05132002 - Heather Stark

If anyone wants to use this for a source or whatever, I don't mind, but I would appreciate recognition (contact me here). This is the edited, shorter version of a very long ethics paper I wrote for a class.

To see a brief summary of the main points of this essay, please go here.

Routine Infant Circumcision
        To most people in the United States today, male circumcision is not something that is considered an ethical issue;  the reason may be due to how common it is in our society.  A large majority of males in America are routinely circumcised; it wasn’t until the 1970s that doctors even asked parental permission to perform this surgery on infants (Fliess).  However, despite the fact that most Americans don’t recognise routine infant circumcision, or RIC, as an ethical subject, there are multiple small groups lobbying to get it outlawed, and many more people who protest the procedure (NOCIRC).
          To make one thing clear: RIC is not circumcision to treat a disorder in a child or adult.  This category includes only the infant males who are circumcised for social or preventative medicinal reasons.  This category may or may not include religious circumcisions, though the topic will be briefly addressed anyway.  This paper will not discuss the morality of circumcision in general; it is discussing the morality of routinely circumcising male infants regardless of their medical situation.
          The act of circumcision is the removal of the prepuce from a person’s genitals.  In females, this is the removal of the clitoral hood; in males, it is the removal of the foreskin.  The foreskin is approximately 15 square inches in size on the adult male (“Penis and Foreskin”), and protects the glans of the penis, as well as serving multiple sexual functions during intercourse (Fliess).  The foreskin consists of two layers – soft mucosa and ridged mucosa (Fliess) which contains muscles, blood vessels and a high concentration of nerves, all of these serving to make the foreskin one of the most sensitive parts of the penis (Fliess).
          The worldwide male circumcision rate is 20%, and consists mostly of Muslims, Jews, and Americans (“Fact Sheet”).  The number of infant circumcisions performed in America has been declining, however about 57% of males born in our nation today are still circumcised (Bollinger).  Though religious male circumcision has been around for thousands of years, RIC was started in America as a way to curb masturbation (Fliess; “General Info”), and at one point doctors claimed it cured a number of maladies ranging from paralysis to epilepsy to mental retardation (Fliess).
          Circumcision used to be performed without anaesthetic, but today most hospitals recommend the use of some form of it.  The two most popular methods are EMLA cream or lidocaine injection (AAP “Policy Statement”).  Both of this have a fairly good success rate, and are known to only cause allergic reactions in very small amounts of the population (Larratt).  Even still, it is estimated that only 4% of infants receive either of these two methods (Salvatore).
          The issue of ethics in circumcision today stems from the pro-intact belief that the choice to circumcise belongs only to the person who owns the genitals – not the parents, as done today.  Those who support circumcision argue that the potential benefits of circumcising outweigh the issue of personal rights.  The following arguments are addressed in order of severity – starting out from social customs ending with personal rights.  In each section, a least one argument, and its accompanying rebuttal is present. Though my opinion is present in the end, this is an attempt to give the most unbiased and evenly presented account of evidence from both sides of the issue.
          Just as female circumcision is prevalent in certain parts of Africa due to social customs, male circumcision is performed in the United States largely for this reason (Morris; “Frequently Askes”; “To Look Like Others”).  Though there are several potential medical benefits brought about by circumcision, the American Academy of Pediatrics, or AAP, acknowledges that these alone are not beneficial enough to warrant surgery on an infant (“AAP News”).  This is where societal standards come in.  Many parents choose to circumcise their infant so that he will look like his father, brothers or peers (“To Look Like Others”).  It is a commonly held belief that circumcision is necessary for a boy to feel comfortable (“Frequently Askes”).
          However, various studies have concluded that most male children do not know or care about the circumcision status of their father, brothers or peers (“To Look Like Others”).  It is also important to understand that an intact boy can be circumcised later if he chooses (“Frequently Askes”) or has problems, but a boy who has been circumcised cannot do anything about it.  Furthermore, due to the dropping rate of RICs performed, an intact boy might not necessarily be in a minority amongst his peers in the near future (Bollinger).  There is an inconsistency within the AAP regarding genital mutilation; in the case of female genital mutilation, they say that it should not be allowed “regardless of cultural and social issues,” (Committee on Bioethics) however, the statement for male genital mutilation suggests that parents take “cultural and social issues into consideration” (Task Force on Circumcision) regardless of lack of medical necessity.
         It is commonly stated that circumcision improves the cleanliness of the penis (Morris).  This is an argument often used by supporters of circumcision, and has been a popular belief for thousands of years (Task Force on Circumcision).  Smegma, which is usually only present on an intact penis (and within females), can produce an odour, and can also is attributed to a lack of cleanliness (Morris).  Build-up of smegma can be unhealthy and unsightly if the penis is not washed regularly (Morris).
