Having been born female and having only raised children sporting the same anatomy, I admit I have had few (if any) conversations referring to male circumcision. I’ll also confess to my ignorance of the nitty-gritty. What–exactly–was removed and how? And why? I discovered that what I had once judged, in my females-only vacuum, a simply gratuitous and unnecessary practice is better contemplated through a more nuanced, though tangled, tension of risk/benefit vs. ethics/values vs. social/personal context.
To explore this, I plucked a few morsels from prevailing health and medical ethics literature, spoke to a friend who had been circumcised as an infant and I had the great fortune to access the very salient insights of Dr. Syed Adnan Hussain, an Assistant Professor of Religious Studies at Saint Mary’s University in Halifax. Not only does Dr. Hussain specialize in studies of modern Islam in South Asia and North America, he is a Muslim with a non-Muslim spouse and a father to prematurely-born twin boys whose personal experience and observations paint a robust, multi-faceted illustration of the complexity of the topic.
A snippet of background
The word comes from Latin circumcīdere “to cut around” and most dictionaries abruptly define it as “removal of the prepuce or the cutting off of the foreskin.” The foreskin is an extension of the penile shaft and covers the glans, or head, of the penis. The role of the foreskin is not fully understood, but it could be to keep the glans moist, protect the penis in the womb or enhance sexual pleasure – to suit their basic purpose, human genitalia have evolved to work together as harmoniously and comfortably as possible. At birth, the inner surface is adhered to the glans surface and gradually separates. Circumcision was probably practiced as far back as 4th millennium BCE, and there are tomb-carving depictions from earlier than 2000 BCE. It is not known whether original practitioners did so for hygienic, sacrificial or rite-of-passage reasons, but it has long been a significant marker of group cultural and religious identity.
Although males can be circumcised at any age, it is simplest and the least risky when performed on very young, full-term infants with no significant medical issues. There are four methods used, with the Gomco clamp being the most common method in Canada and the US. In infants and very young children, anaesthesia is minimal and healing is normally complete within a week with very little bleeding (using the clamp method) involved. In older children and adults, the procedure is more complex and requires either local or general anaesthesia, suturing and greater surgical skill. Complications can include pain, excessive bleeding and bruising, sepsis, poor cosmetic effect, lacerations of the skin and injury to the glans. When performed in a clinical setting under sterile conditions, complications are normally few and typically minor. When performed as a ritual, circumcision may happen in a non-clinical setting (though less and less so) performed by a surgically trained practitioner and is widely considered safe and acceptable.
Who, where, and why?
The World Health Organization (WHO) estimates that approximately 30-33% “…of the world’s males aged 15 years or older are circumcised.” As a cultural event, it is often an initiation rite, a deeply entrenched expression of belonging or a means of social conformity. The WHO reports, “In the majority of these cultures, circumcision is an integral part of a rite of passage to manhood, although originally it may have been a test of bravery and endurance. Circumcision is also associated with factors such as masculinity, social cohesion with boys of the same age who become circumcised at the same time, self-identity and spirituality.” A WHO survey done in Denver, Colorado, showed that 90% of circumcised fathers chose to have their sons circumcised. In the Philippines, boys are typically circumcised between 10 and 14 years of age with “two thirds of boys choosing to be circumcised simply ‘to avoid being uncircumcised’, and 41% stating that it was ‘part of the tradition’.” In the Republic of Korea, 61% of respondents feared being ridiculed if they avoided the procedure. Degree of education completed and socio-economic status also correlate with increased rates of circumcision. Many perceive that circumcised men are preferred by female partners and that it improves sexual pleasure, however, no robust evidence supports this.
