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Re: The fallacy of the phimotic child and other lingering ignorance

Dear editor,

I am currently in an ongoing discussion on Richard Dawkins' forum with a young man who claims to be in an administrative position in an NHS clinic in London where male circumcisions are performed. He took it upon himself to quote anonymously some of the referral letters from GPs that it was his job to process. I suspect his aim was to try to legitimise the circumcision referrals that he deals with. Instead, it aroused a couple of gasps of disbelief from me.

His posting can be found here: http://richarddawkins.net/forum/viewtopic.php?f=1&t=44534&p=1661121#p1659369

And these are the excerpts that particularly made my jaw drop:

"Thank you for referring this eight year old young boy with the history of inability to retract the prepuce since birth. He has been okay with it for a while, but quite recently he has been troubled with recurrent infections and you have kindly treated him with doses of antibiotics. There are no other medical problems.

On examination, he has got evidence of tight phimosis.

We discussed about the various management options for phimosis at this age and finally we agreed upon on doing the circumcision. After having explained the risk involved in the procedure, I have placed him on the waiting list for GA circumcision as a day case. We hope to see him shortly."

The use of language here is certainly interesting. If we are to believe that this excerpt is legit, and not fabricated by this person - would it appear that there are some GPs on the NHS who are not aware of the fact that the foreskin is usually not only completely non-retractile at birth, but also FUSED to the glans? An anatomical fact that has been known unequivocally since Douglas Gairdner published The Fate of the Foreskin in late 1949. Almost 60 years ago. Are there some GPs who are lacking this basic knowledge about human male physiology?

Then of course there is the mention of "phimosis at this age". That's right, phimosis that apparently needs treating at eight years old. Again, would it appear that some GPs are still ignorant that the prepuces of males (and females for that matter) have no set date for becoming retractile - that some aren't able to fully retract until puberty - and that it poses absolutely no problem to the owner of the penis pre-puberty?

And I can't but have an overwhelming suspicion that forcible attempts at retraction are the root cause of the reported recent spate of infections. Are some GPs genuinely ignorant about the consequences of forcible retraction?

Another case of referred childhood circumcision for "phimosis":

"This young boy is complaining of tight foreskin. He is not able to retract it backwards and he never complains of any infection or lower urinary tract symptoms.

On examination, the foreskin is tight and when retracted back it is quite painful. I am going to arrange for him an appointment at our Day Stay Unit to have circumcision, something he agreed on. We will keep you updated with the outcome."

A boy with no "problems" besides the fact that his foreskin won't go back. The GP actually tells us he forcibly retracted the foreskin in the letter, and considers it news to the reader that this is in fact painful.

By the sounds of things, from the fact that he did the complaining himself, and the circumcision was apparently discussed with him and not his guardian - I suspect this may be more a case of a self-conscious and worried young teen than a younger child.

There is no trace of conservative treatments being offered to the boy - such as topical steroids and gentle stretching - as have been proven to resolve phimosis in the vast majority of cases, and may well be appropriate for the boy's age-group. There isn't even a hint that the doctor discussed with him that the phimosis would likely resolve itself by the time he reached 18.

Are some GPs still locked into the mindframe that complete amputation of the prepuce is the standard/only/best treatment for phimosis? And what about other issues like BXO and frenulum breve? How many GPs are aware that there are conservative and effective treatments for these issues that don't immediately resort to cutting a sizeable piece of densely innervated flesh from the genitals? Do these same GPs treat female genitals with the same flippancy, I wonder?

In light of this ignorance - I would like to offer these resources that may be of use to ANY readers (lay or professional) to read, digest, and come to their own conclusions:

A brief article explaining the care of the intact penis, covering the varying ages of full retraction and why forcible retraction should not occur: http://www.cirp.org/library/hygiene/

The definition of phimosis and the conservative treatment thereof: http://www.cirp.org/library/treatment/phimosis/

The conservative treatment of BXO: http://www.cirp.org/library/treatment/BXO/

Unfortunately I cannot find anything particularly on frenulum breve, except for a couple of news articles discussing frenuloplasty - which is one option that at least doesn't cut it ALL off. Does anyone know if gentle stretching can resolve frenulum breve?

I'd appreciate any thoughts from anyone in the medical circle on this matter.

Thanks in advance,

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Re: Circumcision of males lessens female pleasure

Dear Editor,

I am amused by Allen B Shaw's defense of male circumcision while stating, "... removal of the clitoris reduces female sexual pleasure, its unjustifiable purpose."

A small word to the good doctor. As a circumcised WASP female, born and raised in Kansas, I can assure you that clitoridectomy indeed reduces female sexual pleasure and is unjustifiable, but circumcision of the male also detrimentally impacts not only male but female sexual pleasure as well.

All circumcision began in the USA as a means of lessening everyone's sexual pleasure. i find sex with a circumcised male to be completely useless, whereas sex with an intact male works just fine, though I may never know the potential that is available to normal, natural, uncut female bodies. I suspect that cut men also may never begin to know what they have been missing. We can only guess.

I suspect it takes two natural, whole bodies to make really fine music.

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Re: The double standard for male and female suffering

Dear Editors,

Fox and Thomson found it "striking" that male and female genital cutting are treated so very differently in law. One explanation for this is that men are expected to endure pain whereas women should be sheltered and protected.

Such an assertion is easy to dismiss as academic theorising. However, the effect of this cultural blindness can be demonstrated in the reports of the Sydney Morning Herald to the forcible circumcision of men, women and children in Ambon, Indonesia, on 27 January 2001 http://www.cirp.org/news/morningherald01-27- 01/

Dominating the Herald report was a courageous woman, Christine Sagat. She revealed the atrocities that she and others had suffered at the hands of the fanatics, and was even willing to be photographed.

