The following article by Mihail Evans was published by the British Medical Journal, 19 February 2011
New legislation in France has led to more debate on whether wearing the veil amounts to the sexual repression of Muslim women. Islam’s treatment of women is a regular topic in the Western press, yet few jump to the defence of Muslim and other little boys subjected to childhood circumcision. Indeed, the circumcision of the grandson of President Sarkozy, ironically a proponent of the veil ban, made only the gossip pages in France. As a permanent surgical genital alteration, circumcision is arguably a much more serious matter. After all, a Muslim woman has, at least in theory, the option to throw away her veil. The circumcised man’s foreskin has been thrown away already.
Few countries have banned male circumcision, but even symbolic alternatives to female genital mutilation are banned in almost all Western jurisdictions. While I was a student, a female academic at my institution published a piece supportive of male circumcision. This prompted a thought experiment: suppose we found a male academic supportive of the surgical modification of female genitals. Would his views be accepted? Why can a Jewish woman speak openly to defend male circumcision and a Somali man not defend female circumcision?
Physiological research has undermined beliefs that the foreskin is “just a flap of skin” and shown it to be an integral part of the penis. With the foreskin considered an erogenous, multifunctional tissue, the established view of circumcision as a non-damaging excision is fatally undermined. It would be more appropriate to change our terminology, to speak of male genital mutilation rather than circumcision in the same way that we use female genital mutilation and not cliteradectomy.
Finland is among the few places where male circumcision is illegal, although recent judicial decisions have backtracked on this law, making exceptions for some religious circumcisions. Bulgaria banned male circumcision in the 1980s, but more as part of a cultural war on its Muslim minority than out of any overtly humanitarian concern. My partner is Bulgarian, and it amazes me that under law in the United Kingdom I could legally take my son there and subject him to the sort of horrific circumcision recorded by a Bulgarian current affairs programme, yet my Somali neighbours would be prosecuted for attempting to appease traditional opinion by replacing female circumcision with a symbolic pinprick to the clitoral hood. The absurdity of the legal situation in the UK is exposed by the conviction of a man under child pornography legislation for possessing images of a traditional circumcision (BBC News, 21 Nov 2003, http://bbc.in/fzV3h0). Apparently images are illegal but the act is not.
We rarely glimpse more than the very tip of the iceberg of the sexual and psychological damage caused by male circumcision. One symptom is the considerable number of men interested in foreskin restoration. That any man would be prepared to spend several hours a day for several years using taped, weighted, and tensioned devices to try to regrow a foreskin is testimony to the suffering caused in some cases. In browsing online forums such as www.restoringforeskin.org, you get a sense of the great missing continent of male conversations that are unspeakable in public: the Iranian brought up in the West who always feels something is missing when he sleeps with a woman, or the gay American man depressed that he does not have the penis he was born with, like his European lover.
I am amazed at how male circumcision in developed countries is treated simply as a question of opinion. On online parenting sites, such as www.emmasdiary.co.uk and www.babymania.com, it is often treated as just another parental option, up there with bottle or breast. Most women in the UK do not circumcise their sons, but if a mother says she has had her son circumcised “to be like daddy” or for “tradition,” hardly an eyelid is batted.
I was shocked by some comments from mothers, which seemed more callous than would be tolerated if gender roles were reversed. In one a mother wrote “LOL” (“laugh out loud”) after telling the forum that her circumcised 4 year old “wants his old penis back.” In another, a mother from South Africa says she has kept the dried foreskin “in case he wants it back later.” Elsewhere on the web, it is completely acceptable to express a preference for a “cleaner” circumcised penis on women’s sites such as www.cosmopolitan.co.uk. I cannot imagine that a man who advocated ways of making the vagina more “attractive” and “hygienic,” let alone by surgical means, would be given a moment’s hearing. Would it be acceptable for a man to say he wanted to scare girls by training as a female circumciser? Of course not, but the Times can print an interview in which the actress Isla Fisher jokes that she would like to train as a mohel to give boys a scare (“The comic world of Isla Fisher,” Times, 25 Jan 2009, http://bit.ly/hgjEdV).
