Jump to comment:

• Muddled thinking and unsubstantiated assumptions
  Robert S. Van Howe
  Published on: 18 May 2017
• Circumcised by Force
  Michael Glass
  Published on: 18 May 2017
• Male circumcision as a public health policy: ethical challenges
  Michel L. GARENNE
  Published on: 18 May 2017

• Published on: 18 May 2017

  Muddled thinking and unsubstantiated assumptions

  • Robert S. Van Howe, Physician

  The analysis of the role of circumcision as a preventive for HIV infection provided by Rennie et al. is driven by the social norm to circumcise [1] and shows a failure to appreciate the place of circumcision within the context of other HIV preventives, the ethics of recommending a health care intervention, the applicability of proxy-consent, and everyone's right to autonomy and security of person. In addition, the analysis is...

  Show More

  The analysis of the role of circumcision as a preventive for HIV infection provided by Rennie et al. is driven by the social norm to circumcise [1] and shows a failure to appreciate the place of circumcision within the context of other HIV preventives, the ethics of recommending a health care intervention, the applicability of proxy-consent, and everyone's right to autonomy and security of person. In addition, the analysis is riddled with inaccuracies and unsubstantiated assumptions [2]. Finally, circumcision as an intervention for the general population may be misplaced.

  Where circumcision fits in:

  Three randomized clinical trials of the impact of adult circumcision on HIV infection risk were recently completed in Africa.[3-5] Although the subjects were randomized, the studies have several serious methodological problems including selection bias, high crossover rates, lead time bias, expectation bias (both on the part of the subjects and the investigators), possible coercion for subject sign up (free circumcision, two weeks pay, and two years of free health care), attrition bias, questionable randomization practices, and early termination (which amplified the lead time bias). These studies only followed the subjects for 18 to 24 months, so the long-term impact is unknown. The treatment effect was fairly small with an absolute risk reduction ranging from 0.9% to 1.8%. The relative risk reduction was 53% to 60%. The cost per circumcision ranged between $55 and $69. Extrapolating these results to the general adult African population, using circumcision to delay the acquisition of HIV would costs between $1269 and $3911 for each case of HIV averted.[6] However, as the Rennie et al. have pointed out, there are serious doubts about the ability to duplicate these result outside of a research setting.

  By contrast, a study using aggressive surveillance and treatment of sexually transmitted infections found that it cost only $217.62 (1993 USD) per HIV infection averted. HIV risk was reduced by 42%, the sexually transmitted infections in study population were treated, and no one lost the most sensitive portion of their penis.[7] Condoms, when used consistently, offer about 99% protection. They cost between 2¢ and 2.5¢ each.[8] So for the cost of one circumcision in Africa, 3500 condoms could be secured. That's enough for protected daily intercourse over the next ten years.

  A concerted effort of promoting condom use with commercial sex workers in Thailand substantially reduced the HIV infection rate there.[9] Likewise, an approach of ABC (Abstinence, Be faithful, Condoms) reduced the rate of HIV in Uganda was by 50%.[9] Rennie et al. do not need to wait for "[o]ther, less invasive and more effective methods of HIV prevention" to be discovered, because they already exist.

  Male circumcision is not as promising as a vaccine. Vaccines that are commonly administered offer over 90% protection from illness despite repeated exposure. The HIV vaccines, to date, have not shown as much promise, which explains why they are not currently in use. To compare circumcision to a vaccine is like comparing the use of oral contraceptives to using the rhythm method to prevent pregnancy.[10]

  Finally, if condom use offers 99% protection, what value does circumcision add? Basically, circumcision is for men who want to engage in risky sexual behaviors but need to believe they have done something to reduce their risk.

  THE ETHICS OF "RECOMMENDATION"

  The definition of "recommend" is to put forward something with approval. In a given medical situation a physician can consider the interventions and respond in four ways: 1) to actively discourage the intervention, 2) to offer no advice, 3) to offer the intervention as an alternative, or 4) to recommend the intervention. Rennie et al. make the assumption that the intervention of male circumcision falls into the fourth category without making the case that this is appropriate.

  If an intervention is more likely to result in harm than benefit, then the physician should actively discourage it. If the risks and benefits are equally matched or unknown or minimal, then no advice is appropriate. For interventions with potential benefits the distinction between recommending it and offering it as an alternative involves comparing the alternatives regarding effectiveness, side effects, invasiveness, costs, availability, and expected compliance.

  For example, primary enuresis has four interventions: 1) do nothing and 15% will resolve spontaneously each year, 2) vasopressin, which is moderately successful but has a high relapse rate and is very expensive, 3) imipramine, which is successful while you stay on it, is inexpensive, but is extremely hazardous if moderate amounts are ingested accidentally, and 4) operant conditioning using a enuresis alarm, which has a moderate initial expense, has no side effects, and cures the condition in 85%. Of these alternatives, the enuresis alarm is the recommended therapy because it is the most successful, has the least side effects, and in the long term is the least expensive of the active interventions. The only issue may be compliance. The two medications could be offered as alternatives, with the physician noting why they are offered but not recommended. Circumcision as a preventive for HIV infection needs to be compared to the alternatives. The ABC approach is more effective (99%-100% protection versus 50%), less expensive (the money to provide one circumcision in Africa can purchase 3500 condoms), has fewer side effects (and has the additional benefits of protecting against sexually transmitted diseases and unwanted pregnancies), is less invasive (no bodily parts are amputated), and are more readily available (especially in developing nations). The only unsettled component is compliance. Compliance can depend on social pressures and how persuasively health care workers promote condoms.

