In Finland, lawmakers recently voted to make an existing ban on female genital mutilation more explicit by outlining punishments for such manipulation under the Finnish criminal law. This bill’s passage was widely applauded as it furthers the global efforts to eradicate female genital mutilation (FGM). While the bill received majority support in the parliament, a contentious debate ensued around an amendment in the bill that would potentially outlaw non-therapeutic male circumcision. The amendment related to circumcision was eventually removed from the bill, and circumcision remains legal in Finland. This new FGM law brings back into focus the ethics of non-therapeutic infantile circumcision.
As an immigrant physician working in the American health care system, I have a distinct insight into the cultural and ethical aspects of non-therapeutic male circumcision, both within and outside the U.S.
Circumcision is one of the most ancient surgical procedures and is believed to have evolved as an adaptation of castration and penile amputation. The erect penis was viewed as a symbol of power, which led to it being amputated and even collected as a trophy after the war. Such mutilation was often a mortal injury, and circumcision was thus adopted as a less radical, yet a humiliating alternative. There is also simultaneous evidence that circumcision was performed for hygienic reasons in the Egyptians’ early elite classes. Other reasons responsible for the origin and spread of circumcision are believed to be a rite of passage, a mark of cultural identity, and a ceremonial sacrifice to the gods. The earliest depictions of ritualistic circumcision are found in Saqqara’s Egyptian necropolis in what is widely believed to be a priesthood initiation ceremony. From a punishment imposed on enemies and slaves, circumcision soon transformed into a sign of nobility, aristocracy, and priesthood.
The Jews adopted circumcision from the Egyptians. Male infants in the Jewish faith are circumcised under a covenant between Abraham and God. Despite its near-universal prevalence amongst Muslims, the Quran has no mention of circumcision. It is not prescribed in most forms of Christianity and is not customary in Hinduism and Buddhism. The popularity of circumcision in English-speaking industrialized countries, including the U.S., increased under the Victorian establishment, which believed that circumcision was beneficial against a wide range of conditions, including masturbation, syphilis, and urinary incontinence. Since then, the science has evolved, and misconceptions have cleared, but circumcision continues to remain popular in the U.S. Today, three in four non-Jewish and non-Muslim American boys undergo non-ritualistic circumcision. Parents’ major reasons to approve circumcision are perceived improvement in hygiene, decreased transmission of sexually transmitted infections, decreased incidence of penile cancer, and notably, the circumcised status of the father. However, the conclusions of the scientific studies showing the benefits of circumcision remain contentious. The AAP estimates a one percent incidence of UTI is in male infants regardless of the circumcision status. Other benefits of circumcision, namely, decreased transmission of sexual infections like HIV and decreased incidence of penile cancer, do not apply until after first sexual intercourse. A sound ethical argument can thus be made to defer circumcision until the age of sexual consent.
The reasons in support of the criminalization of FGM can be extrapolated and applied to non-therapeutic circumcision. Like girls, boys have a right to grow up with their genitals intact and decide for themselves whether they would like to get circumcised or not. Adolescents are able to comprehend and consent to minor medical procedures like wisdom tooth extraction; circumcision should be no exception. Deferring circumcision until the age of sexual consent will allow individuals to report pain and early signs of potential complications; infants do not have such ability. Voluntary male circumcision is surgically less challenging and has a distinct ethical advantage of letting the individual decide how an intimate body part should look and function. The consent, in voluntary cases, would also be obtained after adequate consideration of alternatives. Circumcision counseling can be coupled with education about safe sexual practices and the role of barrier contraceptives in decreasing the transmission of sexual infections. Additionally, gender reassignment surgery is technically demanding when the penis is circumcised. Delaying circumcision would afford transgender individuals the opportunity to have a desired genital and sexual phenotype. Cancer of the penis, on the other hand, is one of the rarest malignancies accounting for about 0.15 percent of all incident cancers. A recent meta-analysis showed that in half of the cases, penile cancer is associated with human papillomavirus (HPV) infection. Counseling about the role of HPV vaccination in preventing penile cancer vis-à-vis circumcision should thus be imperative in pre-procedure consent.
Furthermore, male circumcision stands out as the only body part removal performed on healthy, low-risk individuals without their explicit consent. Despite the significantly higher prevalence of breast cancer, in contrast to penile cancer, a prophylactic mastectomy is only done in exceptional cases and in patients carrying a high-risk cancer mutation.
Non-therapeutic circumcision thus violates one of the cardinal ethical rules in medicine, namely, autonomy – the ability to decide the best medical recourse for oneself. Until deferment of non-therapeutic male circumcision to age of consent becomes a norm, hospitals should ascertain that these considerations are highlighted and discussed before obtaining consent from the guardian or parent. This will preserve autonomy, freedom of choice, and the freedom to be who the individual chooses to be: circumcised or uncircumcised but from a self-made decision.
Sumeet Dua is a radiologist.
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