An editorial in the January edition of the (Australian) Journal of Paediatrics and Child Health calls circumcision a “bizarre mutilation” and dismisses claims that it contributes to hygiene or improves child health. The editorial, by the editor in chief, David Isaacs, covers several aspects of both ritual and “health” circumcision, runs through the origins of circumcision as a religious/cultural rite in the region bordering the Red Sea, and comments that “there seem to be insufficient health benefits for circumcision to have evolved through natural selection”. He also devotes some attention to the rise of medically-rationalised circumcision of infants in nineteenth century Britain and the USA, and although the discussion is brief, he correctly notes that at that time the principle selling point for the operation was that it would discourage masturbation in infants and boys. Professor Isaacs concludes with a question that deserves greater debate – “Should the autonomy of an infant to choose when he is older outweigh his parents’ right to choose to have their infant son circumcised?” – but does not explore this issue. His remark that circumcision is no laughing matter seems undermined by the rather flippant style in which the editorial is written. Overall its message is that circumcision is primarily a cultural ritual and from a medical point of view too trivial a matter to be discussed in medical journals.
The editorial, followed by our comments, appears below.
What is the name of the useless bit at the end of a penis? A man of course, but circumcision is no joke. If you crave controversy, choose a topic concerned with sex or religion. The ancient ritual of circumcision meets both criteria. In the second century BC, tribes on the Red Sea, now Egypt, practised both female and male circumcision. One possible explanation relates to the belief that gods were bisexual and humans, like gods, had both a female and a male soul. The man’s female soul which resided in the prepuce and the woman’s male soul which resided in the clitoris had to be removed for healthy gender development. [1] An alternative theory is that female circumcision was a means for men to control women’s sexuality. Islam is opposed to female circumcision and Muslims attribute its continued practice in some Africa countries to traditional custom, not to religion. The modern re-naming of female circumcision as female genital mutilation is a clear ethical statement opposing this practice.
Male circumcision, unlike female circumcision, is incorporated into major religions. Neonatal circumcision is practised routinely by Jews, Muslims and some African Christians while adolescent circumcision is a common tribal manhood initiation ceremony. The World Health Organization estimates that 650 million or 30% of all males aged over 14 are circumcised, 70% of whom are Muslims. [1] That the bizarre mutilation of ritual male circumcision is so customary suggests some deep significance. There seem to be insufficient health benefits for circumcision to have evolved through natural selection. Freud suggested that circumcision represented a metaphorical ritual castration of the son by his father to control the son’s Oedipal rivalry.
Whatever the veracity of psychological explanations for male circumcision, its historic and geographic spread is intriguing. The ancient Greeks hated circumcision and the practice consequently declined under Greek rule. From about 1900, however, male circumcision became common in the United States, Australia and other English-speaking countries. In the UK there was a clear social gradient. It was purportedly impossible for a boy to attend Eton with either his foreskin or his tonsils intact. Neonatal circumcision, whether religious or cultural, was often performed without either analgesia or anaesthetic. This further example of our barbaric denial of neonatal pain, following neonatal surgery for pyloric stenosis and other conditions, is now unconscionable. A Cochrane meta-analysis shows that dorsal penile nerve block and, to a lesser extent local anaesthetic cream, is markedly superior to placebo. [2] Inadequate pain relief for circumcision persisted into the 1990s but is no longer tenable.
What happens to the foreskin after circumcision? Many are discarded but intriguing uses include incorporation into face creams and anti-ageing cosmetics, skin grafts, and as the foreskin fibroblast cell lines to feed stem cells, grow viruses and produce beta-interferon. In Africa, the foreskin may be dipped in brandy and eaten by the patient or the circumciser. [1]
There are some controversial medical benefits of male circumcision. In Africa, male circumcision halves the risk of a man acquiring HIV heterosexually. [3] Infant male circumcision reduces the risk of urinary tract infection (UTI) significantly, but because only 1% of normal boys has a UTI, 111 boys need to be circumcised to prevent one UTI. Since 2% of circumcisions are complicated by infection or haemorrhage, therapeutic circumcision should be reserved for boys with recurrent UTI or severe vesicoureteric reflux. [4] There is no evidence that circumcision improves hygiene, although this and the fond belief that it prevented masturbation were the main motivating factors in twentieth-century Western countries.
