• Circumcision

One common mistake in discussions about the ethics of infant male circumcisionⁱ is to attempt to answer the question of the practice's permissibility by appealing to general principles and bypassing the empirical evidence about purported benefits and harms of the practice.

Joseph Mazor1 avoids the mistake of appealing only to general principles. He correctly argues that it is not sufficient to invoke a child's right to bodily integrity or to self-determinationⁱⁱ. Moreover, he does not appeal to parents’ rights to religious or cultural freedom in order to make his case for the permissibility of parents having their sons circumcised for religious or cultural reasons.

However, in invoking empirical considerations, he is insufficiently careful. For example, he includes, on the negative side of the circumcision ledger, a reduction in sexual pleasure, yet it is not clear that even his own reasoning warrants this. The problem is that he seems to want both, to acknowledge the absence of clear evidence for this claim, and to accept it as one of the costs of circumcision.

He says that Michael Benatar and I2 ‘carefully reviewed the medical evidence’1 about circumcision. In the paper that he cites, we noted that competing claims were made about the effect of circumcision on sexual pleasureⁱⁱⁱ and we established that no conclusion could be drawn from the limited and conflicting evidence available on this question. Dr Mazor notes that critics could point (selectively) to those studies that lend support to the conclusion that circumcision reduces sexual pleasure, but he concedes that this would be controversial,1 and he says that he ‘will largely take’ our ‘conclusions about the medical costs and benefits as given for the purposes of this paper’.1 However, he also says ‘it is not implausible to assume (as I will for the purposes of this paper) that, on average, male circumcision moderately reduces sexual pleasure for the circumcised individual’.1 But the claim that ‘it is not implausible’ to make this assumption is compatible with the claim that ‘it is not implausible’ to make the opposite assumption. This is because the claim that it is not implausible to assume that circumcision reduces sexual pleasure asserts much less than the claim that the balance of evidence suggests that circumcision does have this effect. When the evidence conflicts it is not implausible to assume that either side is right, but this does not mean that one is actually warranted in assuming one of the sides.

In fairness, it must be said that Dr Mazor does provide a justification for his assumption. One part of it is theoretical: he says ‘given the number of nerve endings in the foreskin’ one would expect there to be less sensation in their absence. The other part of the justification is purportedly empirical. He refers to ‘the experience of reduced pleasure for many men who have experienced sex both ways’ (although he provides no supporting reference). Both components of the justification are flawed. Theoretical projections are often empirically unsubstantiated, and in this particular case they are, as the evidence on the relative sexual pleasure of circumcised and uncircumcised men is limited and conflicting. There are some men who report less pleasure after circumcision, but there are studies that have shown no decrease4 ,5

Michael Benatar and I were careful not to make claims that exceeded the available evidence. Dr Mazor does not advance the discussion by adding a speculative harm to the list we considered. Curiously, although he does add this item to his list of the costs of circumcision, the conclusion he reaches is very similar to the one that we reached, namely that it is morally permissible for parents to decide whether or not to circumcise their sons. One reason why the purported moderate reduction in sexual pleasure does not lead him to think that circumcision is impermissible is that he further speculates that it is ‘not … unreasonable’ to think that the moderate reduction may lead to behavioural changes that constitute a net advantage.1 Thus, the second speculation neutralises the first one.

This is one reason why Dr Mazor's table of the relative costs of circumcising and not circumcising an infant boy is a little confusing, and why some caution should be exercised in reading it. A purported cost of circumcising is presented, but the table does not indicate that Dr Mazor thinks that the cost may actually yield a net advantage. (It is not the case that the costs on the same row in each column correspond in any way.) Moreover, there are issues about how one individuates and itemises the costs, and then how one weighs them up against one another. Clearly Dr Mazor does not intend his readers to infer from the fact that he lists more costs of circumcising than costs of not circumcising, that the net advantage lies in not circumcising.

Evidence is not static, and the evidence about circumcision has evolved, albeit only marginally, in the decade since we published our paper. Most importantly, the earlier evidence for a protective effect of circumcision against HIV has been reinforced by three major studies that were published more recently6 ^– 8 Each of these studies was terminated early by the data and safety monitoring boards because of the clear protective effect they demonstrated, and the consequent ethical problems of withholding circumcision from the control subjects in the studies^iv. The new evidence does not warrant a stronger conclusion—that parents ought to circumcise their sons or that routine neonatal circumcision should be recommended—but it certainly provides parents with further evidence for counting protection against HIV as a benefit of circumcision. Dr Mazor is correct that we need to attend to such benefits and not dismiss them by appealing to the rights of a child. If circumcision is a net benefit to a child, parents do not violate his rights to bodily integrity or self-determination by circumcising him. Careful attention to (the evidence for) the costs and benefits of circumcision to the child himself is thus essential.