Religious practice
Two major religious groups especially favour the practice. In Judaism, the traditional practitioner is referred to as a mohel and the ceremony is called a Bris Milah. It is an outward symbol of the covenant between Abraham and God, and described as such in the Torah. In Arabic culture, practitioners are called motaher. Though not mentioned in the Qur’an, Islam may regard it as either a confirmation of the relationship with Allah (God) or an emulation of the Prophet Muhammed where it falls into the category of Sunnah, the traditions of Muhammed. Dr. Hussain explains, “…it is generally thought that he was born without a foreskin. Some accounts state that it was cut on the seventh day after his birth. Muslims do not worship Muhammad, but rather, many consider him the ‘best of men’ and as such if he did something it may be worthy of respect.” Christianity, Hinduism, and Buddhism are largely neutral on the matter.
Cures what ails you
In Western culture, a different story. By the late 1800s, it became common as a procedure especially to discourage masturbation, perceived as the “cause” of many physiological and psychological disturbances, and it followed as a “cure” for other ailments such as paralysis and motor problems, presumed to be exacerbated by excessive genital stimulation (much eye-rolling as I write this). A slightly more rational (if not entirely iron-clad) correlation was recognized between circumcision – presumed to be more hygienic – and a lower prevalence of sexually transmitted infections (STIs), even then not known to be caused by masturbation!
Shaky medical ground
By the mid-1900s, a majority of Canadian male infants were circumcised, but since 1996, the Canadian Paediatric Society’s position has been that routine circumcision is not advised and in recent years, the average has reduced to 32%. In 2015, based on a review of 1596 medical articles, CPS published a revised position that circumcision may benefit some individuals who bear some risk factors – there is some convincing evidence that urinary tract infections (UTIs) are less common in circumcised males – but in Canada, these factors are not always terribly compelling. As such, it is not regarded as a necessary medical procedure and therefore provincial and territorial plans do not typically cover the cost. To date, the most persuasive evidence in its favour has been a correlation between male circumcision and reduced HIV/AIDS presence among males in regions such as sub-Saharan Africa, where these diseases are prevalent. But even this evidence is fraught.
Clean cut, clean conscience?
The presence of the foreskin means that there is an inner mucosal surface which is conducive to microorganisms that could result in reproductive tract and other infections, possibly related to poor hygiene, which has all proven difficult to measure and ascertain. It may help to keep in mind that the female genital/reproductive surface is similar in also being a thin, mucosal surface designed to be moist under normal, healthy circumstances. Those who observe stricter practices of hygiene might expect to see lower rates of STIs and urinary and reproductive tract infections, though again, the evidence is not incontrovertible. The risks of these conditions in developed countries are arguably low and may favour treatment by more conservative means such as antibiotics. The thinness of the inner surface could present a greater opportunity for ulceration, making the body more susceptible to contracting HIV. Indeed, a study found that this location had a higher risk of HIV infection than the cervix, the primary site of HIV infection in women, but this opportunity might be outweighed by the other purported protective properties of the foreskin. Furthermore, let us not forget that one of the most powerful tools against HIV (and other infections) is condom use. ‘Nuff said.
The hygiene element would also lend itself as compatible with religious doctrine. Think, “Cleanliness is next to godliness” (not actually phrased this way in the Christian Bible but implied liberally). Dr. Hussain explains that, in Islam,
… the tradition discusses it in terms of fitra, or acts necessary for cleanliness and being refined, which include the following: clipping the mustache, letting the beard grow, using toothpicks, snuffing water to wash the nose, cutting nails, washing the finger joints, plucking hair under the armpits, shaving pubic hair and washing one’s private parts with water (and perhaps washing the mouth with water).
There is no denying that hygiene is widely regarded as a social, even moral, virtue and there are valid health benefits. The burning question is: why can’t an uncircumcised person be expected to achieve it without surgery?
