On the ethics of non-therapeutic circumcision of minors, with a pre-script on the law

By Brian D. Earp (Follow Brian on Twitter by clicking here.)

PRE-SCRIPT AS OF 25 SEPTEMBER 2012: The following blog post includes material from an informal article I wrote many years ago, in high school, in fact, for a college essay competition. I would like to think that my views have gained some nuance since that time, and indeed with increasing speed, as I have researched the topic in more detail over the past several months–specifically during the period of a little over a year since the blog post first appeared online. Since quite a few (truthfully: many thousands of) people have come across my writings in this area, and since I am now being asked to speak about circumcision ethics in more formal academic company, I feel it is necessary to bring up some of the ways in which my thinking has evolved over those many months.

The most significant evolution is away from my original emphasis on banning circumcision. I do maintain that it should be considered morally questionable to remove healthy tissue from another person’s genitals without first asking for, and then actually receiving, that person’s informed permission; but I also recognize that bringing in the heavy hand of the law to stamp out morally questionable practices is not always the best idea. It is a long road indeed from getting one’s ethical principles in order, to determining which social and legal changes might most sensibly and effectively bring about the outcome one hopes for, with minimal collateral damage incurred along the way. Until enough hearts and minds are shifted on this issue, any strong-armed ban would be a mistake.

In the long term, however, I think the moral goal remains: that each male newborn should have the same legal protections enjoyed by his sisters, designed to preserve his sex organs in their healthy, intact form until such time as he is mentally competent to make a decision about altering them, surgically or otherwise.

The project for the meantime is to work on hearts and minds.

I am grateful to the many hundreds of individuals who have left thoughtful comments on my sequence of posts on the ethics of circumcision, and I look forward to developing my arguments in ever more sophisticated ways in the coming months and years as this important debate continues. I am especially grateful to those of my interlocutors who have disagreed with me on various points, but who have done so in a thoughtful and productive manner. May we all aim at mutual understanding, so that the best arguments may emerge from both sides, and so that the underlying points of genuine disagreement may be most clearly identified. — B.D.E.

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Routine neonatal circumcision in boys is unethical, unnecessary, and should be made illegal in the United States. Or so I argue in this post.

Yet lawmakers in California, it is now being reported, have introduced a bill with the opposite end in mind. They wish to ban legislation that could forbid circumcision-without-consent. What could be going on?

The story begins in San Francisco earlier this year. Anti-circumcision advocates—“intactivists” as some evidently like to be called—collected more than 7,700 signatures to introduce a ballot initiative which, if passed, would outlaw needless, nonconsensual circumcision within city limits. The point of the initiative was that routine circumcision is a medically unnecessary act of surgical interference–one that removes healthy, functional genital tissue, and does so without the consent of the person whose body is being permanently modified. Since this action fits the definition of criminal bodily assault in most Western legal jurisdictions, it should not be allowed.

In July, however, a San Francisco Superior Court Judge ordered that the measure be struck from the ballot. The ruling held that only California State, as opposed to individual municipalities like San Francisco, could legally regulate “medical procedures.” The judge also said that such a measure would violate protections of religious freedom under the U.S. Constitution.

What should we make of this ruling? I will start with the “religious freedom” aspect, and simply point out that such arguments can be taken too far. What if my religion says I can punch you in the face? Or slice into your genitals without consent? Polygamist Warren Jeffs, leader of a notorious Mormon sect, was recently sentenced to life in prison for raping children in the name of God. So there is a line somewhere, and part of my argument will be that neonatal circumcision crosses that line. It’s not as bad as holy rape, but it crosses the line. I’ll come back to this later.

As for the legal calculus concerning state-level versus city-level lawmaking, I don’t have much to say. In my view, it is the ethical issue that has to be settled first; and the law must follow once the moral lines are drawn.

So why is medically elective circumcision, performed without consent, unethical? I’ll give you a succinct argument, courtesy of Georganne Chapin. Ms. Chapin is founder and director of the Hudson Center for Health Equity & Quality. She writes in the L.A. Times:

My argument against circumcision of children and infants is no more and no less than that it’s a human rights issue. All people, male as well as female, are entitled to bodily integrity, and nobody — for any reason — has the right to cut off part of another person’s body when that person is too young to understand and to consent.

Under bioethical principles, parental consent for medical treatment is permitted only if the treatment being considered will save the life or health of the child. Circumcision is not medically necessary, and so it violates those principles, as well as that child’s entitlement to a complete body, his own personal freedom and autonomy.

