Male and Female Circumcision

Male and Female Circumcision Medical, Legal, and Ethical Considerations in Pediatric Practice Male and Female Circumcision Medical, Legal, and Ethical Considerations in Pediatric Practice

Edited by George C. Denniston. University of Wmhington Seanle, Washington Frederick Mansfield Hodges Wellcome Unitfor the History of Medicine University of O.$onl Oxford, England and Marilyn Fayre Milos National Organization of Circumcision Information Resource Centers San Anselmo, California

Kluwer Academic /Plenum Publishers New York, Boston, Dordrecht, London, Moscow Llbrary of Congress Cataloglng-in-Publication Data

Male and fenale circumcision : medical, legal. and ethical considerations in pediatric practice / edited by George C. Oenniston. Frederick Mansfield Hodges. andMarilyn Fayre Milos. p. cn.. "Proceedings of the Fifth International Synposiua onSexual Mutilations: Medlcal. Legal. andEthical Considerations in Pediatric Practice, held August 1998. in Oxford, Eng1and""T.p. verso. 5-7. Includes bibliographical references and index. ISBN 0-306-46131-5 1. Circumcision Congresses. 2. Fenale clrcumclsion Congresses. 3. Circumcision--Moral and ethical aspects Congresses. 4. Fenale circuncision--Moral and ethical aspects Congresses. I. Denniston. George C. 11. Hodges. Frederick Mansfield. 111. Milos, Marilyn IV. Fayre. International Symposium on Sexual Mutilations (5th : Oxford. England) l998 : GN484.H35 1999 172'.2--dc21 99-37490 CIP

Proceedings of the FiInternational Symposium on Sexual Mutilations: Medical, Legal, and Ethical Considerations in Pediatric Practice, held August 5-7.1998, in Oxford, England ISBN. 0-306-46131-5

0 1999 Kluwer Academiclplenum Publishers 233 Spring Street, New York, N.Y. 10013

No part of this book may be reprodud, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying. microfilming, recording, or otherwise, without written permission from the Publisher

Printed in the United Statesof America In those countries where the circumcision of children is an accepted part of life, perfectly rational, intelligent, and well-meaning adults believe that they have a right to cut off parts of their children’s sexual organs. They alsobelieve that circumcision isan inconsequential matter. Others believe that they haveno choice but to circumcise their children. Even in the rest of the world, most people are unperturbed by that fact that 13.3 million boys and 2 million girlsare circumcised each year. The paradox implicit in this situation is glaring. On the onehand, the world has become increasingly aware, asnever before, of the child’s need for special protections under the law. Children are now seen as complex beings with inalienable rights pecu- liar to their vulnerable status. On the otherhand, the exploitation of children is on the rise. It is easy to object to sexual slavery and child labour-for here, the perpetrators are identifiable and the law is clear. In the case of circumcision, however,objection is more problematic, because the perpetrators areless easy to identify. Society must ask whether the abolition of circumcision is possible without vilifying caringparents who believe they are acting inthe best interest of their children, medical doctors who believe that they are adhering to good medical practice, or religious leaders who struggle to maintain religious cohesion inan era of competing ideologies. At the Fifth International Symposium on Sexual Mutilations, held from 5 to 7 August 1998, at the University of Oxford, a panel of experts in the fields of medicine, law, ethics, sociology, anthropology, history, religion, and politics came together to discuss these very issues from a medical, legal, and ethical viewpoint. For those who are unfamiliar withthe primary issues inthe human rightsand scientific discourseover circumcision, a brief summary of the main points will be of use. The primary problem with circumcisionis not the lack of adequate anaesthesia, the infliction of surgical risk, or the rateof mortality or morbidity, although these are issues of considerable importance on theirown. Regardless of the reasons, motivations, or rationaleof those who circumciseor condone the circumcision of children, regardless of the amount of tissue removed, and regardless of the physical consequences of its removal, the problem with circumcision is the unavoidable human rights implications of permanently removing healthy tissue from a person who has not consented to its removal and who must livethe rest of his or her life with the consequences of that removal. In the United States, for example, whereneonatal male circumcisionbecame a widespread phenomenon during the ColdWar era, and where medical doctors perform and rationalise the procedure, circumcision isa problem, among other reasons,