'They told me to undress and sit on a chair which was covered with white cloth. "Open your legs," they said. I saw under the chair a coconut shell filled with water and a kitchen knife. I said, "Oh My god, what would happen to me?" I was so scared, upset too. But I did not dare to resist them. I didn't want to be killed. "At first the woman soaked her fingers in the water and then inserted them into my vagina as she looked for the clitoris. After she found it she pulled it out, took out the kitchen knife and cut it. That hurt very much. I shed tears. They left just like that without giving me any medication."

She was not the only one who suffered this brutal assault. Her niece, who was eight months pregnant, and her mother who is in her 70s were also circumcised.

Christine's body healed, but the emotional scars remained: "I was lucky. I had some money and went to the store immediately to get antibiotics. My scar healed quite fast, but the sad, humiliated feeling stayed until today."

She elaborated: " I feel like I'm no long 'complete' both as a person and a woman."

However, she also acknowledged something else: "I know the men suffered more than us women. The circumcision hurt them more than it did to us because their scars could not heal fast. Several of the men I knew got serious infections after suffering from severe bleeding."

What happened to Kostantinus Idi was much less prominently reported, tucked in an article entitled, 'Terror attacks in the name of religion'

"I could not escape," he said. "One of them held up my foreskin between pieces of wood while another cut me with a razor ... the third man held my head back, ready to pour water down my throat if I screamed.

"But I couldn't help but scream and he poured the water. I kept screaming aloud and vomited. I couldn't stand the pain."

However, there was another indignity.

'Idi said one of the clerics urinated on his wound, saying it would stop infection.

"All of the men at the house were cut using the same razor," he said. "That night they circumcised about 60 men. I was bleeding all over and had nothing to cover my wound. I was told to take a bath but it kept bleeding until the next day. I could not imagine any greater pain. One of my friends got infected and was taken to hospital when we arrived in Ambon."

Without doubt, men and women and children suffered terribly at the hands of their assailants. All suffered physical, emotional and sexual assault. All were exposed to infection. However, the men had the added danger of excessive bleeding, for the human foreskin has an exceptionally rich blood supply.

While no one should minimise the sufferings of women, the reporting of this atrocity consistently underplayed the suffering of the men. Both Christina Sagat and, Kostantinus Idi showed enormous courage in telling their story to Herald reporters. Christina was exceptionally brave in agreeing to be photographed. However, Christina's story was told in an article of that name with a heading an inch high, Kostantinus's story was tucked into a secondary article on the same page entitled 'Terror attacks in the name of religion'.

The Herald's leading article began: "Islamic extremists are committing atrocities against women and children" An illustration of Christine Sagat praying before a statue of Jesus had the caption: "Fear and pain Christina Sagat, one of hundreds of Christians forcibly circumcised by Muslim clerics."

Almost the entire attention has been directed towards Christina, so forced circumcision was presented as an outrage against woman rather than an abuse of both sexes.

Letters published the following Tuesday (30 January) didn't even mention the men's suffering: '[W]hen "religious" action means forced female circumcision we need to ask whether this is religious freedom or criminal behaviour.' Dave Burrows, Marrickville

'The most vile and abhorrent act must be female circumcision in the name of religion, happening on our doorstep in Ambon.' Alastair Browne, Cromer Heights

This last comment so impressed the editor, that it was used as a caption for all the letters about the situation in Ambon.

Christine Sagat stated that the men suffered even more than the women did. However, this point was not followed up. Why?

One reason could be that the acceptance of infant circumcision blinds us to atrocities such as the forced circumcision of the men in Ambon. Infants are frequently circumcised without anaesthesia when only a few days old. Like Kostantinus Idi, these tiny babies also scream and show other signs of distress. And, despite our best efforts, some suffer infections, too.

If we allow this to happen to tiny babies, what moral ground have we to protest against the same thing happening to grown men?

In our society, there is an enormous indifference to men's health. Male death rates during the working years are double and even triple the comparable female death rates. Male suicide rates are much higher than comparable female suicide rates.

Enormous efforts are made to prevent, treat and cure breast, uterine and ovarian cancer in women. By comparison, prostate cancer is a poor relation, and testicular cancer, though it is mainly afflicts young men, is almost ignored in the media. There is far more attention to road fatalities (a general problem) than to workplace fatalities (a predominantly male problem), even though workplace incidents kill more people overall.

Send letter to journal:
Re: Re: Boo to circumcision

Dear Editor

Allen B Shaw suggests that individuals commenting on the BMA Guidance on male circumcision should declare if they are bereft of, or the proud possessors of a prepuce. He also says that 'surely there must be some bold spirits among the circumcised, articulate enough to protest about the violation of their own rights in childhood. Yet no sound is heard.'

First therefore I will declare that I was circumcised for no medical reason and have no memory of having an intact body. I consider that I have been genitally mutilated. Unlike Allen B Shaw however, I am fully aware of my loss. I do not need to have lost a limb to know that I would be at a disadvantage if I was without one. The same reasoning applies to a foreskin.

With regard to his comments that 'No sound is heard', I am the General Manager of NORM-UK, a registered charity formed to help men who have been damaged either physically or psychologically by circumcision. We have now handled in excess of 5,000 enquiries. The sound is there if people are prepared to listen.

Following the publication of the Fox and Thomson report, our Chairman Dr John Warren has written to the All Party Group on Men's Health asking them to investigate the situation. We agree that the Medical Ethics Committee of the BMA has more work to do in this respect.

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Re: Hurrah for circumcision

Dear Editor

I am delighted that Trevor Perry agrees that the debate about the medical aspects of male circumcision is not closed, because most correspondents think that it is.

