In his contribution to the Journal of Medical Ethics, Joseph Mazor1 makes a logical case, based on the premises underlying his reasoning, for his article's primary thesis: he concludes that parents have the prerogative to determine the ‘best interests’ of their infant son in a circumcision decision. If the facts of the matter were ultimately no different from what he adduces, one could admit the soundness of his argument. But the paper is flawed by some questionable assumptions and grievous incompleteness.

First, the author insufficiently explores the profound implications of a serious equivocation in the term ‘circumcision’ that is common throughout the literature. He does superficially reference the article on ‘Circumcision’ in The Jewish Encyclopedia, which describes in detail the actual steps involved in brit milah versus brit periah.2 Despite this general allusion, though, he hardly discusses the matter further, as though the distinction were practically irrelevant. It does have fundamental import, however. Milah is merely a token clip of the very tip (the overhang flap or akroposthion) of the prepuce, which leaves most of the organ system (including all its essential functions) intact. This was evidently the version practiced in biblical times under the old Abrahamic–Mosaic covenant, before the Talmudic guardians of Judaic ethnic and religious identity proposed (around 150 AD) a means to prevent Hellinising Jewish men from attempting foreskin restoration by stretching their remaining preputial tissue forward. The rabbis mandated the replacement of milah with the more drastic procedure of periah, a radical surgery that cuts and tears from the penis its entire covering, leaving the glans irreversibly denuded. Unlike traditional milah, the innovation of periah necessarily has significant adverse consequences (delineated below).

Second, Mazor concedes that circumcision (periah) might cause a ‘moderate’ reduction of sexual pleasure in the lad's mature years, but he thinks this possibility is tolerably balanced by the alleged theoretical or statistical benefits that circumcision advocates (Benatar and Benatar,3 in particular) often mention. Since this point seems in his mind to be the only real secular drawback for parental deliberation about adverse effects when determining the best interests of their son, this hinge contention demands refutation. A moderate decrease in sexual pleasure is a far cry from what actually occurs under the modern method of circumcision, adopted by the Victorian medical establishment that introduced the periah form to the Anglophone Western nations in the nineteenth century.4 ,5 The author never adequately addresses exactly what the foreskin is and what role it is supposed to play in human anatomy and physiology—almost taking it, along with circumcision itself, as an abstraction.

But this entire controversy revolves around some very concrete matters. Dr Paul Fleiss elaborates a litany of devastating results of complete posthectomy (periah): obliteration of ‘more than 3 feet of veins, arteries, and capillaries, 240 feet of nerves, and more than 20000 nerve endings’, along with dartos muscle and usually the frenulum; desensitisation of the glans (a naturally internal organ) due to successive layers of keratinisation from constant exposure and abrasion; drying out of the mucous membrane of the glans from the loss of emollient sebaceous glands in the foreskin; alteration of innate structure by engraving ‘a large circumferential surgical scar on the penile shaft’, which ‘interrupts the normal circulation of blood throughout the penile skin system and glans’, thus ‘creating backflow instead of feeding the branches and capillary networks beyond the scar.’ The loss of such a great portion of epithelial tissue ‘permanently immobilizes whatever skin remains, preventing it from gliding freely over the shaft and glans’, which ‘destroys the mechanism by which the glans is normally stimulated.’6

Careful scholarly research supports the judgment of doctors such as Fleiss about the havoc wrought by modern circumcision.7 One prominent study enunciates a series of definitive verdicts contradicting the claim that on balance elective circumcision has benefits that might conceivably serve in the best interests of the child, outweighing the risk factors. As Cold and Taylor8 state: ‘In males, circumcision is essentially a partial penile mucosectomy. The urethral meatus is exposed and prone to irritation. … During circumcision, the frenular artery may also be ablated, depriving the anterior urethra of its major blood supply. The combined effect of urethral ischaemia and irritation results in the development of meatal stenosis [a narrowing of the urethral opening, constricting the flow of urine] in 5–10% of circumcised males. The risk of glanular injury when tearing the fused penile mucosa, and the development of meatal stenosis, makes circumcision in the newborn period inadvisable.’

Indeed, more than a potential ‘moderate’ decrease in future function—let alone pleasure—is at stake: ‘The prepuce is primary, erogenous tissue necessary for normal sexual function. The complex interaction between the protopathic sensitivity of the corpuscular receptor-deficient glans penis and the corpuscular receptor-rich ridged band of the male prepuce is required for normal copulatory behavior’ so that ‘the moist, lubricated male preputial sac provides for atraumatic vaginal intercourse.’ Accordingly, ‘surgical excision [of preputial tissue] should be restricted to lesions that are unresponsive to medical therapy…. The complex anatomy and function of the prepuce, along with the fused prepuce/glans penile mucosa in the immature penis, dictates that neonatal circumcision be strictly avoided. ... If external genital tissue must be excised to combat a disease process that threatens the child's health, and is unresponsive to medical therapy, then the amount of tissue should be limited so as to preserve the anatomy and function of the external genitalia.’8