V vi Preface because it violates the individual’s rightto freedom from unwanted medical procedures. More fundamentally, as the legal experts represented in this collection demonstrate, parental consent for surgical procedureson children is only valid in situations of imme- diate medical necessity consequent to severe injury, deformity, or disease.’ The presence of a normal foreskin or clitoris can neither be classified as an injury, a deformity, or a disease. In terms of basic human rights, circumcision violates the individual’s right to bodily integrity. It violates the right to autonomy over one’s own body,and it violates the individual’s right to protection from such intrusions while he is developmentally incapable of defending his own interests. Regardless ofthe alleged social, religious,or medical benefits of male and female circumcision, the human rights violation created by circumcision remains. Given these factors, one must consider that the circumcision of children may not be the most effective means for expressing parental solicitude, medical goodwill, or religious cohesion. There could be a less burdensome way of achieving these goals. From a non-legal, non-ethical, and purely scientific standpoint, the medicalised rationale offered to justify routine neonatal circumcision is distinguished by an ideol- ogy that largelyignores biologic mechanisms and relies,instead, on anecdotes, theories, testimonials,and on what are purported to be ancient practices. Whatsets the circumcision hypothesis apart from rational, evidence-based medicineis that it has not been scientifically tested through the marshalling of rigorous evidence of safety and efficacy, as required by national regulatory agencies. The continuously shifting medicalised rationale for circumcising children is fervently promoted despite not only the lack of good clinical evidence of effectiveness and public health necessity, but also in spite of the presence of a rationale that violates fundamental scientific, biological, and anatomical laws. The proffering of statistics-based papers, mostof which have obvious methodological flaws, comparing disease rates in dissimilar populations for whom circumcision status is merely a mark of social class, is not a substitute for randomised, controlled clinical trials. Moreover,the fact that developed, non-circumcising countries, such asthe nations of Europe, enjoy markedlysuperior levels of public health than the United States, and, ironically, in preciselythose areas of public health where circumcision is saidto be of benefit, underscores the need for the general scientific community to re-evaluate its uncritical stance towards circumcision. The landmark studies by respected scientists suchas R. S. Van Howe, C. M. Cold, and others,that are presented inthis volume, reveal the powerfulscientific truths that can be realisedthrough rigorous testing and analysis of previously untested theories and unsound medical practices. Another important issue in the circumcision debate is terminology.As a result of carefully-honed messages issuedby medical professionals with an interest in the con- tinuation of circumcision, most American parents have also been led to believe that circumcision is inconsequential, that it has no effect on the functions of the penis, and that it may have medical benefits. When parents are asked whether they want their newborn son circumcised, the very fact that medical professionals ask the question lends an aura of legitimacy to the procedure. It would never occur to most American parents that they were being asked if they wanted to have their child mutilated. No culture that practices the circumcision of children considers it to be a mutilation. Stedman’s Medical Dictionary defines mutilation as, “Disfigurementor injury by removal or destruction of any conspicuous or essential part of the body.”’ Male circumcision clearly entails the removal of a conspicuous part of the body. It inflicts an Preface vii irreparable injury and alters the appearance of the penis. The question, then, is not whether circumcision is a mutilation, but whether it is productive to refer to it as a mutilation when discussing it. Whilethe designation of mutilation is clinicallyaccurate and objective, in practice,it is subjectivelyapplied. Most cultures that practice some form of ritualised or medicalised cutting of the sexual organs of children regard their own brand of cutting as harmless, but regard the brands of genital cutting practised by other cultures as mutilations. This double- standard stems from the inherent xenophobia of most cultures. Americans,for example, rarely consider their own practice of male circumcisionto be a mutilation, but they do consider even the mildest and least invasive forms of female circumcision, as practised in Egypt or Somalia, as mutilations. For Egyptians,for whom both male andfemale circumcision have been normalised, this American double-standard is incomprehensible. Ironically, the United States has its own historyof medicalised female circumcision, but because it was practised by doctors for allegedly legitimate medical indications,it was not considered a mutilation. Mutilation, then, is the stigma of “the other.” It connotes cultural, religious, and racial boundaries. The organisers of the International Symposia on Sexual Mutilations have pre- ferred to use the term “mutilation” for a variety of reasons. First, the use of the term “mutilation” is designed to inspire thoughtful debate and reflection among those cultures that consider their form of circumcision to be normal but consider the forms of circumcision found in other cultures to be mutilating. Only when one can see oneself reflected in the eyes of another can a meaningful dialogue begin. Second, “circumcision” is not a broad enough term to encompass the range of ritual sexual surgeries to which children are subjected around the world, all of which comprise the remit of the symposia. Thepenile subincision of Australian Aborigines is not accurately described as circumcision. The penileflaying of Yemenand Saudi Arabia is not accurately described as circumcision. The clitoridectomy of African girls is also not accurately described as circumcision. Third, and most importantly, “mutilation” is the term pre- ferred by the very individuals who havebeen subjected to ritual childhood genital surgeries and who now work to replace these practices with non-surgical alternatives. It is the belief of the organisers of the symposia that the feelings of those who have been marked by ritual childhood sexual surgeries should have precedence over the feelings of the perpetrators of these practices. We honour the affected individuals by respect- ing their choice of terminology. That circumcision is a form of sexual or economic exploitation of children is also a factor that is often unrecognised. In many African communities,the circumcision of both male and female children provides a significant percentage of the economic support of a whole societal caste, usuallythe caste of blacksmiths. In 1996 alone, inthe United States, neonatal male circumcision generated between $136,052,000.00 and $162,540,000.00 for physician circumcisers? In addition to this, human foreskins have now become the raw resources of the new economic epoch of biotechnology. The increasing consolidationof corporate control over neonatal circumcision, as well as the technologies to exploit the commercial potentials of the foreskin, is alarming, especially when we stop to consider the unique vulnerability of the child and the tremendous profits to be gained. Transnational biotechnology corporations, such as Advanced Tissues Science, Organogenesis, and BioSurface Technology, have emerged to reap unprecedented corporate profits from the development and sale of marketable products made from harvested human foreskins.“In 1996, Advanced Tissue Sciences, which manufactures and markets the foreskin-derived Dermagraft product, could boast a viii Preface

