Medical ethics, human rights and law

Circumcision is more than a medical or health issue. Bodily integrity is recognized as a fundamental human right, basic to the autonomy of the individual and guaranteed by law.

Introduction

In the decade that followed the passage and ratification of the United Nations Convention on the Rights of the Child in 1989 there has been a proliferation of studies by legal scholars, human rights experts and bioethicists who have developed convincing arguments that medically unnecessary circumcision of non-consenting minors is a violation of accepted principles of medical ethics and human rights. Some commentators have even raised doubts as to the legality of the procedure. Important landmarks include essays showing that “informed consent” for such an intervention constitutes a “legal and ethical conundrum”; that the justifications for such an operation as a prophylactic measure cannot override the ethical objections; and that circumcision of boys is a violation of the rights of the child. Other scholars have shown that the ethical and physical harm arguments against female genital mutilation apply just as strongly to circumcision of boys, that the physiological parallels of the two sets of procedures are very close, and that there is no justification for quarantining discussion of male circumcision from female genital mutilation (FGM).

Circumcision promoters refer to the objections to circumcision on medical ethics and human rights grounds as “nebulous”, but these issues are really central to the whole question. No matter how great the benefits of circumcision may be, the fact remains that the foreskin belongs to its owner as surely as his fingers, toes, ears, liver and any other organ. The only situation where it can be ethically removed without consent is in a life-threatening emergency, or in order to address a deformity, injury or disease that has not responded to conservative treatments after reasonable efforts.

The fact is that even if all the benefits of circumcision claimed by its promoters were true, it would only amount to a case that might persuade a cautious adult to elect the procedure for himself. The case was never sufficient to justify doing it to children without consent. Individuals are entitled to make their own choices about how they manage their health, and should not be deprived of normal body parts merely because somebody else thinks they would be better off without them. The reason circumcision promoters insist that ALL boys be circumcised at birth is not because it is less painful or less harmful at that time – on the contrary, the evidence runs quite the other way – but because babies lack the power to resist, and if everybody is circumcised they will regard the condition as normal and never know what they are missing when they grow up.

If the benefits of circumcision were as great as its promoters claim, and if it is indeed a biomedical imperative for the 21st century (as one keen circumciser has claimed), you would expect adults to be convinced by the argument and to be queuing up to get it done. The fact that this does not happen (except in the exceptional case of certain African countries awash with American cash), and the vast majority of adult men prefer to hang on to their foreskin, is in itself a sufficient reason not to impose the cut on innocent children.

Personal preference the key issue

According to a standard textbook on medical ethics, the basic principles of modern bioethics are summed up under the headings beneficence (the good of the patient); non-maleficence (not harming the patient in any way); autonomy (respecting the patient’s individuality and dignity as a human being); and justice (treating the patient in the same way as others with respect to his condition). [1] On the basis of second two of these principles, doctors should respect the wishes of the boy on such an intimate matter as circumcision; and should not treat him differently from the way in which they would treat girls if parents brought in their daughter and asked that she be circumcised.

The principle of autonomy was recognised in 1996 when the Australasian Association of Paediatric Surgeons agreed that the key issue to consider when faced with parental requests for circumcision of a minor was the likely future preferences of the boy: it was “opposed to male children being subjected to a procedure, which had they been old enough to consider the advantages and disadvantages, may well have opted to reject the operation and retain their prepuce.” In 1999 BJU International published an analysis of a survey which showed that hundreds of men in the United States had experienced moderate to severe physical and psychological injury as a consequence of their “routine” circumcision as infants. [2] Circumcised boys are more likely to feel mutilated and deprived if they grow up among peers who have not been circumcised, but both the BJU study and a more recent Australian survey show that even when they grow up among predominantly circumcised age-mates, many circumcised men can still feel humiliated and resentful. [3]

Unfortunately, this intelligence seems to be taking a long time to reach certain members of the Australian medical profession. In February 2010 a doctor in New South Wales, commenting on a (dubious) report that the incidence of circumcision in Queensland was rising, stated that circumcision was generally safe but that there were still slight risks of infection of deformity of the penis. He added that “full informed consent was important”, but he seems to have been unaware that minors cannot give consent. What business did he have to be encouraging the practice (the only possible effect of his remarks) when the policy of the RACP is that there is no medical indication for routine circumcision of normal male infants? If there is no medical indication, it is a non-therapeutic procedure and should not be performed on a minor. [4]

This reference to “risk” indicates a serious misunderstanding of the rules for non-therapeutic surgery. We often hear arguments that circumcision is justified or not justified on the basis that the benefits exceed the risks of the surgery or that the risks of surgery exceed the benefits. But the risk/benefit rule was devised for therapeutic procedures, where there is a pathological condition that requires treatment. In the case of normal male infants and boys, there is no pathology to treat, meaning that circumcision is a non-therapeutic procedure and hence is governed by far stricter rules. According to the judgement of the High Court in Marion’s Case, non-therapeutic procedures carried out on children are unlawful unless approved by the Family Court. This rule has been applied when parents have sought sterilisation of mentally impaired girls, and many legal scholars and authorities on medical ethics have argued that it should also be applied to circumcision of healthy boys. [5]

Gender justice

A striking indication as to the anomalous status of circumcision is that the criminal code in most States imposes severe penalties for the performance of any cutting of the female genitals, no matter how mild, and is completely silent about the cutting of the male genitals, no matter how severe. Yet it has been argued that most instances of female genital mutilation are less damaging than many instances of male circumcision; that female circumcision also offers health benefits; and that arguments based on bodily integrity and human rights must apply as much to males as to females.

Australia’s obligations under the Sex Discrimination Act 1984 and as a signatory to the Convention on the Rights of the Child require the national and state governments to treat males and females equally and without discrimination on the basis of sex, and to take action to eradicate traditional practices harmful to children. Article 24 (3) of the Convention requires parties to take “all effective and appropriate measures with a view to abolishing traditional practices prejudicial to the health of children.” In the wake of this development several states passed laws to prohibit any form of female circumcision, and the Commonwealth specifically excluded such procedures from the Medical Benefits Schedule. Although there was nothing in the wording of the Convention to suggest that it did not include male children, no action has yet been taken to protect them. Although the Medicare guidelines state that payments are not available for cosmetic or clinically unnecessary procedures, a rebate for circumcision is still provided, thus subsidising and encouraging the procedure and sending a signal that it is socially and ethically acceptable. This failure to take any action to protect boys is increasingly recognised as constituting, as a recent article in the Australian Journal of Human Rights argued, “a hidden human rights violation”.

References

1. Tom L. Beauchamp and James F. Childers, Principles of Biomedical Ethics(Oxford University Press 1977, and many subsequent editions)

2. Tim Hammond, A preliminary poll of men circumcised in infancy or childhood, BJU International , Vol. 83 (Supp. 1), 1999, 85-92

3. Laurence Cox and Robert Darby, Objections of a sentimental character: The subjective dimension of foreskin loss, in Chantal Zabus (ed.), Fearful Symmetries: Essays and Testimonies around Excision and Circumcision (Amsterdam and New York: Rodopi, 2009)

4. Brisbane Times, 20 February 2010

5. For example, Gregory J. Boyle, J. Steven Svoboda, Christopher P. Price, J. Neville Turner, Circumcision of healthy boys: Criminal assault? Journal of Law and Medicine, Vol. 7, 2000, 301-310. “Non-therapeutic” is defined by the Commonwealth Family Law Rules 2004 (Medical Procedure Applications) as any procedure “not for the purpose of treating a bodily malfunction or disease”. A similar definition is used by the Tasmania Law Reform Institute: “circumcision is non-therapeutic if it is performed for any reason other than remedying or treating an existing disease, illness or deformity of the body. … A circumcision performed for the purpose of preventing or reducing the likelihood of possible future disease, illness or deformity of the body (a prophylactic circumcision) is a non-therapeutic circumcision.” TLRI, Non-therapeutic Male Circumcision, Issues Paper No. 14, June 2009, para. 1.3.5

Recent news

Circumcision violates child’s right to an open future

A paper in the Journal of Medical Ethics (on-line first, January 2013) argues that non-therapeutic circumcision (is ethically objectionable and legally borderline because it violates a child’s right to an open future. This principle is widely accepted in ethical and legal circles and has often been applied to limit the power of parents to indoctrinate children into particular political beliefs or cultural identities. It has less often been applied to bodies rather than minds, and never previously to permanent bodily alterations such as circumcision. In this paper, the author (Dr Robert Darby) elucidates the open future principle and consider whether it is applicable to non-therapeutic circumcision of boys, whether performed for cultural/religious or for prophylactic/health reasons. He argues that the principle is highly applicable to non-therapeutic circumcision (NTC), and concludes that NTC would be a violation of the child’s right to an open future, and thus objectionable from both an ethical and a human rights perspective. Dr Darby suggests that NTC is similar to designer deafness (i.e. causing a child to suffer hearing loss) because it also results is sensory deprivation, and also that circumcision is comparable to smoking, in that it is really a bad habit that causes long term harm to the body. Preventing a child from smoking and protecting his foreskin have the same rationale: to preserve the body for future use and ensure that the future adult is able to make autonomous decisions about such intimate personal matters.

