circumcision Archives - Prindle Institute

Images of men dressed in pure white with a vibrant mark of blood around their crotch have littered front pages in past weeks. The Bloodstained Men are protesting the practice of male circumcision – removal of the foreskin from the penis. This surgical practice, although less common in many European countries, is widely accepted and largely performed for social, aesthetic, or religious reasons. The World Health Organization estimated that somewhere between 76-92% of people with penises are circumcised in the United States.

While the practice of circumcision has a long history and has been endorsed by many Western doctors, does this make it ethical?

The Bloodstained Men, and other anti-circumcision activists, would argue that it does not: circumcision is a violation of genital autonomy and is a purely aesthetic surgery that only works to detract sexual pleasure and is performed without the consent of the child. Others, meanwhile, support circumcision, citing its possible medical benefits and ability to increase social, romantic, and sexual acceptance. How can we reconcile these two conflicting views?

Consulting our ethical convictions regarding female genital mutilation (FGM) may bring some clarity on this issue. The practice of altering the female genitalia – either by removing the clitoris, parts of the labia, or closing the vagina – has long been considered a morally impermissible intervention in Western society, and on valid grounds. Still, it must be determined whether our condemnation of FGM should inform a similar objection over male circumcision.

Most significantly, many cite FGM as problematic in its attempt to limit sexual autonomy, maintain ideals of purity, and uphold societal expectations around sex and femininity. The intent behind the procedure, then, may be the key to our acceptance of circumcision. Circumcision has long been a religious custom in the Muslim and Jewish faiths, but gained popularity in the United States for different reasons. Most integral to its growth in practice was a belief that circumcision could cure physical and mental health issues, provide an indication of wealth and social status, and prevent masturbation. Although these reasons may have led to its popularity, they have long been proven incorrect, and now the intent behind circumcision is typically associated with ideas of cleanliness, health, or social acceptance (with a focus on genital uniformity with one’s father or peers).

Are these justifications more morally permissible than those for FGM? Like FGM, there is a historic desire to suppress sexual autonomy paired with a current desire to gain social acceptance, and in both cultures the procedure is viewed as an accepted social custom done to benefit a child in some way. It is possible, then, that an evaluation of impact, rather than intent, will prove more useful for our discussion.

FGM is denounced by its lack of medical benefits, and more broadly by its medical risks, with severe forms causing difficulties birthing, infections, and psychological trauma. Does the moral difference, then, lie in the benefits of circumcision? Possible benefits include a decreased risk for HIV or urinary tract infections, easier hygiene, and social acceptance, with the belief that uncircumcised persons will face social persecution, bullying, or romantic/sexual ostracization. Do these reasons warrant genital surgery?

Research has found that these benefits are much more slight than once believed, especially when making a consideration for policy within the United States where HIV rates are quite low and may be better addressed with proper access to condoms, the drug PREP, or comprehensive sex education. In addition, circumcision, like FGM, reduces sexual pleasure; the foreskin, much like the clitoris, houses a majority of the nerve endings in the penis, so its removal reduces sensation. It is widely known, now, that circumcision is not a medical necessity, yet the practice remains a social custom. Social reasons for circumcision may be convincing, but are also similar to those that inform FGM.

Is social normativity enough to warrant the removal or change to a perfectly healthy organ, especially if it reduces pleasure? Even if there are some medical benefits, is this a decision that should be made for a child?

This discussion really comes down to a conversation about informed consent. For surgeries under the age of 18, parents are given the authority to provide consent for their children; this sacrifice of rights is necessary to serve the medical interests of the child. In the case of circumcision, though, there is absolutely no medical necessity; it is a surgery that involves the removal of a natural part of a healthy organ, an organ that increases pleasure later in life. Should parents be able to consent to surgeries that are not medically necessary?

The value we place on bodily autonomy suggests that this is not a decision that should be made by parents, especially as it is often motivated by a desire to “fit in.” Personal autonomy and the right to control one’s own body, especially such an intimate organ, should supersede social and cultural norms. If we do decide respecting cultural customs and desires for social acceptance are more important than our ethical understanding that people should have the right to control their bodies, why do we denounce FGM?

When evaluating the two procedures, it seems as though circumcision shares many of the qualities that make FGM unethical, so shouldn’t we deem circumcision unethical as well? If we decide to continue the practice of circumcision, where must we fall on the issue of FGM? In order to come to a conclusion about circumcision, we must reckon with our moral attitudes towards FGM and determine whether our values of consent and pleasure are more important than our need to conform to social and cultural customs.