… Circumcision is a so-called cure that’s in search of a disease. The vast majority of men in the world are intact, and they are not suffering from illness or infection. There is no justification for cutting off a body part for a hypothetical future disease, especially ones like STDs that can be prevented in ways that don’t involve mutilation. It’s crazy that we don’t think it’s crazy.

Harvard’s Daniel Halperin, a lecturer in international health, disagrees. In the same article, he offers this riposte:

Circumcision provides a number of health benefits. It reduces the risk of HIV and penile cancer in men. It also reduces the risk of several other sexually transmitted infections in both men and women, including syphilis and herpes, and of cervical cancer in women. Urinary tract infections in infants are about 10 times less likely if the boy has been circumcised.

In Africa, there have been three randomized trials … demonstrating that circumcision reduces heterosexual HIV infection in men by at least 60%.

In countries where there is not good access to running water, another reason to circumcise is hygiene. And in a study of nurses in a U.S. geriatric unit, about 90% were strongly in favor of circumcision because it was difficult to bathe uncircumcised men in their 90s. When we look at a baby and we think about circumcision, we have to think not just about that baby but that he’s going to turn into a man and, eventually, an old man.

… If circumcision has health benefits, and the parents want to do it for medical or religious or other reasons, that should be allowed and the access should be there.

Hold on a minute. “Other reasons” … ? Including what? Does this mean that parents should be allowed to surgically modify their son’s genitals for any reason at all? What about sheer whim? It seems so. Dr. Halperin then summarizes his argument like this:

I’m not interested in pushing circumcision but in making the service readily available to everybody who wants it.

On this last point, actually, I agree. Wholeheartedly. Circumcision should be readily available to “everybody who wants it” – No questions asked. Everybody who wants it performed on himself, that is. Armed with this common sense ethical principle, let us now see if we can figure out whether any newborn baby has ever “wanted” to be circumcised. Actually, it’s hard to tell, since newborn babies can’t form sentences and hence can’t articulate their views. But they do seem to experience the procedure as painful, even traumatic, and they resist as much as they can. On this metric, we should cautiously conclude that they really, really don’t want to be circumcised.

Could we wait a bit, perhaps? And let the babies decide on such matters when they’re no longer babies? When they can do things like use words to express thoughts? Then they might tell us things like: “No, thank you; I like my penis just the way it is.” Or, “Please cut off my foreskin; I really don’t want it anymore.”

But it will reduce their risk of getting STIs! Will it? This is contested. But just for the sake of argument, let us grant that properly-performed circumcisions (i.e., in a hospital setting) may in fact cut down on STD receptivity, at least to some degree. OK then, why not pass this information on to males of our species when they’re actually starting to have sex, and see how many choose, at that time, to sign themselves up for your treatment? Show them your studies. Lay the evidence before them. Cajole, coax, convince—just don’t coerce. Let them decide about their own bodies when they have the mental capacity to process what you’re selling. Little babies simply aren’t the at-risk population when it comes to sex-related diseases.

Also, lots of things reduce the risk of getting STIs. Wearing a condom for instance. This procedure has triple benefits: it’s undertaken by choice, it’s way more effective at preventing disease transmission than circumcision, and it doesn’t require the involuntary removal of a portion of a little boy’s penis.

But circumcision can reduce HIV infections in Africa! The evidence here does seem somewhat stronger (though it is not without its critics). Again, however, so can many other interventions. And insofar as those interventions happen to be consensual and non-violent, they too are to be vastly preferred on moral grounds. In any case, the three studies showing a partial effect of circumcision in reducing female-to-male transmission of HIV (but not the other way around) were performed on adult volunteers, not on infants – so there is much less to worry about ethically. Furthermore, there is little reason to think that the African findings would translate to developed nations, where patterns of HIV transmission (and access to basic hygiene) are very different.

Finally, what is this nonsense about bathing old men, and then asking their nurses what they think about circumcision? “We think it’d be jolly great. It would sure make our lives easier.” But what the nurses think is irrelevant. I suggest that we ask the old men how they would feel about being circumcised, and go from there.

Of course, that’s the whole point. Dr. Halperin wasn’t suggesting that we allow male human beings to decide, at each successive stage of their mentally mature lives, whether or not to keep their own foreskins. He was saying that we should decide for them, days after birth, just in case there are issues like awkward genital-soaping a full century later.

At this point, it occurs to me, you may have the idea that the foreskin of the penis is nothing but a disease-incubating, hard-to-clean nuisance, my moral points notwithstanding. But you’d be wrong. The foreskin serves more than one important function.

