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Circumcision: What should be done?
  1. Hanoch Ben-Yami
  1. Correspondence to Professor Hanoch Ben-Yami, Department of Philosophy, Central European University, 9 Nador Street, Budapest 1051, Hungary; benyamih{at}ceu.hu

Abstract

I explain why I think that considerations regarding the opposing rights involved in the practice of circumcision—rights of the individual to bodily integrity and rights of the community to practice its religion—would not help us decide on the desirable policy towards this controversial practice. I then suggest a few measures that are not in conflict with either religious or community rights but that can both reduce the harm that circumcision as currently practiced involves and bring about a change in attitude towards the practice, thus further reducing its frequency. These measures are the compulsory administration of anaesthetics; the banning of the metzitzah b'peh; and having an upper age limit of a few months on non-therapeutic circumcision of minors. I conclude with general considerations on why the steps taken towards the reform of circumcision should be moderate.

  • Circumcision
  • Moral and Religious Aspects
  • Rights
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Circumcision is an extremely painful operation,1–4 with possible complications that cannot be ignored,5–8 and when performed without anaesthesia it has long term adverse behavioural effects.9 ,10 It has negligible if any medical benefits, certainly in Western societies.11–15 It apparently reduces the pleasure of sexual intercourse both of the circumcised man and of his partner.16–18 When inflicted on a minor it effects, without the possibility of an appropriate consent, an irreversible bodily change which the person might come later to regret. And it bears the marks of its origins in superstition: the cutting of the genitalia as some kind of pagan sacrifice to a primitive deity, expressing the complexes people have had throughout the ages with their sexuality.19 For all of these reasons circumcision should be eliminated.

Yet circumcision is a central practice in both Judaism and Islam, a practice so strongly entrenched in custom that the great majority of those practicing these religions cannot at present even conceive of giving it up. Both Judaism and Islam are obviously sufficiently rich to survive without difficulty the elimination of this practice, and in fact its elimination would only make them more attractive and easier to accept and follow by many; but at present most believers do regard circumcision as absolutely essential. Banning circumcision of minors, therefore, would generate much tension and animosity within society; many people would not abide by the law; and the harm incurred by the civil unrest that would probably ensue might be greater, and even much greater, than the benefits gained by reducing the number of circumcisions through banning the practice. Moreover, the fact that in the past attempts to prohibit circumcision have frequently been the result of anti-Semitism would inevitably taint any current attempt to illegalise it, especially in a Europe in which the extreme right is gaining in power and Muslims and Jews are often the target of hate and violence to varying degrees. In addition, making circumcision illegal might strengthen the convictions of Jews and Muslims that the practice is an integral part of their identity, and thus might even bring a greater number of people of these religions to practice it, seeing the practice as an act of defiance of the persecuted. Banning circumcision would therefore be a grave mistake.

Of course one might claim, and it has been claimed, that circumcision is against the right of the child to the integrity of his body, and as such it should be banned as a matter of moral principle. On the other hand, people also have the right to freedom of religion, even if we think that their religion involves some otherwise detrimental practices, and illegalising circumcision of minors might seem to be against this right.

Moreover, if one claims that the right to freedom of religion of one person (the parent) cannot involve interference with the bodily integrity of another (the child), then we can describe circumcision as falling under a community right. A child should be brought up as a member of a community; not to be such a member he would have to be, as Aristotle said long ago, either a beast or a god, either less or more than human. Our well-being and full development essentially depend on our belonging, from our very first days, to some community. And which community we are to belong to is not given to our choice during our first years of life. In addition, a community has, first, the right to engage in practices that define and constitute its identity, even if these practices are otherwise gratuitous or even detrimental to some degree. The existence of such defining practices is often an integral part of the well-being of the community's members, even if and sometimes because they are otherwise unjustified. And these practices obviously include religious ones. Second, growing up in a community necessarily involves, given human psychology, forsaking some freedom of choice even as adults: it is often practically impossible to change habits, preferences and convictions that we acquired during our childhood. Accordingly, for the well-being of the child we should allow the community to which he will belong, and which he cannot choose, to apply to him some practices whose only justification, at least from an outsider's point of view, is that they are constitutive of membership in that community, even if these practices are otherwise detrimental and will compromise the freedom of the child once he grows up. To have any worthwhile future as adults, the dream of a totally open future to children must be forsaken.

