Back in 2017, Moodley and Rennie published a paper in the Journal of Medical Ethics entitled ‘Penile transplantation as an appropriate response to botched traditional circumcisions in South Africa: an argument against.’1 As the title suggests, we took a critical view towards penile transplantation as a way of responding to the problem of young men in South Africa experiencing genital mutilation and amputation as a result of traditional circumcision practices. Our main conclusion was that prevention is key: (...) social, cultural and political strategies to prevent mutilations and amputations should be prioritised, rather than surgical solutions, particularly in low-resource communities. Van der Merwe, who led the surgical team for the first successful penile transplantation in Stellenbosch, South Africa, has responded to our views, and in what follows, we will distill and evaluate his main arguments. Cost and access to services : Van der Merwe states that our position is mostly based on costs, that is, that penile transplantation is expensive and it is unrealistic to think that young men in traditional communities will be able to avail themselves of such services. Against this, Van Der Merwe argues that the actual cost of penile transplantation can be favourably compared with another, more established medical intervention, that is, renal transplantation. Of course, cost comparisons are difficult with a new intervention when it is …. (shrink)

This symposium includes twelve personal narratives from parents about making the decision whether to circumcise their infant male children. The authors of the narratives include five fathers and seven mothers. Nine of the 12 parent authors opted to circumcise their infant sons, though the reasons they stated for doing so varied. Most of the parent authors relied on cultural or social beliefs, religious guidance, or a desire for sameness with the infant's father. Parents who didn't circumcise their male (...) infants discuss their convictions about autonomy, bodily rights, and the medical benefits of circumcision versus the harm or pain caused by the procedure. The symposium includes four expert commentaries on the narratives that are informed and enriched by the commentators' expertise in pediatric bioethics, healthcare ethics, gender studies, Jewish law and tradition, and the medical and surgical techniques of circumcision. (shrink)

Ongoing global efforts to circumcise adolescent and adult males to reduce their risk of acquiring HIV constitute the largest public health prevention initiative, using surgical means, in human history. Voluntary medical male circumcision (VMMC) programs in Africa have significantly altered social norms related to male circumcision among previously non-circumcising groups and groups that have practiced traditional (non-medical) circumcision. One consequence of this change is the stigmatization of males who, for whatever reason, remain uncircumcised. This (...) paper discusses the ethics of stigma with regard to uncircumcised adolescent males in global VMMC programs, particularly in certain recruitment, demand creation and social norm interventions. Grounded in our own experiences gained while conducting HIV-related ethics research with adolescents in Kenya, we argue that use of explicit or implicit stigma to increase the number of VMMC volunteers is unethical from a public health ethics perspective, particularly in campaigns that leverage social norms of masculinity. Ongoing global efforts to circumcise adolescent and adult males to reduce their risk of acquiring HIV constitute the largest public health prevention initiative, using surgical means, in human history. VMMC programs in Africa have significantly altered social norms related to male circumcision among previously non-circumcising groups and groups that have practiced traditional (non-medical) circumcision. One consequence of this change is the stigmatization of males who, for whatever reason, remain uncircumcised. This paper discusses the ethics of stigma with regard to uncircumcised adolescent males in global VMMC programs, particularly in certain recruitment, demand creation and social norm interventions. Grounded in our own experiences gained while conducting HIV-related ethics research with adolescents in Kenya, we argue that use of explicit or implicit stigma to increase the number of VMMC volunteers is unethical from a public health ethics perspective, particularly in campaigns that leverage social norms of masculinity. (shrink)

Traditional male circumcision is a deeply entrenched cultural practice in South Africa. In recent times, there have been increasing numbers of botched circumcisions by untrained and unscrupulous practitioners, leading to genital mutilation and often, the need for penile amputation. Hailed as a world’s first, a team of surgeons conducted the first successful penile transplant in Cape Town, South Africa in 2015. Despite the euphoria of this surgical victory, concerns about the use of this costly intervention in a (...) context of severe resource constraints have been raised. In this paper, we explore some of the ethical implications of penile transplants as a clinical and public health response to the adverse consequences of traditional male circumcision. Given the current fiscal deficits in healthcare and public health sectors, how can one justify costly, high-technology interventions for conditions affecting a small section of the population? Since botched traditional male circumcisions are preventable, is a focus on penile transplantation as a form of treatment reasonable? Finally, do such interventions create undue expectations and false hope among a highly vulnerable and stigmatised group of young men? In this paper, we argue that given limited healthcare resources in South Africa and competing healthcare needs, prevention is a more appropriate response to botched traditional circumcisions than penile transplants. (shrink)

