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MALE INFANT CIRCUMCISION: ETHICAL CONSIDERATIONS

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We recently welcomed Thomas Athanasius into the world, our sixth child and third son.  As with our other two boys, we had to decide whether to circumcise him.  We’ve never found the question easy to resolve.  The opinions of family and acquaintances on the issue tend to be shallow.  Websites can be unreasonably prejudiced in favor or against.  Even the views of doctors we’ve found to mirror the biases of the community.  The following reflections are my attempt ethically to work through the question.  I offer them to our readers for whatever they’re worth.

For decades circumcision was practiced in the U.S. uncritically on socio-cultural grounds with little medical, public health or cultural justification.  In recent years the public conversation has taken a more serious tone.   This is good.  Since the procedure involves surgery, albeit minor, with the attendant risks that accompany any surgery; and since it’s performed on a person at a particularly vulnerable stage of development; the question, even for religious observers, should never be taken lightly.

The term circumcision comes from two Latin words meaning to “cut around,” referring, of course, to the circular incision cut around the head of the penis for removing the foreskin.  Neonatal circumcision entered into U.S. pediatric practice around 1900.  By 1933, approximately 32% of newborn American boys were being circumcised; within ten years the number had more than doubled [1].  And by the 1970s, as many as 91% were being circumcised [2].  As the period of paternalistic medicine gave way to a more critically assertive patient, the number of circumcisions declined so that by 2005 approximately 56% of infant boys were being circumcised [3], still a high percentage.

In deliberating over this question, the chief consideration is the wellbeing of the child.  Since he is unable to grant consent to the procedure, those morally responsible for him must consent on his behalf.  Although it can be morally legitimate to accept more than a minimal risk of harm to oneself that’s not otherwise necessary for the fulfillment of one’s duties (e.g., it can be legitimate to ride a motorcycle with no helmet), it is not legitimate to impose such a risk upon someone else without their consent, especially someone as vulnerable as a newborn, without clearly promised benefit.  So parents considering whether to circumcise their baby boy should carefully consider the possible risks in light of the hoped for benefits before making the decision.

What are some risks?  They chiefly include hemorrhage, infection, and accidental genital mutilation.  A 1993 essay in the British Journal of Surgery states that “although hemorrhage and sepsis are the main causes of morbidity, the variety of complications is enormous.  The literature abounds with reports of morbidity and even death as a result of circumcision” [4].  Since precise records of the numbers of circumcisions performed in the U.S. as well as the number of circumcision-related complications are not kept by the federal government and not by all hospitals, the frequency of complications cannot be known with precision.  The American Academy of Pediatrics (AAP), a proponent of circumcision, quotes studies suggesting the frequency is as low as 0.2 to 0.6 percent [7]; while other sources, usually more critical of the practice, suggest a rate as high as 2 to 10 percent [5].  Either way, the risks entailed are only legitimate to accept on behalf of a newborn when manifest benefit is clearly promised.  Three types of benefit are commonly set forth as justifying circumcision: religious, therapeutic, and social.  I will briefly look at each.

Circumcision for religious reasons
Circumcision as a religious rite dates back to ancient Egypt.  Some of the earliest mummies ever uncovered have been found to be circumcised.  Jews also have practiced male circumcision for centuries as a rite of passage—a permanent visible mark in the flesh signifying membership in the covenant community.  Orthodox and Conservative Jews still circumcise their boys, usually on the child’s eighth day of life, by a Mohel.  Muslims too practice religious circumcision even though the rite is not prescribed in the Koran.  Presently, about sixteen percent of the world’s men are circumcised, the majority on religious grounds.  Since a family’s faith, especially a monotheistic faith, constitutes a very serious commitment on the part of its members, a sacred rite symbolizing membership within the religious community that nurtures that faith has a high degree of importance.  In my opinion, the minor but real risk of harm posed by the practice is legitimate for Jews and Muslims to accept for these religious reasons.