First, it protects the soft, moist, and sexually-sensitive glans penis from environmental irritation. The “head” of a circumcised penis, in contrast, can become dried out and tough, as well as desensitized, as it rubs against clothing and other foreign elements year after year. Second, it serves a sexual function as well. The nerve endings on a foreskin’s inner surface become exposed when the penis is engorged—while the foreskin glides over the glans during intercourse—potentially increasing pleasure for both partners and making vaginal dryness less likely a problem.

In fact, circumcision first became a standard medical practice in the US, and subsequently a mindless cultural habit, specifically as a means to combat masturbation. The aim, that is, was to reduce the sexual functions of the penis:

In cases of masturbation we must, I believe, break the habit by inducing such a condition of the parts as will cause too much local suffering to allow of the practice being continued. For this purpose, if the prepuce [foreskin] is long, we may circumcise the male patient with present and probably with future advantage; the operation, too, should not be performed under chloroform, so that the pain experienced may be associated with the habit we wish to eradicate. (“On An Injurious Habit Occasionally Met with in Infancy and Early Childhood.” The Lancet, Vol. 1; 7 April 1860.)

We’ve moved past the folly of anti-masturbationism; we should move past the habit of circumcision as well.

Just one more point before I close. I want to address the “religious” issue head on—not the puritanical one about masturbation, but rather the matter of circumcision’s being a rite for Jews and Muslims. Some say that cutting off foreskins is sacred to members of these faiths, and that no one has a right to criticize the religious and cultural traditions of other groups. I simply disagree. If secular circumcision is unethical for the reasons I have described; then religious circumcision is unethical for similar reasons (as some religious circumcisers will freely admit). The problematic aspects of involuntary genital surgery don’t simply go away when you cloak them in tradition.

I know that some will find this view offensive. Consider this message from a man named Steve:

Circumcision is the basic covenant between God and a Jewish male. It is non-negotiable for Jews. Sorry Brian, you’re entitled to your non-Jewish opinion, but we’ve been doing very nicely for 5,771 years with this ancient tradition of our people. And I don’t even know who the hell you are, but this kind of nonsense just pisses me off.

To Steve, and to others who push this line of thought, here is my reply. I understand that circumcision has been going on for a long time. And I know it’s a very important custom for many people. I don’t think that those considerations on their own, however, can in general justify a given ritual or action. After all, our species has engaged, in the past, in many rituals and behaviors that we now consider cruel. I won’t list examples.

With respect to circumcision’s being a covenant between God and a Jewish male, that is certainly a further point to consider. I do understand that that’s how very many people, especially more traditional or literal-minded Jews, interpret certain passages within the Hebrew Bible (never mind that more than 50% of American Jews may be atheists). But there are very many explicitly God-endorsed customs and rituals in the same text that are no longer followed, even by the most devout of the devout. This makes me think that we have an evolving practical and moral sense by which we, as a rational beings, over time, re-interperet and re-consider old customs. I submit that circumcision should be re-considered along these lines. You might be interested to know that there are a growing number of Jews who believe that circumcision is barbaric, its long pedigree notwithstanding. And some moderate Muslims reject the practice as well.

Implicit in my response to all this is the following. I don’t think that the creator of the universe, if there is such a thing, really wants anyone to shear off little babies’ foreskins. On the evidence available for such a view, that very same creator wants all manner of problematic things that no one takes seriously today. So at least be consistent. In any case, even if I sincerely believed that God said to me, “As part of our covenant, you must cut off part of your child’s genitals without asking his consent,” I would have to decline on moral grounds.

I leave you with a quote from the anthropologist Donald Symons. He refers in this passage to female genital cutting, some forms of which, of course, are more invasive and can be much more harmful than male circumcision. But other forms, including ‘ritual nicking’ of the clitoris or clitoral hood, are actually less invasive (but are nevertheless prohibited in the West). Either way, it is the underlying point about culture as a motivation for violence that I want to draw attention to:

If only one person in the world held down a terrified, struggling, screaming little girl, cut off her genitals with a septic blade, and sewed her back up … the only question would be how severely that person should be punished, and whether the death penalty would be a sufficiently severe sanction. But when millions of people do this, instead of the enormity being magnified millions-fold, suddenly it becomes “culture,” and thereby magically becomes less, rather than more, horrible…

Magically indeed. And in 2011, we have California lawmakers trying to outlaw the banning of “culture” such as this. You know how I feel about it. What say you?