ABSTRACT

The principle of the child’s right to an open future was first proposed by the legal philosopher Joel Feinberg and developed further by bioethicist Dena Davis. The principle holds that children possess a unique class of rights called rights in trust – rights that they cannot yet exercise, but which they will be able to exercise when they reach maturity. Parents should not, therefore, take actions that permanently foreclose on or pre-empt the future options of their children, but leave them the greatest possible scope for exercising personal life choices in adulthood. Davis particularly applies the principle to genetic counselling, arguing that parents should not take deliberate steps to create physically abnormal children, and to religion, arguing that while parents are entitled to bring their children up in accordance with their own values, they are not entitled to inflict physical or mental harm, neither by omission nor commission. In this paper I aim to elucidate the open future principle and consider whether it is applicable to non-therapeutic circumcision of boys, whether performed for cultural/religious or for prophylactic/health reasons. I argue that the principle is highly applicable to non-therapeutic circumcision, and conclude that NTC would be a violation of the child’s right to an open future, and thus objectionable from both an ethical and a human rights perspective.

The paper concludes:

The child’s right to an open future complements the four principles of bioethics developed by Beauchamp and Childress by meeting the objection that children cannot possess rights because they lack moral autonomy and the capacity to make rational choices. Children may lack such autonomy now, but as adults-to-be they will develop such autonomy in the normal course of their growth. It also supports and extends the argument of Hodges et al that additional scrutiny is demanded when we make decisions about non-essential surgery on children, especially when it entails removal of functional body parts. One of the compelling features of the principle is its alignment with John Locke’s proposition that parental authority derives from their duty of care towards their children and is limited by the interests of the latter. Circumcision is analogous to smoking, eating junk food and not cleaning one’s teeth because it causes long term harm to the body and reduces its future functionality. Forcing children to brush their teeth or endure painful vaccinations, preventing them from smoking and protecting their foreskin all have the same rationale: to preserve the body for future use and ensure that the future adult is able to make autonomous decisions about such matters. The open future principle both constrains parents and gives them authority – constrains them from cutting off their children’s future options, but gives them the authority to prevent their children from recklessly doing the same.

Source: Robert Darby. The child’s right to an open future: Is the principle applicable to non-therapeutic circumcision? Journal of Medical Ethics, on-line first, 30 January 2013

Journal of Medical Ethics, July 2013: Special issue on the ethics of male circumcision

Circumcision: A medical or a human rights question?

Arguments against circumcision of boys

by Gert van Dijk

Recently an article appeared in KN [Catholic News, Amsterdam] by Rabbi Lody van de Kamp, who hauls me over the coals [literally “breaks the staff”] about the fact that the policy of the Royal Dutch Medical Association (KNMG) is to discourage non-therapeutic circumcision of boys. Yet the reasons for such discouragement are clear. Circumcision of boys may be performed only by physicians when there are medical benefits attributed. Circumcision without medical need is contrary to the cardinal rule for doctors “in the first place, do no harm” and to the rule that children who are not able to decide for themselves should be treated only when it is medically necessary. That is the premise of the KNMG, the organization of and for physicians.

Destructiveness

The International Convention on the Rights of the Child (ICRC) says that the government is required to ensure that harmful traditional practices be abolished. The science is undeniable that circumcision is harmful. A circumcision means 25 to 50 percent of the healthy tissue of the penis is removed. An adult man’s foreskin has about the surface area of a postcard. The operation is not is not a “simple snip”: doctors are often confronted with complications of circumcision. Immediately after the operation, an infection or bleeding occurs in two to five percent of the boys, which sometimes requires hospitalization. Many boys (up to twenty percent) later get a stricture of the urethra, causing problems with urination and possibly bladder problems. Still later circumcised men and their partners get sexual problems more often than non-circumcised men, because a circumcised penis is less sensitive. Also, many men complain about the fact that they were circumcised without their consent. Any medical benefits - such as a possible reduced risk of HIV transmission [in unprotected heterosexual intercourse] - are relevant at a later age and are no justification for circumcision in childhood.

Discriminatory

The ICRC also says that there may not be discrimination between boys and girls. It is noteworthy that in the Netherlands all forms of female circumcision are forbidden - even in symbolic form, with no tissue being removed - but that circumcision of boys is tolerated. Why is it that Jewish and Muslim boys are not equally protected by law as girls?

Religious freedom or physical integrity?

The debate about circumcision of boys is often presented as a conflict between the right of the child to physical integrity and the right of parents to religious freedom. What is often forgotten is that the ICRC also guarantees the child’s right to his own freedom of religion. This freedom implies that it is permissible for a child to be educated in religion, but also that the child should keep the freedom to choose a different opinion later. This means that the child should remain protected from irreversible physical alterations. A German court recently ruled that the right to religious freedom of parents is limited by the child’s right to physical integrity. This legal ruling fits into a debate about circumcision of boys being conducted in almost the entire Western world, even within religious groups. In Israel, a growing group of parents refrain from circumcising.

Social pressure

Many parents who still perform circumcision do so because of social pressure from their parents and grandparents, not from religious feelings. In America, a growing number of Jewish parents, together with religious leaders, have developed alternative rituals in which the child can be included in the religious community, but without violating the integrity of the child's body.

Growing resistance

The growing resistance to circumcision of boys comes not only from the medical profession and secular society, but also from religious communities themselves. The debate has nothing to do with anti-semitism or anti-religion, as is sometimes suggested. It is a manifestation of a growing awareness that children have the same fundamental rights as adults. If it is not permissible for a man to be circumcised against his will, why is it permissible to do the same to a child?

Personal choice

Circumcision is a personal choice for which people have different reasons. Fortunately we live in a country where people are free to make that choice. But let it be a choice that the person makes for himself, because ultimately there is only one person who should decide whether or not to remove a healthy part of the body, and that is the man himself.

Gert van Dijk chair of the bioethics committee of the Royal Dutch Medical Association

Translation courtesy of Circumsitions.com

Non-therapeutic circumcision violates rights of the child - Slovenian Ombudsman

Varuh clovekovih pravic RS ([edited] Google translation), February 2012

Circumcision of boys for non-medical reasons is a violation of children's rights (Obrezovanje fantkov iz nemedicinskih razlogov je kršitev otrokovih pravic)

A complainant asked the Ombudsman to assess whether circumcision of boys is interference with the rights of the child, especially if it is done only for religious reasons and is not justified on health grounds. The complainant considered that [such] interference [by] the Slovenian doctors is harmful but he does not know all the negative consequences [of prejudice] (subconscious trauma, impotence, infection, etc..). Before preparing the opinion, we examined available scientific literature on the issues, [especially] the article by Damian Korošec, published in the magazine Lawyer, Volume 50 (1995) entitled [Circumcision - pointless] banality of surgery. Inquiries were sent to the College of Experts on General Surgery, the National Medical Ethics Commission of the Slovenian Republic and the Health Insurance Institute of Slovenia.

... Expanded expert committee for surgery ... sen[t] us the conclusion that the circumcision of boys for non-medical reasons is not medically justified. Indications for professional intervention are listed in the professional urological literature. The Office of the Commission for Medical Ethics has sent us a long answer, which we summarize in its opinion of principle: "ritual circumcision of boys for religious reasons in our country, [for] legal and ethical reasons is unacceptable, and doctors should not perform it."...

The Health Insurance Institute of Slovenia [w]as asked for information concerning payment [for] circumcision (annual number of interventions, the price of services) and how the issue of payment is arranged, if medical intervention is not indicated, but is carried out only at the request of the individual or his legal representatives. The Institute replied [to us] that [they have] no information on the annual number of interventions; the delivery price that society pays health care providers is €34.88. When intervention is not medically indicated, service is not covered by the compulsory health insurance, so [it is for] the patient or his agents to pay [for] the intervention.

... [We] decided to examine the situation with regard to some important issues of human rights and especially children's rights. The United Nations Convention on the Rights of the Child obliges States Parties to take all appropriate legislative, administrative, social and educational measures to protect the child from all forms of physical or mental violence, injury and abuse, while in the care of parents, legal guardians or any other person who care for him (article 19 CRC).

The Constitution of the Republic of Slovenia in the 56th Article [grants the] child special protection and care [under] the 35[th] Article as everyone is guaranteed the inviolability of physical and mental integrity. These provisions clearly show that any intervention in the physical integrity of children is limited and justifiable only for medical reasons. If there is a medical indication, that is, to protect the health of the child, circumcision [may] be [performed]; such intervention is a legitimate and legal, and [the] permission [of] a parent [who] has responsibility for the child's development [is] required or allowed. If for any reason parents would not [allow an] indicated medical intervention, the competent authorities [may] determine possible dereliction of duty [in] caring for the child and take the necessary measures provided by law.