Despite global and local attempts to end genital mutilation, in their various forms, whether of males or females, the practice has persisted throughout human history in most parts of the world. Various medical, scientific, hygienic, aesthetic, religious, and cultural reasons have been used to justify it. In this symposium on circumcision, against the background of the other articles by Hutson, Short, and Viens, the practice is set by the author within a wider, global context by discussing a range of (...) rationalisations used to support different types of genital mutilation throughout time and across the globe. It is argued that in most cases the rationalisations invented to provide support for continuing the practice of genital mutilation—whether male or female—within various cultural and religious settings have very little to do with finding a critical and reflective moral justification for these practices. In order to question the ethical acceptability of the practice in its non-therapeutic forms, we need to focus on child rights protection. (shrink)

The ethical propriety of routine male infant circumcision has been debated in journals of medicine and law for many years. This article explores the issue from historical, medical, and moral perspectives. Two essentially different forms of circumcision (one more drastic than the other) are distinguished. Discussion focuses on the effects of the more radical kind of nontherapeutic surgery on a normal healthy child’s body: whether it constitutes a mutilation, whether it is medically warranted, and whether it is (...) ethically defensible in light of general philosophical principles and Catholic moral doctrine. The conclusion questions the social bias favoring parental choice to circumcise a non-consenting son. National Catholic Bioethics Quarterly 12.1 (Spring 2012): 99–128. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Proudly Jewish—and Averse to CircumcisionLisa Braver MossI've always had a strong sense of my Jewish identity—and I've always had grave misgivings about circumcision. It used to seem that these [End Page 86] statements were at odds with one another. Now I'm on a mission to integrate the two.I'm married to a man who's also Jewish. In the late 1980s, we had two sons, whose circumcisions I agreed to. (...) Brit milah (the covenant of circumcision) is intended as a spiritually meaningful act symbolizing the agreement between God and the Jewish people. But for me, the experience was so upsetting that I didn't feel God's presence. In spite of all the arguments in favor—the weight of tradition, wanting my boys to be accepted in the Jewish world, and so on—I came to regret my acquiescence.I began to explore reasons to question circumcision from a Jewish point of view, publishing articles in Jewish magazines and speaking at conferences. Rather than focusing on the medical pros and cons, I wrote about Jewish law and ethics, and spoke with many rabbis. I was hoping to deepen Jewish dialogue on this topic, which was oddly off-limits in a culture that values intellectual inquiry.Besides helping me understand more about Judaism, my research and writing was a way of living with my guilt. I had succumbed to—and put my boys through—a tradition that went completely against my maternal instincts. This schism had made me doubt myself as a new mother. What kind of parent was I if I couldn't be a fierce protector of my newborn baby? It was not a positive or welcoming way for me to enter into motherhood.I blamed myself. I hadn't done medical research before my boys were born, trusting instead in the longevity of the tradition and the claim that circumcision is more hygienic. I bought into the medical justifications for circumcision—all of which, I later learned, fail to acknowledge the erogenous nature of foreskin tissue and its physiological function. If I'd known more; if I'd thought more deeply about infant trauma; if I'd taken my own spirituality more seriously—I would have fought for a different outcome, despite the pressure I felt as a Jewish person.Years went by. I wrote a novel about Jewish circumcision, then co-wrote a book of alternative bris ceremonies for families opting out of circumcision. Slowly, I came to understand that blaming myself for agreeing to circumcise my sons was not only a waste of time, but also missed the larger point. I'm not alone in my objections to this ancient tradition. Indeed, many Jewish parents get through the event with white knuckles, emotional detachment, alcohol, or sedatives rather than with genuine religious feeling. Shouldn't their spiritual authenticity matter? Shouldn't mine have mattered?In Judaism, every commandment (of which circumcision is one) should be approached with kavanah, or spiritual intent. Thus, my non-spiritual feelings about the circumcision tradition are problematic from a Jewish point of view. I should have been able to tell the rabbi I didn't really believe circumcision was what God wanted me to do. I wish I'd been guided in coming to a decision that reflected my actual spirituality. Instead, all that seemed to matter to anyone was getting the deed done.Going against my instincts and spirituality was not just my failing—it also represented an institutional failing. Jewish leaders and rabbis aren't trained to respond compassionately to those averse to circumcision. Even parents merely questioning the practice may be subjected to judgment, lectures, and condescension. Parents deciding not to circumcise may face all that and more: in some synagogues in the U.S., boys that have not been circumcised are currently being denied bar mitzvah.