Legislation to outlaw male circumcision was put forward in Massachusetts, and although it was defeated campaigns continue in other states (see www.mgmbill.org). Dutch doctors also discussed a ban last year (BMJ 2010;340:c2987, doi:10.1136/bmj.c2987). But given the experience of Finland, which had to make religious exceptions after it initially banned all circumcisions, a better way to protect the genitals of young boys might simply be to use existing laws. The Tasmanian Law Reform Institute has suggested that male circumcision may breach existing child protection laws (http://bit.ly/eLfxId). And the media have hinted at the possibility of a test case in the UK (“Ritual circumcisions ‘illegal’,” Mirror, 17 Nov 2009, http://bit.ly/4GviWc). Finally, little boys in the West might be given the same rights as their sisters, but resistance is peculiarly high and comes from the most surprising quarters.
Dr Evans is a former postdoctoral researcher in ethics and philosophy, University of the West of England; mihail@riseup.net
Source: Brit Med J 2011;342:442 (19 February 2011)
Manzoor Memon, Chigwell, UK
As a medical student in a Muslim country, I never heard from peers or as a GP in East London any request for reversal of circumcision. The obsessive disorder with size and shapes of different parts of the body is a medical rather than ethical issue. The young boys with phimosis as a result of poor hygiene were referred for circumcision. Evans has ignored the scientific proof in BMJs (8th and 15th jan.2011) printed under short cuts or Guardian (21.6.2010) reporting 4 year study confirming male circumcision reduces HIV by 60%, hence 80% of Zimbabwean men aged between 15 and 29 are targeted in circumcision (painful stage) scheme aimed at reducing HIV infections. To outlaw circumcision in the USA (70% male circumcision) or stop vaccinations in third world is unscientific and young children should be covered by existing UN regulations on prevention of disease. Islam and Judaism recommend male circumcisions (Jesus peace be upon him was circumcised on the 8th day too). The female mutilation is cultural in some parts of Africa which predates Islam, Christianity and Judaism. Finally when woman goes in labour parity of sexes disappears.
Paquita C.B. de Zulueta, GP, Hon Senior clinical lecturer, Imperial College, London
Evans courageously questions the ethical justification for male circumcision. As a GP I have often seen the raw lesions left by the surgery, the infections sometimes caused, the clear distress, and, on more than one occasion, a worrying mutilation of the penis whereby more than the foreskin had been removed. I find it odd that this practice is permitted in countries where there are no significant clinical benefits to the procedure. People cite the reduced risk of cervical cancer, but this has been addressed with the introduction of the HPV vaccine, or they cite the higher incidence of rare diseases, such as penile cancer. HIV protection is not relevant in developed countries with low incidence. But even, if for the sake of argument, it were to provide significant protection to some diseases, do we conduct other elective procedures, such as appendicectomy, on children, in case they later on develop appendicitis (the risk of appendicitis in the USA is cited as being 0.25%)? The site of the wound is also relevant: an area that is particularly sensitive, exposed to urine and faeces, and in the context of an infant who cannot make sense of his distress and who cannot give consent.
Evans is quite right to refer to the fact that many men seek to restore their foreskins by drastic means in order to enjoy more satisfying sexual lives or simply to restore their bodily integrity. Googling 'Restoring foreskin' yields 703,000 entries. The issue is sensitive because of the religious context, but arguably we need to consider the differences in hygiene and medicine as well as attitudes to children that existed at the time of the religious injunction as compared to the modern day, when we now have (finally!) the Convention of the Rights of the Child. The great religions promote compassion as a fundamental tenet - where is compassion in all of this? At least it should be done when the individual is autonomous and can make the choice authentically and freely, even if the surgery is more complicated. Some fathers justify it on the grounds of wanting their sons to be 'like them'. But do we insist that our children have to have the same anatomical defects that we have? And finally is the issue of cleanliness and purity not something to do with a disgust towards our 'animal' bodies rather than being based on sound scientific evidence?