One could therefore argue that the fact that (1) circumcision of children cannot be done with their informed consent and (2) it infringes upon their freedom of choice even in adulthood—with respect to what they can do with, or have done to, their own bodies—does not constitute a strong reason to oppose the practice of circumcision as a community right: the well-being of children makes it necessary anyway that they be members of communities that have the right to such practices.

If circumcision inescapably and unarguably caused highly significant harm, either physical or mental—as do foot binding and some forms of female circumcision—or even if such harm were probable, then freedom of religion and community rights could not be adduced as sufficient reasons for leaving the practice legal. But this does not appear to be the case, as is evinced by the millions of circumcised men around the world who are both physically and mentally healthy.

Of course, I do not mean by this last statement that the fact that many and probably even most men who were circumcised as infants do not regret or complain about having been circumcised shows that the practice is not totally intolerable. Many slaves and non-emancipated women, having been indoctrinated from childhood with the belief that theirs is the natural state, or perhaps struggling to come to terms with a condition they deemed unavoidable, have acquiesced in it or even assisted its continuation. This psychological attitude only makes such practices even more abominable, as they might deprive people not only of their rightful freedom but even of their love of it, compromising human dignity even further. Thus, while discontent with having been subjected to a practice is a reason to oppose it, lack of discontent is not in itself a reason to support it. Instead, my assertion that infant male circumcision need not be intolerably harmful in and of itself—although, as mentioned in the first paragraph of this paper and as will be discussed below, it is so under some ways of performing it—is a result of my personal acquaintance with thousands of circumcised and uncircumcised men, and the impression I have formed that the former need not be less physically or mentally healthy than the latter simply in virtue of having been circumcised.i

So which right is more important: the right to bodily integrity or the right to be raised in a community with all its constitutive customs and beliefs? And how could one balance between the significance of infringing on this or that right? I have no idea how this can be done in the present case, or even whether it can be done at all. I therefore think that approaching the issue from the perspective of human rights would not help us to decide on the desirable policy towards circumcision.

What should be done instead, I think, is to use some widespread consensuses currently surrounding circumcision in order to constrain the practice in several ways, ways that minimally infringe on religious and community rights. First, this would already reduce the harm circumcision currently involves. Second, and in the long run more importantly, it would change the perception of circumcision, even in the eyes of those practicing it. This, I believe, would gradually bring about a reduction in the number of circumcisions, as well as additional changes in the form of the practice that would further reduce the harm incurred by the operation. I shall suggest a few such measures that I think are feasible in the present context.

Local anaesthesia

Circumcision is an excruciating operation with significant long term behavioural effects if performed without local anaesthesia (see references above). This is a more than sufficient reason to have it performed only with at least local anaesthesia. Moreover, circumcising with the administration of anaesthetics does not contradict any religious doctrine, and so religious authorities cannot justify objecting to it. Accordingly, a law that prohibits circumcision without anaesthesia can be passed without powerful objections from religious communities. This law would at the very least significantly reduce the suffering that so many babies are needlessly subjected to, and which no adult would ever have tolerated. In addition, only a medically qualified person can administer anaesthetics. So, if the law allowed circumcision only with the administration of anaesthetics, the person performing the operation would have to be a medic, who would also be more qualified to treat complications, for example, haemorrhage, if they were to arise.

But additional benefits would also accrue from such a law. The whole procedure would become more expensive and some parents who were not certain whether to circumcise their sons might consequently fail to do so. And if we carry the logic of this measure further, the law could allow circumcision only in clinics specifically certified to perform the operation. This has full medical justification, since circumcision, like any other operation, should be performed only in appropriate, sterile conditions, and this measure is not opposed to any religious doctrine. It is indeed opposed to the Jewish tradition to celebrate the event at home, but operation and celebration could be separated, as they often are today among the more secular Jews. Since the state need not financially cover the operation, as it does not cover the expenses involved in the Bar Mitzvah ceremony or the Eid al-Fitr feast, again the financial burden on parents would increase. And this would further reduce the number of families circumcising their sons.