One correspondent argues that removal of the richly innervated prepuce delays ejaculation. Now rapid ejaculation may have had evolutionary benefit, when wild animals or rivals often interrupted coitus. In more civilised times we would wish to prolong coitus to enhance female satisfaction. Perhaps it is a sacrifice that man should make for his mate, if not his maker. On the other hand removal of the clitoris reduces female sexual pleasure, its unjustifiable purpose. Those circumcised for medical reasons, whose predilection is variety not constancy, should also remember that circumcision offers some protection against HIV. Students will forgive an old doctor for reminding them that yesterday’s dogma is today’s anathema, and may yet be dogma tomorrow.

I am also grateful to Trevor Perry for following my lead in coming out of the closet. But our frankness is useless until all contributors follow suit. I am also grateful to him for reminding me that the important issue is whether those circumcised for religious, not medical reasons, object to what was done. Unless he can show that many of those object, then Fox and Thomson are indeed patronising them, however learned they might be.

Otherwise Trevor Perry is misguided. I quoted Fox and Thomson, when I said that men may wish their sons to resemble them, and they quoted four other authors. Perhaps he should read their article.

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Re: Re: Boo to circumcision

Dear Editor

Allen Shaw's suggestion, that Fox and Thomson have made an "unwise" proposal in urging legal sanctions against male circumcision, is poorly founded.

His first premise is muddled. In hypothetical language, Shaw suggests that the presence or absence of an author's prepuce "may" lead papers to be "rationalisations of emotional attitudes." Primarily, this argument should be discounted because he provides no substantial evidence that males do indeed "all wish others of our sex to resemble us." This, the lynchpin of the premise, is an assumption. Shaw's argument would be better served if he could cite actual subjectivity on the part of the authors in the text, instead of conjecturing about the possibility of subjectivity.

Shaw's second premise is as wanting. He misconstrues the authors as assuming "that the medical case against circumcision is beyond doubt." First, the authors have not made this assumption. Instead, they have cited authoritative evidence, based on empirical observations, that at best, the harm to benefit ratio is difficult to ascertain, and at worst, the harms outweigh the benefits. Included in Fox and Thomson's analysis is the link to medical responsibility with regard to surrogate consent. Shaw's own words, that "it is hard to know the balance," confirm the authors' message: there is not enough medical justification for surrogate consent to be acceptable. At the very least there ought to be a moratorium on infant circumcision until substantial and clear knowledge is gained. Again we find that Shaw has not proven Fox and Thomson's proposal to be "unwise."

His next opposition to legal restrictions is as conjecturally misguided as his first. The perpetuation of the practice of genital mutilation is not self-justifying. Considering that unnumbered voices, contrary to Shaw's assumption, are being heard condemning circumcision, that the majority of males living today are not circumcized, and that annual circumcision rates are declining in the United States, we have reason to believe, using Allen's logic, that people, including males, are recognizing the ethically questionable nature of circumcision, including its harms. Shaw is even welcome to consider me "some bold spirit among the circumcised, articulate enough to protest about the violation of their own rights in childhood." As for Fox and Thomson being "patronising," it is fair to consider them as learned bioethicists whose duty is to inform popular opinion, medicine, and law. Their criticism of the BMA is within this duty.

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Re: Male circumcision should no longer masquerade as medical treatment

Dear Editor,

Fox and Thomson[1] have injected a note of rationality into debate over male circumcision with their conclusion that there is no compelling legal authority for the view that the practice is lawful. They have presented a thorough critique of the BMA's 2003 guidance document.[2] It is however instructive to examine the statement from the BMA guidance that "Male circumcision in cases where there is a clear clinical need is not normally controversial" against the advice "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 evidence for the efficacy of conservative treatment is, in most cases presently treated by circumcision, overwhelming. As this deviates from the standard teaching of the medical curriculum, it is appropriate to outline the evidence in respect of what have recently been considered the main clinical indications for male circumcision.

Uncomplicated phimosis can be treated by potent topical steroids or by simple conservative surgery.[3-5] Clearly it is inappropriate to remove histologically normal tissue since this is amenable to plastic correction. Paraphimosis too can be treated by an overwhelming array of conservative treatments.[6] Balanitis should be treated in accordance with clinical guidelines.[7] Recurrent balanitis can be managed by restriction of washing with soap.[8]

Current medical teaching has it that preputial lichen sclerosus, otherwise known as "BXO",[9] is an "absolute" indication for circumcision. Lichen sclerosus should however be treated according to clinical guidelines.[10] At least one controlled trial has confirmed that topical steroids will effectively treat "BXO" in a percentage of cases.[11] A greater number of less rigorous studies have shown that potent topical steroids are effective for phimosis involving lichen sclerosus.[12-17] The percentage effectiveness appears to be directly related to the potency of the steroid used. A success rate of 70% has been reported by Jorgensen for clobetasol diproprionate.[12]

Three recent studies undermine the Law Commission's argument for stating that circumcision is not, by their definition based on reducing sexual pleasure, a mutilation.[18-20] Decreased sexual satisfaction secondary to circumcision has been demonstrated in 17%,[18] 27%[19] and 38%[20] of patients. Moreover, since it comprises a wound under section 20 of the Offences against the Person Act, 1861, male circumcision's lawfulness must be in serious doubt. Indeed it may arguably constitute grievous bodily harm.

Male circumcision would be ethical and appropriate only in cases of severe preputial lichen sclerosus which do not respond to conservative treatment; or in rare cases where the prepuce is irredeemably damaged due to necrosis or malignancy. The time has come for medical associations to caution their members that the removal of normal tissue from normal unconsenting children is always unethical. The medical school curriculum must urgently be updated to remove spurious clinical indications for this outmoded form of treatment.

References

1. Fox M, Thomson M. A covenant with the status quo? Male circumcision and the new BMA guidance to doctors. J Med Eth. 2005; 31(8):463﷓9.