Antony D. Lempert, GP, Wylcwm Street Surgery, Knighton, Powys
Evans highlights well the disparity in the application of guiding principles to two distinct, though related scenarios. Some make the mistake of confusing this approach with weighted comparison of the relative harm of each. Non-therapeutic genital cutting of boys and girls causes different sets of serious problems; the principle of avoiding harm remains the same. Scales of harm are as unhelpful here as, for example, when considering the varied and overlapping harms of physical or emotional child abuse.
In this context, calls not to mention non-therapeutic genital cutting of boys and girls in the same sentence display unhelpful gender discrimination. Failure to fully comprehend the basic premise that adults should not even touch, let alone cut, any child's genitalia for any purpose other than cleaning, dressing, medical examination or immediately necessary surgery, leaves boys and girls similarly unprotected.
The GMC provides guiding principles for doctors treating those without the capacity to make their own decisions. (1)
It seems to be an act of faith not to compare the different application of these same principles in boys and girls.
The evidence of harm for 'ritual circumcision' has been well-documented (2) & (3). No medical association in the world recommends non-therapeutic childhood genital surgery. To claim supposed therapeutic benefit for non-therapeutic surgery is an oxymoron and undermines scientific integrity. Without therapeutic benefit, cutting the body of a person unable to either consent or defend himself, is a criminal assault. All children deserve protection from such serious avoidable harm.
(1) GMC Consent guidance: Making decisions when a patient lacks capacity 76a-c
(2) Williams & Kapila British Journal of Surgery, Volume 80, 1231 -1236, October 1993.
(3) Sorrells et al BJU International 99 (4): 864-869, April 2007)
Eleanor F Zimmermann, 4th Year Medical Student, Peninsula Medical School
In response to Ms MacDonald and Mr Dalton, I would like to urge both to reconsider their views of comparing male circumcision to female genital mutilation (FGM).
Male circumcision is although largely unconsented genital surgery that carries potential health risks, female genital mutilation (FGM) has such a long list of acute and long term complications that, as Dr Clarke clearly states, brings FGM to a completely different status where risks and ethical considerations are concerned. FGM is not confined to clitoridectomy - Type III (infibulation) involves excision of part or all of the external genitalia (the clitoris, labia minora and labia majora) with stitching of the labia minora or majora to narrow of the vaginal opening. (1) Young women who have undergone this type of FGM commonly suffer from a number of complications, including difficulty urinating, dysmennorhhea and also haematocolpos (accumulation of blood in the vagina). (1) When it comes to labour, these women have to be defibulated (surgical re-opening of the scar) in order for the baby to be delivered safely. (2) Obstetric management of these women is extremely complicated, and not without risks. (2)
It has also been shown that women commonly avoid normal gynaecological screening such as smear tests and STI screening due to the difficulties associated with vaginal examinations. (3)
In most cultures the legs of the victims are bound together after the procedure, and there are cases where some girls have broken their limbs due to being restrained during the procedure. (1) Children who have been brought back from 'holidays' having been mutilated don't feel able to communicate about their experiences, and often suffer from not only psychological complications but also recurrent urinary tract infections and dysmenorrhea, consequently often missing a number of days in education. The guardian has published a short documentary highlighting some of these problems: http://www.guardian.co.uk/uk/video/2010/jul/25/girls-facing-female-circumcision
Although FGM is illegal in the UK, there have not yet been any prosecutions, (4) and mutilation is still being performed, both through parents taking their children abroad, and through 'cutters' being flown over to perform FGM on a mass scale in communities. (3)