________In the Jewish world, we tend to look upon circumcision as the one monolithic tradition: we assume that every Jewish male is circumcised and that no one talks about or questions this. The truth is that throughout our history, there have been males who, for various reasons, did not undergo the ritual... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:A Brit Milah for Eliezer Herschel ben Yonatan AryehMolly SinderbrandFor observant Jews, the choice to circumcise one's son is not a choice. Technically, it is a contractual obligation; the belief is that male circumcision is part of a holy covenant with God. The word for ritual circumcision, brit milah or bris, literally means "covenant [of circumcision]." Circumcision is a physical symbol of a relationship (...) with the divine. It is the commandment that encompasses all other commandments. It is, thankfully, only required of men (women, they say, are naturally closer to divinity). Circumcision is when a baby boy enters the Jewish community, eight days after birth, and when he gets his name. He becomes somebody. To choose otherwise— and some may choose otherwise—is to choose not to be part of the contract, and by extension, not be part of the Jewish community. And a community is one of the most valuable things a person can have.I was not always an observant Jew, though I was raised in a Jewish household. I essentially fell into observance over a period of 10 years, starting with studying ancient Hebrew with a language-loving rabbi in high school and eventually leading to weekly attendance at an orthodox shul, which I joined shortly after first tasting the vegan cholent at kiddush. It was much easier to make friends in [End Page 91] the Jewish community than in my competitive and mildly misogynist graduate program, and frankly, I liked them better. I received kindness and support when I needed it, and gave it back equally, especially around having children. Having children is difficult under any circumstance, but it is especially difficult in social settings where it is seen as abnormal, strange, or even selfish. The Jewish community normalized having children and created a respite from the judgment of the secular world. When I was pregnant at work, I got comments like "It looks like you're having twins!" and "Are you sure you don't have pre-eclampsia? You look awfully large"; at shul, I got pep talks, encouragement, and the traditional "b'sha'a tova"—"may it happen at a good time."Eventually, after having two kids in a two-bedroom rowhome, my husband and I moved to a mostly-Jewish suburb just outside the city. It is the kind of place where everyone says "Gut Shabbes" (a good Sabbath) to each other on Saturdays, but not one in which all the men wear black hats and study Torah all day (though some do). That is, folks live Jewish lives, but interact with the outside world as well. After a few months, it felt like home.This was the context in which I decided—or rather, did not have to decide—to circumcise my son. It was the natural result of the decision to be part of a community that places value (and even membership) on the ritual of circumcision. I made that decision years earlier and have been continuously reaffirming it since. Every day I wake up is a day I decide to be an observant Jew, and I decide to do so in order to be a member of an observant community. The decision to circumcise was yet another decision to be part of that community, which has given me so much joy, support, and meaning. Why would I deny my son—and myself—that community?In addition, not needing to make any decisions was itself a kind of relief. I have heard of mothers—including my own—off in a room crying, needing comfort, unable to be there for the circumcision. That did not happen for me. Despite a history of rather severe perinatal depression and anxiety, including suicidal ideation less than a week before the event, I was completely fine. Maybe my comfort came from the fact that I already had two children; this was not my first newborn, though it was my first bris. Maybe, after almost two years of COVID, circumcision did not seem like such a big deal. Maybe I was just glad someone else would hold the baby for a while. But I think at least part of it was the happiness that... (shrink)

Newborn male circumcision is a minor surgical procedure that has generated significant controversy. Accumulating evidence supports significant health benefits, most notably reductions in urinary tract infections, acquisition of HIV and a number of other sexually transmitted infections, penile cancer, phimosis, paraphimosis, balanitis and lichen sclerosis. While circumcision, like any surgical procedure, has risks for complications, they occur in less than 1 in 500 infants circumcised and most are minor and require minimal intervention. The CDC and the American (...) Academy of Pediatrics believe that health benefits of circumcision outweigh the risks. For this reason, the AAP believes that parents should be allowed to make the decision concerning circumcision of their male infants after receiving non-biased information on health risks and health benefits. (shrink)