$663,000,000.00 market capitalisation performance? Harvested foreskins are also used in a wide range of applications by the multi-billion-dollar pharmaceutical industry. The prospect of the commercial exploitation of children through circumcision is one of the most important issues ever to face humanity. Foreskin harvesting and the patenting of foreskin-derived products strike at the coreof our .beliefs about the very nature of life. Do human bodies and human bodyparts have intrinsic,or merely utility, value? The last great debate of this kind occurred in the nineteenth centuryover the issue of human slavery.Abolitionists argued that every human being had“God-given” rights and, therefore,could not be made the personal commercial property of another human being. Today, weare reliving this debate, but rather than entire human beings, specific human bodyparts are now the focus of corporate appropriationand exploitation. Certainly, none of the boys whose foreskins are being harvested for commercial exploitation receive any share in the profits generated by their unwitting contribution. We have yet to ask whether our most basic birthright should become a source of corporate income; The majority of American parents have yet to consider whether the steady stream of pro-circumcision messages they have been receiving from certain corners of the medical industry is in part attributableto the intense profitability of circumcision to circumcisers, hospitals,insurance companies, pharmaceutical corporations, and now, biotechnology corporations. As the varied topics included in this collection suggest,the highly visible, multi- dimensional problems inherent in the circumcision of non-consenting citizenshas stim- ulated responses from scientists and scholars working in a wide range of disciplines. This collectionof papers, like the symposium from which it emerged, was inspired not only by a desire to bring together some of the best work being done on this subject, but also by a recognition that theproblem of male and female circumcision encourages multidisciplinary ventures. Certainly, the topics presented in the papers that follow do not exhaust those being considered by investigators of the scientific, religious, and human rights implications of male and female circumcision, and readers areinvited to consult the previous volume in this series for alternative approaches6 While the approaches of some fields-law and medicine most notably-dominate the work cur- rently being done, there remain several topics that have only begunto get the attention they merit. We hope that this collection will encourage further study in these and other areas. It is further hoped that the papers presented here will spark a thoughtful and respectful scientific dialogue,one that will lead to greater understanding, clarity, and, perhaps, to greater respect for children of every race,gender, creed, and nationality.