  Based on this comparison, it would be unethical for health care workers to recommend circumcision over the ABC approach. At best circumcision can be offered as an alternative while making it clear that it is less effective, more invasive, more expensive, and has more side effects than the ABC approach.

  To recommend an intervention when more effective, less expensive, less harmful, and less invasive alternatives exist would be unethical.

  PROXY CONSENT AND THE CIRCUMCISION OF NEWBORNS

  Rennie et al. correctly characterize the position of circumcision advocates, such as Benatar and Benatar, who believe that neonatal circumcision does not threaten the health and the safety of the infant sufficiently to disallow a parent's right to have their child circumcised for non-medical reasons.[11] They fail to address the assumptions that underlie this position.

  The first assumption is that circumcision in newborns is ethical. This premise needs to be established, as it is rather easy to argue the alternative. For example, the American Academy of Pediatrics Committee on Bioethics states that surgery on a newborn is only ethical when there is a medical indication (such as disease, trauma, or deformity) and waiting until the child is old enough to give their own consent would result in further illness or loss of health.[12] A similar approach has also be upheld in the legal system.[13] Without a compelling medical indication that cannot be obtained without waiting, circumcision fails to meet this criteria.

  The second assumption is that parents have a right to direct a physician to circumcise their infant. We have addressed this issue in detail elsewhere, and after looking at ethical and legal standards, parents do not have the authority (legally or ethically) to provide proxy consent for the procedure.[13] To date, the only justification in the literature for parents having the authority to direct a physician to circumcise their child refused to engage the ethical or legal arguments, but focused on the political arguments.[14] Rather than assume that parents have this authority, Rennie et al. need demonstrate that they are ethically entitled to this authority.

  The third assumption is that a neutral outcome is sufficient to justify a surgical intervention on a non-consenting minor. This has two components, namely that the outcome is neutral and that neutrality is a sufficient justification. Cost-utility analyses have at best found circumcision to be health neutral,[15-17] while a more comprehensive cost- utility analysis found neonatal circumcision impairs overall health.[18] For the sake of argument, it can be assumed that the outcome of newborn circumcision is neutral.

  Performing a surgery on a non-consenting infant to obtain a neutral result is unethical for several reasons. 1) It violates his right to bodily integrity and security or person.[19] 2) It takes advantage of a person in a vulnerable group. In another realm of medical ethics, the Helsinki Declaration and US Federal Regulations require additional protections for children involved in clinical research because of their vulnerability and that the child is exposed to minimal harm.[20,21] 3) A neutral outcome can be obtained without intervention, which is much less invasive and incurs no financial cost or use of resources. 4) Physicians receive financial remuneration for performing the surgery. For a physician to perform a surgery that benefits the physician without benefiting the patient is considered unethical by the American Medical Association.[22]

  To validate the third assumption, Rennie et al. need to demonstrate that infants are not entitled to bodily integrity or security of person, are not a vulnerable group in need of additional protections, that circumcision meets the minimal harm standard, and that physicians are not financially reimbursed for the procedure.

  In contrast to accurately portraying the position of those favoring circumcision, Rennie et al. characterize the positions of those who object to circumcision by providing a strawman. The ethical objections to neonatal circumcision extend well beyond noting an absence of a defined and sustainable benefit and a reliance on the principle of "do no harm." Additional objections would include the permanent loss of the most sensitive portion of the penis,[23] inadequate pain control,[24] serious surgical complications (including death),[25] and violating the infant's right to bodily integrity.[19]

  Comparisons of parental proxy-consent for therapeutic interventions and vaccinations and parental proxy-consent for circumcision are likewise not valid. Parents can give proxy consent for prophylactic and preventative measures if they preserve either public or private health. Circumcision does not meet these criteria.[26] The authors need to find an example where parents are allowed to give proxy-consent for the removal of healthy, non-deformed tissue in an infant. The most logical equivalent would be the removal of the prepuce in females. Even though there is evidence that surgically altering female genitals is associated with decreased risk of HIV infection in Africa,[27] such an intervention is currently illegal in the U.S.

  AUTONOMY, WHAT AUTONOMY?

  The authors argue that there are several aspects of circumcising immediately prior to the time of sexual debut that reflect positively on the infant option. Anyone who has been in an automobile with an adolescent behind the wheel knows that the perception of risk among young men at sexual debut is highly distorted. This may apply to sexual practices as well as driving. Yet, there has to be a point at which autonomy is fully vested in the individual and not their guardians. The authors argue "Given the vagaries of adolescent decision-making and the gravity of the decision, parents may reasonably wish to choose circumcision for their infants rather than wait for their sons to decide for themselves." The authors are afraid that many men in their adolescence might refuse circumcision from not accurately accessing their risk for HIV infection. A more likely explanation for the low rate for volunteer circumcision in young adults (3 per 1000[28]) is that genitally intact males value their foreskins.

