clarity.
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