George C. Denniston Frederick Mansfield Hodges Marilyn Fayre Milos

REFERENCES

1. Committee on Bioethics Informed consent, parental permission, and assent in pediatric practice. Pediatrics 1995;95:314-7. 2. Stedman’s Medical Dictionary. 25th Edition. Baltimore:William’s & Wilkins. 1990:1009 3. According to statistics released by the National Center for Health Statistics, 1,204,000 males were circumcised in 1996. The median fee per circumcision in 1995 was $113 for paediaticians and $135 for obstetricians [Pediatricians’ latest charges Medical Economics 1995;14(11):34.] 1,204,000 x $113 = $136,052,000; 1,204,000X $135 = $162,540,000. Preface ix

4. Hodges A short history of the institutionalization of involuntary sexual mutilation the United F. A in States In: Denniston GC, Milos MF, eds Sexual Mutilations: Human Tragedy. New York and London: PlenumPress 199717-40.[here, p. 35.1. 5. Hall CT. Biotech’s big discovery.San Francisco Chronicle. (October 25,1996): El, E4. 6. Denniston GC, Milos MF, eds. Sexual Muti1ations:A HumanTragedy. New York and London: Plenum Press 1997. ACKNOWLEDGMENTS

Among the many people to whom we owe a tremendous debt of gratitude, we wouldlike to mention Ken Brierley, John A. Erickson, Matthew Orlando, Sheila Curran, Peter Ball, Tina Kimmel, David Smith, Storm Schumacher, Shelton Kartun, Andrew Tinson, Peter Whyer, and John Dalton. We are also deeply indebted to Tim Hammond, Sairus Patel,Shanti Poona, Norm Cohen, Kate Edmiston, and Jim Bigelow. Finally, we would liketo express our deepest appreciation to the contributors for allow- ing us to publish their work.

xi CONTENTS

Section 1. Keynote Address 1. Evolutionary Cultural Ethics and Circumcision of Children ...... 1 N. Toubia

Section 2. The Anatomy, Physiology, andHistology of the Human Prepuce 2. Anatomy and Physiology of the Human Prepuce ...... 9 S. Scott

3. Anatomy and Histology of the Penile and Clitoral Prepuce h-Primates: Evolutionary Perspective of Specialised Sensory Tissueof the External Genitalia ...... l9 C. J. Cold and K. A. McGrath

4. Significance and Function of Preputial Langerhans Cells...... 31 G. L. Williams

Section 3. Current Research on Circumcision and Phimosis

5. The History of Phimosis from Antiquity to the Present ...... 37 F. M. Hodges 6. Diagnosis and Treatment of Phimosis ...... 63 S. C. Donne11

7. Anaesthesia for Circumcision: A Review of the Literature ...... 67 R. S. Van Howe

8. Neonatal Circumcision and HTV Infection ...... 99 R. S. Van Howe XiV Contents

Section 4. Genital Mutilation: Religious and Cultural Considerations

9. Muslims’ Genitalia in the Hands of the Clergy: Religious Arguments about Male and Female Circumcision ...... 131 S. A. Aldeeb Abu-Sahlieh