However, if has medical circumcision the child is [not] indicated, but is only [a] result of his parents' beliefs (religious or otherwise), such intervention is no legal basis. This [is so] whether [or not] the child is explicitly opposed [to] the intervention. Intervention in the physical integrity of a child solely because of the desire of his legal representatives or guardians, therefore, constitutes an inadmissible interference in his body and is in our opinion the evidence of criminal behavior.

The Patients Rights Act (Official Gazette. 15/08) in [part] 26 stipulates that a patient who is capable of making prior free and informed consent is not permitted to [undergo] medical procedure or medical care, [without such consent] except in cases provided by law. For children, the Patients' Rights Act provides that, generally [over] 15 i[s] the ability to consent, unless the physician, according to [their] maturity assess[es] that it [i]s not [able]. A child before the age of 15 but under the law generally is not able to consent, with the doctor in these cases, estimated to be in this position. The Act specifically provides that a child's opinion regarding the treatment takes into account the extent possible, if it is able to express an opinion and if [he] understand[s] the significance and consequences.

The Constitution recognizes the right of parents, in accordance with their beliefs, to provide their children with religious and moral education. ... Guidance on religious education, in our opinion does not include the right of parents [due] to mere religious belief [to] choose to intervene in the child's body. We therefore believe that circumcision, for reasons other than medical, is not permitted and constitutes unlawful interference with the child's body and thus violates his rights.

... [P]arents are primarily responsible for the development of children's health, but also they must in all cases take into account the child's interest as a guide in decision making. Also, in deciding their rights [they] are limited by the rights of others, in this case, therefore, their children, ... . The right to religious freedom does not justify interference with the right to physical integrity of another, so we believe that circumcision for non-medical reasons, may only be [with] the child's consent, subject to the conditions provided for by law on patients' rights, therefore, usually after 15 years of age.

Slovenian news item at http://www.sta.si/en/vest.php?s=a&id=1723904

Details (in Slovenian) can be found at:

http://www.varuh-rs.si/medijsko-sredisce/aktualni-primeri/novice/detajl/obrezovanje-fantkov-iz-nemedicinskih-razlogov-je-krsitev-otrokovih-pravic/?cHash=7364092ccb

Jewish critics of circumcision becoming more vocal

Over the last hundred years or so, and particularly over the past decade, a remarkably strong movement against circumcision among Jewish people has emerged. This development may surprise people, but it is a logical development of the modernisation and integration that began in the early nineteenth century, as European Jews were freed from the ghettos and joined the mainstream of modern life. In the process they naturally questioned many ancient observances and practices. Such questioning is also an expression of commitment to human rights, going back to the European Enlightenment of the eighteenth century (the Declaration of the Rights of Man and Citizen), strengthened by the Universal Declaration of Human Rights just after the Second World War. The principles developed here asserted an individual’s right to freedom, autonomy, and personal rights, of which the most basic was control over his or her own body. Given their own sad history of discrimination and persecution Jewish people have naturally been at the forefront of campaigns for human rights in many areas other than freedom of religion. This critical trend also derives from new historical information about the origin of circumcision (male and female) in Egypt and Africa, scientific discoveries about the damage caused by circumcision, and a desire on the part of individuals to observe a higher level of spiritual ethics.

This movement to question and often reject circumcision includes Jewish Rabbis, scholars, parents, intellectuals and educators, both in the United States and in Israel itself. In the United States, especially, Jewish people are so prominent in the general anti-circumcision and child protection movements that the controversy over circumcision is sometimes seen as a debate internal to the Jewish community. That would be a mistake: human rights are enjoyed by all humans, simply by virtue of their birth. The Jewish people’s long experience of, and heroic resistance to, persecution and discrimination has naturally made them particularly sensitive to human rights issues, so it comes as no surprise to see the most thoughtful members of the community having doubts about a practice that is increasingly seen as unconscionable denial of individual autonomy and personal choice - in short, a violation of those same rights that Jewish people invoke when defending their own religious freedom and cultural/personal identity.

Click here to see the remarkable range of web-based Jewish voices that question, criticise, doubt and reject circumcision.

Scholar criticises double standard on male and female genital mutilation

In an article published in the scholarly journal Ethnicities, Matthew Johnson criticises the double standard commonly applied to male and female genital cutting and argues that if male circumcision were examined objectively and with the same criteria that are applied to female genital mutilation it would be seen as another “traditional practice prejudicial to the health of children” and thus a violation of human rights.

Abstract

For liberals like Martha Nussbaum, Female Genital Mutilation (FGM) has come to mark the boundary of toleration. By impairing physical, sexual and psychological functioning, the likes of Nussbaum believe the non-western practice to fulfil, most clearly, the conditions for proscription according to the harm principle. However, those same liberals assume the western practice of male circumcision, generally, to be benign or, even, necessary. As there is seen to be no harm, there is no reason to intervene. I argue that this assumption is erroneous, highlighting evidence that suggests that, according to the criteria of sexual diminution, pain and coercion employed by liberals to criticize FGM, circumcision can be viewed as a harmful act of Male Genital Mutilation (MGM). I highlight the qualitative similarities in the harmfulness of FGM and MGM in order to establish in Nussbaum an empirical and, I argue, ethnocentric oversight in which the criteria of harm are inadequately applied to the latter. I then attempt to identify the obstacles to Nussbaum’s recognition of this harm, arguing that she is party to culturally constituted beliefs in the medical and sexual necessity of the practice and, importantly, the methodological tenet of gender oppression. Having attempted to explain obstacles to the recognition of harm, I then consider the possibility that Nussbaum’s inconsistency is grounded in toleration of religious obligation, arguing that MGM should stimulate certain liberals to reconsider their engagement with theology. My aim is to enable liberals to overcome, often justifiable, claims of ethnocentricity, in order to develop a consistent approach to harmful cultural practices.

Matthew Johnson, Male genital mutilation: Beyond the tolerable?, Ethnicities, Vol 10 (2), September 2010, 181-207

Full text can be downloaded free from Sage Publications or circumcisionandhiv.com

American legal precedent confirms child’s right to reject circumcision:

The case of Boldt v. Boldt

A long-running legal saga in the United States was finally resolved in late 2009, when courts in the state of Oregon ruled that a parent could not compel a child over which he had custody to get circumcised against the boy’s will. The case is of considerable interest in its potential to limit the power of parents to impose circumcision and similar physical alterations on children and in its implicit recognition that children have their own rights – to physical integrity and freedom of conscience and religion – independently of their parents’ belief.

Read full details of Boldt case on this site

Australian inquiries question ethics and legality of non-therapeutic circumcision of minors

Two recent inquiries have highlighted the doubtful status of involuntary circumcision – and all medically unnecessary circumcision of male minors is involuntary because they have not sought the operation and have not given consent.

Human Rights Consultation

The first is a Human Rights Consultation held by the Commonwealth government in April-June, seeking public comment on the Australian human rights framework and suggestions for strengthening it. Several submission to the Consultation focused on the problem of circumcision of male minors, pointed out that they have no legal protection at all from such surgery, and urged that action be taken to give them greater security. One of these submissions discussed Australia’s obligations under international human rights covenants in some detail and argued that the most effective short term reform to reduce the incidence of involuntary circumcision was to delete medically unnecessary circumcision from the Medical Benefits Schedule, thus ensuring that rebates under Medicare were paid only when the surgery was medically necessary.

Read full text of submission here.

Tasmanian Law Reform Institute inquiry

The second inquiry is a paper by the Tasmanian law Reform Institute on the legal status non-therapeutic circumcision of male minors. By “non-therapeutic” the TLRI means any circumcision operation that is not necessary to treat an existing injury, deformity or disease. Non-therapeutic thus includes prophylactic circumcision – that is, the precautionary amputation of the foreskin in the belief that it will reduce the risk of contracting diseases to which the person may be exposed at some later date. This is the most common variety of circumcision practised in Australia today.

The TLRI paper suggests that non-therapeutic circumcision of male minors violates agreed principles of human rights and medical ethics and could even be illegal because there was no informed consent from the subject of the operation, and surrogate (parental) consent could not be valid unless there was a genuine need for such a radical intervention.

The Sydney Morning Herald reacted with predictable alarm to these suggestions in an illogical editorial that would fail the most basic clear-thinking test, simultaneously admitting that circumcision without the consent of the person being cut was immoral, yet still trying to defend the right of adults to do it to children. Particularly telling was its admission that criticism of and objections to the practice are as old as the practice itself. The SMH wants to insinuate that because they are old-hat, such objections should be ignored; but the real lesson is that if the practice is so controversial and debated there can never have been widespread agreement as to its value or legitimacy. In the context of such doubt, disagreement and uncertainty the only person with the right to decide whether to have it done is the individual man or boy, girl or woman. Anything else is coercion.