2. British Medical Association. The law and ethics of male circumcision: guidance for doctors. London: BMA, 2003.

3. Dewan PA, Tieu HC, and Chieng BS. Phimosis: is circumcision necessary? J Paediatr Child Health. 1996;32(4):285﷓9.

4. Berdeu D, Sauze L, Ha-Vinh P and Blum-Boisgard C. Cost- effectiveness of treatments for phimosis: a comparison of surgical and medicinal approaches and their economic effect. BJU Int. 2001;87:239﷓244.

5. Van Howe RS. Cost-effective treatment of phimosis. Pediatrics. 1998;102:E43.

6. Little B, White M. Treatment options for paraphimosis. Int J Clin Pract. 2005; 55(9):591﷓3. 7. No author identified. National guideline for the management of balanitis. Sex Transm Infect. 1999; 75(Suppl 1):S85-8.

8. Birley HDL, Walker MM, Luzzi GA, Bell R, Taylor-Robinson D, Byrne M, Renton AM. Clinical Features and Management of Recurrent Balanitis; Association with Atopy and Genital Washing. Genitourin Med. 1993; 69:400- 3.

9. Hinchliffe SA, Ciftci AO, Khine MM, Rickwood AMK, Ashwood J, McGill F, Clapham EM, van Velzen D. Composition of the inflammatory infiltrate in pediatric penile lichen sclerosus et atrophicus (balanitis xerotica obliterans): a prospective, comparative immunophenotyping study. Pediatr Pathol. 1994; 14:223-233.

10. Neill SM, Tatnall FM, Cox NH. Guidelines for the management of lichen sclerosus. Br J Dermatol. 2002; 147:640-9.

11. Kiss A, Csontai A, Pirot L, Nyirady P, Merksz M, Kiraly L. The response of balanitis xerotica obliterans to local steroid application compared with placebo in children. J Urol. 2001; 165(1):219-20.

12. Jorgensen ET, Svensson A. The Treatment of Phimosis in Boys, with A Potent Topical Steroid (Clobetasol propionate 0.05%) Cream. Acta Derm Venerol (stockh). 1993; 73(1):55﷓56.

13. Pasieczny TAH. The treatment of balanitis xerotica obliterans with testosterone propionate ointment. Acta Derm Venerol (stockh). 1977; 57:275-7.

14. Dahlman-Ghozlan K, Hedbald MA, Von Krogh G. Penile lichen sclerosus et atrophicus treated with clobetasol diproprionate 0:05% cream: a retrospective clinical and histopathalogical study. J Am Acad Dermatol. 1999; 40(3):451-7.

15. Neuhaus IM, Skidmore RA. Balanitis Xerotica Obliterans and Its Differential Diagnosis. J Am Board Fam Pract. 1999; 12(6):473-6.

16. Poynter JH, Levy J. Balanitis xerotica obliterans: effective treatment with topical and sublesional corticosteroids. Br J Urol. 1967; 39:420-5.

17. Vincent MV, MacKinnon E. The response of clinical balanitis xerotica obliterans to the application of topical steroid﷓based creams. J Pediatr Surg. 2005; 40(4):709-12.

18. Masood S, Patel HR, Himpson RC, Palmer JH, Mufti GR, Sheriff MK. Penile sensitivity and sexual satisfaction after circumcision: are we informing men correctly? Urol Int. 2005; 75(1):62-6.

19. Coursey JW, Morey AF, McAninch JW, Summerton DJ, Secrest C, White P, Miller K, Pieczonka C, Hochberg D, Armenakas N. Erectile function after anterior urethroplasty. J Urol. 2001; 166(6):2273-6.

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Re: Boo to circumcision

Dear Editor,

Although Fox and Thomson make interesting comments on the BMA guidance on male circumcision, their proposal to make it unlawful is unwise.

First, there is room for doubt about the objectivity of views on this matter. They declare no interests, but can this be true of any male writer? They point out that fathers want their sons to resemble themselves, and to a degree we may all wish others of our sex to resmble us. Therefore male authors should state whether they are bereft of, or are proud possessors of a prepuce. If most opponents of circumcision are intact, and most defenders are mutilated, we may wonder to what extent papers are rationalisations of emotional attitudes. As Ayer might have said "boo to circumcision". Of course arguments must still be countered. If my guess is wrong, it will be reassuring. Accordingly I must confess to dispossession, and having no memory of my brief time intact on this earth, perhaps do not know what I am missing, figuratively speaking.

Next they assume that the medical case against circumcision is beyond doubt. But there is a substantial body of contrary opinion. The truth is probably that some suffer, some benefit, and most are little affected: it is hard to know the balance.

They wish to protect the human rights of the infant, but surely there must be some bold spirits among the circumcised, articulate enough to protest about the violation of their own rights in childhood. Yet no sound is heard. Indeed many give retrospective approval by circumcising their own sons. Among them are doctors, who might not allow social pressure to make them harm their children. So is it not a shade patronising of the authors to defend those, who will later deny any need for defence?

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Re: Re: A decontextualised analogy

Dear Editor,

Michael Benatar's defense of his "narrow point" linking circumcision with "breast reduction, liposuction and rhinoplasty" does not address the issue of what constitutes "mutilation" in the case of infant circumcision. Where an adult may not feel deprived of his or her prepuce when amputated with his or her personal consent, an infant never has that choice. An infant's screams of protest make the deprivation an absolute and can never be anything other than a mutilation by definition when done for non- therapeutic reasons. It has everything to do with the consent issue and simply cannot be separated from it. It should also be noted that proxy consent in most Western countries is invalid in the case of female circumcision and is, by logical extension, invalid in the case of infant male circumcision as well. For a myriad of social, political, and religious reasons, the law is not being applied equally.