The reports online and on Youtube claiming that FGM is healthier and cleaner are outrageous. If we analyse the article sited in these videos, (5) the authors suppose the link between reduced HIV prevalence and FGM is based on confounders such as age at circumcision, type of circumcision and ethnicity. In fact women who have undergone FGM are less likely to engage in intercourse - either they can't, or they take no pleasure in it. This would be much like publishing an article looking at congenital impotence and HIV prevalence, concluding that impotent men have a significantly lower HIV prevalence, and claiming impotence is a protective factor for STI transmission. I have no doubt such a paper would get rejected by any publisher. In comparison, Brewer et al published results from a cross-sectional study showing an increased rate of HIV in those who had undergone either FGM or male circumcision.(7)
When scientifically justifying the published studies claiming a reduced HIV transmission rate amongst circumcised males and speculating on the effect of FGM, HIV target cells, especially Langerhans cells that are present in the external genitalia may offer a link. Langerhans cells are present in the foreskin of males, and throughout the genitalia, but especially in the ectocervix of females. (8)
As Ms MacDonald mentions of male circumcision: "In suggesting that forced male circumcision is justified where he may (possibly) reap some future reduction in cancer, HIV or even just smegma we open the door for these people to prove their case and demand a similar excision be promoted or pushed on women and girls." Similarly, the online resources that are pro-FGM are open to misunderstanding and abuse. Male circumcision is not comparable to female genital mutilation, although I agree that consideration should be given to banning male circumcision in childhood, and allowing for adults to make a fully informed decision as to whether they want the procedure or not.
1. RCOG. Female Genital Mutilation and Its Management. Green-top Guideline. No. 53. 2009
2. Rashid M, Rashid M. Obstetric management of women with female genital mutilation. The Obstetrician & Gynaecologist. 2007;9:95-101
3. FORWARD. Female Genital Mutilation: Information Pack. 2002
4. Carroll J. Metropolitan Police Authority. Female Genital Mutilation - MPS project Azure. Report 8. 2010 http://www.mpa.gov.uk/committees/cep/2010/101104/08/
5. Stallings, R.Y., Karugendo, E.. "Female circumcision and HIV infection in Tanzania: for better or for worse? (3rd IAS conference on HIV pathogenesis and treatment)". International AIDS Society. http://www.ias- 2005.org/planner/Presentations/ppt/3138.ppt.
7. Brewer D, Potterat J, Roberts J, Brody S. Male and Female Circumcision Associated With Prevalent HIV Infection in Virgins and Adolescents in Kenya, Lesotho, and Tanzania. Ann Epidemiol.2007;17:217- 226.
8. Decatur M. Could Female Genital Cutting decrease the risk of HIV infection in a similar manner as male circumcision and if so, what implications does this have for Female Genital Cutting eradication efforts? http://www.ucl.ac.uk/network-for-student-activism/w/Could_Female_Genital_Cutting_decrease_the_risk_of_HIV_infection_in_a_similar_manner_as_male_circumcision_
and_if_so%2C_what_implications_does_this_have_for_Female_Genital_Cutting_eradication_efforts%3F
Paul M Mason, Barrister-at-Law, Hobart, Tasmania
Ann Savage's contribution neatly highlights the central conundrum of this male/female issue, namely the tension between cultural relativism and sex discrimination. One might have thought that the bonding and sense of passage into adulthood lay in the 3 months seclusion rather than the medically unnecessary surgery. But the European "solution" she describes opted for the latter over the former, and in pursuit of a modern European educational norm. Who interfered with overseas cultures in that case? And did those teenage boys give their own free and fully informed consent?
As for girls; does not the goal of eradicating FGM/C (the culturally neutral UNICEF acronym) represent a colonialist interference with cultural needs? I have heard this argument put by a Kikuyu Kenyan PhD herself cut as a child. Intact girls, in Egypt for example where 97% are cut in some degree (UNICEF/WHO figures), suffer social isolation and embarrassment analogous to that of boys with foreskins differing from their own cultural norm.
The ethical constant here is patient autonomy. No one should deny a mature intelligent adult - like Ann Savage for instance - the right to seek (and pay for) medically unnecessary cosmetic surgery on any part of her body. But no Doctor should perform it on her without her own consent at the behest of her parents.
