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 l0987654321 A CAP. record for this book is available fromthe Library of Congress. All rights reserved 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, regard- less of the amount of tissue removed, and regardless of the physical consequences of its removal, the problem with circumcision is the unavoidable human rights implica- tions 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 pres- ence 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 medi- calised 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 cir- cumcision 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 circumci- sion 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 cir- cumcision 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