Table Of ContentMale and Female
Circumcision
Medical, Legal, and Ethical
Considerations in Pediatric Practice
Male and Female
Circumcision
Medical, Legal, and Ethical
Considerations in Pediatric Practice
Edited by
George C. Denniston.
University of Wmhington
Seanle, Washington
Frederick Mansfield
Hodges
Wellcome Unitf or the History of Medicine
University of O.$onl
Oxford, England
and
Marilyn Fayre Milos
National Organization of Circumcision
Information Resource Centers
San Anselmo, California
Kluwer Academic /Plenum Publishers
New York, Boston, Dordrecht, London, Moscow
Llbrary of Congress Cataloglng-in-Publication Data
Male and fenale circumcision : medical, legal. and ethical
considerations in pediatric practice / edited by George C.
Oenniston. Frederick Mansfield Hodges. anMda rilyn Fayre Milos.
p. cn..
"Proceedings of the Fifth International Synposiua onS exual
Mutilations: Medlcal. Legal. andE thical Considerations in Pediatric
Practice, held August 5-7. 1998. in Oxford, Eng1and""T.p. verso.
Includes bibliographical references and index.
ISBN 0-306-46131-5
1. Circumcision Congresses. 2. Fenale clrcumclsion Congresses.
3. Circumcision--Moral and ethical aspects Congresses. 4. Fenale
circuncision--Moral and ethical aspects Congresses. I. Denniston.
George C. 11. Hodges. Frederick Mansfield. 111. Milos, Marilyn
Fayre. IV. International Symposium on Sexual Mutilations (5th :
l998 : Oxford. England)
GN484.H35 1999
172'.2--dc21 99-37490
CIP
Proceedings of the F iI nternational Symposium on Sexual Mutilations:
Medical, Legal, and Ethical Considerations in Pediatric Practice,
held August 5-7.1998, in Oxford, England
ISBN. 0-306-46131-5
0 1999 Kluwer Academiclplenum Publishers
233 Spring Street, New York, N.Y. 10013
l 0 9 8 7 6 5 4 3 2 1
A CAP. record for this book is available fromt he Library of Congress.
All rights reserved
No part of this book may be reprodud, stored in a retrieval system, or transmitted in any form
or by any means, electronic, mechanical, photocopying. microfilming, recording, or otherwise,
without written permission from the Publisher
Printed in the United Stateso f America
In those countries where the circumcision of children is an accepted part of life,
perfectly rational, intelligent, and well-meaning adults believe that they have a right to
cut off parts of their children’s sexual organs. They albseol ieve that circumcision isa n
inconsequential matter. Others believe that they haven o choice but to circumcise their
children. Even in the rest of the world, most people are unperturbed by that fact that
million boys and 2 million girlsa re circumcised each year.
13.3
The paradox implicit in this situation is glaring. On the oneh and, the world has
become increasingly aware, anse ver before, of the child’s need for special protections
under the law. Children are now seen as complex beings with inalienable rights pecu-
liar to their vulnerable status. On the otherh and, the exploitation of children is on the
rise. It is easy to object to sexual slavery and child labour-for here, the perpetrators
are identifiable and the law is clear. In the case of circumcision, however,o bjection is
more problematic, because the perpetrators arel ess easy to identify. Society must ask
whether the abolition of circumcision is possible without vilifying carinpga rents who
believe they are acting int he best interest of their children, medical doctors who believe
that they are adhering to good medical practice, or religious leaders who struggle to
maintain religious cohesion ina n era of competing ideologies.
At the Fifth International Symposium on Sexual Mutilations, held from 5 to 7
August at the University of Oxford, a panel of experts in the fields of medicine,
1998,
law, ethics, sociology, anthropology, history, religion, and politics came together to
discuss these very issues from a medical, legal, and ethical viewpoint. For those who
are unfamiliar witht he primary issues inth e human rightsa nd scientific discourseo ver
circumcision, a brief summary of the main points will be of use.