Further, Mr. Benatar asserts that "appearance-altering removal of healthy tissue is not a sufficient condition for mutilation." While this may possibly be true in the case of an adult making a free choice, it is not true in a case where the amputation is forced upon an minor child without medical necessity. Nor is the circumcision of a child merely an appearance-altering ablation, but is, as the ground-breaking research of Taylor, Lockwood, Cold and others clearly shows, the forced excision of a highly innervated, functional structure indispensable to normal sexual function.[1-8]

These researchers show that the prepuce is a unique, complex structure composed of thousands of specialized nerves working in concert with Meissner’s corpuscles, vascular systems, and stimuli receptors that have evolved over millions of years to maximize human sexual experience. Such an amputation deprives an individual of a normal penis and of the full range and depth of sexual pleasure it provides. It would be analogous to cutting off an index finger or big toe to the functioning of hand or foot. This, by any definition found in any standard English dictionary is a mutilation when done for no therapeutic reason and against the victim's will. To permanently amputate any body part from the non-consenting for non-therapeutic reasons is an ethical lapse of significant gravity and has no place in a modern medical context. Fox and Thompson and many others in the legal and ethical fields have taken note of this and are now in the process of making this outmoded, medical and cultural relic accountable to law and ethics [9-19].

Rio Cruz, PhD
Executive Co-Director
International Coalition for Genital Integrity

References

1. Winkelmann, R. K. 1956. The cutaneous innervation of human newborn prepuce. Journal of Investigative Dermatology 26(1):53– 67. 1959

2. Lakshmanan, S., and S. Prakash. 1980. Human prepuce: Some aspects of structure and function. Indian Journal of Surgery (44):134–37.

3. Taylor, J. R., A. P. Lockwood, and A. J. Taylor. 1996. The prepuce: Specialized mucosa of the penis and its loss to circumcision. British Journal of Urology 77:291–95.

4. Halata, Z., and A. Spaethe. 1997. Sensory innervation of the human penis. Advances in Experimental Medicine and Biology 424:265–66.

5. Fleiss, P. M., F. M. Hodges, and R. S. Van Howe. 1998. Immunological functions of the human prepuce. Sexually Transmitted Infections 74(5):364–67.

6. Cold, C., and K. McGrath. 1999. Anatomy and histology of the penile and clitoral prepuce in primates. In Male and female circumcision: Medical, legal, and ethical considerations in pediatric practice, ed. G. C. Denniston, F. M. Hodges, and M. F. Milos. New York: Kluwer Academic/Plenum Publishers.

7. Cold, C. J., and J. R. Taylor. 1999. The prepuce. British Journal of Urology International 83 (Suppl. 1):34–44.

8. O'Hara K, O'Hara J. The effect of male circumcision on the sexual enjoyment of the female partner. BJU International 1999; 83, Suppl. 1:79-84.

9. Brigman, W. E. 1984. Circumcision as child abuse: The legal and constitutional issues. University of Louisville School of Law. Journal of Family Law 23(3):1984–85

10. Dwyer, J. G. 1994. Parents’ religion and children’s welfare: Debunking the doctrine of parents’ rights. California Law Review 82(6):1371–1447.

11. Denniston, G. C. 1996. Circumcision and the code of ethics. Humane Health International 12(2):78–80.

12. Chessler, A. 1997. Justifying the unjustifiable: Rite v. wrong. Buffalo Law Review 45:555–612.

13. Smith, J. 1998. Male circumcision and the rights of the child. In To Baehr in our minds: Essays in human rights from the heart of the Netherlands, ed. M. Bulterman, A. Hendriks, and J. Smith, 465–98. Utrecht: Netherlands Institute of Human Rights, University of Utrecht.

14. Price, C. 1999. Male circumcision: An ethical and legal affront. Bulletin of Medical Ethics, May, 13–19

15. Povenmire, R. 1999. Do parents have the legal authority to consent to the surgical amputation of normal, healthy tissue from their infant children? The practice of circumcision in the United States. Journal of Gender, Social Policy and the Law 7(1):87–123, 1998–99.

16. Van Howe, R. 1999. Involuntary circumcision: The legal issues. BJU International 83(Suppl. 1):63–73.

17. Boyle, G. J., J. S. Svoboda, C. P. Price, and J. N. Turner. 2000. Circumcision of healthy boys: Criminal assault? Journal of Law and Medicine 7:301–10.

18. Somerville, M. A. 2000. Altering baby boys’ bodies: the ethics of infant male circumcision. In The ethical canary: Science, society and the human spirit, M. A. Somerville, 202–19. Toronto: Viking.

19. Svoboda, J. S., R. S. Van Howe, and J. G. Dwyer. 2000. Informed consent for neonatal circumcision: An ethical and legal conundrum. Journal of Contemporary Health Law Policy 17:61–133.

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Re: Circumcision not equally balanced between harms and benefits

Dear Editor,

Fox and Thomson's critique of infant male circumcision and the BMA's updated guidance to doctors rightly focuses on the "harm/benefit assessment which lies at the heart of the male circumcision debate." A common error made by circumcision proponents is that the benefits and harms are so equally balanced that it's a toss up.

This is incorrect. To count a medical intervention as having benefit or therapeutic value requires that the "benefit" greatly outweighs the risks and harms necessary to obtain it. Further, that the intervention is the only rational way to obtain these proffered benefits and that they are necessary to the overall health of the child. Infant circumcision does not fill any of these criteria. Neither does it take into consideration the obvious fact that the prepuce has a valid, beneficial, and evolutionary purpose and justifiably belongs to the owner, not his parents, his religion, his peer group, the medical establishment or anyone else. Under these circumstances, we are no more justified in amputating an infant's foreskin against his will than we are in cutting off an ear, nose or limb unless there is clear medical necessity and the amputation is the least invasive treatment available.