John P Warren, Retired Consultant Physician
Mihail Evans's Personal View this week on genital cutting is most welcome. It is time for a debate among society at large, and particularly ethicists, lawyers, politicians, health professionals and child welfare agencies about the subject of non-therapeutic male circumcision of children. This procedure, carried out on healthy infants and boys too young to consent, defies all the normal standards of medical ethics, and exposes children to unnecessary pain and mutilation, as well as risk of complications. It can legally be performed by individuals without any medical qualification, who may be ignorant of surgical techniques and who cannot prescribe pain controlling medication.
Dr Baombe's Rapid Response of 19 February mentions the distress of uncircumcised adolescent boys in countries where circumcision is common practice, but these boys have a remedy, that is to opt for circumcision. On the other hand boys and men who have been circumcised early in life and are distressed to discover their mutilation have no effective remedy, apart from non-surgical foreskin restoration, which takes years of applying tissue expansion techniques to the remaining penile skin. Even then, the result is not the same as a natural foreskin, as the lost specialised nerve endings do not regenerate.
Laura J MacDonald, Norm-UK
Mihail Evans is right to highlight the double standards around our response to male and female circumcision (1). The responses which suggest that the spectre of HIV justifies male child circumcision are illogical. Real world data starkly contradicts the conclusions drawn from the controlled circumcision trials (2). But this is not the point. With women at double the risk of heterosexual aquisition of HIV(3) (and male circumcision offering them no reduction in risk) the real question is: why has no research been undertaken into the STD effects of a comparable female medical excision and/or keratinisation?
Labial tissue for example is already known to be at greater risk of infections than foreskin - with myconium smegmatis ten times more prevalent in women!(4) This puts the 'hygiene' issue into perspective and shows the hypocrisy of those women who prefer their boys and men surgically 'cleansed'. Female circumcision advocates around the world from Dr Fuambai Ahmadu in Chicago, to Cleansexy on youtube; to Sheikh Yusuf Al Qaradawi in Egypt; to the Assalaam Foundation in Indonesia all claim health benefits follow their preferred form of female circumcision.
In suggesting that forced male circumcision is justified where he may (possibly) reap some future reduction in cancer, HIV or even just smegma we open the door for these people to prove their case and demand a similar excision be promoted or pushed on women and girls. As such those who promote forced male circumcision undermine the rights of all of us.
1.BMJ 2011;342:d978
2. USAID Report February 2009 Levels and Spread of HIV Seroprevalence and associated factors: evidence from national household surveys
3. http://www.avert.org/women-hiv-aids.htm
4. Morrison AI. Non-specific urethritis investigated by Ziehl-Nielsen staining of the urethral discharge. Br J Vener Dis 1969; 45: 55-7
John D Dalton, Trustee, NORM-UK
In anticipation of the howl of protest that "female genital mutilation is in no way comparable to male circumcision", the two are to an extent directly comparable. Both remove normal tissue from the genitals of someone with no disease and who gives not personal consent. Female circumcision may in some cases be more damaging than male circumcision, but that is not he point. Rather the question is how it might later be perceived by the person whose body is altered. Non- therapeutic surgery is only ethically acceptable in the case of informed consenting adults.
The question remains as to why every current GMC guidance document makes an explicit exception to non-therapeutic male circumcision. In the absence of such an exception the GMC guidance would clearly preclude non-therapeutic child circumcision. Perhaps the GMC would like to explain why there should be such an exception?
It seems strange that people can assert that male and female genital cutting cannot be compared when many experts have in fact compared them. What these deniers seems to mean is that male and female circumcision is not the same thing, a claim that nobody has ever made. But the fact that they are not the same does not mean that they do not have features in common, nor that they cannot be usefully compared. There has been a spate of articles over the past decade explaining both the similarities and differences between male and female genital cutting, and analysing the double standard to which Dr Evans refers, and we suggest that those who still have their head in the sands on this issue ought to do a bit more homework before they come out with their outdated assumptions.
Further information of ethics page
Further information about female genital cutting