A new twist to the debate

Circumcision: Let the owner of the foreskin decide

An article in the Canadian Medical Association Journal suggests that it is wrong to circumcise male infants, but that the operation could reasonably “be offered” to boys just before puberty. This is the opinion of Dr Noni Macdonald, a professor of pediatrics at Dalhouisie University, who writes that since the “potential benefits” of circumcision kick in only after males become sexually active, it would make more sense to offer circumcision to 11-year olds than to do it to babies. “The [infant] isn’t at risk of HIV and sexually transmitted diseases, because they’re not sexually active, so why are we rushing to do it at that time?” She wonders why people are more likely to accept circumcision of a baby, who cannot give any kind of consent, and for whom the operation is of no benefit at all, than of a pre-teen, who might have at least some chance of understanding his options.

Good questions, but we do not feel that Professor Macdonald has come up with the right answers. She is correct to say that it is unethical to circumcise anybody without informed consent, and also that infants cannot possibly derive any benefit from such an operation, but we cannot agree that it would be acceptable to routinely “offer” to circumcise boys at 11 or 12 years of age. If boys at that age are not considered capable of consenting to sexual relations with other people, they are certainly not competent to consent to having part of their genitals surgically removed – an irreversible step, far more radical than mere sexual activity.

Another objection is that the average 11 year old does not have sufficient maturity, independence or knowledge to agree to such an operation, and is too subject to pressure from parents, relatives and peers to be able to make a free and informed choice. If circumcision provides some degree of protection against sexually transmitted infections (a contentious point), the only logical age at which a male can legally consent to circumcision would be the same as the age of consent for sexual purposes – that is, from 16 to 21 years, depending on the jurisdiction. In other words, if it is wrong to perform circumcision in infancy, it is equally wrong to perform it at any time before legal adulthood.

Full details of the proposal and a critical analysis by CIA follow.

1. Report in Canada National Post

A new study has reignited the ongoing debate over circumcision, with a provocative new suggestion by a leading Canadian researcher: Wait until boys are 11 or 12 before they are circumcised, and allow them a say in the decision. Dr. Noni MacDonald, professor of pediatrics at Halifax’s Dalhousie University, says that since the potential benefits of circumcision only begin to set in once males become sexually active, there may be merit in offering circumcision to young boys “rather than their baby brothers.”

She makes the provocative suggestion in the latest issue of the Canadian Medical Association Journal, in response to new evidence from large trials in Africa concluding the benefits of male circumcision in cutting the risk of HIV in heterosexual men there. “The [infant] isn’t at risk of HIV and sexually transmitted diseases, because they’re not sexually active, so why are we rushing to do it at that time?” Dr. MacDonald said. “If you’re really going to do this, we need to think of the timing. Why aren’t we offering it to peripubertal boys, when it’s going to be relevant?”

The Canadian Paediatric Society is in the process of trying to decide what to say about the topic. Several committees are reviewing the African data, said executive director Marie Adele Davis. The Ottawa-based group’s current position is that the benefits and harms of circumcision are so evenly balanced that it does not support recommending circumcision as a routine procedure for newborns.

Circumcision rates in Canada are falling, but it remains one of the most frequently performed surgical procedures worldwide. Dr. Neil Pollock, a Vancouver-based doctor who has performed more than 30,000 circumcisions, says routinely postponing the decision on the procedure is off the mark. “If it makes sense to do it later in life, it makes sense to do it earlier,” he said in an interview. He adds that having the surgery while in infancy makes it safer and less painful for the baby, and less costly for the medical system.“ Parents are always called upon to make decisions for their children, what they believe to be in their best interest,” he said. “If you explain to any 11-year-old what you were proposing, likely an 11-year-old would never consent to have that done.”

Because Canada has a much lower HIV rate than Africa, it isn’t clear how applicable the African studies are to the North American experience. A recent U.S. analysis estimated that neonatal circumcision would reduce the 1.87% lifetime risk of HIV among men, but only by about 16%. “It’s not a huge decrease,” noted Dr. MacDonald.

To those squeamish about a procedure that is deemed to be too painful and uncomfortable for a pre-teen, she says: “Why are we fine with doing it to a baby but not a young man? “It’s curious that a painful elective procedure of no major benefit to the infant until years later would ever be deemed more acceptable than the same procedure for a peripubertal boy,” Dr. MacDonald writes in the CMAJ. What’s more, unlike infant boys, older boys can give consent. “The baby gets no choice, the parents make the decision,” she said. “An 11-, 12-, or 13-year-old boy could really make a decision on their own about this.”