Interestingly, the Ecumenical Council of Florence, in its Bull of Reunion with the Copts (Feb. 4, 1442), addressed the question of the legitimacy of Christians accepting circumcision.  It teaches that anyone who places hopes in the legal prescriptions of the Old Testament, including in circumcision, as necessary for salvation, as if faith in Christ without them was not sufficient, sins mortally.  It ends saying,

Therefore [the Roman Catholic Church] strictly orders all who glory in the name of Christian, not to practice circumcision either before or after baptism, since whether or not they place their hope in it, it cannot possibly be observed without loss of eternal salvation. (Tanner, Decrees of the Ecumenical Councils, vol. 1, p. 576)

Don’t misunderstand the text.  The council fathers envisage here circumcision chosen for the reasons prescribed in the Old Testament.  If chosen under this specification, it implied a person believed the Jewish practice was necessary for Christians.  The text condemns such reasoning.  The text clearly doesn’t mean to address, however, circumcision as a therapeutic practice.  And, in fact, Pius XII taught (apparently) in one of his radio messages that “circumcision is [morally] permissible if, in accordance with therapeutic principles, it prevents a disease that cannot be countered in any other way” [6].  In other words, circumcision should not be chosen by Christians for religious reasons; but it may rightly be chosen for therapeutic reasons.  This turns the moral analysis to the question of whether the practice is medically indicated.

Circumcision as a therapeutic procedure
Several professional medical associations have weighed in on the question.  The Council on Scientific Affairs of the American Medical Association classifies neonatal male circumcision as a non-therapeutic procedure [7].  Since the foreskin of the penis does not constitute a diseased condition, therapeutic intervention is not required.  Likewise, the AAP, in its policy statement on circumcision, writes:

“Existing scientific evidence demonstrates potential medical benefits of newborn male circumcision; however, these data are not sufficient to recommend routine neonatal circumcision” [8].

In the absence of extenuating circumstances, “the procedure is not essential to the child’s current well-being.”

Some have recommended circumcision for reasons of hygiene.  But the AAP reports that “there is little evidence to affirm the association between circumcision status and optimum penile hygiene” [8].  Moreover, it called reports that circumcised males have a higher degree of genital sensitivity and hence sexual satisfaction “anecdotal.”  And other reputable researchers have claimed to demonstrate the opposite [9].  Along the same lines, the American College of Obstetricians and Gynecologists, in a joint publication with the AAP entitled “Guidelines for Perinatal Care,” designated infant male circumcision as an “elective procedure” [10].  These statements suggest that there are not sufficient therapeutic reasons for routinely circumcising infant boys.  It follows that the condition Pius sets forth for legitimately choosing the procedure is not met.

What about HIV transmission? Several studies published between 2006 and 2007 demonstrate that male circumcision reduces sexual transmission of HIV from women to men by as much as 60% [11].  A 2006 NIH study of two randomized controlled trials, one in Kenya and the other in Uganda, showed, respectively, 53% and 48% reductions in HIV acquisition among circumcised men over uncircumcised men [12].  The evidence in these studies seems compelling [13].  The World Health Organization has recommended that male circumcision be included in the HIV prevention plans of thirteen African countries [14].  Although changes in behavior should be the primary means for controlling the transmission of HIV, if there are good reasons to believe that an at-risk population could be significantly benefited by circumcision, and that the population could not reasonably be expected to reform its behavior in the short run, a policy (at least a temporary one) of routine infant circumcision could be justifiable until more permanent and reliable solutions become possible.

Social reasons for circumcision
It may be obvious by now, but I do not think that concern for a boy’s appearance and peer acceptance are alone adequate reasons to amputate a functional body part, albeit one of minor importance.  In fact, such procedures—again, when not performed for strictly therapeutic reasons— seem to me to fall under the condemnation of acts of mutilation (see CCC, no. 2297).  This is not to say that no social threat is serious enough to warrant subjecting a baby to the risks of circumcision.  Perhaps in countries under Islamic law where an uncircumcised male may be subject to considerable disadvantages, the choice would be legitimate.  Such conditions do not prevail in Western nations where diversity is increasingly held to be the highest virtue.