The primary problem with circumcisioni s not the lack of adequate anaesthesia,
the infliction of surgical risk, or the rateo f mortality or morbidity, although these are
issues of considerable importance on theiro wn. Regardless of the reasons, motivations,
or rationaleo f those who circumciseo r condone the circumcision of children, regard-
less of the amount of tissue removed, and regardless of the physical consequences of
its removal, the problem with circumcision is the unavoidable human rights implica-
tions of permanently removing healthy tissue from a person who has not consented to
its removal and who must livet he rest of his or her life with the consequences of that
removal. In the United States, for example, wheren eonatal male circumcisionb ecame
a widespread phenomenon during the ColdW ar era, and where medical doctors
perform and rationalise the procedure, circumcision isa problem, among other reasons,
V
vi Preface
because it violates the individual’s rightt o freedom from unwanted medical procedures.
More fundamentally, as the legal experts represented in this collection demonstrate,
parental consent for surgical procedureso n children is only valid in situations of imme-
diate medical necessity consequent to severe injury, deformity, or disease.’ The pres-
ence of a normal foreskin or clitoris can neither be classified as an injury, a deformity,
or a disease.
In terms of basic human rights, circumcision violates the individual’s right to
bodily integrity. It violates the right to autonomy over one’s own bodya, nd it violates
the individual’s right to protection from such intrusions while he is developmentally
incapable of defending his own interests. Regardless oft he alleged social, religiouso, r
medical benefits of male and female circumcision, the human rights violation created
by circumcision remains. Given these factors, one must consider that the circumcision
of children may not be the most effective means for expressing parental solicitude,
medical goodwill, or religious cohesion. There could be a less burdensome way of
achieving these goals.
From a non-legal, non-ethical, and purely scientific standpoint, the medicalised
rationale offered to justify routine neonatal circumcision is distinguished by an ideol-
ogy that largelyi gnoresb iologicm echanisms and relies,i nstead, on anecdotes,
theories, testimonials,a nd on what are purported to be ancient practices. Whats ets the
circumcision hypothesis apart from rational, evidence-based medicinies that it has not
been scientifically tested through the marshalling of rigorous evidence of safety and
efficacy, as required by national regulatory agencies. The continuously shifting medi-
calised rationale for circumcising children is fervently promoted despite not only the
lack of good clinical evidence of effectiveness and public health necessity, but also in
spite of the presence of a rationale that violates fundamental scientific, biological, and
anatomical laws. The proffering of statistics-based papers, mosto f which have obvious
methodological flaws, comparing disease rates in dissimilar populations for whom cir-
cumcision status is merely a mark of social class, is not a substitute for randomised,
controlled clinical trials. Moreovethr,e fact that developed, non-circumcising countries,
such ast he nations of Europe, enjoy markedlys uperior levels public health than the
of
United States, and, ironically, in preciselyt hose areas of public health where circumci-
sion is saidt o be of benefit, underscores the need for the general scientific community
to re-evaluate its uncritical stance towards circumcision. The landmark studies by
respected scientists sucha s R. S. Van Howe, C. M. Cold, and otherst, hat are presented
int hisv olume,r eveal the powerfuls cientific truths that can be realisedt hrough
rigorous testing and analysis of previously untested theories and unsound medical
practices.
Another important issue in the circumcision debate is terminology.A s a result of
carefully-honed messages issuedb y medical professionals with an interest in the con-
tinuation of circumcision, most American parents have also been led to believe that
circumcision is inconsequential, that it has no effect on the functions of the penis, and
that it may have medical benefits. When parents are asked whether they want their
newborn son circumcised, the very fact that medical professionals ask the question
lends an aura of legitimacy to the procedure. It would never occur to most American
parents that they were being asked if they wanted to have their child mutilated. No
culture that practices the circumcision of children considers it to be a mutilation.