The SMH editorial and the reply by Paul Mason, Tasmanian Commissioner for Children, follow.

Editorial: Arguments as old as the practice

MORE than a billion men are circumcised and billions more have undergone the ritual over the centuries. The practice is both ancient and commonplace. Yet now we are supposed to accept the argument, promoted in some ethical circles, that circumcision is both dangerous and an infringement on the rights of the child.

Any surgical procedure, however minor, is dangerous if performed crudely. The world is full of risks, with children the most vulnerable. What matters is proportionality. A report from the Tasmanian Law Reform Institute, released this week, suggests that, in the absence of specific laws relating to the practice of circumcision, it may be an abuse of the rights of the child. The report goes so far as to countenance that circumcision itself may, by its very nature, be an act of cruelty, law or no law.

The matter has been given an airing after the Tasmanian Children’s Commissioner, Paul Mason, sought guidance from the institute for the handling of cases where, for example, a dispute arises over whether a child should be circumcised. This is a nettlesome legal issue because cultural practice is divided and the law is largely silent. The cultural direction in Australia is moving away from circumcision. Western medical organisations no longer recommend routine neonatal circumcision. What used to be commonplace, involving more than 90 per cent of male infants born in Australia in the 1950s, has become a minority position. Only about one in seven newborn boys are circumcised. The majority of circumcisions involve religious customs, largely the rites of Muslims and Jews.

The arguments for and against male circumcision are as old as the practice itself. In Australia, the procedure has a negligible rate of serious physical injury. Proponents argue the practice leads to lower rates of infection from sexually transmitted diseases, and has no adverse impact on sexual function. Opposition has largely come in the form of ethical arguments over the rights of the child being compromised by a procedure performed for no reason other than cultural practice, with the possibility of later psychological injury. The argument that circumcision involves psychological risks is finding growing support in medical studies.

Common sense suggests that in a dispute between or within families over whether to circumcise, prudence favours leaving the child untouched. Common sense also suggests that where both parents want their child circumcised there are no compelling medical, legal or ethical grounds for not doing so.

Sydney Morning Herald, 4 June 2009

Comment

The Sydney Morning Herald’s editorial is quite in accord with its longstanding practice of giving prominent publicity to every half-baked slander against the foreskin that posthephobic toilers in America’s bloated medical research industry cook up, and ignoring the vast body evidence to the effect that circumcision of minors is a harmful, cruel and unnecessary procedure that violates the rights of the child and is already technically illegal under existing laws of assault, mayhem and molestation – as the Queensland Law Reform Commission found in 1993.

So long as ignorant editorial writers use their unaccountable power to champion bad habits it is unlikely that there will be any laws to restrict the practice of male genital mutilation, let alone the degree of protection from female genital mutilation afforded to women. The key facts that refute the editorial’s concluding pontification are its earlier admissions that circumcision has always been a controversial and contested operation, and on a world scale a minority practice. These facts alone dictate that the only person entitled to make an irreversible decision about the shape of his penis is its owner.

At least the SMH had the decency to publish Paul Mason’s letter, pointing out the crazed illogic in the editorial’s position. The way some circumcision promoters attempt to argue, you would think it was a large chunk of their brain that had been surgically removed in infancy.

The paper by Tasmanian Law Reform Institute is here

Stopping circumcision a matter of human rights

Your editorial (“Arguments as old as the practice”, June 4) misrepresents my input into the Tasmanian Law Reform Institute’s issues paper on the validity of parental consent to unnecessary circumcision, and reveals a glaring non sequitur.

You conclude that “there are no compelling medical, legal or ethical reasons for not” operating on a boy without his informed consent -- but only after observing that “the law is silent”; that circumcision “may be an act of cruelty”; that medical organisations no longer recommend routine circumcision; that “the possibility of … psychological risks is finding growing support in medical studies”; and that “prudence favours leaving the child untouched”.

I did not refer the issue to the institute in connection with cases where a dispute arises whether to circumcise: the law is pretty clear that it will not proceed in those cases. I referred it in the context that babies are human beings and all human beings have the right to bodily integrity assured by the Universal Declaration of Human Rights (1948). I referred it in the context that the first principle of the Hippocratic Oath is “Do no harm” and that the irreversible, invasive and painful removal of any neurologically complex external organ of a powerless patient at the request of a third party is an ethical travesty.

Your editorial seeks to seduce readers into denying babies and children their legal and human rights, while taxpayers are footing the bill through Medicare - circumcision is the only item that requires no medical indication for payment. One reason for its declining popularity in the West since the 1970s may be the influence of women, who see their babies as perfect and not for cutting: from this perspective unnecessary circumcision is a feminist issue.

Paul Mason Commissioner for Children, Hobart

Letter: Sydney Morning Herald, 6 June 2009

See also Paul Mason's London speech on children's rights and child protection

Age op-ed writer calls circumcision male genital mutilation

It's child abuse and it's time it was cut out

by Catherine Deveny

The Age (Melbourne), October 24, 2007

People give plenty of reasons for circumcising their male children, writes Catherine Deveny. But most of them don't amount to anything.

NO ONE seems to be able to explain to me why the circumcision of baby boys is not considered child abuse. Why in 2007 is it still acceptable for parents to have their babies' foreskins ripped off? How can it be legal, let alone ethical, for any human being to choose for another human being's body to be irreversibly mutilated? No medical reason, no rational thought and in many cases no aesthetic. Just because.

I suggest that we should ban the use of the term “circumcision” and force people to use the term “genital mutilation”. Because that's what it is. It's not “a personal choice”, because that person is not making a choice. It's human rights abuse.

The We Circumcised For Religious Reasons camp justify genital mutilation citing religion. They embrace the parts of religious texts that suit them and dismiss the ones that don't. And when I say “they”, not all of them do. Many believers I know have all applied a little rational thought to the equation and just decided not to inflict unnecessary pain on their child or expose them to avoidable risk. They've decided to file that bit of the Holy Book under the other things that just don't fit; like selling your daughter into slavery or killing your neighbour if they work on the Sabbath.

What kind of God would disapprove of you, stop loving you, or not give you eternal life if you don't mutilate your child's genitals? That doesn't sound like a nice kind of God. And what caring community would shun you, judge you or ostracise you for not inflicting genital mutilation on your child?

Then we have the We Circumcised Our Boys So They Look The Same As Their Father camp. Sure, it's not fair for me to pick on people less fortunate in the brains department than the rest of us, but when they are subjecting innocent children to genital mutilation I'm going in swinging. I'm not going to bother asking the hard question “why do you need them to look like their father?”, because you cannot reason with something that has not come from reason but from mindlessness.

I ask the So They Look The Same As Their Father camp, why stop there? If you want them to look the same as their father, dye their hair, have them undergo cosmetic surgery and if the father has any tattoos or facial hair, sort that out too. Related to this camp is the We Circumcised Our Boys Because A Circumcised Penis Looks Nicer camp. We are talking the shallow end of the intelligence pool here. How would they feel if they had had their nipples, nose or ears cut off by their parents when they were a child because their parents thought “it looked nicer”? I must say that I do applaud these two camps on their frankness and honesty despite it revealing their stunning stupidity. After all, they could do what others do and make the decision for no rational reason and then rationalise it by joining the We Circumcised Our Boys For Health And Hygiene Despite Looking Closely At The Research camp.

I have read the various studies suggesting that circumcision may reduce the spread of HIV and cervical cancer. I have also read the studies disproving the circumcision-reduces-infection myth. Here in Australia, all of these risks can be effectively and safely managed with condoms and cleanliness. That's right, a bit of frangers and face washers, rubbers and rubbing. Why would you expose a child to an unnecessary medical procedure and all the risks that come with it when you could teach them how to clean themselves and use a condom? Because you can, I suppose. By the same logic, removing all your children's teeth would prevent them getting fillings.

Unless, of course, there is a sound medical reason to circumcise. And when I say sound, I mean sound as in last resort. I don't mean that you walk into a GP with a seven-year-old with a constricted foreskin that is not retracting and walk out with a referral to a surgeon to have your child's genitals mutilated, as a family I know could have.

One of their sons had that very problem. They were offered a referral to a surgeon to have him circumcised. They didn't like the sound of that. Luckily they didn't have private health insurance, because that meant that they were given a referral to the Royal Children's Hospital, where they saw a general pediatric surgeon, or as their son referred to her, a Dick Doctor.

Yes, she said, he could be circumcised, but she was having great success using an ointment available over the counter from the chemist. Three days later, the boy had a retracting foreskin. And two years later, he still does. The wonders of a health service on a budget as opposed to a private business. So if he wants to get himself circumcised as an adult, that's his choice. And he'll have that choice. Because when you circumcise someone, you can't uncircumcise them.

