IMAJ • VOL 15 • JANUARY 2013 EDITORIALS

In Defense of Ari Z. Zivotofsky PhD1 and Alan Jotkowitz MD2

1Brain Science Program, Bar Ilan University, Ramat Gan, 2Department of Medicine, Soroka University Medical Center and Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel

a Jewish male dies uncircumcised, even perhaps diminishes the pleasure is Key words: male circumcision, medical ethics, an infant who has not reached day 8, his indubitable. autonomy, religion, body is circumcised before burial. IMAJ 2013; 15: 39–42 Although the primary motivation for It is interesting that some opponents Jewish circumcision has always been reli- of circumcision still believe in this medi- gious rather than medical, have been eval myth. aware that there may be medical implica- Antiochus (IV) Epiphanes, the Syrian- n this issue of IMAJ Naimer [1] pres- tions. For example, , Greek occupier of the in the I ents the case of an apparently healthy the famed medieval Jewish , physi- second century BCE, outlawed circumci- newborn infant who underwent ritual cir- cian and philosopher, postulated [3]: sion on penalty of death (1 Maccabees, cumcision that was complicated by exces- 1: 60-61), as did Hadrian, the Roman sive bleeding which led to the infant being Similarly with regard to circumci- emperor in the second century CE, and taken to the operating room for explora- sion, one of the reasons for it is, in the Soviet Union in the 20th century. tion and suturing of the bleeding site. The my opinion, the wish to bring about The first major attack on circumci- next day the head of the hospital’s plastic a decrease in sexual intercourse and sion in the modern era took place in the surgery department explained to the a weakening of the organ in question, German states during the period 1843– parents that there was harm done to the so that this activity be diminished 1857. It was known as the Circumcision- infant’s penis, necessitating a full-thickness and the organ be in as quiet a state fragen and centered on the supposed skin graft to repair the damage. In review- as possible… None of the activities risks the rite posed to society’s health [4]. ing the pictures, Naimer maintained that necessary for the preservation of Influenced by the medical community’s crit- the whole procedure was superfluous as the individual is harmed thereby, nor icism of circumcision, some of the German the penis was perfectly normal after the is procreation rendered impossible, states began dictating licensing and training ritual circumcision. Since we do not have but violent concupiscence and lust requirements for mohelim (ritual circumcis- intimate knowledge of the medical details, that goes beyond what is needed ers) and regulating specific aspects of the we are not in a position to discuss the are diminished. The fact that cir- practice. These laws were similar to those particulars of this case but it gives us an cumcision weakens the faculty of that applied to midwives and demanded opportunity to address some controversial sexual excitement and sometimes medical oversight of mohelim. Interestingly, issues related to circumcision. Drawing of a bas-relief found Historical perspective in the tomb of With the possible exception of trephin- Ankh-Mahor, ing, circumcision is probably the oldest approximately operation known to humankind. There 2350 BCE, first excavated in 1899 are 6000 year old mummies that show evidence of having been circumcised, and Egyptian drawings [Figure] almost as old depict circumcision being perform- ed with stone knives [2]. Circumcision, known as in Hebrew, is man- dated by the Bible for Jewish males and in the Koran for Muslim males. An indica- tion of its religious significance is that if