Circumcision is a rich ethical topic. Should the autonomy of an infant to choose when he is older outweigh his parents’ right to choose to have their infant son circumcised? Who should pay? Non-therapeutic circumcision is rarely publicly funded. The RACP is revising its recommendations on circumcision, but previously did not recommend routine male circumcision, while acknowledging that informed parental choice should be respected. Circumcision is a topic for endless debate. But no laughing matter.
Professor David Isaacs
Editor-in-Chief, Journal of Paediatrics and Child Health
Children’s Hospital at Westmead (Sydney)
disaacs@chw.edu.au
References
1. Wikipedia. Circumcision. Available from: http://en.wikipedia.org/wiki/Circumcision [Accessed March 2010].
2. Brady-Fryer B, Wiebe N, Lander JA. Pain relief for neonatal circumcision. Cochrane Database Syst. Rev. 2004; 3: CD004217. DOI: 10.1002/14651858.CD004217.pub2.
3. Siegfried N, Muller M, Deeks JJ, Volmink J. Male circumcision for prevention of heterosexual acquisition of HIV in men. Cochrane
Database Syst. Rev. 2009; 2: CD003362. DOI: 10.1002/14651858.CD003362.pub2.
4. Singh-Grewal D, Macdessi J, Craig J. Circumcision for the prevention of urinary tract infection in boys: a systematic review of randomised trials and observational studies. Arch. Dis. Child. 2005; 90: 853–8.
Although we welcome Professor Isaacs' description of circumcision as a “bizarre mutilation” and his dismissal of the many claims for its “health benefits” in children, there are a few aspects of his editorial that demand comment.
1. It is very unlikely that the persistence and spread of circumcision have anything to do with any supposed “deep significance” of the rite. The persistence arises simply from the fact that it is usually performed by powerful adults on infants or children who have no capacity to say No; it is more like a bad habit, handed down thoughtlessly from father to son, not so different from smoking. As to the spread of circumcision, this is explained by the comment that 70 per cent of the world’s circumcised men are Muslims; in other words, the large number of circumcised men simply reflects the wide distribution of Islam, the armies of which conquered vast swathes of central and southern Asia, northern Africa, south-east Asia and eastern Europe from the 8th to the 17th centuries. In India, Hinduism, and in south-east Europe, including Greece, Christianity resisted mass conversion, but in Africa, central Asia and south-east Asia the new religion wiped out the indigenous cultures and imposed circumcision on the conquered populations.
2. Muslims do not traditionally practise neonatal circumcision. The canonical age for circumcision in Islam is eight years, though in places such as Turkey it is usually done at any time between the ages of 6 and 9, in an elaborate ceremony with much dancing and drinking, and a certain amount of kicking and screaming from the central figure. As circumcision is medicalised, however, more parents are doing it in the manner of the Jews and modern Americans, soon or very soon after birth, in a coldly clinical rather than a warmly celebratory setting. Once medicalised in this way, circumcision loses whatever cultural significance it might have had.
3. It is not true, as Isaacs states, that “Islam is opposed to female circumcision and Muslims attribute its continued practice in some Africa countries to traditional custom, not to religion.” For one thing, unlike the major Christian denominations, Islam has no central authority determining doctrine. This means that every local preacher is free to interpret the sacred writings in pretty much any way he chooses, issue rulings and fatwas, call for the murder of blasphemers such as Salman Rushdie, and generally make up his own rules. Many Muslim authorities are strongly in favour of female circumcision, which is widely practised in north Africa, parts of the Middle East and among Muslims in Malaysia and Indonesia. Criminalisation of female genital mutilation in countries such as Egypt has had very little impact on local practice. Much the same comment as that quoted could as truthfully be made about male circumcision. There is no mention of circumcision in the Koran, and but the prophet Mohammed is reported to have stated that “Circumcision is a sunnah for the men and a makrumah for the women”. (Note the reference to men and women: nothing about boys and girls.) The term sunnah means customary or traditional; the term makrumah means meritorious. The most you could conclude is that circumcision was customary for men and meritorious for women, and thus desirable for both but obligatory for neither.