  If the newborn is not circumcised we are confronted with the thorny issue of assent of the adolescent. Rennie et al. appear to endorse a position in which assent is only valid if the adolescent agrees with his parents to be circumcised.[29] If this is the case, then why bother with obtaining assent? The authors have positioned themselves into an ethical quagmire. On one hand they feel perfectly comfortable denying autonomy rights to the infant, but uncomfortable denying the same rights to a 16- year-old. This antithetical position is common where the cultural tradition of altering the genitals of newborn boys has a greater priority than individual autonomy and the right to security of person.

  The authors fail to acknowledge that the adolescent may have very good reasons for not assenting. The adolescent may want to follow the creed of his religion and not engage in fornication or adultery and marry a woman with the same belief structure and diligence. There is clearly no need for this male to be circumcised. Likewise, a decision to use condoms consistently would provide risk reduction well above that of circumcision. These are rational decisions that reduce the risk of HIV to nearly zero and avoid a painful surgery that removes the most sensitive portion of the penis. To circumcise this person without consent is battery. Any physician who would perform a circumcision on an adolescent without their assent would be acting in an unethical manner.

  One problem with many adolescents is that are not articulate enough to express the reasoning behind their decisions. Although adolescents make many poor decisions, they have the autonomy to make them.

  The authors also suggest that circumcising in the newborn period obviates the need to "conveying information about sexuality and HIV/AIDS to the young person." This is frightening, especially when everyone promoting circumcision for prevention of HIV still recommends consistent condom use and education. If HIV infections are important enough to violate the child's autonomy, then the risk of infection is important enough to teach young people about risks.

  UNSUBSTANTIATED ASSUMPTIONS

  1) Rennie et al. assert that the protective effect of circumcision is greater when performed earlier in a male's life based on one study, when other studies have provided conflicting results.[30,31] More importantly, there are no studies that demonstrate that infant circumcision decreases the risk of HIV infection.

  2) Rennie et al. assert that "Circumcision at an early age can also avoid the thorny problem of risk compensation" and that "it is unlikely that the intervention would have an impact on a man's HIV risk perception." This assertion is made without reference. To the contrary, a representative population survey of men in the United States, where nearly all of circumcised men are circumcised as infants, found that circumcised men were more likely to engage in high-risk sexual behaviors,[32] which suggests that risk compensation does occur following infant circumcision.

  3) The authors state, "Opponents of neonatal circumcision typically argue that surgical removal of a healthy child's foreskin without his informed consent is always wrong." It is interesting that the authors are inclined to believe that only opponents of neonatal circumcision would make such a claim, when nearly every mainstream bioethicist would argue that any medical intervention in a non-emergent setting without informed consent violates the patient's autonomy rights.[33]

  4) The authors fail to understand the differences between circumcision and vaccinations. Vaccines are given primarily for infectious diseases for two reasons: to prevent infection in the individual and to prevent spread of the infection in the community. Vaccines that are currently administered have very high efficacies. Just because a vaccine exists, it does not mean it is routinely recommended. For example, there is a vaccine for tuberculosis (TB), but it is not used in the United States because it has low efficacy and the incidence of TB in U.S. is low enough that administration of the vaccine interferes with proper, timely diagnosis of the TB. Vaccines are used because they are effective, have an acceptable rate of side effects, and are the best available option. Circumcision of infants is not known to be effective. For the illnesses that circumcision proponents believe to be impacted by neonatal circumcision, there are other less invasive, more effective interventions. The authors then ask the readers to imagine what it would be like if research showed that the neonatal circumcision could offer long-term vaccine-level protections against HIV transmission. Under ideal conditions in a research setting with coerced and motivated subjects, 50% protection was seen. This is far short of the 90% protection that is generally expected from vaccines and 99% protection the ABC can provide. Likewise, in the absence of a long-term study, long-term protection can only be speculated. Currently there are no long-term studies planned.

  FOCUS ON HIGH RISK POPULATIONS

  Finally, the timing of circumcision is a moot point. Currently, the only sustained epidemic of heterosexually transmitted HIV is occurring in sub-Saharan Africa. This epidemic is driven by the high sexual partner exchange rate and having concurrent sexual partners in large open sexual networks.[9] A country's HIV infection rate is not associated with male circumcision rate, but rather social factors that promote these high risk behaviors.[34] According the James Chin, a prominent HIV/AIDS epidemiologist, a sustained heterosexual HIV epidemic without these high risk sexual behaviors is nearly impossible.[9] Consequently, general implementation of circumcision outside of sub-Saharan Africa would have little impact on an epidemic that is not going to happen. Chin recommends that our energies be focused on those populations exhibiting high-risk behaviors and partners of those already infected with HIV. It is impossible to predict what behaviors an infant will exhibit in later life.

  ACKNOWELEDGEMENTS, COMPETEING INTERESTS, FUNDING:

  None.

  References:

  1. Waldeck SE. Using male circumcision to understand social norms as multipliers. U Cinn L Rev 2003; 72: 455-526.

  2. Rennie S, Muula AS, Westreich D. Male circumcision and HIV prevention: ethical, medical and public health tradeoffs in low-income countries. J Med Ethics 2007; 33: 357-61.

  3. Auvert B, Taljaard D, Lagarde E, et al. Randomized, controlled intervention trial of male circumcision for reduction of HIV infection risk: The ANRS 1265 Trial. PLoS Med 2005; 2(11): e298.