Circumcision of male children "a hidden human rights violation"

In the April 2007 issue of the Australian Journal of Human Rights , Ranipal Narulla argues that circumcision of male minors should be recognised as a violation of human rights

Synopsis

Male circumcision is an accepted practice within Australian society, despite the fact that female circumcision is widely reviled in the Western developed world. This article will consider why society and the law treat circumcision of males and female differently. Analysis will focus upon the circumcision of male children in Australia, with reference to the United Kingdom and the United States of America. The similar social history of the practice within these jurisdictions is instructive when critically analysing the Australian context. The discussion will encompass the circumcision of all male children, as the issues of lack of consent and the imposition of a parent's religious and cultural norms upon the child are consistent for all minors, with specific focus on neonatal children where such extreme youth creates additional vulnerability. The absence of domestic law in Australia dealing with the circumcision of male children invites analysis of the protection afforded under international human rights instruments to which Australia is legally bound. This article deconstructs the medical myths that surround the circumcision of male children, and in so doing makes a strong argument for the need to recognise circumcision of male minors as a human rights violation.

Ranipal Narulla, “Circumscribing circumcision: Traversing the moral and legal ground around a hidden human rights violation”, Australian Journal of Human Rights, Vol. 12, April 2007, pp. 89-118

The Australian Journal of Human Rights is published by the Australian Human Rights Centre at the University of New South Wales

Male and female circumcision not so different

An article in a leading international journal, the Medical Anthropology Quarterly, questions the “quarantining” of male circumcision from female genital mutilation and calls for both less gender discrimination and more respect for the rights of boys.

Abstract

This paper offers a critical examination of the tendency to segregate discussion of surgical alterations to the male and female genitals into separate compartments - the first known as circumcision, the second as genital mutilation. It is argued that this fundamental problem of definition underlies the considerable controversy surrounding these procedures when carried out on minors, and that it hinders objective discussion of the alleged benefits, harms and risks. The variable effects of male and female genital surgeries are explored, and a scale of damage for male circumcision to complement the World Health Organization's categorisation of female genital mutilation is proposed. The origins of the double standard identified are placed in historical perspective, and a brief conclusion makes a plea for greater gender neutrality in the approach to this contentious issue.

Robert Darby and J. Steven Svoboda, “A Rose by any other Name: Rethinking the Similarities and Differences between Male and Female Genital Cutting”, Medical Anthropology Quarterly , Vol. 21, September 2007, pp. 301-323.

A PDF of the article can be downloaded here.

Bundaberg circumcision scandal demonstrates vulnerability of boys and need for protection

In Australia it is evident that boys are in far greater need of protection from genital mutilation than girls. On a world scale it has been estimated that some 13 million boys are circumcised each year, compared with only two million girls subjected to FGM. Societies that circumcise girls are found in Africa, the Middle East and parts of south-east Asia, but the practice is all but unknown elsewhere, except among immigrants from these regions. It might be argued that the laws against FGM that have been passed in many western countries are aimed at a problem that scarcely exists. In Australia, as in the United States, however, thousands of boys annually are the victims of circumcision procedures, the vast majority of which are not required for any health reason and are certainly not desired by the child. Nor is there any reason to think that such a procedure in his best interests, neither short nor long term.

As an example of how vulnerable boys are, the Tasmanian Issues Paper describes a case in Bundaberg in 2002, when an estranged father who had been denied custody of the two boys (aged 5 and 9) from his former marriage took advantage of a regular visit to race the boys off to a surgeon and have them circumcised. Although the frantic mother made efforts to have him prosecuted, he was let off without even a slap on the wrist. The boys were traumatized and bitter. Even more shameful than the father’s conduct was that of the surgeon, who made no attempt to consult the views of the mother, the feelings of his two terrified and unwilling “patients”, or even if the father was entitled to authorise the operation (which he was not). There was a half-hearted attempt to prosecute the father, but there would have been better grounds for prosecuting the surgeon, who acted without the informed consent of a person with the authority to give that consent. In this case the father’s motivation arose from his Turkish-Islamic background, but it could just as easily have been a young mother who had been alarmed by scaremongering assertions on talk-back radio, or the advertising of “circumcision specialists”, or urban legends about the dreadful fate awaiting boys whose foreskins were not snipped off before it was too late, such as getting caught in their zipper, becoming infected, ultimately succumbing to gangrene and causing the boy’s death (as Brian Morris solemnly warns parents in his pamphlet, In Favour of Circumcision).

Read full account of Bundaberg incident here

Male and female circumcision in Australia: Legal and ethical issues

Female circumcision (the removal of any part of the female genitals) is legally prohibited, and is in fact a criminal offence, in New South Wales, Victoria, South Australia and the Australian Capital Territory. It is a practice rejected and abhorred by people all over Australia. Despite this, widespread circumcision of male infants and boys arouses few protests and continues to be unregulated. In 1993 the Queensland Law Reform Commission concluded in their research paper, Circumcision of Male Infants:

"On a strict interpretation of the assault provisions of the Queensland Criminal Code, routine circumcision of a male infant could be regarded as a criminal act. Further, consent by parents to the procedure being performed may be invalid in light of the common law's restrictions on the ability of parents to consent to the non-therapeutic treatment of children."

The full text of the report is available here

For further information on the legal position of male and female circumcision in Australia is available at

http://www.cirp.org/library/legal/Australia/

In an article in the Australian Journal of Law and Medicine Christine Mason criticised the double standard by which the circumcision of girls and women is prohibited or discouraged while the circumcision of male infants and boys is permitted with little regulation and even advocated. She points out that the World Health Organisation used to employ the term female circumcision but introduced the expression female genital mutilation (FGM) at a conference in Ethiopia in 1990, supposedly because it carried "heavier moral weight" - though it may be suspected that another reason was to demarcate it from male circumcision, which the WHO did not propose to combat. (Ethiopians practise both male and female genital mutilation.)

Mason has a useful discussion of the different procedures which may be covered by the term FGM. She also points out that, in contrast to the way in which the adverse impact of male circumcision is usually underestimated and trivialised, most people overestimate and exaggerate the harm done by female circumcision. Although it is very damaging to sexual function and often carries additional adverse side-effects, it is not true that circumcised women necessarily become incapable of sexual sensation or pleasure, and it seems that many are still capable of orgasm.

The article emphasises that consent is the central concept in all surgical treatments, since "all medical treatment is preceded by the patient's choice to undergo it"; without consent, even the least touching amounts to the tort of battery. Legal cases have established that the rights of parents to impose medical procedures on children decline as the children get older, and further that children (even if intellectually disabled) have the right to provide informed consent to treatment. If a procedure is not medically required, (Marion's case, 1992) has established that circumcision may not be performed without the approval of the Family Court.

In relation to male circumcision, Mason points out: "Since a child cannot be consulted and the process is painful and unnecessary at birth, such decisions should only be made by an adult male. As with adult female surgery, an adult male in full possession of his senses should be able voluntarily to elect to be circumcised". She quotes another legal authority, who states: "It is illogical that male circumcision has not been considered with the [female genital mutilation] prohibition. Surgical cutting and disfiguring of a healthy genital organ is consistent with male and female circumcision. … [Since] the differences appear to be based largely on socially constructed ideals, and not on facts, it is suggested there should be no distinction based purely on gender".

(David Richards, "Male circumcision: Medical or ritual?", Journal of Law and Medicine, Vol. 3, 1996, p. 372)

Mason concludes that tolerance of male circumcision makes it much harder to eliminate and actually encourages female circumcision, and she quotes one activist as stating: "Female circumcision will never stop so long as male circumcision is going on. How do you expect to convince an African father to leave his daughter uncircumcised as long as you let him do it to his son?" It is hypocritical and counter-productive for the USA to urge African and Islamic cultures to eliminate female circumcision while American doctors continue to enforce the mass circumcision of male babies.

She concludes: "Changes are required to educate against both male and female infant genital surgery whilst also amending the existing legislation in order to permit adult consent to such procedures. This both protects children and allows freedom of minority practices when a person is old enough to voluntarily and freely decide for himself or herself. In the long term, it may even lead to the eradication of the practice altogether."

Christine Mason, Exorcising excision: Medico-legal issues arising from male and female genital surgery in Australia, Journal of Law and Medicine, Vol. 9, 2001, pp. 58-67.

Further information

Gregory Boyle, J.S. Svoboda and Christopher Price, "Circumcision of healthy boys: Criminal assault?", Journal of Law and Medicine, Vol. 7, 2000, pp. 301-10.

Britain: Circumcision of minors unethical unless there is pressing medical necessity

The British Medical Association (BMA) has revised their 2003 Guidance on the Law and Ethics of Male Circumcision. The revised guidance dated June 2006 and reissued on 12 November 2007 reaffirms the statement “to circumcise for therapeutic reasons where medical research has shown other techniques to be at least as effective and less invasive would be unethical and inappropriate”.