          However, as announced in the statement by the AAP, it has been found that there is little evidence suggesting there is truth in the belief that being uncircumcised is unhygienic (Task Force on Circumcision).  Those who lobby against circumcision also believe that problems with hygiene should be treated with education on proper cleaning practices, rather than surgery.  While smegma build-up can be unhealthy, normal amounts of it can provide several benefits; the substance contains several natural proteins that help kill harmful bacteria (“Penis and Foreskin”), and working as a natural moisturiser (Fliess) – all of which are lost when circumcised.
          The strongest support for circumcision comes from the potential medical benefits, which the AAP recognises in its statement on circumcision (Task Force on Circumcision).  The first of these potential benefits is the decreased risk of penile cancer (Morris), which is a type of skin cancer that occurs on the shaft of the penis.  This type of cancer can still occur in circumcised men, but it much more prevalent in intact men (Morris). 
          However, the anti-circumcision position argues that both the AAP and American Cancer Society are critical of the studies that released these results (ACS; “General Info”).  Penile cancer is more likely to be caused by multiple sexual partners and smoking.  In some populations where the circumcision rate is very low, the rate of penile cancer is even less than the United States, showing that penile cancer is probably linked to other factors, and is mostly unrelated to circumcision.  Furthermore, the penis can still be circumcised upon diagnosis if the cancer is located on the foreskin – however, if already circumcised, the penis must be partially or fully amputated.  Even still, statistically, a man is more likely to get breast cancer than cancer of the penis – or complications from the circumcision itself (ACS).
          Another potential medical benefit of circumcision is the lessened risk of urinary tract infections.  Studies have shown that in the first year of life, uncircumcised boys are 10 times more likely to develop a UTI (Task Force on Circumcision).  RIC supporters argue that this potential protection against this dangerous infection is beneficial enough to merit the surgery.
          On the other side, pro-intactivists point out that even at ten-fold risk their circumcised counterparts, the risk is still extremely low in males (Task Force on Circumcision), and that circumcision does not protect babies from UTIs, as they can still get them regardless of circumcision status (Task Force on Circumcision).  The rate of infection from a circumcision wound is the exact same as the rate of infection from a UTI (“Rebuttal”).  Also, UTIs can be treated with simple antibiotics, making invasive surgery unnecessary.  Even then, the potential benefit only exists in the first year of life (“Circ and Urinary”), and some studies have found no statistical difference in rates of UTIs between young circumcised and intact boys.
          Phimosis is the inability to retract the foreskin, which is estimated to occur in 2-10% of uncircumcised men (Morris).  Originally it was believed that this disorder, which can cause “ballooning of the penis” during urination, was harmful to the kidneys (Morris), but this was later proved to be a normal function of many intact children (“Rebuttal”).  Even though ALL infants are unable to retract the foreskin (the foreskin remains fused to the glans like a fingernail until later in life), many young boys are circumcised to prevent this rare disorder long before it can be diagnosed.  While removal of the foreskin will indeed prevent such a disorder from occurring, it can easily be treated instead with steroid cream or stretching methods.
          Balanitis and posthitis are two other medical reasons that circumcision may provide protection against. Balanitis is the inflammation of the glans of the penis, and posthitis is the inflammation of the foreskin.  Balanitis can also occur in circumcised boys, though posthitis is virtually limited to intact boys (Task Force on Circumcision; Morris).  However, The AAP acknowledges that the difference between circumcised and uncircumcised boys developing balanitis is statistically insignificant (Task Force on Circumcision).  Both are rare and can be treated without surgery, or with surgery upon diagnosis.
          Several studies suggest that circumcised men have a lower incident of STDs, including AIDS, syphilis and HPV (Morris; Task Force on Circumcision).  Because of the lower incident of HPV, which can cause cervical cancer in women partners, circumcision can be sited as a benefit in preventing both STDs and the cancers associated with it (Morris).
          However, the AAP, American Cancer Society and American Urological Association acknowledge that these studies are extremely conflicting (ACS; AUA; Task Force on Circumcision); some show less occurrence rather than more, and most have no statistical difference at all.  It is suggested that the higher incident is due to other factors (“Advocates and Critics”).  Furthermore, because STDs can be prevented with safe or monogamous sex, the studies do not provide a good reason to support RIC (ACS; AUA; Task Force on Circumcision).
          Circumcision has a very low complication rate immediately following surgery, the most common being an abnormal amount of bleeding.  Complications occur in an estimated 1-3% of circumcisions (Task Force on Circumcision).  It is suggested by pro-circs that the benefits of routine infant circumcision outweigh the risks and complications of the procedure, especially since the percentage of complications that result is a very low number, and complications are usually not serious.
          However, in later years other complications from circumcision may become obvious, and range from skin tags to severe scarring (“Complications”).  Due to the loss of the foreskin, the glans remains unprotected, causing skin to keratinise, which dulls sensitivity. Statistics on these problems are unknown; however, there is a library of anecdotal evidence, examples and case studies found in medical journals and online (“Complications”).