Stedman’s Medical Dictionary defines mutilation as, “Disfiguremenot r injury by
removal or destruction of any conspicuous or essential part of the body.”’ Male cir-
cumcision clearly entails the removal of a conspicuous part of the body. It inflicts an
Preface vii
irreparable injury and alters the appearance of the penis. The question, then, is not
whether circumcision is a mutilation, but whether it is productive to refer to it as a
mutilation when discussing it. Whilteh e designation of mutilation is clinicallya ccurate
and objective, in practicei, t is subjectivelya pplied.
Most cultures that practice some form of ritualised or medicalised cutting of the
sexual organs of children regard their brand of cutting as harmless, but regard
own
the brands of genital cutting practised by other cultures as mutilations. This double-
standard stems from the inherent xenophobia of most cultures. Americanfso,r example,
rarely consider their practice of male circumcisiont o be a mutilation, but they do
own
consider even the mildest and least invasive forms of female circumcision, as practised
in Egypt or Somalia, as mutilations. For Egyptiansfo, r whom both male andf emale cir-
cumcision have been normalised, this American double-standard is incomprehensible.
Ironically, the United States has its own historyo f medicalised female circumcision, but
because it was practised by doctors for allegedly legitimate medical indications,i t was
not considered a mutilation. Mutilation, then, is the stigma of “the other.” It connotes
cultural, religious, and racial boundaries.
The organisers of the International Symposia on Sexual Mutilations have pre-
ferred to use the term “mutilation” for a variety of reasons. First, the use of the term
“mutilation” is designed to inspire thoughtful debate and reflection among those cul-
tures that consider their form of circumcision to be normal but consider the forms of
circumcision found in other cultures to be mutilating. Only when one can see oneself
reflected in the eyes of another can a meaningful dialogue begin. Second, “circumci-
sion” is not a broad enough term to encompass the range of ritual sexual surgeries to
which children are subjected around the world, all of which comprise the remit of the
symposia. Thep enile subincision of Australian Aborigines is not accurately described
as circumcision. The penile flaying of Yemen and Saudi Arabia is not accurately
described as circumcision. The clitoridectomy of African girls is also not accurately
described as circumcision. Third, and most importantly, “mutilation” is the term pre-
ferred by the very individuals who havbee en subjected to ritual childhood genital sur-
geries and who now work to replace these practices with non-surgical alternatives. It
is the belief of the organisers of the symposia that the feelings of those who have been
marked by ritual childhood sexual surgeries should have precedence over the feelings
of the perpetrators of these practices. We honour the affected individuals by respect-
ing their choice of terminology.
That circumcision is a form of sexual or economic exploitation of children is also
a factor that is often unrecognised. In many African communities,t he circumcision of
both male and female children provides a significant percentage of the economic
support of a whole societal caste, usuallyt he caste of blacksmiths. In 1996 alone, inth e
United States, neonatal male circumcision generated between $136,052,000.00 and
$162,540,000.00 for physician circumcisers? In addition to this, human foreskins have
now become the raw resources of the new economic epoch of biotechnology. The
increasing consolidationo f corporate control over neonatal circumcision, as well as the
technologies to exploit the commercial potentials of the foreskin, is alarming, especially
when we stop to consider the unique vulnerability the child and the tremendous
of
profits to be gained. Transnational biotechnology corporations, such as Advanced
Tissues Science, Organogenesis, and BioSurface Technology, have emerged to reap
unprecedented corporate profits from the development and sale of marketable prod-
ucts made from harvested human foreskins.“I n 1996, Advanced Tissue Sciences, which
manufactures and markets the foreskin-derived Dermagraft product, could boast a
viii Preface
$663,000,000.00 market capitalisation performance? Harvested foreskins are also used
in a wide range of applications by the multi-billion-dollar pharmaceutical industry.