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not all officials agreed with this policy. For specifically outlawed circumcision. The In Germany, the current attack on example, in 1844, Dresden’s medical offi- anti-circumcision movement achieved circumcision is not via legislation but cer criticized the governmental oversight, unprecedented success when a group of rather through the judicial system. A argued for the sanctity of religious rites, “intactivists” (people who believe that Cologne regional court ruled in June stated that it was a religious custom that infant boys have a right to keep their fore- 2012 that circumcision of male infants should remain free and untouched, and skins “intact”) gathered enough signatures was equivalent to causing grievous bodily refused to implement the state law [4]. At to put a circumcision ban on the ballot. harm, a criminal act. The specific case the time, this debate was limited to German- In addition to differing on the medical involved a 4 year old Muslim boy who speaking lands, and even there it did not merit of circumcision, critics accused was circumcised by a physician at his attempt to ban circumcision but rather backers of the referendum of violating parents’ request. Several days later the focused on regulating it for health reasons. the First Amendment’s protection of reli- boy suffered heavy bleeding and the doc- In contrast to Europe, in the United gious freedom. Indeed, the referendum tor was charged. The court acquitted him States in the mid-20th century neonatal explicitly stated that the ban would apply of causing harm but found that the right circumcision became almost routine, with to religious , and, if it had of the child to keep his physical integrity reports of up to 95% of newborn infants passed, parents in San Francisco could trumps the rights of parents to observe being circumcised [5]. One of the first have received a year in jail, a $1000 fine, or their religion. Under German law, this concerted attacks against circumcision in both, for circumcising their sons. The ref- ruling is final and cannot be appealed to the U.S. was a book published by Joseph erendum never made it to the November the Federal Constitutional Court. Thus, Lewis in 1949 [6]. It was an outrageous ballot because a Superior Court judge the only way to permit ritual circumci- polemic, with little fact, and blamed cir- ruled in July that as “a widely practiced sion is via legislation that would clarify cumcision for almost everything including medical procedure,” the city could not the balance between religious freedom allergies, stammering, rheumatic fever and ban it because California state law forbids and protection of physical integrity. The heart disease. This sort of absurd attack municipalities from regulating medical government of Angela Merkel is actively continued with John Foley who wrote procedures allowed by the state. working on such legislation. that “circumcision has few, if any medical Within the last year an anti-circum- This was not the first time that courts benefits. Any link between circumcision cision movement has become active in found circumcision to be . It and the prevention of genital cancer is at Denmark. They claim that there is no anti- occurred previously in Germany and else- best unproved” [7]. He reports a case (!) semitic element involved, but that they view where. For example, in 2006, a state court “in which an infant was being delivered … it as a basic human right to have an intact in Düsseldorf convicted a Muslim ritual and just as the penis came into view, the body and any non-medically indicated circumciser of causing dangerous bodily obstetrician seized it and circumcised it.” surgery on a child is tantamount to assault. harm after he circumcised seven boys in They assert that studies purporting to show what was described in the court as dirty that circumcision has medical benefits are and unhygienic conditions. In a widely Recent developments irrelevant in a modern western country like reported case, in 2010 a Jewish Finnish The most severe infringement on the Demark where there is good health care couple was ordered to pay their own son free practice of religious circumcision is and proper hygiene, and that there are more 1500 Euros in for causing bodily probably in Sweden. A 2001 law requires effective methods, such as condom use, of harm after they hired a British to all circumcisers to be certified by the preventing sexually transmitted diseases. circumcise him in 2008. National Board of Health, be accompa- They further cite a study by Frisch et al. [8] In summary, modern movements op- nied by a physician or an anesthesia nurse, that reports a downside to circumcision – posing child circumcision no longer base and mandates that anesthetic be applied namely, that a significantly larger number of their arguments on religious motives but beforehand. The World Jewish Congress circumcised men and their female partners on the claims that circumcision has risks labeled this “the first legal restriction on report sexual problems than do uncir- (short term and long term), is devoid of Jewish religious practice in Europe since cumcised men and their female partners. health benefits, and, as a consequence of the Nazi era” (see http://www.circumsti- It should be noted that the conclusions of those two, constitutes assault on a non- tions.com/Sweden.html ). this study have been challenged on meth- consenting child. In 2011 there was an attempt to ban odological grounds [9]. The Danes argue circumcision outright in the city of San that it is logical that in a country in which Francisco. Unlike in Germany where the child welfare is protected to the extent that Defense of circumcision court held that circumcision violated an spanking is universally banned, a procedure We feel that there is no ethical justifica- existing general law, in San Francisco that inflicts pain and is not medically war- tion to ban circumcision for the following the goal was to pass a targeted law that ranted should be banned. reasons:

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• The ethical basis of modern medical lower than child or adult circumcision reasons. These procedures are usu- ethics is autonomy and human free- and during the period where additional ally performed on pre-teen children dom. Numerous ethical codes have medical benefits exist. In addition, a and involve many treatments that can endorsed this concept as the corner- recent study [13] that evaluated the cost last over several years. There is also stone of medical ethics. For example, to the health care system of falling U.S. not insignificant pain involved. But the Physician Charter on Medical infant circumcision rates projects that a they are allowed because parents are Professionalism endorsed by over one decrease to 10% in the rate of male cir- thought to be acting in the best inter- hundred medical societies worldwide cumcision will increase lifetime health est of the child. This argument would states as one of its cardinal principles: care costs by about $407 per man and not hold for so-called female circum- $43 per woman. Once the cost of the cision, which involves far greater risk, Physicians must have respect for procedure is figured in, along with the carries no known medical benefit, and patient autonomy. Physicians must costs of potential complications, net includes unquestioned life-long harm. be honest with their patients and health care costs would be expected to empower them to make informed rise by about $505 million. The evidence presented by Kacker and decisions about their treatment. Patients’ decisions about their Tobian [11] and the American Academy care must be paramount, as long • Like any surgical procedure there are of Pediatrics [13] in conjunction with as those decisions are in keeping potential risks involved. The of standard ethical principles are all in favor with ethical practice and do not old were acutely aware of the danger of permitting infant male ritual circum- lead to demands for inappropriate involved in circumcision, and knew cision. However, it is not the medical care [10]. that some infants might actually die, benefit of circumcision that leads us to usually from blood loss. Jewish law believe that religious infant circumci- For example, autonomy is used as a mandates minimizing the risk by sion should be freely permitted in open basis for the ethical justification of eutha- delaying circumcision of sick infants societies. Although Jewish law forbids nasia. A suffering patient can decide he or and banning the circumcision of a permanent tattoos, we strongly feel that she no longer wants to live and in many boy for whom it poses a risk. A recent parents should have the right to tattoo jurisdictions can legally arrange for a phy- Israeli study that looked at complica- their children if it is a significant part of sician to end their life. An adult patient tions from infant circumcision found their religious or cultural norm and is can also obviously decide that he wishes that the overall rate was very small, within reason. to be circumcised. It is also universally approximately 0.34%. Probably more It seems clear to us that freedom of accepted that parents are the decision significant was that the type of com- religion, parental privilege, and public makers for their minor children. They are plications following circumcision health considerations all support the assumed to be acting in the best interest performed by mohelim and physicians continuation of ritual male infant cir- of the child. This right is only taken away were similar. In explaining this, the cumcision in the developed and develop- when there is immediate danger to the life authors suggest that it may be related ing world. Naimer [1] emphasizes that it of the child. We are unable to see why the to the expertise of the mohelim, in is imperative that physicians be educated courts and some liberal ethicists want to that it is the sole or main occupation about ritual circumcision and that mohe- take away this parental decision making. for many and they are therefore profes- lim be properly trained. We certainly sional and experienced [14]. A larger, agree with him on those points. • As extensively documented by Kacker American hospital-based study found and Tobian [11] in this issue of IMAJ, an even lower rate; about 1 of every 476 Corresponding author: Dr. A. Jotkowitz there is now an abundance of medical circumcisions [15]. That compares to Jakobovits Center for , evidence that circumcision is medically approximately 1 of 20 for refractive Faculty of Health Sciences, Ben-Gurion University beneficial, particularly in the preven- eye surgery. It is important to note that of the Negev, Beer Sheva 84101, Israel tion of sexually transmitted diseases. both circumcision studies were dealing email: [email protected] This year the American Academy of with infants and not older children. References Pediatrics released a statement based 1. Naimer S. Unnecessary full-thickness skin grafting on 5 years of evaluation, concluding • Other cosmetic procedures performed for routine circumcision: when ignorance is far from that “the health benefits of newborn on children are accepted in the western bliss. IMAJ Isr Med Assoc j 2013; 15: 51-2. male circumcision outweigh the risks” world. For example, no one questions 2. Schneider T. Circumcision and ‘uncircumcision’. [12]. It is worth noting that this policy the right of the parent to have exten- S Afr Med J 1976; 50 (14): 556-8. 3. Maimonides. The Guide to the Perplexed. Trans- statement specifically referred to new- sive orthodontic treatments performed lated by Shlomo Pines, University of Chicago, 1963, born circumcision when the risks are on their children for purely cosmetic Part III, Chapter 49, page 609.