As a result of the reduced numbers of parents who circumcise their sons, the social pressure to circumcise would be reduced. Moreover, those who did not circumcise their sons would in their turn, in their attempt to make their behaviour and their sons’ status acceptable in their community, encourage other parents of their community not to circumcise theirs. And as most parents feel much distress from the obvious suffering they force on their sons in case they do circumcise them, in this way a derivative and effective force against circumcision would be generated. This is not merely abstract and uncertain theoretical speculation: in the last decade or so we have witnessed a steep increase in the number of Israeli parents who do not circumcise their sons, to a significant degree for the reasons just mentioned.20

Metzitzah b'peh

This part of Jewish circumcision, practiced by all orthodox Jews and many others, involves the sucking of blood from the infant's penis after his foreskin has been removed. The extremely orthodox perform the sucking directly by mouth from the wounded penis;21 others might perform it through some device. Apart from the health issues involved—there have been several documented cases in which infants incurred herpes and other diseases through oral–genital contact with the circumciser22–24—the practice is simply appalling. No reasonable person can think of it without disgust. And this is true of the great majority of religious Jews as well, including those who would insist on preserving the practice of circumcision in general. The metzitzah is a later addition to the Jewish ritual, which did not exist until the first centuries AD (its earliest mentioning is in the Talmud25). It is not that strongly entrenched in Jewish tradition, and some deeply religious Jews do not perform it. It seems to me that a majority of Jews who practice circumcision in Europe, and possibly worldwide apart from Israel, would welcome the prohibition of the metzitzah. There shall of course be some opposition, but most Jews would consider its prohibition as a removal of a burden. Banning the metzitzah may therefore be feasible and would constitute important progress.

And again, the longer term effects might be even more significant. Some Jews, the extreme orthodox, would try to preserve the practice of the metzitzah. But in order to do so they would have to travel abroad, perhaps to Israel, and many would not be able to afford it. The great majority of Jews would simply abandon the practice. Consequently, legitimising circumcision without metzitzah from the point of view of the Jewish Halachaii would become necessary. I think that this can be done, for as I have said the practice is a later addition, not strongly entrenched in tradition. And as the Hebrew saying goes, the gates of interpretation are always open. But this reinterpretation of the Halacha would demonstrate that the practice as a whole can be reinterpreted. And since many Jewish parents are ambivalent about circumcision, being in a state of conflict between preserving the tradition and not inflicting unnecessary pain and harm upon their sons, there would be additional pressure on the religious authorities to reinterpret additional parts of the Halacha regarding circumcision. Some rabbis already consent to or tolerate brit ceremonies that do not include the removal of the foreskin,26 and the pressure coming from Jewish parents would bring more rabbis to follow in their path. Progressively mitigated circumcision ceremonies would spread, mainly driven from within Jewish communities and not forced on them.

Age of circumcision

Although in Judaism circumcision must be performed on the eighth day after birth, there is no similar prescription in Islam. It is a quite common practice to circumcise the Muslim boy when he is between 5- and 10-years-old. Traditionally this is done by several adults forcing the boy on some bed or other surface, while another one cuts the boy's genitalia, without any anaesthetics, causing in the process excruciating pain and creating a physical wound that takes a long time to heal.27 But mentally, one rarely heals from such a trauma. Sexual complexes and aggression, to some degree, seem inevitable. And of course such behaviour encourages aggression also for the adults involved in the operation. This practice must be eliminated. Moreover, even if the operation is performed under general anaesthesia, a mitigated psychological trauma, due to the painful interference with one's sexual organs, seems simply inescapable.

Circumcision, according to Islam, can be performed at an earlier age, and indeed many do perform it when their son is still a baby. Accordingly, if the law would prohibit circumcising children past a certain age, this would not disagree with any Muslim doctrine. Freedom of religion or community rights could not therefore justify objecting to it. The exact maximal age is hard to determine: the child should be young enough not to remember or even understand what he has undergone. The first 6 months seem acceptable; whether circumcision later in the first year of life should also be tolerated is hard to say. The borderline between the case in which local anaesthesia is still sufficient and that in which general anaesthesia is already necessary should also be taken into consideration. But if some such maximal age were prescribed by law, much violence might be saved from society.