The guidance confirms that there is rarely any clinical need for circumcision: “normal anatomical and physiological characteristics of the infant foreskin have in the past been misinterpreted as being abnormal. The British Association of Paediatric Surgeons advises that there is rarely a clinical indication for circumcision. Doctors should be aware of this and reassure parents accordingly”.

The most significant revision in the new guidance is in respect of the legal situation. The guidance states that, if it was shown that circumcision where there is no clinical need is prejudicial to a child’s health and wellbeing, it is likely that a legal challenge on human rights grounds would be successful. The guidance further states that, if damage to health were proven, there may be obligations on the state to proscribe it. The UN Convention on the Rights of the Child, which has been ratified by the UK, requires ratifying states to “take all effective and appropriate measures with a view to abolishing traditional practices prejudicial to the health of children”.

Full statement from BMA available here

Victims of unwanted circumcision "entitled to compensation"

Speaking on the BBC on 11 November 2005, the Chair of the British Medical Association Medical Ethics Committee, Dr Michael Wilkes, said that men who resented having been circumcised as children were entitled to compensation.

Interviewer: I'm here at the British Medical Association to ask Dr. Michael Wilkes about circumcision and in particular whether it's true that unnecessary circumcisions are being carried out.

Dr. Wilkes: There is hardly a reason to circumcise a little boy for medical reasons because those medical reasons don't exist. We do accept as a by definition of medical reasons and benefit medically that comes from that, that the Jewish Faith have a strong tradition and therefore a strong claim to continue this practice.

Interviewer: Medically what reason would there be to circumcise either a youngster or an older person.

Dr. Wilkes: The vast majority of cases for instance of non retractile foreskin, which is a developmental thing, it just takes time, sometimes for the tissue between the foreskin and the glans of the penis, the sensitive part of the penis, to break down so the foreskin can be put back. It's often a question either of time or of very gentle manipulation, certainly not surgery.

Interviewer: So the people of NORM UK that feel that as if they've been circumcised for the wrong reasons – in the past do you think doctors have circumcised for no good reason maybe.

Dr. Wilkes: Yes I do, I do, and I suspect that some people from NORM UK, those who are not members of the strong Jewish tradition for instance or maybe slightly less persuasive that – certainly in Muslim tradition – the majority of people who have been circumcised in the past for what was put to them or put to their parents as good medical reasons were probably no such thing and those people certainly have a right to make a claim that what was done to them was an unnecessary and premature intervention at a time when they had no capacity or say in the matter.

Broadcast in Outlook, BBC World Service, 11 November 2005, 12.05 pm.

Further information at Norm-UK

Further information on legal aspects of circumcision

Legal scholars question ethics and legality of circumcision of minors

In two articles in recent issues of major international journals covering medical ethics and human rights, two British legal experts have questioned the ethics of circumcising male infants, comparing it to female genital mutilation, and have even thrown doubt in whether any such surgery on an individual without his or her consent can be regarded as legal.

Abstracts of the two articles, in the Journal of Medical Ethics and the International Journal of Children's Rights, are given below.

1. "A covenant with the status quo?"

This article offers a critique of the recently revised BMA guidance on routine neonatal male circumcision and seeks to challenge the assumptions underpinning the guidance which construe this procedure as a matter of parental choice. Our aim is to problematise continued professional willingness to tolerate the non-therapeutic, non-consensual excision of healthy tissue, arguing that in this context both professional guidance and law are uncharacteristically tolerant of risks inflicted on young children, given the absence of clear medical benefits. By interrogating historical medical explanations for this practice, which continue to surface in contemporary justifications of non-consensual male circumcision, we demonstrate how circumcision has long existed as a procedure in need of a justification. We conclude that it is ethically inappropriate to subject children – male or female – to the acknowledged risks of circumcision and contend that there is no compelling legal authority for the common view that male circumcision is lawful.

Fox M, Thomson M. A covenant with the status quo? Male circumcision and the new BMA guidance to doctors. J Med Ethics 2005;31:463-9.

2. Short Changed? The Law and Ethics of Male Circumcision

Routine neonatal male circumcision has generally failed to excite medico-legal attention. Notwithstanding recent debates in the ethical literature, notably in special issues or symposia in the Journal of Medical Ethics (2004, 30) and American Journal of Bioethics (2003, 3), the law has yet to engage seriously with this issue. In a forthcoming contribution to an emerging medico-legal debate we have suggested that neglect of this issue is partly attributable to the way in which routine infant male circumcision (and its attendant effects and risks) is typically characterised in opposition to female circumcision for rhetorical and political reasons (Fox and Thomson, 2005). The result is that, while female circumcision is constructed as morally and legally unacceptable within a civilised society, male circumcision is characterised as a standard and benign medical practice. In this article our focus turns to the related failure to engage in a full cost/benefit analysis of the practice and the harm it causes to boy children.

Marie Fox and Michael Thomson, Short Changed? The Law and Ethics of Male Circumcision/. International Journal of Children’s Rights 2005;13:161–181

Further discussion at Circumstitions

Male circumcision and female genital mutilation: Problems of definition

Scandinavian authorities seek stricter regulation of circumcision to protect boys

In Scandinavian and European countries circumcision was never practised (except in medical emergencies) and was all but unknown until recent times, when significant numbers of immigrants from the Middle East and Africa (mainly Muslims) arrived, and wished to maintain traditional customs - particularly their traditional ways of circumcising their sons and daughters. They expected local doctors to perform the procedures for them. This posed a severe ethical dilemma for both the medical profession and law-makers, for two reasons. First, there was the danger that if the doctors refused such requests, parents would exercise a kind of blackmail by getting their boys and girls circumcised by unskilled ethnic operators on the proverbial kitchen table, where there was high risk of additional injury, infection and severe harm. Secondly, there was a problem for the principle of equal treatment on the basis of sex. Most European countries had passed laws making any form of female genital mutilation illegal, but although they also had laws and treaties that were supposed to prevent discrimination on the basis of sex, none had passed any laws covering circumcision of males. Unlike girls, boys were completely unprotected.

The response from Scandinavian medical authorities was to seek stricter regulation of circumcision. Many doctors would have preferred to see circumcision of boys banned outright until the age of consent (16 or 18), but they recognised that this would pose problems for devout Jewish parents, who traditionally perform circumcision (of boys only) on the eighth day. They have therefore compromised by setting stricter standards and procedures for the surgery, while continuing to deplore the practice of both male and female genital cutting as a serious violation of the rights of the individual and of medical ethics.

Norway: Medical authorities criticise ritual circumcision and urge its abandonment

The following article by Pal Gulbrandsen appeared in Tidsskrift for den Norske laegeforening [Norway], Volume 121, Number 25: Page 2994, [Journal of the Norwegian Medical Association, Volume 121 Number 25: Page 2994.]

Ritual circumcision of boys

The Council for Medical Ethics states that ritual circumcision of boys is not consistent with important principles of medical ethics, that it is without medical value, and should not be paid for with public funds.

The council has sent a statement to the board of the Norwegian Medical Association on this matter. Among other things, the council says that ritual circumcision of boys has no established medical benefit. Even with the use of local anaesthesia, the procedure causes pain and is associated with certain risks of medical complications. The Council for Medical Ethics states that circumcision of boys is not consistent with important principles of medical ethics laid down as general determinations in Paragraph 1 ( 1) of the Norwegian Code of Ethics for Doctors. These require doctors to uphold human health, and to cure, relieve and comfort. The council points out that it is an important factor that the child cannot give consent.

According to the council, doctors should be allowed to refuse to perform ritual circumcision as a matter of conscience. The council makes a point of noting that, when performed, even if not for medical reasons, that circumcision is a surgical operation that must be carried out according to correct principles of surgery and with proper anaesthesia. In line with the Code of Ethics for Doctors 12, it should not be paid for by the public health service. The council invited relevant religious leaders in our community to work on replacing circumcision with symbolic rituals that do not involve a surgical procedure.

Cite as: Gulbrandsen P. Rituell omskjæring av gutter. [Ritual circumcision of boys.] Tidsskr Nor Lægeforen [Journal of the Norwegian Medical Association] 2001;121(25):2994.



Source: http://www.cirp.org/library/ethics/gulbrandsen1/

Finland: Child protection agencies call circumcision of minors unethical

Central Union for Child Welfare, Helsinki, Finland

Statement on male circumcision

30 September 2003



Submission to the Task Force convened by the Ministry of Social Affairs and Health to inquire into the regulation of male circumcision.

The Central Union for Child Welfare in Finland opposes the circumcision of boys except when necessary to treat a disease. Circumcision violates a boy's sexual integrity and alters his body, having physical and behavioural effects. Female circumcision is rightly viewed as inhumane sexual mutilation and is punished as an assault. Boys are guaranteed the same legal protection.

The Central Union for Child Welfare considers that the bodily integrity of minors should not be violated by circumcision except when medically necessary to treat a disease. The actions of society should be based on unconditional respect for the physical integrity of minors. That is why the Central Union for Child Welfare considers that no one has the right to consent to this invasive operation on a child's behalf, except in relation to treatment of a disease. The Central Union for Child Welfare believes children have a right to special protection. The Child Custody and Right of Access Act prohibits the subjection of children to exploitation and humiliating treatment.