10. Evangelical Christianity and Its Relation to Infant Male Circumcision ... 173 J. D. Bigelow

11. A Jewish Perspective on Circumcision ...... 179 J. Goodman

12. Circumcision: An African Point of View ...... 183 G. B. Tangwa

13. Unifying Language: Religious and Cultural Considerations ...... 195 J. P. Baker

Section 5. Psychological Aspects of Genital Mutilation

14. Motivations for Modifications of the Human Body ...... 201 G. Zwang

15. Psychoanalysis of Circumcision ...... 209 M. Tractenberg

16. Post Traumatic Stress Disorder After Genital Medical Procedures ...... 215 J. Menage

17. ‘Ijrranny of the Victims: An Analysis of Circumcision Advocacy ...... 221 G. C. Denniston

18. Epidemiological, Medical, Legal,and Psychological Aspects of MutilatedlAt-Risk Girls in Italy: A Bioethical Focus ...... 241 P. Grassivaro Gallo, L. Araldi, F. Viviani, and R.Gaddini

19. Circumcision in America in 1998:Attitudes, Beliefs, and Charges of AmericanPhysicians ...... 259 C. R. Fletcher

20. Facing Circumcision: Eight Physicians Tell Their Stories...... 273 B. Katz Sperlich and M. Conant

21. Neonatal Circumcision from a Primal Health Research Perspective...... 275 M. Odent

22. Celebrating Phallos: Healing Men and Culture...... 279 J. Zoske Contents xv

Section 6. Foreskin Restoration: Historical and Contemporary Considerations

23. The History of Foreskin Restoration ...... 285 D. Schultheiss

24. Current Practices in Foreskin Restoration: The State of Affairs in the United States, and Results of a Survey of Restoring Men ...... 295 R. W. Griffiths

25. Foreskin Restoration (Circumcision Reversal) ...... 303 J. P. Warren

26. The Man Behind Restoration...... 311 M. M. Lander

Section 7. The World-Wide Campaign.to End Genital Mutilation

27. A Comprehensive Approach for Communication about Female Genital Mutilation in Egypt ...... 317 S. Abd el Salam

28. The History of Circumcision in the United States: A Physician’s Perspective ...... 331 M. L. Sorrells

29. Genital Mutilation in Ireland: A Public Health and Human Rights Report ...... 339 L. Massie

30. Challenges to Circumcision in Israel: The Israeli Association Against Genital Mutilation ...... 343 A. Zoossmann-Diskin and R. Blustein

31. Activism on the World Wide Web:The Role of the Internet in the Dissemination of Circumcision-Related Information ...... 351 M. M. Sarkis

Section 8. Current Problems in Medical Publication

32. Peer-Review Bias Regarding Circumcision in American Medical Publishing: Subverting the Dominant Paradigm ...... 357 R. S. Van Howe 33. An Analysis of Bias Regarding Circumcision in American Medical Literature ...... 379 P. M. Fleiss xvi Contents

34. Publication on Circumcision in the Medical Literature: The Role of an Editor ...... 403 H. N. Whitfield

Section 9. Legal and Ethical Considerations of Genital Mutilation

35. Circumcision and Virtue Ethics ...... 409 M. M. Lander

36. Respect in the Context of Infant Male Circumcision: Can Ethics and Law Provide Insights? ...... 413 M. A. Somerville

37. Male Non-Therapeutic Circumcision: The Legal and Ethical Issues ..... 425 c. Price

38. Attaining International Acknowledgment of Male Genital Mutilation as a Human Rights Violation, and a Written Intervention ...... 455 J. S. Svoboda

39. Some Thoughts on Legal Remedies ...... 471 D. J. Llewellyn

40. The Doctor as Expert Witness in United States Courts ...... 485 J. L. Snyder

41. The Oxford Declaration: A Call for the Prohibition of the Genital Mutilation of Children ...... 495 C. A. Bonner

Appendix 1: Declaration of Genital Integrity ...... 505

Appendix 2 Circumcision: Information, Misinformation, Disinformation ..... 507 E. Wallerstein

Appendix 3: Resources ...... 519

Contributors ...... 523

Index ...... 529