The health benefits of male circumcision are wide rangingIn this issue, John Hutson has reiterated the conventional Western medical view that “the surgical argument for circumcision of all neonatal males at present is very weak” and he criticises many of the circumcisions performed in later childhood, without anaesthesia, as “physically cruel and potentially dangerous” [see page 238].1 He is also of the opinion that “the diseases which circumcision is able to prevent are uncommon or even rare”. (...) But therein he errs, and greatly errs.He cites only two publications dealing with the protective effect of male circumcision against HIV infection, and makes no mention of the important recent meta-analysis of Weiss, Quigley, and Hayes2 which shows conclusively from a large number of studies that …. (shrink)

Ethical challenges surrounding the implementation of male circumcision as an HIV prevention strategyResearchers have been exploring the possibility of a correlation between male circumcision and lowered risk of HIV infection almost since the beginning of the HIV/AIDS epidemic.1 Results from a randomised controlled trial in South Africa in 2005 indicate that male circumcision protects men against the acquisition of HIV through heterosexual intercourse,2 confirming the findings from 20 years of observational studies.3 Circumcised men in (...) the South African trial were 60% less likely to acquire HIV than their uncircumcised counterparts. A mathematical modelling study, based on the South African trial, estimates that the practice of male circumcision could avert two million new HIV infections and 300 000 HIV-related deaths over the next 10 years in sub-Saharan Africa.4 More recently, two randomised controlled trials in Kisumu, Kenya and Rakai, Uganda showed, respectively, 53% and 48% reductions in HIV acquisition among circumcised men than uncircumcised men in the trial.5 These results strongly suggest that male circumcision could play an important role in the struggle against the continued rise in new HIV infections. However, as observers noted at the 2006 XVI International AIDS Conference in Toronto, Canada, excitement about the potential epidemiological impact has overshadowed the debate over the difficult translation of research on male circumcision, into policy and practice.6 Similar calls for caution have been raised before and elsewhere.7,8The topic of male circumcision carries an enormous amount of ethical baggage. Male infants, worldwide, are circumcised for various medical, social and/or religious reasons. Circumcision is a cultural act and a surgical procedure; medical reasons are not the only reasons to circumcise that people have found and continue to find as compelling. Benatar and Benatar9 have argued that—when …. (shrink)

A recent judgment by a lower court in Germany brought the problem of ritual male circumcision to the consciousness of the wider public and legal academia. This essay weighs in on this emerging discussion and argues that ritual male circumcision is not covered by parental authority. It first considers and dismisses the best interest of the child test, which is the most widely used test of parental authority in legal practice. Instead, the essay proposes what it (...) terms the autonomy conception of parental authority, according to which parental authority must be exercised such as to ensure that the child will become an autonomous adult. While parents may raise their child in line with their ethical, including religious, convictions, respect for his autonomy requires that this be done in a way that allows the child to later distance himself from these values; this implies, among other things, that irreversible physical changes are impermissible. (shrink)

Whilst there have been serious attempts to locate the practice of male circumcision for religious motives in the context of the (respective) religion's narrative and community, the debate, when referring to a clinical context, is often more nuanced. This article will contribute further to the debate by contextualising the Islamic practice of male circumcision within the clinical setting typical of a contemporary hospital. It specifically develops an additional complication; namely, the child has a pre-existing blood disorder. (...) As an approach to contributing to the circumcision debate further, the ethics of a conscientious objection for secular motives towards a religiously-motivated clinical intervention will be explored. Overall, the discussion will provide relevance for such debates within the value-systems of a multi-cultural society. This article replicates several approaches to deconstructing a request for conscientious refusal of non-therapeutic circumcision by a Clinical Ethics Committee (CEC), bringing to light certain contradictions that occur in normatively categorizing motives for performing the circumcision. (shrink)

Khalafzai, Rida Usman There is currently much debate about the medical and ethical issues related to male circumcision. This article explores this controversial subject in the light of current research.