Study says wait until age 11 for circumcision, by Sharon Kirkey and Michael Fraiman
National Post (Canada), 5 April 2011

Comments from readers

The comment from Simon in Toronto is of particular interest

Quote from Dr Pollock: “If you explain to any 11-year-old what you were proposing, likely an 11-year-old would never consent to have that done.” That’s about as solid an argument against circumcision as anybody should need. Basically, he’s saying that the best reason to cut babies is because they can’t tell you to stop. It neatly – and brutally – clarifies the moral injustice of the practice.

The African studies have already been shown to be unreliable due to lack of controls or proper monitoring of participants. Also, what in the world would any data from there have to do with anything here? Cultural and social practices, economic conditions, health care options and political difference are too large to allow for a legitimate comparison. Correct me if I’m wrong, but I’ve never heard of groups of Western men gang-raping pre-pubescent girls because they think that will cure them of/protect them from HIV/AIDS, as has been reported from parts of Africa.

All of my sons are uncut. They are natural, whole and healthy. Why the heck would somebody want to subject them to the painful cutting-off of a valuable piece of an important body part? It’s time for our society to put the bizarre practice of circumcision into the dustbin of history.

… as is this from Vancouver Sun

Circumcision perpetuated by lack of consent

Re: Circumcision best left for prepubescence, disease expert says, April 4 “Why are we rushing to do it (circumcision) at that time (infancy)?” asks Dr. Noni MacDonald. Although those with a financial or other personal interest in perpetuating routine circumcision [such as Neil Pollock, Terry Russell, Mateen Jabbar, Brian Morris etc] will never admit it, the simple reason is that infants are the most powerless human beings in our society. Circumcision proponents know very well that if restricted to cases where informed consent of the circumcisee were sought, the procedure would vanish overnight.

Greg Depaco, Vancouver Sun, 7 April 2011

Reference:  Noni McDonald, Male circumcision: get the timing right, Canada Medical Association Journal 2011;183(7):872. PDF available; send request through Contact form on this site.

2.  Comment: Do we really want to see Routine Peripubertal Circumcision?

Professor MacDonald makes an interesting suggestions, but her comments are marred by several mistakes, an uncritical attitude to recent pro-circumcision literature, and a complete failure to understand the rules of informed consent. To take the last point first, it is simply wrong to say that an 11- or 12-year-old boy can give informed consent to circumcision, an operation that makes dramatic and irreversible changes to both the appearance and function of the organ that probably means more to him than any other. Boys of that age are not considered capable of consenting to sexual relations with other people, and even if they agree to have sex with somebody the other party will be regarded as guilty of sexual assault. Why should circumcision be treated any differently? If “peripubertal” boys at are not considered capable of consenting to sexual relations with others, they are certainly not competent to consent to having part of their genitals surgically removed.

Another consideration is that the average 11 year old does not have the maturity or knowledge to agree to such an operation, and is too subject to pressure and coercion from parents, relatives and peers to be able to make a free and informed choice. If circumcision provides some degree of protection against sexually transmitted infections (a contentious point), the only logical age at which a male can legally consent to circumcision would be the same as the age of consent for sexual purposes – that is, from 16 to 21 years, depending on the jurisdiction. In other words, if it is wrong to perform circumcision in infancy, it is equally wrong to perform it at any time before legal adulthood.

Sexual coercion in tribal societies, Korea and the Philippines

Professor MacDonald’s contention that circumcision at puberty provides “the opportunity for informed choice by the proposed recipient of the procedure. The boy can give assent” is contradicted by the experience of both tribal societies and of modern societies such as South Korea and the Philippines. Tribal societies have been performing initiation rites on “peripubertal” boys and girls, sometimes involving circumcision and other genital mutilations, for thousands of years, but the children have no more opportunity to decline the operation than to fly to the moon. If they object they are subject to violent coercion, and if they run away they are ostracized from the tribe and very likely to die. Circumcision of boys at around 11 years of age is pretty much universal in both South Korea and the Philippines, and in both societies the combination of social expectation, peer pressure and the fact that the boys are still children subject to parental discipline means that they have not the slightest chance of being able to say “No thanks” [1]. But unless they can decline without prejudice to their future social status, there is no possibility of an informed choice. It’s simply coercion with a velvet glove.

Experience in South Korea, where circumcision was introduced in the 1950s as a result of US influence following the Korean War, and has since become an entrenched “tradition”, shows that once circumcision becomes an unavoidable social custom it is likely to persist long after the temporary medical emergency that gave rise to it has disappeared. Medical treatments can be introduced and abandoned quite easily; social traditions are far more intractable.