Cuts both ways
The war wages on about both the science and the medical ethics. Two recent articles in The Journal of Law, Medicine & Ethics, one entitled “Newborn Male Circumcision with Parental Consent, as Stated in the AAP Circumcision Policy Statement, Is Both Legal and Ethical” by Michael T. Brady and a direct reply, “Circumcision Is Unethical and Unlawful”, by J. Steven Svoboda et al, illustrate the polarization in few uncertain terms. In 2007, The American Academy of Pediatrics (AAP) Task Force on Circumcision attempted to address the earlier “lukewarm” position on neonatal circumcision by assembling a committee comprised of a wide range of experts. Brady, a board member, asserts that based on this diverse expertise and the findings from a comprehensive survey of 1031 well-designed studies, the benefits of early circumcision outweigh the small risks. Stopping short of recommending the procedure, it comes out clearly in support of respecting parental preference so long as there are no obvious contra-indications. Above all else, the AAP rests its case on the potential for future risk reduction as the studies showed “…clear evidence of significant health benefits, particularly relating to reduction in urinary tract infections, HIV infection, sexually transmitted infections, specifically HPV, HSV and syphilis, penile cancer [and] phimosis….”
Svoboda argues the AAP’s position and science is flawed, and mounts a case that renders circumcision tantamount to child abuse, saying “the circumcision of healthy boys occupies an anomalous position that is inconsistent with the norms of medical practice” whose ethics bar “proxy consent to surgery that is not medically necessary” and that “few things are less reasonable than for physicians to make medical decisions as to whether a procedure will be performed on the basis of non-medical factors such as the religion, culture, or personal beliefs of their patients’ parents.”
While Brady contends that the function of the foreskin is unknown, Svoboda counters that there is ample evidence suggesting that this highly enervated tissue has several functions, not the least of which is a protective one. One might also ask if not knowing the function of a normal piece of anatomy, and even if there were no function, justifies removing it (ask your doctor about male nipples). Furthermore, while the AAP feels that the benefits outweigh the risks, “…the risk/benefit structure the AAP invokes is inapplicable to male circumcision as it [the risk/benefit structure] was created for therapeutic procedures…” which newborn circumcision, typically, is not.
The two articles hotly dispute the most compelling argument that circumcision may be justifiable. Brady says that the HIV/AIDS study done in 3 African countries “…clearly defined the role of circumcision in the reduction of HIV acquisition in heterosexual males.” However, its soundness is precarious in some respects.
- No studies have demonstrated that circumcision protects men who have sex with men.
- The study found that the male-to-female incidence of transmission actually increased when men were circumcised.
- The opposite result has been found in other countries.
- As the African study was conducted in poverty-stricken areas, it did not take into account populations who would have access to clean water and better hygiene.
Svoboda maintains that, given the rarity of UTIs in male children and penile cancer in general, the practice is unjustified – “European experts also note that performing 100 circumcisions in an effort to prevent one UTI will cause two ‘cases of hemorrhage, infection, or in rare instances, more severe outcomes such as death.’” And he notes that it is not logical to remove a healthy foreskin “…any more than any other part of the body that might one day fall prey to disease.” Phimosis, when the foreskin opening prevents it from being retracted to expose the glans, is the most common condition requiring therapeutic circumcision but even this is currently suspected of being over-diagnosed and other viable solutions (topical medication and stretching exercises) are available.
The cut-off point: Whose decision is it anyway?
A more contemporary concern is that of informed consent and agency. The decision is exclusively made by the parent or caregiver (or some other authority), but would the child have chosen this as an adult? Brady says, “Opponents of circumcision recommend that any decision about male circumcision be deferred until age 18 years... However, many of the health benefits that can be achieved by circumcision are lost if the procedure is deferred to age 18 years.” Most of us, to some degree or other, do not question the rightness of making decisions for our dependents, without their consultation, that will impact their future well-being. From expecting them to uphold our religious or social values like church-going or arranged marriages, to ear-piercing, spanking or demanding that they give old, creepy uncle Fester a hug out of politeness, we don’t always agree on or practice the same things. But many of us have a degree of (sometimes shaky) respect for other parents’ right to make sometimes vastly different choices on behalf of their children, so long as we judge, at worst, it does little to no harm, or at best, it’s “for their own good”. Lately, though, this “right” has come under scrutiny (often for very good reason) and often due to the sometimes hard-to-nail-down concept of “autonomy” as it applies to young children.
A father's decision
The debate is poignantly illustrated in Dr. Hussain’s journey with his twin boys. Born and raised a Muslim, he never questioned the certainty that any male children of his would be circumcised.