This study set out to investigate the influence of male circumcision and other factors on sexually transmitted infections in Botswana. A syndromic approach, which diagnoses a sexually transmitted infection based on the presence of urethral discharge or genital ulcers rather than on laboratory tests, was used. The data were from the 2001 Botswana AIDS Impact Survey where a nationally representative, randomly selected sample of men and women aged 1064 years who had ever had sexual intercourse. The logistic regression (...) technique was executed to examine the association between male circumcision and self-reported urethral discharge or genital ulcers, while controlling for all other independent variables in the analysis. The main finding of this study was that among men who are circumcised, the odds for self-reported urethral discharge or genital ulcers are significantly lower than for those men who are not circumcised in both urban and rural Botswana. The analysis also showed that the odds in favour of self-reported urethral discharge or genital ulcers, for men who drink alcohol, are twice as large as those for men who do not drink alcohol, controlling for all other independent variables in the analysis. Religion and ethnicity also came through as factors exerting a protective influence against self-reported symptoms of sexually transmitted infections. The conclusion is that while male circumcision appears to be significantly associated with the risk for self-reported urethral discharge or genital ulcers, it is man’s behaviour, irrespective of ethnicity or religious dictates, that continues to play a vital role in protection against self-reported symptoms of sexually transmitted infections in Botswana. (shrink)

This paper considers Habermas’ model of a post‐secular political order in the light of the debate on male circumcision that arose in Germany after a court ruled that male circumcision was an unjustifiable act of bodily harm. Central to this model is the idea that religious reasons can only become effective in central legal institutions when they are translated into secular reasons. My paper demonstrates that there are two distinguishable readings of this proviso. On the one (...) hand, there is a broad reading according to which it is only necessary to reach a conclusion that is in line with the democratic principle stating that all citizens can be regarded as co‐legislators even if non‐generalizable value orientations might then shape the interpretation of fundamental rights (in the case of circumcision, the right to bodily integrity). On the other hand, a truly secular (narrow) reading would avoid the inclusion of non‐generalizable value orientations. The debate on circumcision demonstrates that these two interpretations lead to different and conflicting modes of justification. The broad reading allows for a justification of male circumcision, whereas the narrow reading makes such a justification unlikely. In addition, the filtering function of the proviso is weakened in a broad reading. (shrink)

Newborn male circumcision has potential benefits and advantages as well as disadvantages and risks. Families will at times have medical questions regarding newborn male circumcision that clinicians must be prepared to answer.

Around a third of men worldwide are circumcised. It is probably the most commonly performed surgical procedure. Circumcision is also one of the oldest forms of attempted human enhancement. It is and has been done for religious, social, aesthetic and health reasons.Circumcision has a variety of benefits and risks, many of which are discussed in this issue. There is some dispute about the magnitude and likelihood of these benefits and risks. Some argue that the risks outweigh the benefits (...) and circumcision should not be performed on children who are not competent to make their own decisions.If the risks of circumcision clearly outweighed the benefits, great harm has been done and is being done globally through this procedure. Around a third of all men would have been harmed. This is an extraordinary public health injury. Presumably, many would be entitled to compensation.The fact that relatively few people think that the situation is as bad as this indicates that most people implicitly believe that circumcision is not generally a significant harm, if a harm at all. One might thus conclude either that: It is not clear from existing evidence whether the risks of properly performed circumcision outweigh the benefits, or vice versa.Or 2. If circumcision is against the interests of an infant or young child, it is only mildly so.In general, people should make their own decisions about body modification and human enhancement when this is possible. Such an approach speaks in favour of waiting until a child becomes an adult to make his or her own decision about circumcision. And procedures which are not clearly in a child's interests should not be performed on that child. However, religious …. (shrink)

Non-therapeutic circumcision violates boys’ right to bodily integrity as well as to self-determination. There is neither any verifiable medical advantage connected with the intervention nor is it painless nor without significant risks. Possible negative consequences for the psychosexual development of circumcised boys (due to substantial loss of highly erogenous tissue) have not yet been sufficiently explored, but appear to ensue in a significant number of cases. According to standard legal criteria, these considerations would normally entail that the operation be (...) deemed an ‘impermissible risk’—neither justifiable on grounds of parental rights nor of religious liberty: as with any other freedom right, these end where another person's body begins. Nevertheless, after a resounding decision by a Cologne district court that non-therapeutic circumcision constitutes bodily assault, the German legislature responded by enacting a new statute expressly designed to permit male circumcision even outside of medical settings. We first criticise the normative foundations upon which such a legal concession seems to rest, and then analyse two major flaws in the new German law which we consider emblematic of the difficulty that any legal attempt to protect medically irrelevant genital cutting is bound to face. (shrink)