The Constitution guarantees physical integrity. The Constitution's preparatory work explicitly establishes that religious freedom does not extend to violating the integrity of another person. Thus a child should be treated as an individual who is completely protected from birth until the age of majority. Deliberately causing pain and injury is defined in the Penal Code as maltreatment and is subject to prosecution. The Convention on the Rights of the Child, ratified by Finland, demands that states parties undertake to abolish traditions harmful to children.

The Council of Europe Convention on Human Rights and Biomedicine, to which Finland is a signatory and which Finland is preparing to ratify, prohibits giving consent to an intervention on behalf of an incapable person, unless it is for the direct benefit of that person.

The position of the Central Union for Child Welfare is that boyhood circumcision should not be permitted. The Union hopes that the task force of the Ministry of Social Affairs and Health will discuss methods to bring about cultural changes that protect children's physical integrity and lead to an end to circumcision. Circumcision should be permitted only on individuals who are of age, regardless of whether they are male or female, and only after determining they have consented freely, without coercion.

Heikki Sariola

Original document in Finnish: Poikien ympärileikkaus

Translated by Dennis Harrison

Source: http://www.courtchallenge.com/news/lskl1.html

Danish authorities question legality of circumcision

Articles in Danish magazine Politiken compare male circumcision to female genital mutilation and call for a ban on circumcision of boys. They should have the same protection from unnecessary genital alterations as girls.

Article by Uffe Hastrup, 20 November 2002



Article by Lau Sander Esbensen

The Chairman of Danish Council of Medical Ethics has called for ban on circumcision of boys before the age of consent; he states that "no adult is entitled to carry out irreversible surgery on a child, unless it is for health reasons"; and that "prior to eighteen years of age, Danish children have a right to be protected from ritual interventions which can cause pain or permanent damage".

Full text of article translated here.

Canada: Medical authorities call circumcision of minors a human rights violation

In their policy on circumcision realeased in July 2004, the College of Physicians and Surgeons of the Canadian province of British Columbia called circumcision both unnecessary and a mutilation.

Doctors Fear Circumcision Violates Human Rights:

B.C. MDs' governing body says many consider the procedure "unwarranted mutilating surgery"

New British Columbia doctors' guidelines that suggest circumcising male babies may be a human-rights abuse could put a chill on doctors who perform the surgery. "Routine infant male circumcision is an unnecessary and irreversible procedure," say the B.C. College of Physicians and Surgeons guidelines." Therefore, many consider it to be unwarranted mutilating surgery. "Many adult men are increasingly concerned about whether their parents had the right to give consent for infant male circumcision."

The guidelines refer to an infant's Charter and United Nations rights to security of person and bodily integrity.

"Most physicians reading this are going to feel a certain degree of apprehension about doing or continuing to do circumcisions," said Vancouver pediatrician Dr. David Smith. "No physician wants to be in practice and sued 10 years later for a procedure they did that was acceptable 10 years earlier."

The blood-loss death of one-month-old Ryleigh McWillis two years ago after a circumcision at Penticton Regional Hospital raised a public outcry that led to the new guidelines, said Dr. Peter Seland, in charge of ethics for the college.

"There are no medical benefits when you balance the risks and benefits," Seland said. "People can make their own ethical decisions but they need to be informed." Provincial health officer Dr. Perry Kendall, speaking as an individual, drew a parallel between routine male circumcision and the much reviled practice of female circumcision in sub-Saharan Africa. "You're mutilating the genitalia," he said.

The Province, Vancouver, B.C.

Wednesday, July 14, 2004, Page A19

by Ethan Baron, Staff Reporter

B.C. college tightens its circumcision recommendation

By Lynn Haley, Medical Post, July 6, 2004

VANCOUVER Opponents of circumcision are applauding a new policy statement issued by the B.C. College of Physicians and Surgeons.

Dr. Peter Seland, deputy registrar (ethics) of the college, said the new statement is intended to help physicians navigate this minefield.

The statement advises that circumcision may be carried out only when it is in the best interests of the child. It also says the procedure has no medical or prophylactic values and that doctors must advise parents of the associated risks including urinary tract infection, urinary retention, meatal stenosis and hemorrhage (as was seen in a recent B.C. case that resulted in the death of a one-month-old boy).

Doctors are under no obligation to circumcise the child at the request of parents, the statement says. "There is a never-ending stream of concerns that we get at the college around this issue," said Dr. Seland. "There is nothing in terms of the intensity of the debate that separates this from abortion. People have very strong views about this issue.

"But when you cut through it all and examine it, it appears there is still a small portion of our society that might have been making the decision without being fully informed as to its implications, making decisions on such flimsy grounds as ‘We want him to be like daddy.' So we really wanted a tool for physicians to look at, and think about where we're at, not just from a medical point of view." The trump of course, Dr. Seland said, is the cultural and religious aspects of circumcision, unlike female genital mutilation which, Dr. Seland says, is off-the-wall. "Since male circumcision is neutral medically, you can't really say that medical indications trump religious preferences," he noted. "The flames were fanned when that baby died in Penticton. It spurred us on to come out with this guideline."

Such a procedure at birth could conceivably have a traumatic effect in later years, said Dr. Seland. "There is (also) the issue that a decision has been made by the parents to do this on weak grounds, and the result is the adult male is denied erogenous pleasure, though I don't know whether anybody will ever know that for certain," he said.

Dennis Harrison, a spokesman for the Canadian group Association for Genital Integrity, welcomes the changes in policy from the college. He says the focus on bioethics and human rights will help provide physicians with the tools they need to guide parents around the complex issues surrounding the procedure. "This is very difficult for many parents, because there is often the conflict between the parents' rights and the child's right," said Harrison. "But in a country like Canada, the vast majority of circumcisions are not done for religious reasons. It's true that parents are responsible for making decisions on behalf of their children, but there is no surgical operation a parent can consent to without medical need, and circumcision is not medically necessary. We applaud the college's guidelines, but we think they could have gone further."

Human rights treaties

United Nations Convention on the Rights of the Child 1989

Article 14

Article 14 (1) gives the child freedom of thought, conscience and religion. This means that he or she is entitled to choose his or her own religion, and that parents do not have the right to impose their own religion, or the rites and customs of that religion, on their children.

Article 14 (1). States Parties shall respect the right of the child to freedom of thought, conscience and religion.

Article 19

Article 19 (1) protects children violence, injury and abuse: violence or injury occurring in a doctor's surgery is not excluded.

Article 19 (1). States Parties shall take all appropriate legislative, administrative, social and educational measures to protect the child from all forms of physical or mental violence, injury or abuse, neglect or negligent treatment, maltreatment or exploitation, including sexual abuse, while in the care of parent(s), legal guardian(s) or any other person who has the care of the child.

Article 24

Article 24 (3) requires signatories to work towards abolishing "traditional practices" harmful to children's well being. These are not spelt out explicitly, but the reference is unmistakably to practices like circumcision, which could not be named out of deference to the many member countries of the UN which practise male or female circumcision or both. This article requires the Australian government to take active steps to discourage and eradicate male and female circumcision; it has taken effective action against female circumcision, but nothing so far towards abolishing male circumcision.

Article 24 (3). States Parties shall take all effective and appropriate measures with a view to abolishing traditional practices prejudicial to the health of children.

Article 37

Article 37 (a) protects children from cruel or degrading treatment: what could be more cruel or humiliating for a nine or a six-year old boy than to have the most interesting part of his penis cut off?

Article 37. States Parties shall ensure that: (a) No child shall be subjected to torture or other cruel, inhuman or degrading treatment or punishment.

The full text of the UN Convention on the Rights of the Child

Australian Medical Association Code of Ethics

The new Code of Ethics recently adopted by the Australian Medical Association has a number of provisions which are relevant to circumcision of minors.

The DOCTOR and the PATIENT

1.1 Patient Care

Consider first the well-being of your patient.

Treat your patient with compassion and respect.

Approach health care as a collaboration between doctor and patient.

2. PROFESSIONAL INDEPENDENCE

(d) Recognise your right to refuse to carry out services which you consider to be professionally unethical, against your moral convictions, imposed on you for either administrative reasons or for financial gain or which you consider are not in the best interest of the patient.

4. The DOCTOR and SOCIETY

(g) Regardless of society's attitudes, ensure that you do not countenance, condone or participate in the practice of torture or other forms of cruel, inhuman, or degrading procedures, whatever the offence of which the victim of such procedures is suspected, accused or convicted.

The full Code of Ethics is available here.

Note that these principles refer to the relationship between the doctor and the patient, and that the AMA recognises that the primary responsibility of the doctor is to the patient. The patient is the person receiving medical treatment, not the person or organisation paying for it. There is nothing in these rules which would justify a doctor amputating a normal foreskin from an infant or child merely because another person with the money to pay for the operation asked to have it done.