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Re: Justifying the Unjustifiable

Dear Editor:

The Benatar brothers once again attempt to “justify the unjustifiable”, as Chessler so aptly put it.¹ One has to admire their dogged defence of their position, even after the American Journal of Bioethics published devastating criticism of their earlier paper.²

Mutilation

They still fail to understand the nature of mutilation. Mutilation is the destruction of appearance or function. Circumcision does both. In addition to altering appearance by replacing normal tissue with scar tissue, circumcision alters function in the following ways:

Protective functions. The foreskin protects the glans penis throughout life. The amputation of the foreskin of infants is well documented to cause meatal ulceration and meatal stenosis.^3-5 The protective foreskin keeps the surface of the glans penis clean, free of infection, smooth, moist, supple, and sensitive.⁶

Gliding action. The looseness of the foreskin allows it to glide back and forth during sexual intercourse.⁷ The gliding action provides effortless penetration⁸ and reduction of friction and chafing.⁹ Circumcision tightens the penile skin and destroys the gliding action, causing difficult insertion¹⁰ and abrasive intercourse.⁹

Sensation. Anatomic investigation shows the foreskin to be highly innervated tissue.¹¹ Excision of the foreskin and its nerves causes weakened erectile function,¹² decreased penile sensitivity,¹² loss of erectile confidence,¹⁰ delayed ejaculation,¹³ and prolonged intercourse,¹⁰ all of which are indicative of diminished sensory input.

Circumcision, therefore, readily qualifies as mutilation.

Surrogate Consent

The Benatars also fail to grasp the distinction between personal consent and surrogate consent.² They cite breast reduction, liposuction, and rhinoplasty as examples of ethical procedures that remove healthy tissue. These procedures are commonly performed on adults who have very broad powers to consent, while non-therapeutic circumcisions usually are performed on children who are legally unable to consent, so the consent can only be granted by a surrogate, usually a parent, who has very limited powers to consent.²

The Benatars improperly attempt to validate parental surrogate consent for non-therapeutic consent by comparing non-therapeutic circumcision to vaccination.² The comparison is inapposite because vaccination enjoys medical approval,¹⁴ while non-therapeutic circumcision does not.

It is well established that surrogate consent must be exercised only in the best interests of the child and no one else.¹⁵ Surrogates and doctors have a duty to protect the child’s rights.^15,16 Parental rights do not override child rights.¹⁶ The attending physician must provide the medical care the child needs, not what someone else wants.¹⁷ Parental consent is not valid unless it is preceded by a physician’s diagnosis of disease and a recommendation for treatment thereof. Parental cultural or ethnic views, family traditions, and the like are not interests of the child and simply do not qualify as excuses to violate his body.¹⁸

Conclusion

The Benatars’ humanitarian efforts would be better directed toward ending circumcision in their native South Africa where numerous youths die from its complications every year.¹⁹

George Hill, Bioethicist Executive Secretary

John V. Geisheker, J.D, LL.M. General Counsel

Doctors Opposing Circumcision
Suite 42
2442 NW Market Street
Seattle, Washington 98107-4137
USA
Web: http://www.doctorsopposingcircumcision.org

References

1. Chessler AB. Justifying the Unjustifiable: Rite v. Wrong. Buffalo L Rev 1997;45:555-613.
2. Benatar M, Benatar B. Between prophylaxis and child abuse: The bioethics of neonatal male circumcision. Am J Bioethics 2003;3(2):35-48.
3. Freud P. The ulcerated urethral meatus in male children. J Pediatr 1947;31(4):131-41.
4. Gairdner D. The fate of the foreskin: a study of circumcision. Br Med J 1949;2:1433-7.
5. Upadhyay V, Hammodat HM, Pease PW. Post circumcision meatal stenosis: 12 years' experience. N Z Med J 1998;111(1060):57-8.
6. Fleiss P, Hodges F, Van Howe RS. Immunological functions of the human prepuce. Sex Trans Inf 1998;74(5):364-7.
7. Lakshmanan S, Prakash S. Human prepuce: some aspects of structure and function. Indian J Surg 1980;44:134-7.
8. Taves D. The intromission function of the foreskin. Med Hypotheses 2002;59(2):180.
9. Warren J, Bigelow J. The case against circumcision. Br J Sex Med 1994; Sept/Oct: 6-8.
10. Shen Z, Chen S, Zhu C, et al. [Erectile function evaluation after adult circumcision]. Zhonghua Nan Ke Xue 2004;10(1):18-9. [PubMed]
11. Taylor JR, Lockwood AP, Taylor AJ. The prepuce: specialized mucosa of the penis and its loss to circumcision. Br J Urol 1996;77:291-5. [PubMed]
12. Fink KS, Carson CC, DeVellis RF. Adult circumcision outcomes study: effect on erectile function, penile sensitivity, sexual activity and satisfaction. J Urol 2002;167(5):2113-6. [Abstract]
13. Senkul T, Iseri C, Sen B. et al. Circumcision in adults: effect on sexual function. Urology 2004;63(1):155-8.
14. Committee on Infectious Disease. Recommended Childhood and Adolescent Immunization Schedule: United States, 2005. Pediatrics 2005:115(2):182. [Full Text]
15. British Medical Association. The law and ethics of male circumcision: guidance for doctors. London: BMA, 2003. [Full Text]
16. Hellsten SK. Rationalising circumcision: from tradition to fashion, from public health to individual freedom—critical notes on cultural persistence of the practice of genital mutilation. J Med Ethics 2004;30:248-53. [Full Text]
17. American Academy of Pediatrics Committee on Bioethics. Informed consent, parental permission, and assent in pediatric practice. Pediatrics 1995;95(2):314-7.
18. Article 20(1). Convention for the Protection of Human Rights and Dignity of the Human Being with regard to the Application of Biology and Medicine: Convention on Human Rights and Biomedicine. Adopted at Oviedo, 4 April 1997. [Full Text]
19. Circumcisions leave 20 dead. South African Press Association, 19 July 2005. [Full Text]

Send letter to journal:
Re: A decontextualised analogy

Dear Editor,

M. Fox and M. Thomson [1] say that we [2] draw analogies between male circumcision and other surgical procedures such as breast reduction, liposuction and rhinoplasty. They argue that such analogies are "seriously flawed" because, unlike circumcision, these other procedures "involve adult patients capable of consenting" to them.