  4. Bailey RC, Moses S, Parker CB, et al. Male circumcision for HIV prevention in young men in Kisumu, Kenya: a randomised controlled trial. Lancet 2007; 369: 643-56.

  5. Gray RH, Kigozi G, Serwadda D, et al. Male circumcision for HIV prevention in men in Rakai, Uganda: a randomised trial. Lancet 2007; 369: 657-66.

  6. Gray RH, Li X, Kigozi G, Serwadda D, et al. The impact of male circumcision on HIV incidence and cost per infection prevented: a stochastic simulation model from Rakai, Uganda. AIDS 2007; 21: 845-50.

  7. Gilson L, Mkanje R, Grosskurth H, et al. Cost-effectiveness of improved treatment services for sexually transmitted diseases in preventing HIV-1 infection in Mwanza Region, Tanzania. Lancet 1997; 350: 1805-9.

  8. Shelton JD, Johnston B. Condom gap in Africa: evidence from donor agencies and key informants. Br Med J 2001; 323: 139.

  9. Chin J. The AIDS pandemic: the collision of epidemiology with political correctness. Oxford: Radcliffe Publishing; 2007.

  10. Garenne M. Male circumcision and HIV control in Africa. PLoS Med 2006; 3: e78.

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

  12. Committee on Bioethics. Informed consent, parental permission, and assent in pediatric practice. Pediatrics 1995; 95: 314-17.

  13. Svoboda JS, Van Howe RS, Dwyer JG. Informed consent for neonatal circumcision: an ethical and legal conundrum. J Contemp Health Law Policy 2000; 17: 61-133.

  14. Viens AM. Value judgment, harm, and religious liberty. J Med Ethics 2004; 30: 241-7.

  15. Chessare JB. Circumcision: is the risk of urinary tract infection really the pivotal issue? Clin Pediatr Phila 1992; 31: 100-4.

  16. Ganiats TG, Humphrey JB, Taras HL, et al. Routine neonatal circumcision: a cost-utility analysis. Med Decis Making 1991; 11: 282-93.

  17. Lawler FH, Bisonni RS, Holtgrave DR. Circumcision: a decision analysis of its medical value. Fam Med 1991; 23: 587-93.

  18. Van Howe RS. A cost-utility analysis of neonatal circumcision. Med Decis Making 2004; 24: 584-601.

  19. Universal Declaration of Human Rights, Article 25(2), G.A. Resolution 217A (III), UN Doc. No. A/810 (1948), adopted December 10, 1948; International Covenant on Civil and Political Rights, UN GA Resolution 2200 A [XXI], December 16, 1966.

  20. World Medical Association Declaration of Helsinki. Ethical principles for medical research involving human subjects. <http://www.wma.net/e/policy/17-c_e.html> (Accessed December 6, 2001).

  21. Code of Federal Regulations. Title 45 Public Welfare. Department of Health and Human Services. Part 46 – Protection of Human Subjects (45 CFR §46).

  22. American Medical Association Council on Ethical and Judicial Affairs. The Code of Medical Ethics: Current Opinions with Annotations. 1996-1997 Edition. Chicago, IL: American Medical Association; 1997.

  23. Sorrells ML, Snyder JL, Reiss MD, et al. Fine-touch pressure thresholds in the adult penis. BJU Int 2007; 99: 864-9.

  24. Van Howe RS. Anaesthesia for circumcision: a review of the literature. In Denniston GC, Hodges FM, Milos MF, eds. Male and Female Circumcision: Medical, Legal, and Ethical Considerations in Pediatric Practice. New York: Kluwer Academic/Plenum Publisher; 1999: 67-97.

  25. Paediatric Death Review Committee: Office of the Chief Coroner of Ontario. Circumcision: a minor procedure? Paediatr Child Health 2007; 12: 311-2.

  26. Hodges FM, Svoboda JS, Van Howe RS. Prophylactic interventions on children: balancing human rights with public health. J Med Ethics 2002; 28: 10-6.

  27. Stallings RY, Karugendo E. Female circumcision and HIV infection in Tanzania: for better or for worse?[abstract] Third International AIDS Society Conference on HIV Pathogenesis and Treatment. Rio de Janeiro, July 25-27, 2005.

  28. Wallerstein E. Circumcision An American Health Fallacy. New York: Springer Publishing Company; 1980.

  29. Shield JPH, Baum JD. Children’s consent to treatment: listen to the children — they will have to live with the decision. Br Med J 1994; 308: 1182-3.

  30. Kelly R, Kiwanuka N, Wawer MJ, Serwadda D, Sewankambo NK, Wabwire -Mangen F, Li C, Konde-Lule JK, Lutalo T, Makumbi F, Gray RH. Age of male circumcision and risk of prevalent HIV infection in rural Uganda. AIDS 1999; 13: 399-405.

  31. Quigley M, Munguti K, Grosskurth H, Todd J, Mosha F, Senkoro K, Newell J, Mayaud P, ka-Gina G, Klokke A, Mabey D, Gavyole A, Hayes R. Sexual behaviour patterns and other risk factors for HIV infection in rural Tanzania: a case-control study. AIDS 1997; 11: 237-48.

  32. Laumann EO, Masi CM, Zuckerman EW. Circumcision in the United States: prevalence, prophylactic effects, and sexual practice. JAMA 1997; 277: 1052-7.

