Family/Healthcare/LGBTQ
Circumcision: If It’s Not Your Body, Should It Be Your Choice?
When done on a newborn, is it medically necessary, tradition, or genital mutilation without consent?
The first time I held a scalpel in my hand was in 1966 as a third-year medical student while on my obstetrics rotation. Our guidance was “see one, do one, teach one.”
The screaming newborn boy was strapped to a “bundle board” by the nurses. I wanted to rescue the infant rather than cut on him, but I had to snip off those emotions as well as his foreskin.
If I recall correctly, we didn’t use any anesthetic. We placed the cigar-cutter-like instrument in place with the nurse’s guidance, clamped down on the foreskin, and cut around the edges. The infant shrieked even louder as I did it.
If students asked if the newborn experienced a lot of pain, the response was, “They’re too young to remember it.” Looking back, it was barbaric.
These infants were a commodity, something of use in our education. In that era, most of them had been born to unwed, teenage mothers who lived in the three homes for young girls, secreted off to these institutions. Most left these homes without their newborns; the social workers told the mothers that it was the right thing to do because they would go to a “better home.”
Someone must have signed a consent form for the procedure. The social workers likely told whoever signed it, “It’s the way things are done.” I doubt they discussed alternatives.
Full disclosure:
I am an old, gay psychiatrist, not a pediatrician or urologist. My family raised me in a Christian tradition. I am also “uncut” — or, “intact,” as is the preferred term. I have some biases.
But we all have biases, don’t we? They are just different from one person to the next. I think it is safer to acknowledge our prejudices and guard against them than to assume we don’t have any.
Physicians attempt to follow “best practices” and read the literature to aid those decisions. But we often choose to read papers that support our beliefs and not those that don’t, and researchers often do their investigation to establish foregone conclusions.
Some will say it’s unprofessional of me to reveal that I am intact. Any talk about penises, particularly about our own, and even more especially about our foreskin, isn’t something done in polite society. It’s like breastfeeding, something that should never be made public. But why do people feel ashamed of talking about foreskin when they freely talk about the appendix, another body part of debatable value?
After participating in a couple of large, online discussion groups for gay men, I decided to write this essay. One group was older gay men, and the other was gay physicians.
Gay men have strong opinions about penises, and many of us have seen more of them than most women or heterosexual men. Gay men have also had to come to terms with being different from what society considers “the norm.”
The older gay men focused more on issues of esthetics and pleasure. The gay physicians were younger and focused on esthetics and pleasure but also discussed issues of ethics, consent, risks and benefits, and medical necessity.
Disclaimer:
Regardless of specialty, almost all physicians have been asked by family and friends about their opinion on the procedure.
My comments here are my opinions and are not medical advice.
I think it is safe to say that the older, gay men didn’t reach a consensus about the pros and cons of the procedure. They based their opinions primarily on a matter of preference.
The gay physicians had a more unified position: The risks are small, but so are the potential benefits. Therefore, except in religious or cultural tradition, why not wait until the person with the foreskin can make his own decision about circumcision? There is no justification for an irreversible, elective surgery without much higher and proven benefits.
Some physicians held much stronger opinions. They referred to circumcision as genital mutilation without consent and a violation of human rights. Many believed that healthcare providers did not give decision-makers enough information about risks and benefits to offer informed consent, nor were they educated adequately about care if they chose to leave the foreskin intact.
In newborn circumcision, parents are proxy decision-makers, and they make decisions in consultation with a physician. Parents make these decisions all the time, and not just about medical care. Parents are confronted continuously with making decisions with which their healthcare providers may not agree, and with which the adult version of that child may also disagree.
Some child advocates say that children have too little autonomy over their bodies, and they believe physicians should perform only necessary and medically indicated surgeries on minors. Everything else should wait.
What is critical is that both the physician and the decision-makers do their due diligence to determine the appropriateness of any medical procedure’s necessity.
The ethical issues
First, do no harm. Will delaying a medical procedure until a child can give consent cause harm to the individual?
Circumcision as tradition
In Judaism, the ritual of circumcision is an ancient practice that has been carried out by Jewish parents for more than 3,000 years. According to the Torah, Abraham was commanded by God to circumcise himself, all male members of his household, descendants, and slaves. Jewish families traditionally hold the ceremony on the eighth day following birth.
Muslims are still the largest religious group to circumcise boys. The Qur’an does not mention circumcision, but in the words of the Prophet Muhammad, circumcision is called a “law for men.” The main reason given for the ritual is cleanliness. Most Muslims see circumcision as an introduction to the Islamic faith and a sign of belonging.