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Iceland will soon vote on a bill that would criminalize infant circumcision. While the medical community is supportive, some Icelanders are concerned. It’s not so much the typical Icelandic parent who wants to retain the right to make this decision, but Jewish and Muslim leaders are concerned that a ban would intrude on core religious practices. Circumcising newborn boys is a religious commandment for both religions.

It’s a little surprising that the Icelandic physicians are united against circumcision. In 2012 the large and influential American Academy of Pediatrics issued a policy statement stating that circumcision has somewhat more health benefits than harms. There’s the pain of the procedure and the small risk of serious adverse effects, but on the other side of the ledger, a salutary effect on rates of penile cancer, urinary tract infections, and HIV infection. The AAP didn’t conclude that parents should circumcise, but on the other hand, how could it make sense for ethicists and doctors to say the opposite: that they shouldn’t, assuming that the AAP is right and circumcision is a little more beneficial than harmful?

The thought of some critics of the practice is that even if circumcision is more good for boys than bad, it takes more than a small balance of benefits over costs to justify removing a body part. Circumcising a boy isn’t like drawing a little blood or removing an infected appendix. The part in question is perfectly healthy and normal and will later be experienced by a boy as a part of his personal body surface. If he gets to keep it, he will most likely later think his foreskin is his to keep or to remove. Thus, there is a “body integrity” case to be made that parents shouldn’t circumcise their babies, even if the AAP’s cost-benefit analysis is correct.

And so, the Icelandic physicians are right to support a ban? Not so fast! A ban would stop a moral wrong, I am prepared to say (I make the “body integrity” argument in my book The Philosophical Parent), but it would impinge on two important things—a person’s autonomy as a parent and their autonomy when it comes to matters of religion or conscience. Now, parental and religious autonomy aren’t absolute; they don’t trump everything. Uncontroversially, the state doesn’t allow parents to be abusive and doesn’t allow every conceivable religious practice, whatever the associated harms (to self, others, animals, the environment, etc.). But circumcision, however suspect, does seem like the wrong kind of thing for the state to forbid.

The problem with state involvement is the subtlety of the argument against circumcision. It does seem to me that it takes more than a small balance of benefits over costs to justify the removal of a normal, healthy body part destined to be experienced by boys and men as “mine.” But I can’t go further and claim it must seem the same way to any reasonable person, as I can with other harms. If the Church of the Missing Toe wants to chop off the small toe of newborn boys, it will be all to the good and perfectly appropriate if the state forbids it. I think ritual toe amputation is wrong and expect anyone else to see it in the same way. But it’s far more subtle and negotiable whether a procedure can be both slightly beneficial, on balance—as circumcision is, according to the AAP—and also morally wrong. It seems misguided for the state to force everyone to behave in accordance with just one of the multiple positions on circumcision that are open to reasonable, well-informed people.

While I do think there are respect-worthy ways of defending circumcision, it’s difficult to see how the religious defense can be among them. The religious defense has nothing to do with costs and benefits. It has to do with ancient scriptures and the notion that a religion should be “marked in the flesh” (Genesis 17). It’s also about parents demonstrating commitment to a religion by doing something difficult. (The medieval Jewish philosopher Maimonides said the point of circumcision was precisely that it is a “hard, hard thing” for a parent to impose on a child, and so a good test of the parent’s religious commitment.) As much as these ideas seem venerable and familiar just because of their long history, how can they be any more respectable than the doings of the Church of the Missing Toe?

So, should Iceland ban religious circumcisions and protect non-religious circumcisions—of which there are very few? It would be an odd and unusual law that prohibits doing something for one reason but allows it for another. After all, the better reason is “available,” whether it’s motivating the agent or not. And so I conclude: no to the ban. Considering that there are not-obviously-wrong medical reasons for foreskin removal, parents should be able to choose it.

But then there’s the how and the when. There may be reasons to circumcise worthy of respect—that’s at least how some reasonable people see it. But surely there are no reasons to circumcise painfully that are worthy of respect. Muslim parents typically have their boys circumcised in hospitals or doctor’s offices, just like non-religious parents. This is not uncommon among Jews as well. In a medical setting, lidocaine injections are available and commonly used (at least in the US).

But among Jews, the more observant have the procedure performed by a “mohel” in a religious ceremony (a “bris”) in the home. These are highly skilled practitioners who work very quickly using traditional tools and techniques but can also offer all the pain relief that’s available in a doctor’s office—lidocaine ointment or even injections. Orthodox mohels, though, reject intrusions on traditional practice. There is no pain relief during the procedure. A religious practice or not, withholding pain relief during a surgical procedure is impossible to defend. The right way forward seems to me to be regulating the way circumcision is performed, not prohibiting it altogether.