INTRODUCTIONIs the non-therapeutic circumcision of infant males morally permissible? The most recent major development in this long-simmering debate was the 2012 release of a policy statement and technical report on circumcision by the American Academy of Pediatrics . In these documents, the US paediatricians’ organisation claimed that the potential health benefits of infant circumcision now outweigh the risks and costs. They went on to suggest that their analysis could be taken to justify the decision of parents to (...) choose circumcision for their incompetent children.1Circumcision and ‘health benefits’The AAP's pronouncement unleashed a firestorm of commentary, much of it censorious. In this issue, human rights attorney J Steven Svoboda and Professor of Clinical Paediatrics Robert Van Howe take the AAP to taski for committing numerous significant errors, both in their analysis of relevant evidence and in basic medical-ethical reasoning.3 In addition, an independent international panel—composed of 38 leading paediatricians, paediatric surgeons, urologists, medical ethicists and heads of hospital boards and children's health societies—has likewise condemned the findings of the AAP. Writing in the journal Pediatrics, these authors state: "Only one of the arguments put forward by the American Academy of Pediatrics has some theoretical relevance in relation to infant male circumcision; namely, the possible protection against urinary tract infections in infant boys, which can easily be treated with antibiotics without tissue loss. The other claimed health benefits, including protection against HIV/AIDS, genital herpes, genital warts, and penile cancer, are questionable, weak, and likely to have little public health relevance in a Western context, and they do not represent compelling reasons for surgery before boys are old enough to decide for themselves.4"My own analysis of the AAP documents—and of ‘health benefits’ defences of circumcision generally—can be found elsewhere.5 Let me turn my attention in this editorial, then, to …. (shrink)

We present an argument in support of the legal prohibition of infant male circumcision (IMC) in developed Western countries. We submit that all IMC, irrespective of whether the motivation behind it be secular or religious, violates children’s rights to self-determination (autonomy) and bodily integrity and is therefore morally illegitimate. And while IMC’s being morally wrong does not entail that it ought to be criminalised, we contend that it should be legally proscribed so as to protect children against harm (...) and to uphold their rights. We consider and reject an argument that an exemption from the legal ban should be granted to religious parents who perceive themselves to be under a moral obligation to subject their male infants to IMC. We argue that since IMC sets back children’s basic interests and violates their rights, there is no room, and no case, for the conferring of a religious exemption. (shrink)

Controversies over the acceptability of male circumcision (MC) are not new to the international bioethical community. I do not expect to add much to the arguments or evidence presented elsewhere, but I want to acknowledge the often-overlooked political element in which the debate is entrenched. In fairness to those sympathetic to the circumcision ban, I will first introduce some supportive arguments to their position. Next, I will show the limits of those critiques, affirming that MC should not (...) be outlawed in any liberal country, but that its permissibility only be evaluated within its medico-ethical dimension without the political charge often associated with the issue. (shrink)

This qualitative research is a philosophical review about analyzing how circumcision can (cannot) be morally justified. It is typically assumed among Muslims that circumcision is mandatory according to Islamic law (Sharia). However, in this paper, I will argue that this is not clear in Islamic texts. Because firstly there is no textual evidence in the Quran about this matter and secondly permissibility of circumcision is not an agreed topic among Muslim scholars. This entails that circumcision is (...) not a necessary part of being a Muslim. Although this idea seems idiosyncratic according to the majority of Muslims, I’m inclined to emphasize that we should not marginalize this idea, rather we have to support it for educational prosperity in Muslim communities. But perhaps more importantly this paper helps to introduce new Muslim intellectuals’ argument that moral reasoning is independent from (and even superior to) Islamic law. Since we do not have ultimate and decisive secular reason (e.g., medical reason) against male circumcision in every occasion, therefore, morally speaking, I believe it is not reasonable to say that male circumcision is always wrong. Muslims who support male circumcision still can find some secular reasons to defend this from their cultural identity. (shrink)

The use of targets to direct public health programmes, particularly in global initiatives, has become widely accepted and commonplace. This paper is an ethical analysis of the utilisation of targets in global public health using our fieldwork on and experiences with voluntary medical male circumcision initiatives in Kenya. Among the many countries involved in VMMC for HIV prevention, Kenya is considered a success story, its programmes having medically circumcised nearly 2 million men since 2007. We describe ethically problematic (...) practices in Kenyan VMMC programmes revealed by our fieldwork, how the problems are related to the pursuit of targets and discuss possible approaches to their management. Although the establishment and pursuit of targets in public health can have many benefits, assessments of target-driven programmes tend to focus on quantifiable outcomes rather than the processes by which the outcomes are obtained. However, in order to speak more robustly about programmatic ‘success’, and to maintain community trust, it is vital to ethically evaluate how a public health initiative is actually implemented in the pursuit of its targets. (shrink)