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Notes

[1] E. Laumann, et al., “Circumcision in the United States.  Prevalence, prophylactic effects, and sexual practice,” JAMA (1997), 277 (13), 1052–57. 

[2] Xu,  Markowitz, et al., “Prevalence of circumcision and herpes simplex virus type 2 infection in men in the United States: the National Health and Nutrition Examination Survey (NHANES), 1999-2004,” Sexually Transmitted Diseases 34 (7) (July 2007), 479–84.

[3] Merrill, Nagamine, et al. “Circumcisions Performed in U.S. Community Hospitals, 2005,” Statistical Brief #45 Agency for Healthcare Research and Quality (Jan. 2008) available at http://www.hcup-us.ahrq.gov/reports/statbriefs/sb45.pdf; retrieved Feb. 2, 2010.

[4] N. Williams, L. Kapila, “Complications of circumcision,” British Journal of Surgery (October 1993), vol. 80, 1231-6 (available at http://www.cirp.org/library/complications/williams-kapila/ ); see also Scurlock J., Pemberton P., “Neonatal meningitis and circumcision,” The Medical Journal of Australia, vol. 1, no. 10 (1977), 332-4.

[5] See D. Griffiths, et al., “A prospective study of the indications and morbidity of circumcision in children,” European Urology, vol. 11 (1985), 184-187; George Kaplan, “Complications of circumcision,” Urologic Clinics of North America, vol. 10, no. 3 (August 1983), 543-549; J. Fraser, et al., “A randomised trial to assess childhood circumcision with the Plastibell device compared to a conventional dissection techinique,” British Journal of Surgery, vol. 68 (1981), 593-595.

[6] Pope Pius XII, Discorsi e messaggi radiodiffusi, t. XIV, Rome 1952, s. 328-329; I was unable to verify the authenticity of this reference.

[7] Council on Scientific Affairs, American Medical Association, Neonatal circumcision (Report 10), Chicago: American Medical Association, 1999.

[8] American Academy of Pediatrics: Task Force on Circumcision, “Circumcision Policy Statement,” Pediatrics, vol. 103, no. 3 (March 1999), 686-693.

[9] W. Master, V. Johnson, Human Sexual Response (Boston, MA: Little, Brown and Company, 1966), 189-191.

[10] American Academy of Pediatrics & American College of Obstetricians and Gynecologists, Guidelines for Perinatal Care, Fifth Edition, 2002 (I assume the 6th edition, 2007, maintains the 2002 policy).

[11] B. Williams , J. Lloyd-Smith, et al., “The potential impact of male circumcision on HIV in Sub-Saharan Africa,” PLoS Medicine (July 2006), vol. 3, no. 7, e262.

[12] See National Institute of Allergy and Infectious Disease (part of the NIH), Adult male circumcision significantly reduces risk of acquiring HIV: Trials Kenya and Uganda stopped early. Press release. http://www3.niaid.nih.gov/news/newsreleases/2006/AMC12_06.htm accessed Feb. 2

[13] The journal Scientific American recently reported (Jan. 13, 2010) on a study that found circumcision effects the microbial environment at the tip of the penis in such a way as to prevent HIV infection.  Certain types of anaerobic bacteria capable of living only in environments with no oxygen flourish in uncircumcised males.  Researchers suggest that these bacteria induce minor inflammation at the penis causing immune cells to congregate and hence raising chances for HIV infection.  The bacteria almost entirely disappear when a male is circumcised.  See www.scientificamerican.com/article.cfm?id=circumcision-penis-microbiome-hiv-infection

[14] See the WHO website: http://www.who.int/hiv/pub/malecircumcision/update_2009/en/index.html accessed Feb. 9.

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