Of course, limiting the age of non-therapeutic circumcision of minors to up to 6 months would not diminish the pain circumcision involves: young children are at least as susceptible to pain as older ones.1 Moreover, due to the higher plasticity of the nervous system of infants, the effects of circumcision pain on long term pain responses might in fact be more deleterious.9 ,10 Accordingly, imposing the mentioned age limit would make sense only if the administration of anaesthetics is also made compulsory. Then, in case anaesthetics are administered, the pain caused by the operation would not be significantly different between the neonatal and the older-child cases, while the psychological trauma involved in the latter would be eliminated. The older child remembers the event, understands what it involves, and interprets the behaviour of the people involved in it, inevitably considering it as a physical and often sexual assault. All of these aspects, which are necessary for a psychological trauma, are beyond the mental capacities of the few-months-old baby. If the current state of society makes it impossible to outright prohibit the interference with the bodily integrity of the child, at least we could minimise the psychological harm incurred by circumcision.

As with the earlier proposals regarding anaesthesia and the metzitzah, a law limiting the age of non-therapeutic circumcision of minors would change the state of consciousness of practitioners with regard to circumcision. Once the law is passed and observed it would help to ingrain in the minds of Jews and Muslims alike the fact that circumcision is a problematic procedure which can and should be questioned. And the grub of doubt, having entered the sour fruit of complacency, will continue gnawing on.

I therefore recommend the following three measures as at least a first stage towards the eventual elimination of non-therapeutic circumcision of minors:

  • Circumcision should be performed only with local anaesthesia and in certified clinics

  • the metzitzah should be prohibited

  • an age of about 6 months should be the maximal age at which non-therapeutic circumcision of minors is allowed.

There are good chances that these measures, or some of them, would be accepted without much opposition from religious communities (excepting the inevitable complaints of some fundamentalist minorities), for they hardly infringe upon the freedom of religious practice and have ample medical and ethical justification. In addition, they would most likely function as the first stage in a longer process that—to large extent due to intra-community factors—would bring about further progress towards the elimination of circumcision.

The chances that these measures would be passed as laws vary between countries, and depend upon the precise form each measure took. It would be much easier, for instance, to make the administration of analgesics during circumcision compulsory than it would be to require that the operation take place in a clinic, at least as regards the Jewish practice. This is both because the tradition is to celebrate the event at home and because the performance of circumcision in a clinic might be much more expensive. But a failed attempt to pass a law often already constitutes progress compared with no attempt at legislation: the exposure of the public to the issue and the heightened consciousness generated in this way are already an achievement. And even if only some measures are initially forced—and even that only in some countries—this would be progress as well. The success of legislation in some countries would create additional pressure on others, especially as it would be obvious that the failure to pass similar laws was due to pressure coming from certain communities and not because there was something unjustified in the suggested legislation itself. Similarly, female suffrage was not introduced overnight all around the world: one domino piece brought down another, sometime almost immediately and sometimes only after a while, until it became inconceivable that women would not have the same voting rights as men. Legislation with regard to male circumcision should be expected to follow a similar pattern.

We should be wary of forcing what we take to be the right way on other people, certainly on other communities. Even if we are certain, and with good reason, that we know what the best path to choose is, it still does not follow that it is best to force it on others. Irrespective of the rightfulness of their target, attempts at a revolution have all too often ended with reigns of terror or the resurgence of older ways of life and thought. Circumcision of children is wrong, but it is also wrong to make it illegal at present. If we can take a gentler step towards its ultimate elimination, then this is what we should do.

Moreover, conviction is no guarantee of truth: unforeseen reasons against illegalising circumcision might be discovered along the way. We should therefore leave such possible reasons the opportunity to reveal themselves. Besides, the complex fabric of society makes it practically impossible to predict the effects that measures touching on millennia-old traditions would have. If we can progress towards a fundamental reform of society and religious practice with moderate but secure steps, we should prefer them over long jumps, which are almost certain to miss their target and end in disaster.

References

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Footnotes

  • Competing interests None.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • i This being said, one should also note that increased consciousness of what circumcision involves—including diminution of sexual function and pleasure—would inevitably bring about greater discontent among men who were circumcised as infants, and in this way generates yet another reason for stopping the practice. The importance of education and of making the relevant information readily available thus gets an additional support.

  • ii Halacha is the collective body of religious laws for Jews, including biblical law and later Talmudic and rabbinic law.

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