  33. Etchells E, Sharpe G, Walsh P, Williams JR, Singer PA. Bioethics for clinicians: 1. Consent. Can Med Assoc J 1996; 155: 177-80.

  34. Talbott JR. Size matters: the number of prostitutes and the global HIV/AIDS pandemic. PLoS One 2007; 2(6): e543.

  Show Less

  Conflict of Interest:
  None declared.

  • Back to top
• Published on: 18 May 2017

  Circumcised by Force

  • Michael Glass, retired

  Dear Editor,

  Rennie, Muula and Westreich are right to draw attention to ethical questions surrounding circumcision. This is particularly important, especially now, when circumcision is being promoted as a way of reducing the chances of contracting HIV. I want to draw attention to something that is clearly unethical: forced circumcision.

  When Muslim extremists forcibly circumcised Christian men, women and...

  Show More

  Dear Editor,

  Rennie, Muula and Westreich are right to draw attention to ethical questions surrounding circumcision. This is particularly important, especially now, when circumcision is being promoted as a way of reducing the chances of contracting HIV. I want to draw attention to something that is clearly unethical: forced circumcision.

  When Muslim extremists forcibly circumcised Christian men, women and children in Ambon, Indonesia, the Sydney Morning Herald, reported:

  ' Victims have told the Herald of multiple cuttings with the same knives and razors that caused many to suffer infections.

  ' In the biggest city in the islands, Ambon, church and other groups have gathered evidence that 3,928 villagers on at least six islands have been forced to convert to Islam under the threat of death, torture or destruction of their homes.

  ' They believe that local Muslim clerics, possibly under duress from extremists, circumcised almost all the converts.

  ' Moderate Muslim leaders have condemned the forced conversions and circumcisions, saying they are contrary to Islamic teachings.

  ' The Muslim Governor of Maluku, Saleh Latuconsina, this week led an investigation team to the island of Kesui, 420 kilometres south-east of Ambon City, after receiving an official report in late December confirming villagers there converted to Islam against their will and were circumcised.' [1]

  Muslim authorities were right to condemn this human rights abuse. One man described what happened to him thus:

  ' "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." '

  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." ' [2]

  A woman described what happened to her:

  ' 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.

  ' I was lucky, I had some money and went to the store immediately to get antibiotics. I know the men suffered more than us women. The circumcision hurt them more that 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.

  ' My scar healed quite fast, but the sad, humiliated feeling stayed until today.' [3]

  While the reporter revealed the suffering of both sexes, the Sydney Morning Herald gave far more prominence to the woman’s story. Letters that followed [4] denounced female genital mutilation but were silent about the forced circumcision of the men. However, Christina testified that the men suffered even more than the women from infections and bleeding and took longer to recover.

  The Koran states, “There shall be no compulsion in religion,”[5] but for centuries, accounts of forced circumcisions have followed Muslim attacks on others. In Iran with the coming of the Muslims, Zoroastrians converted to Islam to avoid being enslaved and were forcibly circumcised [6] . Forced circumcisions followed the capture of British soldiers in India by Tipu Sultan of Mysore after the Battle of Pollilur in 1780 [7] and there are other reports in the Indian media of forced conversions and circumcisions during Muslim rule in India [8] . There are accounts of forced conversions and circumcisions of Armenians in the Armenian Genocide [9] , The1955 pogrom against Greeks and Armenians in Turkey, again resulted in accounts of forced circumcisions [10] . There are also claims of the forcible circumcision of Serbian soldiers in former Yugoslavia [11] . From the Sudan in 2003 came a report of both boys and girls being forcibly circumcised and raped [12] .

  But these aren’t the only ones forcing circumcision on others. In April 2005, a Nepalese boy escaped from a male brothel in Mumbai, India, and revealed details of the trafficking of underage boys in India.

  ' “I spent seven years in hell,” says Raju, now 21, trying hard not to cry. Thapa Magar took him to Rani Haveli, a brothel in Mumbai that specialised in male sex workers and sold him for Nepali Rs 85,000.

  ' A Muslim man ran the flesh trade there in young boys and girls, most of them lured from Nepal.

  ' For two years, Raju was kept locked up, taught to dress as a girl and circumcised. Many of the other boys there were castrated. Beatings and starvation became a part of his life.' [13]

  Forced circumcisions can even happen in Australia. Late in 1996, Irwin Brookdale was drinking with a group of Aborigines on the banks of a river in far north Queensland. After he passed out, a woman in the group felt down his pants, found out that he was not circumcised and called on her companions to ‘make a man out of him.’ They attempted to circumcise him with broken beer bottle and Brookdale ended up in hospital. One man was convicted of unlawful wounding and Brookdale was awarded $10,000 compensation for nervous shock [14] .

  In August 2002 a Kenyan man was stripped naked, frog-marched to a nearby river and forcibly circumcised by traditional surgeons as an excited crowd watched. The police stood by helplessly.[15] In November 2005, the Kenyan Human Rights Commission announced that it would seek prosecutions against politicians for inciting violence against others. One cabinet minister responded “Those who are not circumcised should be taken for a circumcision ceremony.” The Kenyan Human Rights Commission accused the Minister of inciting people to violence.[16] When two elderly men were forcibly circumcised in Busia, Kenya in August, 2006, several arrests were made and the local police chief announced that no- one would be allowed to harass uncircumcised men [17].