Christians have primarily abolished circumcision just as they have eliminated animal sacrifice. At one time, the Roman Catholic church forbade Christians from being circumcised without an unavoidable medical reason. Protestants had never circumcised until the late 1800s. Secular thought introduced the practice in the modern United States, and American Christians seized upon it.
One of the primary reasons Americans adopted the practice of routine infant circumcision was to prevent masturbation. In the late 1700s, masturbation became viewed as one of the most significant health hazards. Medical manuals cataloged the possible dangers. The prevailing idea was that sex should be as infrequent as possible since it depleted your total energy. Circumcision was an attempt to make masturbation less pleasurable.
The foreskin is an extremely erogenous zone and carries out several functions related to both partners’ pleasure and comfort. Removing the foreskin reduces sensitivity significantly and makes masturbation without lubricant much more difficult. Aside from the esthetics, this was the most common concern in older gay men’s discussion group.
The World Health Organization (WHO) advocates for circumcision in the prevention of HIV. Many physicians believe, however, that their recommendations were made on the basis of research done in Subsaharan Africa on heterosexual men, and therefore don’t apply to men who have sex with men. The studies have not been replicated in the U.S., and the physicians in the discussion group say that the effectiveness of circumcision is uncertain while Pre-Exposure Prophylaxis (PrEP) with condoms is nearly 100% effective in preventing HIV.
Medical organizations outside the U.S. have taken official positions against medical circumcision of newborns. European statements rely on evidence-based medicine, rejection of tradition or parental preference, and a concern for the child’s human rights.
The American Academy of Pediatrics (AAP) looked at the same evidence but came to the opposite conclusions. The AAP — the lead agent of this cultural practice for decades — has been deferential to parental choice and tradition. The AAP makes only incidental comments on the human rights of the child.
As English-speaking countries realized that medical theories were wrong, physicians stopped performing circumcisions. Except in the United States. Americans have long forgotten the reasons the practice became entrenched, but the tradition continues because “it’s just what we do” or “I want him to look like Daddy.”
John Harvey Kellogg — yes, the cornflakes guy — promoted circumcision as a punishment:
The operation should be performed by a surgeon without administering an anesthetic, as the brief pain attending the operation will have a salutary effect upon the mind, especially if it be connected with the idea of punishment, as it may well be in some cases. The soreness which continues for several weeks interrupts the practice [of masturbation], and if it had not previously become too firmly fixed, it may be forgotten and not resumed.
Although some have equated circumcision (male genital mutilation) to female genital mutilation (FGM), this is a false equivalency. FGM removes the clitoris and inner lips of the labia and sometimes sews the introitus shut until marriage; this eliminates all possibility of experiencing sexual pleasure. It would compare more closely to the removal of the head of the penis than to circumcision.
Why do we do it?
The question must be asked: If the benefits of the procedure and the risks of it are both small, essentially canceling each other out, why do we do it?
Many physicians believe foreskin has a function, and routine circumcision of male infants without a medical indication is unethical and should be illegal. They add that since minimal additional risk results from delaying the procedure until the foreskin owner is old enough to make an informed choice, what’s the rush to violate the person’s autonomy?
Some would say that if the decision is based solely on tradition, it is virtually no different than scarification procedures performed as tribal rituals in developing countries. What is legal is not necessarily moral or ethical.
Others criticize this surgery as simply a moneymaker for physicians. Some evidence supports this. In areas where insurance doesn’t pay for it, some free-standing, cash-based clinics have developed. Beauty product companies buy baby foreskins for use in beauty products to grow and cultivate new cells. Foreskin fibroblasts are also used to treat burns and diabetic ulcers.
How to care for an uncircumcised penis
How to care for an uncircumcised penis and the medical risks of the procedure go beyond this essay’s scope and beyond the expertise of this author. I’ve included some links to respected discussions at the end of it.
When I was quite young, my mother told me, “Loren, pull the skin on your ‘zooter’ back and clean it every time you shower.” Many believe that soap and water are all that is needed, but often even my mother’s limited care instruction isn’t given.
Physicians need to provide truly informed consent about the risks and benefits of circumcision. And this decision should be made by parents before the birth of their infant; waiting until they are emotionally exhausted from the delivery is not a good time to ask them to make rational decisions.
Although circumcision is far less barbaric now than it was when I was a medical student, the question remains: Is it necessary?
Resources:
American Academy of Pediatrics
American Circumcision (Documentary movie trailer)
Care of the Uncircumcised Penis | Children’s Hospital of Philadelphia
Circumcision: Why Are We Doing This? (Podcast)
How To Care For Your Child’s Foreskin | Kids’ Health New Zealand
Protecting Children’s Rights | Intact America
Read an excerpt of Finally Out here.
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