This criticism, as we have explained elsewhere [3], takes our analogy out of context. We never claimed that circumcision is analogous to these other procedures in every way. Instead, we used the analogy to make one very limited point – that appearance-altering removal of healthy tissue is not a sufficient condition for mutilation. We illustrated this by noting that although breast reduction, liposuction and rhinoplasty involve the removal of healthy tissue they are plausibly not thought of as mutilation. This has nothing to do with the consent issue, which we examined separately.

References

1) M. Fox, M Thomson, "A covenant with the status quo? Male circumcision and the new BMA guidance to doctors" J Med Ethics 2005; 31: 463-469.

2) M Benatar, D Benatar, "Between prophylaxis and child abuse: the ethics of neonatal male circumcision" Am J Bioeth 2003; 3(2): 35-48.

Send letter to journal:
Re: Wrong Focus on Effects

Dear Editor,

Having read your article on the ethics of male circumcision, I can totally agree that no lawful reason can be justified to excise healthy sexual tissue (or any other for that matter) from non-consenting minors.

International law makes clear that it is unlawful to force someone into a religion without their free and non-coerced consent, yet sexual mutilation in the name of religion does exactly that. The right of the child to body integrity exceeds the right of the parent to impose their will upon the child.

Your paper seems to agree with the concept that ritual circumcision is similar to tattooing, ear piercing or violent sports, but to compare the former to the latter reveals a complete lack of understanding of the issue of sexual mutilation. The former removes permanently a large proportion of the sexually erogenous tissue from the male, almost always from a minor and therefore without the free and legal consent of the victim. The latter carry no permanent harm or loss, unless one suffers a debilitating injury during participation in sport, or HIV infection during tattooing and ear piercing. But most importantly, all of the latter can safely be presumed to be carried out with consent. Few minors get tattoos or participate in violent sports.

The greatest error of your paper occurs when you swallow whole the unsubstantiated fiction that circumcision does not alter or diminish the enjoyment of sexual intercourse. You are apparently ignorant of the innervation of the foreskin and ridged band, and of the anatomical studies that have shown that the ridged band and frenulum contain the vast majority of erogenous nerve receptors. The ridged band is always removed, and the frenulum greatly damaged by circumcision when the mutilator does not specifically attempt to remove it all.

Send letter to journal:
Re: Future Laws and Religious Concerns: A USA Perspective

Dear Editor,

Fox and Thompson make a significant contribution to the body of literature about the ethics of neonatal circumcision. If law is to be ethical, how then shall it fulfil a requirement to protect children from unnecessary surgery involving amputation of parts of the genitals? If laws are enacted to prohibit male circumcision, as have been enacted to prohibit female circumcision, should government carve out exceptions for millennia old religious practices that involve such surgery?

Perhaps existing laws, against child abuse and endangerment, are sufficient to prohibit and criminalize infant and child circumcision, but if they continue to be interpreted as inapplicable by prosecutors, new laws may be needed.

In the United States, government curtails certain activities of religious groups that pertain to children of adult adherents. This is done variously by judicial decree or legislative enactment. Courts have ordered physicians and hospitals to provide critical medical care, over the objections of parents, to children of Christian Scientists and Jehovah's Witnesses. In some states where church members practice the handling of deadly snakes to prove their faith, state statutes now prohibit the involvement of children under 18 years of age. In such cases there has been great reluctance to interfere with the religious freedom assured by the Constitution, but government interest in protecting children has prevailed. Since neonatal circumcision sometimes causes death or dismemberment of its subjects, should government have less interest in prohibiting it? Now that research shows that much sensory tissue designed to communicate sexual sensations is lost to circumcision (p.34, Cold & Taylor), should the law be idle regarding infant male circumcision, and the right of a child to decide as an adult what is to become of his prepuce?

Almost all Muslim males are circumcised sometime during childhood or as youths. Many Jewish infants undergo ritual Jewish circumcision, but in the US a majority of Jewish infants receive hospital circumcisions alongside Gentile infants (p.216, Glick). It is often argued that a prohibition on infant and child circumcision is impermissible as it would interfere with the religious desires of Jews and Muslims to circumcise their infants and children. Could they be excluded from the effects of a law of otherwise general application? Would such exclusion send a signal that government regards the human rights of Jewish and Muslim children as less important than those of other children?

One US organization proposes a law, applicable to males, and similar to the national prohibition of female circumcision. Progress is very slow for proponents, hindered by a continuing belief that parents of males must be empowered to decide whether or not to circumcise their sons. Does that belief, and its sustenance of inaction on a law pertaining to male circumcision, threaten the laws against female circumcision? What if some parents of girls invoke their right to equal protection of the law in a constitutional attack on the laws against female circumcision? Indeed, why should they not have rights equal to those of parents of male children? Even if there is no equivalency of male circumcision to female circumcision (there is a good case for some equivalency), don't we now know enough about the adverse effects of male circumcision to decide it should not be performed on non-consenting infants and children?

