Thursday, July 17, 2014

Male Circumcision (MGM) is a Matter of Bodily Autonomy


PURPOSE: This piece will discuss objections and other information relevant to male circumcision (MGM), with a primary focus on the United States. As I am opposed to male circumcision (except in cases where, for whatever reason [e.g., penile cancer], it is absolutely medically necessary, and where adults consent to the operation), I maintain that the procedure should be abolished/outlawed, that the supposed health benefits related to the operation are too poorly evidenced to warrant its continuation or recommendation, and that, ethically, it is no different from female circumcision (FGM), because it destroys individual guarantees of physical integrity and protection, is typically performed without consent, and violates the right of males to bodily self-determination. 

NOTE: Bracketed numbers correspond to references at the end of the post; numbers from other sources which used a similar format were changed to match the numbers from my list (when the same sources were used).
____________________________________

“Routine circumcision is not a medical issue or a social issue. It is a sexual issue and a human rights issue.”

- Frederick Hodges (Medical Historian and Author)

Male circumcision, sometimes referred to as male genital mutilation (MGM), is the excision of the foreskin (prepuce) of the human penis. The practice antedates recorded history [1A], and is not explicitly prohibited in most places of the world. In the United States, the operation is still relatively common (although slowly declining in prevalence), and has become an increasingly controversial and polarizing human rights issue. Several myths, exaggerations, and a wealth of conflicting information surround the procedure today, which has resulted in the present struggle between adversaries of the practice and its advocates. Gradually, however, a growing number of people are beginning to view male circumcision as an abuse comparable to female genital mutilation (FGM), arguing that its practice on newborns, who are unable to refuse or consent, is an infringement of the basic human rights of all males to bodily autonomy and physical protection. Many also dispute the health benefits reported by some organizations and studies, claiming that most of them are either mythical, exaggerated, or are too insubstantially evidenced to warrant the procedure or its recommendation.
____________________________________
The History of Male Circumcision

Two useful resources that provide several links to scholarly and non-scholarly references on male circumcision:
[1B] “History of Circumcision”
____________________________________
The History of Female Circumcision

For an overview of female circumcision, I recommend a paper by Nawal M. Nour, MD, MPH
Department of Maternal-Fetal Medicine, Brigham and Women’s Hospital, Harvard Medical School:

And, another by Robert Darby BA, B Litt, PhD which covers both female and male circumcision:
____________________________________

Proponents of male circumcision have argued that its practice is a religious right, that it is a male rite of passage, and/or that the health benefits associated with the surgery are evident enough to warrant its continuation. The American Academy of Pediatrics (AAP), in 2012, reported that: “New scientific evidence shows the health benefits of newborn male circumcision outweigh the risks of the procedure,” [3] but also stated that there was insufficient evidence of the benefits to officially recommend routine operations. The United States’ Centers for Disease Control and Prevention (CDC) has expressed a similar sentiment, in regard to the surgery’s supposed health benefits: “Male circumcision reduces the risk that a man will acquire HIV from an infected female partner, and also lowers the risk of other STDs, penile cancer, and infant urinary tract infection.” [4]

Several opponents of the procedure, on the other hand, argue that the surgery is superfluous, cruel and painful to infants, violates their basic rights to bodily autonomy and physical protection, and that the reports of its health benefits are either exaggerated, or rife with myths and misinformation. The greatest health-related argument in favor of male circumcision is that undergoing the procedure helps to reduce the risk of men acquiring HIV. However, one website entitled Doctors Opposing Circumcision states that circumcision does not prevent HIV infection, and even goes on to say: “The United States has the highest rate of HIV infection and the highest rate of male circumcision in the industrialized world. Male circumcision, therefore, cannot reasonably be thought to prevent HIV infection.” [5] Other websites, such as cirp.org [6:7] and circumcision.org [8], have reported similar findings and conclusions, calling into question the data which reports such benefits to male circumcision, the ways wherein the information was collected, and the methodologies behind the research.

More from cirp.org: “A recent Centers for Disease Control (CDC) and WHO report confirms previous reports that circumcision does not prevent sexually transmitted diseases (STDs).” [9:10] / And: “Circumcision does not provide protection against penile cancer. Even if it did, it would no longer be necessary due to the expected availability of a HPV vaccine.” [11]
More from circumcision.org: “Circumcision is the only surgery in history ever advocated as a widespread means of preventing disease. In the last fifty years, circumcision proponents in the medical profession have promoted various claims. One medical claim for circumcision is that it decreases the incidence of urinary tract infection (UTI) in the first year of life. However, the UTI studies this position is based on have been criticized by other physicians, most notably by the American Academy of Pediatrics (AAP). They concluded that the test designs and methods of these studies may have ‘flaws.’ A similar study found no confirmed cases of UTI in intact male infants without urinary birth defects. Furthermore, the UTI defense of circumcision is weak, not just because the methods are flawed, but because the logic and reasoning leading to the conclusion are flawed.” [12]