  Kenyan circumcision customs put such pressure on young people that the idea of free agreement to be circumcised must be questioned. One 18 year old Kenyan boy turned on the man who circumcised him immediately after his circumcision, forcing the circumciser to flee for his life.[18]

  In neighbouring Uganda, local uncircumcised men were fleeing into hiding. Mr Dan Wakayaba, 45, the father of seven children, was seized and forcibly circumcised after his wife reported him to the tribal authorities because he wasn’t circumcised. A local official said the authorities could not intervene [19] .

  South Africa has a particular problem with forced circumcisions. In 1999 there was a grisly report of young people being kidnapped, forcibly circumcised and then held for ransom. Those who threatened to expose the people involved were threatened with death. The bodies some of the kidnapped victims were found in shallow graves. The decomposed body of one victim was found – with the genitals cut off. [20]

  In July 2004, when Litha Ntshoza, was seized by relatives, dragged to a field, stripped naked and forcibly circumcised there was an outcry. But not from everyone. Litha’s father said the forced circumcision was for his own good.. When Litha fled the ceremony, bleeding and naked, two policemen took him back to the ceremony. Tribal authorities fined the father because his son ran away from the ceremony [21] South African anti- circumcision campaigner, Dean Ferris, said that circumcision without consent, was "unacceptable and illegal,". However, Rabbi Ruben Suiza, registrar of the Jewish Ecclesiastical Court, responded that "to stop circumcision would be to prevent Jews from practicing their religion."[22]

  In November 2002 Chief Mwelo Nonkonyana, the provincial chairman of the Congress of National Traditional Leaders of South Africa, said traditional leaders would never tolerate hooligans demeaning the custom of circumcision. He called for the traditional surgeon to be prosecuted along with the 30 men who abducted and forcibly circumcised a 48-year-old Port Elizabeth man to be charged,[23] [24] .

  However, early in 2005, when relatives seized a man and forcibly circumcised him, and the police rescued him and arrested and charged the man’s wife and other family members with assault [25] , traditional chiefs were contesting the ‘Westernised’ law that banned forcible circumcisions [26] . In July 2005, when a 35 year old man who was forcibly circumcised died, the police treated the death as a murder [27]. In the Transkei region, when three initiation candidates died after being circumcised, the traditional healer who ran the circumcision school where one of the victims was circumcised was charged under the Eastern Cape’s circumcision law and denied bail.[28]

  These cases show that forced circumcision is a significant issue in itself and a sign of other human rights abuses. A firm stand against forced circumcisions would go a long way towards alleviating this problem. However, there is a reluctance to accept the evidence. Despite the clear evidence in the Sydney Morning Herald of forced circumcisions in Ambon, Indonesia, a spokesman for Lascar Jihad claimed that though circumcisions took place, no- one was forced to do anything. The BBC report was headed, ‘Maluku refugees allege forced circumcision’ Thus the BBC reduced the outrage to a mere allegation. Also, the defensive reaction of Rabbi Suiza to Dean Ferris’s contention that forcible circumcision was illegal, while understandable as a reaction to an anti-circumcision campaigner, shows that action against the obvious abuse of forcible circumcision could face opposition if it is perceived as an attack on circumcision itself.

  Forced circumcisions are clearly wrong. There is no religious or other justification for them. They are totally unacceptable. Nor is it acceptable to dismiss these outrages as isolated instances of abuse, where little or nothing can be done. In fact, firm action can stop these abuses.

  When 18 children in Kirani High School in Meru, Eastern Kenya were bullied and threatened by older boys because they were not circumcised, the Principal sent the younger boys home to be circumcised.[29] However, the Education Minister George Saitoti said the action was uncalled for and against ministry regulations. "We abhor such a practice and we shall not give any chance to this kind of primitive action in our schools," said Mr Saitoti.[30] This action was controversial for many, but it did make a forceful stand for the rights of students, regardless of circumcision status [31] . Similarly, all who support human rights must support a firm and public stand against forced circumcisions. This is vital, especially in a climate when mass circumcision is being so vigorously promoted.

  Michael Glass

  References:

  [1] Lindsay Murdoch, ‘Terror attacks in the name of religion’The Sydney Morning Herald, Sydney, NSW, Australia,, Saturday January 27, 2001. http://www.cirp.org/news/ morningherald01-27-01/

  [2] Ibid.

  [3] ‘Christina’s story’, Sydney Morning Herald, 27 January 2001 http://old.smh.com.au/news/0101/27/review/ review9.html (accessed 12 January 2003)

  [4] , Michael Glass, ‘The double standard for male and female suffering’, Journal of Medical Ethics, letters 22 November 2005, http://jme.bmjjournals.com/cgi/eletters/31/8/463 (accessed 12 October 2006)

  [5] The Koran: 2:256

  [6] Iran Chamber Society, Religions of Iran “Thousands of Iranians were enslaved by Arabs one way to get out of slavery was to become Muslims since Muslims could not be enslaved and as a result many converted. All these pressures, humiliation at the time of paying jizya, deliberate destruction of temples and forced conversions resulted in massive conversions. There are accounts of Muslim rulers forcing mass circumcision on the newly converted males to make sure they had truly become Muslims.”http://www.iranchamber.com/religions/articles/ zoroaster_zoroastrians_in_iran.php