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4. Judd R. Contested Rituals: Circumcision, Kosher women: a survey-based, cross-sectional study in IMAJ Isr Med Assoc J 2013; 15: 37-8. Butchering, and Jewish Political Life in Germany, Denmark. Int J Epidemiol 2011; 40 (5): 1367-81. 12. Task Force on Circumcision. Male circumcision 1843-1933. Ithaca, NY: Cornell University Press, 9. Morris BJ, Waskett JH, Gray RH. Does sexual Pediatrics 2012; 130 (3): e756-85. 2007. function survey in Denmark offer any support 13. Kacker S, Frick KD, Gaydos CA, Tobian AAR. Costs 5. Osborn LM, Metcalf TJ, Mariani EM. Hygienic for male circumcision having an adverse effect? and effectiveness of neonatal male circumcision. care in uncircumcised infants. Pediatrics 1981; Int J Epidemiol 2012; 41 (1): 310-12. Arch Pediatr Adolesc Med 2012; 166 (10): 1-9. 67 (3): 365-7. 10. Medical professionalism in the new millennium: 14. Ben Chaim J, Livne PM, Binyamini J, Hardak 6. Lewis J. In the Name of Humanity: Speaking a physician charter. ABIM Foundation. American B, Ben-Meir D, Mor Y. Complications of circ- Out Against Circumcision. New York: Eugenics Board of Internal Medicine; ACP-ASIM Foundation. umcision in Israel: a one year multicenter survey Publishing, 1949. American College of Physicians-American Society of IMAJ Isr Med Assoc J 2005; 7: 368-70. 7. Foley J. The Practice of Circumcision – A Re- Internal Medicine; European Federation of Internal 15. Christakis DA, Harvey E, Zerr DM, Feudtner C, Evaluation. New York: Materia Medica, 1966. Medicine. Ann Intern Med 2002; 136 (3): 243-6. Wright JA, Connell FA. A trade-off analysis of 8. Frisch M, Lindholm M, Grønbæk M. Male 11. Kacker S, Tobian AAR. Male circumcision: routine newborn circumcision. Pediatrics 2000; circumcision and sexual function in men and integrating tradition and medical evidence. 105 (1 Pt 3): 246-9.

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Mutations in the gene CIB2 contribute to Usher syndrome and non-syndromic deafness Individuals with the hereditary disorder Usher syndrome interacts with whirlin, a protein that organizes molecular suffer from hearing loss. Associated genetic mutations complexes that maintain stereocilia structure and growth. impair function of the inner ear, where sensory cells fail Suppression of CIB2 expression in zebrafish disrupted to convert sound waves into electrical signals. Riazuddin responses to acoustic stimuli and caused abnormal balance et al. have determined that mutations in the gene CIB2 during movement. Overexpression of CIB2 in cultured cells contribute to Usher syndrome and non-syndromic deafness. decreased the release of calcium from intracellular stores. CIB2 encodes calcium and integrin binding protein 2, CIB2 may help to maintain intracellular calcium homeostasis which is widely expressed in human and mouse tissue. in inner ear cells by sequestering calcium and influencing In the mouse inner ear, the protein localizes to the tips of the release of stored calcium during mechanoelectrical stereocilia of inner ear cells. When deflected by sound signal transduction. waves, ion channels in these hairlike projections open, Nat Genet 2012; 44: 10.1038/ng.2426 triggering a mechanoelectrical signaling cascade. CIB2 Eitan Israeli

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Targeting VEGF-B as a novel treatment for insulin resistance and type 2 diabetes The prevalence of type 2 diabetes is rapidly increasing, with pancreatic islet architecture, improved β cell function and severe socioeconomic impacts. Excess lipid deposition in ameliorated dyslipidemia, key elements of type 2 diabetes peripheral tissues impairs insulin sensitivity and glucose and the metabolic syndrome. The potential use of VEGF-B uptake, and has been proposed to contribute to the pathology neutralization in type 2 diabetes was further elucidated in rats of type 2 diabetes. However, there are few treatment options fed a high fat diet, in which it normalized insulin sensitivity that directly target ectopic lipid accumulation. Recently and increased glucose uptake in skeletal muscle and heart. it was found that vascular endothelial growth factor B Their results demonstrate that the vascular endothelium can (VEGF-B) controls endothelial uptake and transport of fatty function as an efficient barrier to excess muscle lipid uptake acids in heart and skeletal muscle. Hagberg el al. show even under conditions of severe obesity and type 2 diabetes, that decreased VEGF-B signaling in rodent models of type 2 and that this barrier can be maintained by inhibition of diabetes restores insulin sensitivity and improves glucose VEGF-B signaling. The authors propose VEGF-B antagonism tolerance. Genetic deletion of Vegfb in diabetic db/db mice as a novel pharmacological approach for type 2 diabetes, prevented ectopic lipid deposition, increased muscle glucose targeting the lipid transport properties of the endothelium to uptake and maintained normoglycemia. Pharmacological improve muscle insulin sensitivity and glucose disposal. inhibition of VEGF-B signaling by antibody administration Nature 2012; 490: 426 to db/db mice enhanced glucose tolerance, preserved Eitan Israeli

“What you really value is what you miss, not what you have” Jorge Luis Borges (1899-1986), Argentinian short-story writer, essayist, poet and translator

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