Many adversaries to male circumcision have also objected on the basis that it is cruel, and that the pain of undergoing the operation is “severe and persistent.” [13] Regardless of whether or not most men will remember their circumcisions later in life (it has been argued that the trauma of the experience can have long-term deleterious effects [14]), the procedure is agonizing for infants, and the recovery time following the operation, which usually lasts for roughly 7 to 10 days [15], results in days of pain for any child who’s undergone it. Male circumcision, according to circumcision.org, has been described as “among the most painful [procedures] performed in neonatal medicine.” [13]

Likewise, removal of the foreskin of human males results in reduced sensitivity and protection; the prepuce serves an important purpose in protecting the head (glans) of the penis from injury, and is vital for proper, and natural, penile function. [16:A/B] All of these factors comprise a significant portion of the objections to male circumcision made by a growing number of people—many blame the prevalence in society of misinformation about the benefits of the surgery for its perpetuation—but several also argue that a large part of the continued advocacy for the practice is caused by misguided cultural, social, and traditionalistic or religious values.

For Muslims, male circumcision is among the rites of Islam, and is “recommended to be performed on the seventh day of infancy.” [17] In most of Judaism, circumcision is mandatory [18], and the practice is also endorsed by some Christians (especially in the United States). The majority of men circumcised, in the United States and elsewhere throughout the world, tend to be among these three groups, but the effects of their tenets and ideals, along with the falsehoods and half-truths in circulation on the health benefits of the surgery, are pervasive throughout U.S. culture; thus, in many cases (and especially for those with religious affiliations), circumcisions are being performed for both misguided medical and non-medical reasons. The former and the latter are equally strong points of objection for those who oppose male circumcision.

Adversaries to female circumcision (FGM) have argued that “female genital mutilation is a violation of human rights.” [19] On a similar ethical basis, and given the abundant evidence against the purported “health benefits” of male circumcision, opponents of the procedure contend that the cultural or religious principles of some collectives (Muslims, Jews, et al.) should not override the individual human rights of male infants to bodily autonomy/self-determination and physical protection. [20:A/B/C/(D)] Both female and male circumcision are, by definition, mutilation (as they each involve removal of some portion of the human body [21], typically without consent), and thus can be challenged and condemned for the same ethical reasons.

Furthermore, any culture or belief system which opposes bodily integrity and the right to physical protection for anyone is erroneous, and should be overruled or changed; in “Circumcision of Male Infants as a Human Rights Violation,” J. Steven Svoboda argued that male circumcision “violates four core human rights documents—the Universal Declaration of Human Rights, the Convention on the Rights of the Child, the International Covenant on Civil and Political Rights, and the Convention Against Torture,” and he also said that:

“Every infant has a right to bodily integrity. Removing healthy tissue from an infant is only permissible if there is an immediate medical indication. In the case of infant male circumcision there is no evidence of an immediate need to perform the procedure. As a German court recently held, any benefit to circumcision can be obtained by delaying the procedure until the male is old enough to give his own fully informed consent. With the option of delaying circumcision providing all of the purported benefits, circumcising an infant is an unnecessary violation of his bodily integrity as well as an ethically invalid form of medical violence. Parental proxy ‘consent’ for newborn circumcision is invalid.” [20D]

Most people who oppose male circumcision (MGM) do so for the same reasons that numerous people oppose female circumcision (FGM); they believe that it violates the basic human rights of male infants, and this attitude toward the matter is becoming more prevalent each year and decade. In fact, in the United States, the CDC has reported an overall (and continuing) decline in the national rate of male circumcisions: “Across the 32-year period from 1979 through 2010, the national rate of newborn circumcision declined 10% overall, from 64.5% to 58.3% (Table and Figure 1). During this time, the overall percentage of newborns circumcised during their birth hospitalization was highest in 1981 at 64.9%, and lowest in 2007 at 55.4%.” [22] These declines in rate, although not entirely related to cultural shifts, are indicative of a trend which correlates to social changes in perspective on MGM.

National U.S. MGM Rate: 58.3% circumcised in 2010, down from 64.5% in 1979. Greatest decline was in the West, down from 63.9% in 1979 to 40.2% in 2010 (a decrease of 23.7%). The Northeast and South showed marginal increases in their rates of circumcision, and the Midwest had a decrease, but the percentage was insignificant. There were fluctuations up-and-down throughout for each region, with an overall national rate reduction. [22]

An increasing number of people are beginning to view male circumcision as the same sort of basic human rights violation that most of the world now sees female circumcision as. Approximations of the global proportion of circumcised males vary from 1/6 [23A] to 1/3 [23B], and several areas are displaying consistent trends of gradual overall decline in their rates of male circumcisions, including the United States.