The prospect of the commercial exploitation of children through circumcision is
one of the most important issues ever to face humanity. Foreskin harvesting and the
patenting of foreskin-derived products strike at the coreo f our .beliefs about the very
nature of life. Do human bodies and human bodyp arts have intrinsic,o r merely utility,
value? The last great debate of this kind occurred in the nineteenth centuryo ver the
issue of human slavery.A bolitionists argued that every human being ha“dG od-given”
rights and, therefore,c ould not be made the personal commercial property of another
human being. Today, wea re reliving this debate, but rather than entire human beings,
specific human bodyp arts are now the focus of corporate appropriationa nd exploita-
tion. Certainly, none of the boys whose foreskins are being harvested for commercial
exploitation receive any share in the profits generated by their unwitting contribution.
We have yet to ask whether our most basic birthright should become a source of cor-
porate income; The majority of American parents have yet to consider whether the
steady stream of pro-circumcision messages they have been receiving from certain
corners of the medical industry is in part attributablet o the intense profitability of cir-
cumcision to circumcisers, hospitalsi,n surance companies, pharmaceutical corporations,
and now, biotechnology corporations.
As the varied topics included in this collection suggest,t he highly visible, multi-
dimensional problems inherent in the circumcision of non-consenting citizensh as stim-
ulated responses from scientists and scholars working in a wide range of disciplines.
This collectiono f papers, like the symposium from which it emerged, was inspired not
only by a desire to bring together some of the best work being done on this subject,
but also by a recognition that thep roblem of male and female circumcision encourages
multidisciplinary ventures. Certainly, the topics presented in the papers that follow
do not exhaust those being considered by investigators of the scientific, religious, and
human rights implications of male and female circumcision, and readers arei nvited to
consult the previous volume in this series for alternative approaches6 While the
approaches of some fields-law and medicine most notably-dominate the work cur-
rently being done, there remain several topics that have only begunto get the attention
they merit. We hope that this collection will encourage further study in these and other
areas. It is further hoped that the papers presented here will spark a thoughtful and
respectful scientific dialogue,o ne that will lead to greater understanding, clarity, and,
perhaps, to greater respect for children of every race,g ender, creed, and nationality.
George C. Denniston
Frederick Mansfield Hodges
Marilyn Fayre Milos
REFERENCES
1. Committee on Bioethics Informed consent, parental permission, and assent in pediatric practice.
Pediatrics 1995;95:314-7.
2. Stedman’s Medical Dictionary. 25th Edition. BaltimoreW: illiam’s & Wilkins. 1990:1009
3. According to statistics released by the National Center for Health Statistics, 1,204,000 males were cir-
cumcised in 1996. The median fee per circumcision in 1995 was $113 for paediaticians and $135 for
obstetricians [Pediatricians’ latest charges Medical Economics 1995;14(11):34.] 1,204,000 x $113 =
$136,052,000; 1,204,000 $135 = $162,540,000.
X
Preface ix
4. Hodges F. A short history of the institutionalization of involuntary sexual mutilation in the United
States In: Denniston GC, Milos MF, eds Sexual Mutilations: A Human Tragedy. New York and
London: PlenumP ress 199717-40.[ here, p. 35.1.
5. Hall CT. Biotech’s big discovery.S an Francisco Chronicle. (October 25,1996): El, E4.
6. Denniston GC, Milos MF, eds. Sexual Muti1ations:A HumanT ragedy.N ew York and London: Plenum
Press 1997.
ACKNOWLEDGMENTS
Among the many people to whom we owe a tremendous debt of gratitude, we
would like to mention Ken Brierley, John A. Erickson, Matthew Orlando, Sheila
Curran, Peter Ball, Tina Kimmel, David Smith, Storm Schumacher, Shelton Kartun,
Andrew Tinson, Peter Whyer, and John Dalton. We are also deeply indebted to Tim
Hammond, Sairus PatelS, hanti Poona, Norm Cohen, Kate Edmiston, and Jim Bigelow.
Finally, we would likteo express our deepest appreciation to the contributors for allow-
ing us to publish their work.
xi