It is ironic that Fox and Thomson cite Dr Lewis Sayre's work. Sayre's claims of fantastical cures from circumcision are often used to show how strange it is that we have widespread infant circumcision in the English speaking world. What is never mentioned is that Sayre carefully avoided total foreskin amputation, opting instead for removing the tip only of a restrictive prepuce, or for a dorsal slit only, when possible. He appears to have been interested only in immediate, existing pathological phimosis as a cause of disease. He advocated the retention of almost all of the foreskin to preserve most of its functions. He considered more radical cutting to be "unjustifiable mutilation." He also protested widespread routine, or universal, circumcision (pp.158-60, Glick). Is there a lesson, for today's advocates of indiscriminate circumcision, in his desire to preserve as much of the foreskin? Sayre did not have an anti-sexual agenda as did many of his contemporaries, and he acknowledged the value of the male prepuce.

Thanks to Fox and Thomson, we are closer to confronting many long neglected questions about this surgery that has never been adopted by 80% of the world's population.

Richard Russell, JD

Moreno Valley, California

References

Cold, C.J., and Taylor, J.R. "The prepuce," British Journal of Urology, Volume 83, Supplement 1, January 1999.

Glick, Leonard B. Marked in Your Flesh: Circumcision from Ancient Judea to Modern America. Oxford and New York: Oxford University Press, 2005.

Send letter to journal:
Re: Circumcision Bioethics: A Proposal for Reform

To the Editor:

We at Doctors Opposing Circumcision (DOC) are gratified by the publication of this paper by Fox and Thompson.¹ They confirm the position previously taken by the Norwegian Council for Medical Ethics that male non-therapeutic circumcision violates important principles of medical ethics.² Their findings also are consistent with Articles 1, 2, and 20 of the European Convention on Human Rights and Bioethics.³

DOC concurs with their criticism of the British Medical Association (BMA) statement. As previously reported, we think it is deficient in that it fails to recognize 1) the probable unlawfulness of the circumcision of male children, 2) the lack of medical value, 3) the complications, risks, and other disadvantages, 4) the functional value of the prepuce, 5) the inherent violations of human rights, and 6) the clearly unethical nature of child circumcision.⁴

Lawfulness

We also believe that non-therapeutic circumcision of children is already unlawful, because the mutilative nature of circumcision makes it a violation of existing child protection laws. For example, a man from Clark County, Washington, USA currently is in gaol for three years for child assault because he attempted to perform a religiously motivated non-therapeutic circumcision on his son.⁵ Without medical justification, may a parent do by proxy consent what he cannot legally do himself?

We think that, in England and Wales, the circumcision of children is a misdemeanour under the Children and Young Persons Act (1933). The continued performance of non-therapeutic circumcision on children in Britain and elsewhere depends on the failure of public prosecutors to enforce existing law.

Where do we go from here?

Doctors have a clear duty to decline all inefficacious or unethical operations on minors. DOC has prepared a guidance on conscientious objection to the performance of non-therapeutic circumcision on children that provides justification and authority for refusing to perform a non-therapeutic circumcision on a child.⁶ We recommend that all doctors who may be asked to perform a non-therapeutic circumcision of a child download a copy from our website so they may be acquainted with their ethical rights and duties.

Certainly, the Medical Ethics Committee of the BMA has more work to do. A revision to the 2003 statement already is needed because of its original inadequacies.

The General Medical Council needs to grasp this nettle firmly. It is time to cast out its temporizing 1997 policy. A new guidance for doctors that is consistent with the UN Convention on the Rights of the Child (1989) and Articles 1,2, and 20 of the European Convention on Human Rights and Bioethics (1997) is needed.

In a case involving caning, the European Court of Human Rights ruled:

Children and other vulnerable individuals, in particular, are entitled to State protection, in the form of effective deterrence, against such serious breaches of personal integrity.⁷

We believe that this should apply at least as forcefully to cases of bodily mutilation as to cases of caning. Action by Parliament may be necessary to provide effective deterrence.

Medical societies world-wide have an ethical duty to inform their members of the unethical status of non-therapeutic circumcision of children. Medical Licencing Boards have a duty to issue regulations regarding the non-therapeutic circumcision of children to ensure that medical practice in their jurisdiction complies with the highest standards of medical ethics.

These actions will usher in a new era in which doctors respect the legal right of children to genital integrity.

George Hill, Bioethicist Executive Secretary

John V. Geisheker, J.D, LL.M. General Counsel

Doctors Opposing Circumcision
Suite 42
2442 NW Market Street
Seattle, Washington 98107-4137
USA
Web: http://www.doctorsopposingcircumcision.org

References

1. Fox M, Thomson M. A covenant with the status quo? Male circumcision and the new BMA guidance to doctors. J Med Ethics 2005;31(8):463-9. [Full Text]
2. Gulbrandsen P. Rituell omskjæring av gutter. [Ritual circumcision of boys.] Tidsskr Nor Lægeforen [Journal of the Norwegian Medical Association] 2001;121(25):2994. [Full Text] (In Norwegian)
3. Convention for the Protection of Human Rights and Dignity of the Human Being with regard to the Application of Biology and Medicine: Convention on Human Rights and Biomedicine. Adopted at Oviedo, 4 April 1997. [Full Text]
4. Hill G. BMA circumcision guidance has significant omissions. BMJ; Rapid Response: 14 April 2003. [Full Text]
5. Stephanie Rice. Circumcision Attempt—Father sentenced to three years. The Columbian, Vancouver, Washington, Thursday, December 16, 2004.
6. Denniston GC, Geisheker JV, Hill G. Conscientious Objection to the Performance of Non-Therapeutic Circumcision of Children. Seattle: Doctors Opposing Circumcision, 2005. [Full Text] (PDF)
7. A. v United Kingdom. [1998] 2 FLR 959. (In the European Court of Human Rights)