The myths, distortions and exaggerations surrounding the benefits of the procedure are being debunked, and people all across the world are decrying the practice as an infringement of the guaranteed human rights of males to physical integrity, protection and bodily self-determination. Few, if any, professional medical associations are recommending the surgery as a necessity now (due to insubstantial evidence for its benefits), and a greater number of people currently regard the practice as a basic rights violation equivalent to FGM than ever before. All of these elements amalgamated are why the rates of male circumcision (MGM) are slowly decreasing in the United States and elsewhere, but the battle is not yet won.

Regardless of any misguided objections, dubious claims of “health benefits,” or what some belief systems and collectives state, male circumcision is a superfluous and antiquated procedure which violates the basic human rights of every male infant that suffers it. The practice, unless absolutely medically necessary for individual, consensual adult cases, ought to be made illegal everywhere, just as female circumcision (FGM) should be prohibited everywhere (and is in most places). Ethically, there are no (or merely insignificant) differences. People must stop having their male newborns circumcised, and should instead opt to teach their children proper cleanliness routines. It is not cultural or anti-religious bigotry, or ignorance of science, to oppose MGM as FGM is opposed (in fact, the ignorance of science lies with those who favor male circumcision); it is advocacy for the rights of all males to physical protection, bodily autonomy and self-determination.

Author: Krista Milburn [@Femitheist]
____________________________________
NOTE II: The purpose of this piece is not to compare the physical impact or damage of female circumcision (FGM) and male circumcision (MGM); it is a discussion of MGM, and the associations made are conceptual (relating to analogous ethical considerations). It is not intended to elevate one over the other in categorical importance, or to undermine either in any way.

NOTE III: I have recently made a donation to IntactAmerica.org (a group which opposes male circumcision); I encourage everyone to check out their work and consider contributing to their cause (if able).

NOTE IV: If you liked this piece, feel free to share it, and if you have any thoughts on it or the general subjects discussed within, or even purely semi-related topics, please leave them in the comments below. I always enjoy reading the feedback of others whether they liked and agreed with what I had to say or not.

NOTE V: A follow-up article can be found here.
____________________________________
References (Last Accessed on July 17, 2014):

[1] The History of Male Circumcision
A. History of Circumcision pages by Geoffrey T. Falk (Web Page)
B. History of Circumcision pages by Robert Darby BA, B Litt, PhD (Web Page)

[2] The History of Female Circumcision
A. Nawal M Nour, MD, MPH. Female Genital Cutting: A Persisting Practice. Department of Maternal-Fetal Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA. (Web page and PDF)
B. History of Circumcision pages
Robert Darby BA, B Litt, PhD

[3] AAP on Health Benefits; Does Not Recommend Circumcision, but Claims There Are Some:
1) New Evidence Points to Greater Benefits of Infant Circumcision, But Final Say is Still Up to Parents, Says American Academy of Pediatrics
2) Newborn Male Circumcision - More Information from American Academy of Pediatrics

[4] Male Circumcision – From the Centers for Disease Control and Prevention

[5] The Use of Male Circumcision to Prevent HIV Infection
[6] D Sidler, J Smith, H Rode (2008). Neonatal circumcision does not reduce HIV/AIDS infection rates. SOUTH AFRICAN MEDICAL JOURNAL, Volume 98, Number 10: Pages 762-766.

[7] R. S. Van Howe MD FAAP (1999). Circumcision and HIV infection: review of the literature and meta-analysis. Department of Pediatrics, Marshfield Clinic, Lakeland Center, USA. INTERNATIONAL JOURNAL OF STD & AIDS, Volume 10, Pages 8-16.
http://www.cirp.org/library/disease/HIV/vanhowe4/

[8] Circumcision and HIV: Harm Outweighs "Benefit"

[9] History of Circumcision pages by Geoffrey T. Falk (Web Page)

[10] Dave SS, Fenton KA, Mercer CH, Erens B, Wellings K, Johnson AM (2003). Male circumcision in Britain: findings from a national probability sample survey. SEXUALLY TRANSMITTED INFECTIONS, Volume 79: Pages 499-500.
http://www.cirp.org/library/general/dave1/

[11] Penile cancer, cervical cancer, and circumcision

[12] Explaining Claims of Medical Benefits

[13] Infant Responses to Circumcision

[14] Psychological impacts of male circumcision

[15] Circumcision – Recovery (Recovering from circumcision)

[16] Foreskin removal reduces sensitivity; prepuce protects glans (et cetera).

[17] Male Circumcision in Islam

[18] M Amin ud din (2012). Aposthia-A Motive of Circumcision Origin. Iran J Public Health. 2012; 41(9): 84.