          Circumcision has long been an important part of Jewish and Muslim practices after the birth of a child, though the practice has varied in methods through the years.  The majority of circumcisions in America are not done for religious reasons, it is still often sited as a reason to perform circumcision in infants.  On the flip side, a movement of Reform and Independent Jews are seeking to remove the practice from the bris ceremony (Lisi).  A number of Jews already perform the bris “sans milah” (Lisi). Many Christians site religious reasonsfor circumcision, despite the fact that it is a practice of the Old Covenant and frowned upon by early Christian leaders, including Paul.
          One of the most pivotal issues concerning circumcision is its effect on sexual function.  One study done 40 years ago by Masters and Johnson suggested there was no sexual difference between circumcised and uncircumcised men (“Circumcision and Sexuality”), however most newer studies, as well as anecdotal evidence, suggest otherwise.  Many people still believe that there is no difference in sensitivity.  Those who support circumcision, but admit to lowered sensitivity, view it as a good thing because it causes men to “last longer in bed.”
          In truth, the foreskin is a complex double layer of skin that is the most sexually sensitive part of the penis (Fliess).  The foreskin, in adults, averages 15 square inches and includes the ultra-sensitive frenulum – both of which make up a total of one-half of the penis’ erogenous tissue (“Recent Studies”).  The foreskin’s multiple functions aide in both sexual function and sensitivity.  Removal of the foreskin means removal of thousands of nerves (Lisi), and causal of keratinisation of the glans, which significantly reduces sensitivity.  Though most circumcised men do not realise they have experienced a significant loss, those circumcised as adults compare the loss to “sight without color” or “wearing a glove” (“Circumcised as Adults”).
          Parents and doctors have a joint responsibility in the care of children, that is, to keep them from harm.  Many parents feel that making the choice to circumcise their son is in his well-being and is, therefore, not an infringement on personal rights, and many doctors view the practice in a similar fashion. 
          However, a rising number of men are admitting dissatisfaction with being circumcised.  Many resent being "mutilated" or are experiencing side effects from the surgery.  These men feel that permanent alteration to their bodies, outside of medical necessity, is a decision that should have been left up to them as they become adults and could make the educated choice for themselves.  Thus, many would argue that parents and doctors alike are failing in their respective duties towards the child. 
          The practice of RIC brings into question the concept of obtaining informed consent before any medical procedure is performed.  This doctrine operates on the premise that the patient (or in this case, the one making the decision) has the right to be provided with all relevant information regarding the procedure, including risks, benefits, and alternatives.  In many hospitals this important protective measure is disregarded completely, when parents are simply asked if they wish to circumcise, and given a form to sign.  As for the parents, many also question whether one person can ethically give consent to subject another to a permanent bodily alteration in the absence of medical necessity.  In evaluating whether circumcision is in the best interest of a child or whether it violates his personal rights, perhaps the most important thing to consider is the irreversible nature of the operation. An unhappy circumcised man can do nothing but "deal," whereas a man who is unhappy being uncircumcised can always make the decision at any time in his life.
          Routine infant circumcision is a medically unnecessary surgery; few will argue otherwise, regardless of position.  Though a small amount of medical organisations agree that RIC might have potential benefits, all admit that it is unnecessary, if not outright inane. In all my research, I have found that our society is gradually starting to realise the fact that circumcision is unnecessary; there are very few doctors and websites that recommend circumcision for infants outside of religious groups and the questionable Brian Morris.
          While the lack of medical necessity of circumcision holds weight, the main problem I see within the issue is that of rights. As someone who was raised in a culture that highly values personal liberties, I think that choices like this are something that should definitely be left to the person it most directly affects.  Because circumcision will affect a person for their entire lives, whether positively or negatively, the choice should not be taken away by someone else; it should be left to the person whom it affects.  Obviously, this only applies because the procedure is mostly cosmetic; I would not feel this way about something that was essential to the well-being of a child. This would be different if there were no complaints from men who have been circumcised without consent as children, but there are. Many of them.
          Overall, my belief that concludes routine infant circumcision to be unethical lies within the word “routine.”  Because it is medically unnecessary and is not treating anything, and because it has many risks and related problems, I feel that routinely circumcising an infant is not within the child’s best interest.  Legally, parents have a right to make this choice for their children.  However, ethically, parents have no right to make such life altering choices for their child -- regardless of whether the choice may heed positive or negative results – outside of medical necessity. 
          While it is very probable that most parents are genuinely concerned for the child, and are simply misinformed (In fact, I would deem it equally unethical to place blame on a parent who was simply misinformed, as opposed to a parent who knew of the risks and still chose it “just because”), I believe that when parents make cosmetic choices for their child that has a strong likelihood of heeding negative results, I feel they are not looking out for the best interests and wishes of the child, and are not doing their job as a responsible parent.  Therefore, I feel the best approach to this situation is to educate future parents so that they may make informed – and ethical – decisions during parenthood.
          While I don't doubt that there are intact men who wish to be circumcised (and wish there were as kids), I still think it is a lot easier to make them -- rather then the men who dislike being cut -- happy.  The person who has this choice is a lot better off than someone who has no choice at all.


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