Consistent with these observations, another study9 has shown that circumcised men are 4.5 times more likely to use an erectile dysfunction drug than intact men. In all, 18% of adult American men (of whom approximately three-fourths are circumcised) have erectile dysfunction, affecting 18 million men.10 And while the USA represents just 5% of the world's population, with the highest neonatal circumcision rate, it also accounts for 46% of Viagra sales.11 While this association could be explained by any number of factors unrelated to circumcision, one plausible causal link is the truncation of the perineal nerve that occurs during ablation of the foreskin. This nerve runs along the underside of the penis and terminates in the frenulum: it serves a number of sensitive erogenous zones in the human body and is responsible for initiating and maintaining erection.12^–14

Third, the author seems confused at the very outset of his essay about precisely what a violation of bodily integrity is, seeming to conflate it with any incision into bodily tissue. Surgery to correct defects (as in the example he gives of a cleft palate) aims at restoring wholeness: the normal appearance of the body in its natural state. Mere physical cutting into the body does not per se impair integrity. Even when for therapeutic reasons a normal part of the body must be removed to counter disease or remedy injury, this material loss of ‘integrity’ is justified by the principle of totality: the good of the whole overrides the good of a part if that part is truly (not merely hypothetically or speculatively) a threat to the well-being of the whole. On the other hand, modern circumcision (periah), when performed electively to a healthy organ, has no curative value whatsoever; in fact, it has consequences that militate against healthy functioning, namely, deprivation of a natural protective covering for an infant and significant frustration of a man's ability to engage in gentle, non-frictional coitus from the earlier loss of the lubricating, cushioning and gliding mechanism that would have been supplied by his intact prepuce.

Fourth, beyond the subject of disturbed sexual functioning, the author seems not to take sufficiently seriously the potentially life-threatening risks associated with periah itself, which, though perhaps warranted in cases of utter medical necessity, are not at all vindicated as elective trade-offs for some nebulous best interests of the boy as arbitrated by his parents, whether for secular or religious motives.

Fifth, the sort of elective cost–benefit analysis exemplified in Mazor's table—weighing factors that may be deemed to be in line with, or contrary to, the best interests of a child—constitutes a sort of special pleading, curiously being applied only in the case of non-therapeutic male infant circumcisionⁱ. It would seem more pertinent to pre-emptively amputate all tonsils and appendixes, which are far more prone to illness than a prepuce that has been treated with customary hygienic measures (ie, regular washing with warm water and mild soap). The mere fact that there may possibly be some long-term benefits in removing an organ (whether tonsils, appendix or foreskin) does not establish a ‘best interest’ for a child, even when no elders are using him to advance their own ends. Dr William Morgan remarks that ‘appendicitis is responsible for many more deaths than is penile cancer, but routine appendectomy is not yet the rule and is unlikely to become so’; in addition (quoting the verdict of Dr VF Marshall), ‘if cancer prevention is to be an end in itself, then bilateral simple mastectomy in female infants would probably be an even more effective measure,’15 considering that breasts have a greater propensity to carcinoma than the intact penis and their loss would not hinder a woman's direct procreative powers. But, such ethically repulsive routine mutilation would never be seriously entertained (and rightly so) because it is definitely in the best interests of the girl (and not within the jurisdiction of parental authority to decide otherwise) to retain all her inherent endowments, even those that may someday fall victim to disease. On the other hand, periah can (and usually does) detract from (and sometimes even annihilate) a man's potency as the numbing effects of posthectomy on the formerly sensitive frenular delta region become more pronounced with advancing years and ever more stimulation is required for ejaculation.16

Sixth, this leads inevitably to the problem of double standards and gender discrimination,17 ,18 which is supposedly outlawed in the liberal democracies of the Western-influenced world. Any kind of female genital cutting (even a simple nick in the clitoral hood, which would correspond to an act less invasive than the token milah) is now deemed in settled law a prohibited mutilation,19 yet these societies are still debating the ethical permissibility of obliterating an entire (and critical) component of the male reproductive organ under the pretext of prophylaxis.

Although Mazor anticipates this objection, his attempt to blunt its force fails. Specifically, while Mazor does not make it clear just what level of invasiveness of female genital cutting he thinks should be considered morally permissible in his theory, his own arguments, coupled with the relevant anatomical facts, would lead him to condone interventions much more damaging than a ritual ‘nick’ on a little girl's clitoris. This is because periah, which Mazor accepts as being within the purview of parental authority, is as injurious to healthy masculine tissue as total excision of the clitoral hood would be for a woman.

Despite the distinctions throughout his paper between ‘rights’ and mere ‘interests’ that can be trumped by parental authority, Mazor cannot circumvent the hard reality of the integral role of the prepuce in normal sexual functioning. Speculative gestures at hazily-considered ‘levels’ of ‘expected pleasure’ (averaged across whole populations of men) fall flat in the face of what is actually known about the foreskin, including its protective, erogenous and functional-mechanical properties. Any parental decision to remove this structure in its healthy state risks numerous adverse consequences for the child—if not by organic harm as an infant, then as a man suffering from iatrogenic sexual dysfunction.