[19] Eliminating female genital mutilation: an interagency statement - OHCHR, UNAIDS, UNDP, UNECA, UNESCO, UNFPA, UNHCR, UNICEF, UNIFEM, WHO. (The following link has been condensed.)
[20] Religious and Cultural Values vs. Human Rights
[21] The Definition of Mutilation
[22] Male Circumcision Rates Declining & Insufficient Evidence to Recommend Circumcision:
[23] Proportion of Males Worldwide That Are Circumcised Varies from 1/6 to 1/3:
____________________________________
Supplementary Resources (Unused – Last Accessed on July 17, 2014):

1) WHO on Male Circumcision; Claims That There Are Health Benefits to the Procedure:
2) Another Article Arguing That MGM Reduces the Risk of a Man Acquiring HIV:
3) Where FGM is still practiced.
4) WHO – Over 30% of Males Ages 15+ Are Circumcised (Almost 70% Muslim).
5) Rates of Male Circumcision
D. The Maternity Experiences Survey (MES) 2006-2007 – http://www.phac-aspc.gc.ca/rhs-ssg/pdf/tab-eng.pdf
6) Greg Millett: “Circumcision does not affect HIV in U.S. men: study”
http://www.reuters.com/article/2007/12/04/us-aids-circumcision-idUSN0345545120071204

7) World Health Organization (2007).
“Male circumcision: Global trends and determinants of prevalence, safety and acceptability” (PDF).

8) Weiss HA, Larke N, Halperin D, Schenker I (2010). Complications of circumcision in male neonates, infants and children: a systematic review. BMC Urol 10: 2. doi:10.1186/1471-2490-10-2. PMC 2835667. PMID 20158883.
9) Hay W, Levin M (2012). Current Diagnosis and Treatment Pediatrics 21/E. McGraw Hill Professional. pp. 18–19. ISBN 978-0-07-177971-5.
10) Circumcision and urinary tract infection
http://www.cirp.org/library/disease/UTI/
____________________________________
Further Additions (Unused – Last Accessed on February 10, 2016):

11) Robert Van Howe: “A CDC-requested, Evidence-based Critique of the Centers for Disease Control and Prevention 2014 Draft on Male Circumcision: How Ideology and Selective Science Lead to Superficial, Culturally-biased Recommendations by the CDC” (A fantastic critique of the CDC’s 2014 draft on male circumcision.)
https://www.academia.edu/10553782/A_CDC-requested_Evidence-based_Critique_of_the_Centers_for_Disease_Control_and_Prevention_2014_Draft_on_Male_Circumcision_How_Ideology_and_Selective_Science_Lead_to_Superficial_Culturally-biased_Recommendations_by_the_CDC

12) Profit in Circumcision

What most people do not realize is that circumcision is a billion dollar industry. All we have to do is follow the money to see why so many shoddy reports in favor of male circumcision are released, and why folk are so heavily disparaged and attacked for speaking out against the barbaric practice.

A. Circumcision: Who Profits? (The following link has been condensed.)
http://www.thewellspring.com/flex/circumcision-who-profits.cfm

“Circumcision is big business. Neonatal circumcision is the most frequently performed routine operation in the US. Doctors are collecting as much as $240 million yearly to perform 1.2 million needless operations on 1.2 million normal penises. In England, under socialized medicine when physicians were no longer compensated monetarily, the circumcision rate fell to below 0.5%.

And then, there are the hidden factors that raise the cost of circumcision to the healthcare industry. For example, the additional cost of the added average half-day longer hospital stay for circumcised infants is estimated between $250-550 million beyond the charges for the procedure itself. The total cost of all neonatal circumcisions annually performed in hospitals in the US is well over a billion dollars.

Circumcision is extremely profitable for the medical-industrial complex. Human foreskins are in great demand for a number of commercial enterprises, and the marketing of purloined baby foreskins is also an immensely profitable industry. Some examples: Pharmaceutical companies use foreskin in the manufacture of interferon and other drugs and international biotech corporations are procuring cells from amputated foreskins and experimenting with artificial skin. According to a report in Forbes magazine, the annual market for baby-penis-derived products could be $1 to $2 billion. And all of this without the permission of the “donor.” Biotechnology firms like Organogenesis have received fast-lane approval from the FDA for its foreskin-based Graftskin. Doctors, medico-legal experts, and bioethicists were denied the opportunity to request a full hearing and voice their concerns over the ethics of trafficking in and marketing these foreskins.”

B. The CDC Says, Circumcise Your Sons
http://www.livingwhole.org/the-cdc-says-circumcise-your-sons/

“Since circumcision is a billion dollar industry, there’s a lot riding on the CDC’s position, and who do you think sinks big money into the CDC to influence the CDC’s guidelines? The bio-medical and pharmaceutical industries.”