  [7] Robert Darby, ‘A Surgical Temptation: The Demonization of the Foreskin and the Rise of Circumcision in Britain’, The University of Chicago Press, Chicago & London, 2005, ISBN 0-226-13645-0, page 33

  [8] K.N. Pandita, On the Sidelines of Kashmir History Kashmir Herald, May 15 2007, http://www.kashmirherald.com/main.php?t= OP&st=D&no=263 accessed 16 May 2007

  [9] The History Place, Genocide in the 20th Century, Armenians in Turkey, 1915-1918 1,500,000 deaths http:// www.historyplace.com/worldhistory/genocide/armenians.htm

  [10] Kathimerini, Greece’s International English Language newspaper, Tuesday June 28, 2005 – Archive, (accessed 5 August 2006) http://www.ekathimerini.com/4dcgi/ _w_articles_ell_6506581_28/06/2005_57964

  [11] Serbiana http://www.serbianna.com/columns/ mb/032.shtml

  [12] ‘Michael Coren, ‘Sudan’s Slaves’, by, Sun Media, FRONTPAGE, Toronto, Ontario, 25 November, 2003 http:// www.cirp.org/news/frontpage11-25-03/

  A former slave writes of "the rape of girls and boys alike, the forced circumcision of boys and girls, often with them fully conscious and screaming and having to be held down by many people. Sodomy and sadistic torture are common. Living hell."

  [13] Former sex worker’s tale spurs rescue mission, Gulf Times, Doha, Qatar,

  10 April, 2005, http://www.gulf-times.com/site/topics/ article.asp?cu_no=2&item_no=32822&version=1&template_id= 44&parent_id=24 <http://www.gulf-times.com/site/topics/ article.asp?cu_no=2&item_no=32822&version=1& amp;template_id=44&parent_id=24> , accessed, 25 May 2007.

  [14] ‘Court awards man $10 000 for beer bottle circumcision’ http://www.cirp.org/news/1997.10.08_Australia/

  [15] Man forcibly Circumcised as Crowd Watches, The Nation, Nairobi, Kenya, 23 August 2002 http://www.cirp.org/ news/thenation08-23-02/

  [16] Ayub Savula ,“Six ministers on violence List of Shame” The East African Standard, Nairobi, Kenya, Saturday November 12, 2005

  http://www.eastandard.net/hm_news/news.php?articleid=32065

  [17] Ouma Wanzala “Man held over circumcision incident,” Kenya Times, 2006. http://www.timesnews.co.ke/ 18aug06/nwsstory/news5.html

  [18] ‘Drama As 'Cut' Youth Hits Back’. The East African Standard, Nairobi, Kenya, 15 August 2002. http:// www.cirp.org/news/eastafricanstandard08-15-02/

  [19] ‘Bagisu flee circumcision’, The Monitor, Kampala, 25 August 2004 http://allafrica.com/stories/ 200408250493.html

  [20] Sibusiso Bubesi, ‘Children kidnapped and mutilated Boy threatened with death after investigation into circumcision Sunday Times, South Africa, 14 March 1999

  http://www.suntimes.co.za/1999/03/14/news/news03.htm

  [21] Melanie Peters, ‘Rastafarian circumcised against his will’ Sunday Tribune, South Africa, 4 July 2004, http:// www.iol.co.za/index.php?set_id=1&click_id=13&art_id= vn20040704124240917C136839 <http://www.iol.co.za/ index.php?set_id=1&click_id=13&art_id= vn20040704124240917C136839>

  Johnson Mesi, ‘Initiate runs away’ City Vision, Western Cape, South Africa, , 22 July 2004

  http://www.news24.com/Regional_Papers/Components/ Category_Article_Text_Template/0,2430,433_1561694~E,00.html

  [22] Cleveland Jewish News, ‘World News, Circumcision support cuts across cultures’ 24 July 2004 http:// www.clevelandjewishnews.com/articles/2004/07/22/news/world/ aaa.txt

  [23] Lulamile Feni ‘Chiefs condemn forcible initiation’ Daily Dispatch Online 12 November 2004, http:// www.dispatch.co.za/2004/11/12/Easterncape/bcirc.html

  [24] ‘Circumcision: Surgeon held 09/11/2004’, News 24.com http://www.news24.com/News24/South_Africa/ News/0,6119,2-7-1442_1618165,00.html

  [25] Myolisi Gophe, ‘Wife held after husband's forced circumcision’ The Cape Argus’ 2 April 2005, page 4 , http:// www.iol.co.za/ge neral/news/newsprint.php?art_id= vn20050402105526481C764086&sf <http://www.iol.co.za/ ge%20neral/news/newsprint.php?art_id= vn20050402105526481C764086&sf> =

  [26] ibid.

  [27] ‘Botched circumcisions leave more dead’ SABC News 5 July 2005, http://www.sabcnews.com/south_africa/ health/0,2172,107717,00.html

  [28] ibid.

  [29] Noel Mwakugu, Circumcision row divides Kenya town, BBC News, Meru, 16 February 2007, http:// news.bbc.co.uk/1/hi/world/africa/6367807.stm

  [30] Ibid.