Female genital mutilation is the removal or restructuring of healthy genital tissue. Under natural law, mutilation is an intrinsic evil and a grave violation of human dignity. If mutilation alleviates a threat to a person’s well-being, it may sometimes be permissible, but healthy genitals pose no such threat. The purported social benefits of FGM, such as decreased promiscuity, do not justify the practice, because there is no causal relationship between mutilation and virtue. In terms of autonomy, victims are usually children (...) and unable to consent. Parental rights and the rights of religion do not override children’s inherent rights to physical integrity and safety. Current support for minimal forms of FGM in an attempt to reduce the incidence of severe forms will instead prolong the practice and increase the number of victims. Finally, FGM differs from male circumcision in that it destroys the function and integrity of the organs themselves and promotes profound gender inequality. (shrink)

Opinion about neonatal male circumcision is deeply divided. Some take it to be a prophylactic measure with unequivocal and significant health benefits, while others consider it a form of child abuse. We argue against both these polar views. In doing so, we discuss whether circumcision constitutes bodily mutilation, whether the absence of the child's informed consent makes it wrong, the nature and strength of the evidence regarding medical harms and benefits, and what moral weight cultural considerations have. (...) We conclude that nontherapeutic circumcision of infant boys is a suitable matter for parental discretion. (shrink)

It is sometimes argued that the non-therapeutic, non-consensual alteration of children‘s genitals should be discussed in two separate ethical discourses: one for girls (in which such alterations should be termed 'female genital mutilation' or FGM), and one for boys (in which such alterations should be termed 'male circumcision‘). In this article, I call into question the moral and empirical basis for such a distinction, and argue that all children - whether female, male, or indeed intersex - should (...) be free from having parts of their genitals removed unless there is a pressing medical indication. (shrink)

This is a response to Dr Joseph Mazor’s paper ‘The child's interests and the case for the permissibility of male infant circumcision.’ I argue that Dr Mazor fails to prove that bodily integrity and self-determination are mere interests as opposed to genuine rights in the case of infant male circumcision. Moreover, I cast doubt on the interest calculus that Dr Mazor employs to arrive at his conclusions about circumcision.

This article offers a critique of the recently revised BMA guidance on routine neonatal male circumcision and seeks to challenge the assumptions underpinning the guidance which construe this procedure as a matter of parental choice. Our aim is to problematise continued professional willingness to tolerate the non-therapeutic, non-consensual excision of healthy tissue, arguing that in this context both professional guidance and law are uncharacteristically tolerant of risks inflicted on young children, given the absence of clear medical benefits. By (...) interrogating historical medical explanations for this practice, which continue to surface in contemporary justifications of non-consensual male circumcision, we demonstrate how circumcision has long existed as a procedure in need of a justification. We conclude that it is ethically inappropriate to subject children—male or female—to the acknowledged risks of circumcision and contend that there is no compelling legal authority for the common view that male circumcision is lawful. (shrink)

Hymen construction and nontherapeutic male circumcision are medical nonindicated interventions that give rise to specific ethical concerns. In Europe, hymen construction is generally more contested among medical professionals than male circumcision. Yet, from a standard biomedical framework, guided by the principles of autonomy, beneficence, nonmaleficence, and justice, circumcision of boys is, as this article explains, more problematic than hymen construction. While there is a growing debate on the acceptability of infant circumcision, in the case (...) of competent minors and adults the surgery is not questioned. In the case of hymenoplasty, usually requested by a competent patient, it is recommended to only perform the operation after extensive counseling and if there are compelling conditions. The article further explores why attitudes of medical professionals toward both surgeries diverge and seeks to explain how this is largely informed by gendered and socio-cultural understandings. The arti... (shrink)

In a recent issue of the Journal of Medical Ethics, Svoboda and Van Howe commented on the 2012 change in the American Academy of Pediatrics policy on newborn male circumcision, in which the AAP stated that benefits of the procedure outweigh the risks. Svoboda and Van Howe disagree with the AAP conclusions. We show here that their arguments against male circumcision are based on a poor understanding of epidemiology, erroneous interpretation of the evidence, selective citation of (...) the literature, statistical manipulation of data, and circular reasoning. In reality, the scientific evidence indicates that male circumcision, especially when performed in the newborn period, is an ethically and medically sound low-risk preventive health procedure conferring a lifetime of benefits to health and well-being. Policies in support of parent-approved elective newborn circumcision should be embraced by the medical, scientific and wider communities. (shrink)