More on international human rights treaties on this site

Weaknesses of international human rights treaties

Human rights relate to individuals, not to collectives or societies. That is to say, they emerged in the struggle for the autonomy of the individual against traditional religious, monarchical and patriarchal authority, and they were an assertion of the right of each individual to think for him and herself and to enjoy the freedom to live without the close community supervision that characterised traditional (pre-modern) society. Despite this, in recent times human rights have increasingly been interpreted as pertaining to cultures and ethnic/religious groups, which have claimed that they have a "human right" to discipline their members and enforce traditional practices. This is to turn the concept of human rights inside out and to deprive it of any capacity to assist individuals.

Nowhere is this tendency more evident than in international organisations such as the United Nations, which in its interpretation of international human rights treaties has consistently placed the interests of its member states over the interests of their citizens as individuals. And nowhere is this abandonment of the spirit of the Universal Declaration of Human Rights and other treaties more blatant than in its double standards on male and female circumcision: ignoring, condoning or encouraging the former while mounting expensive campaigns against the latter.

In two hard-hitting essays posted here the Palestinian-Swiss legal scholar, Dr Sami Aldeeb, examines the failure of the United nations to live up to its own principles. In the first essay he argues that if physical integrity is a human right, it must apply to boys as much as to girls, and hence that if girls are entitled to protection from circumcision, boys are also so entitled.

In the second essay he analyses the reasons for the double standards so evident at the United Nations and other international agencies, such as the World Health Organisation, thus providing an essential background on the cultural basis for its endorsement of male circumcision as a tactic against AIDS in African countries.

Sami Aldeeb: Circumcision and human rights

Sami Aldeeb: Male and female circumcision: Hypocrisy and double standards at the United Nations

Links to further information

Important collections of legal and ethical articles are available at

http://www.cirp.org/library/ethics/



http://www.cirp.org/library/legal/

Human rights at Circumstitions

Ethics at Circumstitions

A pamphlet issued by Nocirc (USA) , "Answers to your questions about the bioethics of infant circumcision", is available to download in pdf format here: http://www.nocirc.org/publish

An important statement was issued by the British Medical Association in 2003, 2006 and 2007

British Medical Association, Medical Ethics Committee: The Law and Ethics of Male Circumcision - Guidance for Doctors

Margaret Somerville, Altering baby boys' bodies: The ethics of infant male circumcision

Boys too!

A site arguing that under equal opportunity and anti-discrimination legislation, boys should have the same protection against unsought genital alteration that is enjoyed by girls in many western countries.

Association For Genital Integrity

Canadian site documenting a long-running legal case on the legality of routine circumcision of infants

Genital Autonomy (UK)

Attorneys for the Rights of the Child

Female genital mutilation

Amnesty International

Amnesty International correctly defines female genital mutilation as the removal of any part of the female genitalia, by which definition the removal of any part of the male genitalia must similarly be defined as male genital mutilation. Yet Amnesty has been reluctant to take a stand against forcible male circumcision, and you will find nothing about it on their website.

Female Genital Mutilation Education and Networking Project

Forward (UK)

Paul Mason's London speech on children's rights and child protection

Classification of male and female genital mutilation

Dr Sami Aldeeb

Dr Sami Aldeeb is a Palestinian legal scholar now living in Switzerland. He is the author of numerous publications on legal and ethical aspects of male and female circumcision, including analysis of

circumcision and human rights, including right to personal autonomy and modesty;



circumcision and the rights of the child;

circumcision in Muslim law and practice;

debates about circumcision among Jewish and Muslim people.



Most of his publications can be accessed from his website.

Sami Aldeeb's blog (in French)

Religiously motivated circumcision

When people refer to "circumcision for religious reasons" they are generally referring to the practices of Judaism and Islam. Circumcision is traditionally practised by Jewish parents when their baby boys are eight days old, and by Muslim parents when their boys are aged between six and ten years - though there is wide variation here, and these days many Muslims have it done much earlier, following the United States model. This is particularly the case in semi-westernised Muslim countries such as Turkey and Malaysia, where it is increasingly done by doctors in a hospital. A search for "Sunnet" or "Khitan" on Youtube or Google Images will bring up many disturbing images.

Islamic law and custom states that girls should also be circumcised, but in practice this is less frequent, and even where it is done the operation often consists of no more than a semi-symbolic scratch on the vulva or other minor intervention. In many western countries the circumcision of girls has been banned by law.

It is quite wrong, however, to allow cultural or ethnic stereotyping to lead us into the assumption that all Jewish people, or all Muslim people, or all Somalis are in favour of circumcision. In all these communities there is a wide spectrum of views on the issue, ranging from fanatical commitment to determined opposition. In the United States Jewish people are particularly prominent in the various anti-circumcision groups, and critics of circumcision have recently emerged in several Muslim communities as well. A group of Arabs opposed to circumcision have established a Facebook profile. What they have in common is the recognition is that human rights apply to babies and children as well as to adults, and to boys as much as to girls. As Soraya Mire, the Somali filmmaker and activist against forced female genital mutilation, remarked in June 2009:

"The same universal human right to an intact body that I have fought for on behalf of women and girls must apply to boys as well, especially those too young to make an informed decision about the integrity of their bodies. How can it be wrong to surgically alter the genitals of a baby girl without her consent but okay to surgically alter the genitals of a baby boy?"

Circumcision among the Jewish people

For information on Jewish circumcision, see the Circumcision Resource Centre, a US site maintained mainly by Jewish men and women who are opposed to circumcision. Sites established by Jewish men and women opposed to circumcision:

Beyond the Bris (new USA site)

Jews Against Circumcision and Kahal.

They write: "We are educated and enlightened Jews who realize that the barbaric, primitive, torturous, and mutilating practice of circumcision has no place in modern Judaism. Rabbi Moses Maimonides himself acknowledged that circumcision is only done to desensitize the penis and curb masturbation. In ancient Judaism, you could be murdered for disobeying your husband or parents, blasphemy, homosexuality and other so-called crimes that we now realize are not crimes, but freedoms of expression. Jews are some of the smartest people in the world. We are 1/3rd of 1% of the population, yet we hold 33% of Nobel prizes. We are smart enough to understand that mutilating our little boys genitals is not an acceptable practice in modern times."

Jewish voices against circumcision getting stronger (on this site).

Brit Shalom is a non-cutting naming ceremony for newborn Jewish boys. It may be performed by a Rabbi or other experienced lay leader. If desired, providers can aid parents in devising their own ceremony. This ceremony replaces Brit Milah (ritual circumcision). It has also been termed Alternative Brit (or Bris), Brit b'li Milah (Covenant without cutting) and Brit Chayim (Covenant of Life). Further details available at:

http://www.cirp.org/pages/cultural/bris_shalom.html



http://www.noharmm.org/nontrad.htm

A list of celebrants who provide the Brit Shalom ceremony, a non-injurious alternative to Brit Milah are available at

http://www.circumstitions.com/Jewish-shalom.html

A young Jewish American's eloquent critique of circumcision:

Why I will never attend a Brit Milah

On Islamic circumcision

Riad Sattouf's comic strip account of his circumcision as an 8-year old

Some Turks are also critical of circumcision

Information about Turkish circumcision

Turkce Sunnet Hakkinda Bilgi

Information about Moslem circumcision

Muslumanlarda Sunnet Hakkinda Bilgi

Sites maintained by Moslems who oppose circumcision: www.quran.org/khatne.htm and the Quranic Path

The comprehensive study by Dr Sami Aldeeb, To mutilate in the name of Allah or Jehovah: The legitimation of male and female circumcision, is available at www.quran.org/CIRCUMCISION.HTM

Also available at www.fgmnetwork.org/samialdeeb/

Facebook group of Arabs opposed to circumcision

(Mostly in Arabic, some English)

Iranian human rights activist criticises circumcision

As the demand for democracy and individual rights spreads from the developed world to the Middle East and Asia, more people are taking up the cry that bodily integrity - an entitlement implied in the Universal Declaration of Human Rights - applies to all parts of the body. Progressive Jewish people, especially in the United States, have been abandoning circumcision for many years, but until recently few people from a Muslim background dared to question the practice. That silence has now been broken by the Iranian human rights activist, Jahanshah Rashidian, in his recent essay, Circumcision or genital mutilation.

Christianity

Christianity demarcated itself from its Jewish parent by rejecting and then prohibiting circumcision. If it is true that a pious Jewish parent must circumcise his sons, it is equally true that a pious Christian must not.

The Christian Church has repeatedly condemned and sometimes banned circumcision: www.cirp.org/library/cultural/

Catholics Against Circumcision: Catholics recognise that Christianity has traditionally rejected circumcision.

http://www.CatholicsAgainstCircumcision.org

Significant articles on human rights, medical ethics and law