  [31] Lawrence Kinoti, “Circumcision As an Admission Criterion” The East African Standard (Nairobi), February 21, 2007

  http://allafrica.com/stories/printable/200702201384.html

  Show Less

  Conflict of Interest:
  None declared.

  • Back to top
• Published on: 18 May 2017

  Male circumcision as a public health policy: ethical challenges

  • Michel L. GARENNE, Demographer

  Dear Editor,

  The article by Stuart Rennie, Adamson Muula and Daniel Westreich [JME, 33:357], which focuses on the promotion of male circumcision for public health purposes, raises many practical issues, economic issues and ethical issues. The ethics of male circumcision have been already widely discussed, especially from a physician perspective [1]. Here we focus on the arguments developed by Rennie and colleagues...

  Show More

  Dear Editor,

  The article by Stuart Rennie, Adamson Muula and Daniel Westreich [JME, 33:357], which focuses on the promotion of male circumcision for public health purposes, raises many practical issues, economic issues and ethical issues. The ethics of male circumcision have been already widely discussed, especially from a physician perspective [1]. Here we focus on the arguments developed by Rennie and colleagues with emphasis on the population perspective.

  Firstly, to recommend systematic male circumcision, a genital mutilation, as a public health policy raises in itself many ethical concerns. Even with solid epidemiological evidence, male circumcision would not be considered acceptable in most European, Latin-American or Far -East Asian countries, for a variety of reasons ranging from low efficacy to lack of cultural acceptance. Secondly, male circumcision violates basic principles of ethics:

  1) Autonomy: To achieve full efficiency such a policy would have to focus on neonatal circumcision. In this case however, it would violate basic children’s rights, and would be illegal in a variety of countries. As the authors rightly point out, if recommended in adolescence or adulthood it would have a much lower acceptance rate. The argument of “child’s best interest” is highly controversial, since it all depends on who defines it. A European, Latin-American or Far-East Asian family will usually consider their child’s best interest to remain uncircumcised. Comparison with recommended vaccines (authors quote DPT) is misleading since these vaccines have a very high efficacy, a very low rate of complications, no stigma associated with them, and provide huge population benefits at low cost. As a result, most parents all over the world consider vaccination to be in their child’s best interest.

  2) Non-malevolence (first do no harm): Male circumcision does harm the person who endures it: numerous risks associated with the surgical procedure have been described, including death, and in addition male circumcision reduces the sensitivity of the glans, and induces stigmatisation. Furthermore, mass circumcision in countries with poor hygiene could lead to transmission of infectious diseases, ranging from Hepatitis B and C to HIV.

  3) Benevolence: The assumed “benevolence” is also highly questionable, and this has been a recurrent issue over the past 150 years. Male circumcision has been presented as a prevention against a wide array of infectious diseases, cancers, non-communicable diseases, mental disorders, without any serious epidemiological proof. Countries practicing widely male circumcision have basically the same morbidity rates for these conditions as others, and in particular for sexually transmitted infections [2, 3].

  At the individual level, male circumcision offers no protection per se, and most agree that, circumcised or not, when exposed during an intercourse with an infected partner the only protection is to use a condom. When exposed repeatedly, the reduced risk of transmission associated with circumcision will simply delay the date of infection.

  The potential population impact is worth considering, since a reduction in the risk of contamination by males could have some kind of a population impact. However, empirical evidence from Africa tells a different story: a meta-analysis of the 11 DHS/AIS surveys conducted in Africa with data on both male circumcision and HIV seroprevalence indicate the same level of infection for circumcised and uncircumcised men (Odds ratio= 0.97, P= 0.264). These data are collected independently, on large representative samples of the general population, totalling 47976 men, and constitute probably the most convincing piece of evidence of the population impact of male circumcision. Hiding this fact also raises some important ethical issues.

  Alternative strategies:

  Other strategies do exist to control the spread of HIV/AIDS. A mix of changing sexual behaviour (in particular reducing number of partners for young adults) and systematic condom use for risky intercourse were shown to be effective in changing the course of HIV epidemics in various settings, including in Africa [4]. Is it ethical to recommend a strategy for which no population impact has ever been shown, when alternative efficient strategies do exist? In the field of fertility control, contraceptive methods with low efficacy in clinical trials (such as the rhythm method) are not recommended because alternative strategies exist and are more effective. Similarly, in the field of vaccination, vaccines with low efficacy (such as the cholera vaccine) are not recommended, because again alternative strategies exist.

  Lastly, a large program focused on male circumcision might reduce the public efforts already made in the prevention of HIV, and might give false hope to persons who will consider themselves as somehow protected. Both are likely to have negative consequences.

  References:

  [1] Doctors opposing male circumcision. Medical ethics and the circumcision of children. Report, 2006. [available on web site: http://www.doctorsopposingcircumcision.org/pdf/A4-MedicalEthicsReport.pdf

  [2] Darby R. A surgical temptation. Chicago: University of Chicago Press, 2005.

  [3] Aggleton P. Just a snip? A social history of male circumcision. Reproductive Health Matters, 2007;15(29):15-21.

  [4] Low-Beer D, Stoneburner RL. Behaviour and communication change in reducing HIV: is Uganda unique? African Journal of AIDS Research, 2003; 1(2):9-21.

  Show Less

  Conflict of Interest:
  None declared.

  • Back to top