I was compelled to revisit the issue after the boys were born into a state of considerable prematurity (~27 weeks) and as such it was not an option till they returned home. Generally, it seems that the medical establishment has dispensed with the practice in Halifax and we were forced to evaluate it not as a simple practice at birth, but one that would now require general anesthetic (which bears its own risks).
Faced with this, he began studying the history of circumcision within the Muslim community. In doing so, he affirmed that though it is recommended and encouraged, it is not based in scripture but rather practised in homage to the Prophet Mohammed, so therefore not required as such. Though drawn to respect his religious values, he hesitates based not only on health implications, but, since becoming a father, the growing awareness that valuing his children as agents of their own lives and bodies is deeply important. “I am still emotionally connected to the idea that we should circumcise them, but as their age increases, their agency compounds and the choice is simply not mine alone.” Despite being an accomplished and open-minded academic, his emotional motivation for circumcision and his ambivalence about it has been a source of a good deal of anguish.
I needed to shed many tears over the issue. Emotionally there was a desire to have my body shared by my sons and there was a concern that later in life they may blame me for failing in my duty. Ultimately, although I still think that it is important, it will fall to my sons to decide if they elect to the practice. At what age they will have sufficient ability to choose remains to be seen, but I have spoken about it with them during a family bath time.
When asked if he feels reconciled to the outcome and whether the matter may be reconsidered, he remains philosophical,
It always remains a possibility. But my responsibility as a parent is to educate them about the practice in my religious community, which is not shared by their mother, and to give them the pros and cons. For many, circumcision comes down to an issue of “changing that which is already perfect” and perhaps as a parent when the choice was taken from me…I should not now deny a choice that is owed them.
An adult child's perspective
I also asked a long-been-circumcised friend what feelings he harboured, if any, about never having had any say in the matter. In his thoughtful response, he wrestled with an ethical/logical vs. reality/feelings dichotomy.
I've given thought to having had the procedure without consent, and whether my parents had the right to do it (I won't say “consent to it” - they didn't consent to it; they instigated it) and ultimately, I find myself saying “no, they didn't have the right”. That's from an a priori, ethical point of view. The idea of parents altering their kids' bodies to conform with their beliefs – that's really dangerous territory. Although – and here I've played devil's advocate with myself – lots of parents have their kids' aesthetic birth defects “corrected” without their kids' consent – harelips, birthmarks, unsightly but benign tumours, that kind of thing. Strictly speaking, those things aren't therapeutic either – if “therapeutic” means necessary for normal organic function and not, say, to conform to societal norms about how kids should look…I think some parents who opt for circumcision believe they're doing something for the benefit of their child – they're doing it in (however misplaced) good faith… I never talked directly with my folks about my circumcision (that is completely unimaginable in my family) but I do remember my mom talking about circumcision, and saying it was a matter of health & hygiene… So in a way, regardless of how misinformed, she was doing it with my interests in mind… In a nutshell, my feelings: I have no ill will about it at all.
Circumcision is neither necessarily nor even primarily done in the name of health, nor is it always given rigorously researched and soul-searching scrutiny, as Dr. Hussain did. It doesn’t have to be. How do we measure the weight of sincere values against that of medical ethics when the procedure done well in ideal conditions poses such a small threat and may mean a great deal to individual families, including the “circumcisee”? Or, as in the case of my friend, it may have no actual emotional impact at all. Should a voluntary-by-proxy medical procedure ever be governed by personal, social or spiritual convictions, deeply held though they may be? Consider the opposite case where a therapeutically urgent procedure may be denied a person for these same reasons. And, finally, whose choice is it really? When parents make such a decision, they are bound in two senses: bound to the responsibility of choosing in a thoughtful and informed way, and bound to be judged–in either case–by society at large, by closer friends and family, and/or even by themselves, if they experience ambivalence. Parents are entitled to and obliged to obtain the best information available so that they can consider thoroughly their willingness and capacity to bear the potential and proven consequences for, second-most, themselves and, more importantly, their children.