In these respects Islam is quite different from Judaism, which requires the head of the household not only to circumcise his baby sons at eight days, but also his male servants and employees, which makes no mention of women in this context, and in which the rule of circumcision is stated prominently in the first book of the Jewish bible.
Mohammed further laid down five rules for Muslim men: shaving the pubic hair; circumcision; trimming the moustache; plucking the hairs from the armpits; and clipping the nails. These constitute the fitrah, or laws of personal deportment, to which a pious man in pursuit of perfection must conform. According to Dr Sami Aldeeb, “They are not compulsory, but simply advisable”. The vital point about this list is that circumcision is a recommendation for adult men, perhaps no more important than trimming their moustache or shaving their pubic hair. It is thus less obligatory than the rule of prayer five times a day, the pilgrimage to Mecca, fasting at Ramadan or abstention from alcohol and pork. There is certainly nothing in the fitrah which requires parents to circumcise their children.
Sami A. Aldeeb Abu-Sahlieh, Jehovah, his cousin Allah and sexual mutilations, in George C. Denniston and Marilyn Milos (eds), Sexual mutilations: A human tragedy (New York: Plenum Press, 1997)
Sami Aldeeb, To mutilate in the name of Allah or Jehovah: The legitimation of male and female circumcision, Medicine and Law, Vol 13, No 7-8, 1994, pp. 575-622
Sami A. Aldeeb Abu-Sahlieh, Male and female circumcision among Jews, Christians and Muslims: Religious, medical, social and legal debate (Warren PA: Shangri-La Publications, 2001)
4. It is true that non-therapeutic (medically unnecessary) circumcision is rarely publicly funded, but one of the few places where it is funded by the taxpayer out of the health budget is Australia. Medicare provides a no-questions-asked rebate for medically unnecessary circumcision, even though its own guidelines state that rebates are not available for “medical services which are not clinically necessary” or “surgery solely for cosmetic reasons”.
5. It is odd that Professor Isaacs writes that the Royal Australasian College of Physicians “is revising its recommendations on circumcision” when in fact the new policy was issued in October 2010, several months before the editorial was published. In the new statement the RACP maintained the opposition to routine circumcision of male infants and boys that Australian paediatric authorities had first formulated in 1971. The most recent statement is quite clear: “After reviewing the currently available evidence, the RACP believes that the frequency of diseases modifiable by circumcision, the level of protection offered by circumcision and the complication rates of circumcision do not warrant routine infant circumcision in Australia and New Zealand.” Other medical bodies, such as the British Medical Association and the Royal Dutch Medical Association, have issued policies even more strongly opposed to the practice. Only in backward and impoverished places such as the United States and some regions of darkest Africa does faith in the health-giving powers of this mutilation linger. (For details, see statements from medical authorities on this site.)
6. Finally, we are surprised that a professor should cite the Wikipedia as an authority for anything, let alone a topic as controversial as circumcision. This would not have been acceptable in an assignment written by one of his students, and it should not be regarded as acceptable for somebody in a senior academic position. Why go to the Wikipedia, when scholarly texts by David Gollaher, Leonard Glick and Robert Darby are readily available?
David Gollaher, Circumcision: A History of the World’s Most Controversial Surgery (New York: Basic Books, 2000)
Leonard Glick, Circumcision from Ancient Judaea to Modern America (New York: Oxford University Press, 2005)
Robert Darby, A Surgical Temptation: The Demonization of the Foreskin and the Rise of Circumcision in Britain (Chicago University Press, 2005)
Robert Darby, “‘A source of serious mischief’: The demonisation of the foreskin and the rise of preventive circumcision in Australia”, in George C. Denniston, Frederick Hodges and Marylin Milos (eds), Understanding circumcision: A multi-disciplinary approach to a multi-dimensional problem (London and New York: Kluwer Academic and Plenum Press, 2001) Available at History of Circumcision.
Further information on this site