This article brings insights from feminist science and technology studies to bear on recent public debates over the human papillomavirus vaccine, which prevents many cervical cancers, and male circumcision as potential HIV preventive. In the United States, attempts to mandate HPV vaccination have activated intense concerns about female “promiscuity,” whereas talk of promoting circumcision against HIV has triggered scant anxiety about American boys’ sexuality. The authors show how intersections among gender, sexuality, race, and age have shaped responses (...) to these two containment technologies—and how the technologies’ deployment both relies on and reproduces meanings of gender and sexuality that constitute the omnipresent “double standard.” The analysis develops an original feminist sociology of containment, explicating how social relations shape the innovation, reinvention, and use of technologies to contain particular sorts of bodies, fluids, and sexual practices—by whom, under what conditions, and for what purposes. (shrink)

This paper does not attempt to lay out the arguments relating to male circumcision for non-medical reasons. Rather, the aim is to focus more on the process and the problems of a professional body ) attempting to produce any consensus guidelines for its members on an issue which clearly polarises doctors as much as it divides society as a whole. The legal and ethical considerations of male circumcision are inevitably touched upon here but are not the (...) central issue. In 2003, the BMA published professional guidance on this subject. Some thought this a pointless exercise; others saw it as an initiative which simply failed to go far enough. Reservations centred on the fact that the BMA’s guidance—like that of the statutory body, the General Medical Council—explored the issues without either firmly rejecting or accepting non-therapeutic male circumcision. Was it then a fruitless project or a brave start to grasping the nettle? (shrink)

There has been considerable controversy surrounding the routine circumcision of male infants in the United States. This is of particular concern, since the medical establishments of all the other countries of the developed world have abandoned this procedure as having dubious benefits. This article examines the medical pros and cons of neonatal male circumcision in a historical perspective and suggests that the circumstances that led to its establishment as a routine practice are largely absent today. Reasons (...) for its continued use and ethical and moral issues associated with its practice are then examined closely, especially in light of the current debate surrounding female circumcision. The article concludes that the medical and ethical issues surrounding this practice should be more broadly debated until there is some consensus as to its benefits. Prudence dictates that until such a consensus emerges, the practice should be suspended. (shrink)

We critically evaluate arguments in a recent Journal of Law, Medicine & Ethics article by Svoboda, Adler, and Van Howe disputing the 2012 affirmative infant male circumcision policy recommendations of the American Academy of Pediatrics. We provide detailed evidence in explaining why the extensive claims by these opponents are not supported by the current strong scientific evidence. We furthermore show why their legal and ethical arguments are contradicted by a reasonable interpretation of current U.S. and international law and (...) ethics. After all considerations are taken into account it would be logical to conclude that failure to recommend male circumcision early in infancy may be viewed as akin to failure to recommend childhood vaccination to parents. In each case, parental consent is required and the intervention is not compulsory. Our evaluation leads us to dismiss the arguments by Svoboda et al. Instead, based on the evidence, infant male circumcision is both ethical and lawful. (shrink)

Opponents of male circumcision have increasingly used human rights positions to articulate their viewpoint. We characterize the meaning of the term “human rights.” We discuss these human rights arguments with special attention to the claims of rights to an open future and to bodily integrity. We offer a three-part test under which a parental decision might be considered an unacceptable violation of a child's right. The test considers the impact of the practice on society, the impact of the (...) practice on the individual, and the likelihood of adverse impact. Infant circumcision is permissible under this test. We conclude that infant circumcision may be proscribed as violating local norms, even though it does not violate human rights. (shrink)

1. Aim of the guidelines2. Principles of good practice3. Circumcision for medical purposes4. Non-therapeutic circumcision 4.1. The law 4.1.1. Summary: the law 4.2. Consent and refusal 4.2.1. Children’s own consent 4.2.2. Parents’ consent 4.2.3. Summary: consent and refusal 4.3. Best interests 4.3.1. Summary: best interests 4.4. Health issues 4.5. Standards 4.6. Facilities 4.7. Charging patients 4.8. Conscientious objection5. Useful addresses.

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. Male circumcision also 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. Social norm theory predicts that once the circumcision rate falls below a critical value, the social norms that currently distort our perception of the practice will dissolve and rates will quickly fall. (shrink)