The child’s right to an open future

The principle of the child’s right to an open future, as developed by the legal philosopher Joel Feinberg and the medical ethicist Dena Davis, holds that children are adults-to be, and that it is the duty of parents to preserve and protect their options so that they can make choices for themselves in adulthood. This applies not only to affection, food, shelter and education, but also to freedom from irrevocable parental decisions, of which circumcision is a permanent, palpable and unnecessary example [2]. Some children might be able to make an informed choice about circumcision as early as age 11, but by that token it is probably also true that they could consent to sexual relations with other people –a proposition that neither law nor custom is willing to accept. In order to protect the majority from exploitation and coercion, all children must be protected from unnecessary genital surgeries and restricted from the free exercise of sexual choices until the age of consent. The practice with respect to genital surgeries should be no less strict than the rules governing sexual activity.

Best interests and imputed judgement

There are two tests that may be applied when decisions have to be made on behalf of those incompetent to make them for themselves, whether minors or disabled adults. The first is the best interests test. These are the long term interests of the person as a person, taking account of the society in which he/she lives, interests, skills, hopes, wishes etc, and if a minor the person’s interests in the future, as an adult. In the case of Re J, for example, an English court determined that it would not be in his best interests for a 6-year old boy to be circumcised merely because his Muslim father wanted him to be. It would, however, be in the child’s best interests to be given necessary therapeutic medical treatment, such as a life-saving blood transfusion, even if his parents were Jehovahs Witnesses, whose religion prohibited such procedures. It would also be in his best interests to be vaccinated against serious diseases, such as hepatitis B, if he was at risk of infection (say from a parent with the disease), even if the parents were philosophically opposed to vaccination. In both cases the child’s welfare trumps the parents’ wishes. When medical treatment is either necessary to save a person’s life, or provides proven and substantial benefits (such as immunity to serious diseases) without harm, loss of body parts or function, and without a significant risk of complications, it is acceptable to provide it without the informed consent of the recipient.

The other test is the imputed judgement test – the option that an incompetent person would, or would be most likely to, choose for himself if he were competent to make and express an opinion. One way of establishing the answer in relation to medical issues is to ask what competent adults choose when faced with the same question. Most adults would agree to a blood transfusion if it meant the difference between life and death, and most would agree to get vaccinated against a serious disease if they were likely to be exposed to it and at risk of infection. The case of circumcision is even more clear-cut: since a negligible number of adult men in western societies elect circumcision for themselves, we may reasonably infer that if the average minor were asked whether he wanted to get circumcised he would say NO.

In fact, proponents of infant circumcision recognise this perfectly well. It is precisely because they know that the average adult , or indeed any male old enough to be conscious of his body and aware of what circumcision entailed, would also say NO, that they insist that the operation must be done in infancy or early childhood, when the boy has no power to resist. In the news report printed in the National Post above, Dr Pollock stated quite openly: “If you explain to any 11-year-old what you were proposing, likely an 11-year-old would never consent to have that done.” Australia’s leading circumcision crusader, Brian Morris, similarly admits that if the circumcision choice were left to them, many boys would make the “wrong” decision. “Parental responsibility must override arguments based on the rights of the child”, he writes, “parents have the legal right to authorise surgical procedures in the best interests of their children”. When they are old enough to give legal consent males “are reluctant to confront such issues” and are neither “mature nor well-informed enough” to make the right decision for themselves. In other words, Morris concedes that if doctors waited until boys were old enough to make up their own mind, most would not consent to the operation [3].

But from an ethical point of view, as “Simon of Toronto pointed out, the fact that the average vocal adult does not wish to be circumcised is proof that it is wrong to do it to voiceless minors. Those who fail to see this can only be described as morally and ethically disabled. Indeed, when it comes to sexual activity, both law and custom regard assaults on minors far more seriously than assaults on adults, and regard interference with babies as one of the vilest of all possible crimes. But if fiddling with a child’s genitals deserves a stiff gaol sentence, what sort of punishment should be inflicted to those who cut part of them off?

Whether to circumcise not the key question

MacDonald deserves credit for shifting the debate on circumcision away from irrelevant quibbles about the balance of risks and benefits (the so-called pros and cons rubbish), but her own suggestion as to the key question is not much better. The “medically important question” is not at all whether circumcision should be “routinely offered to young male adolescents rather than their baby brothers”, but how we can find an effective method of giving male minors some fraction of the protection against genital cutting currently enjoyed by their sisters.

Too much credence given to HIV-scare circumcision propaganda

Another significant weakness in Professor MacDonald’s essay is her acceptance of a very dubious piece of research on the effectiveness of circumcision as a means of reducing a male’s risk of infection with HIV. She cites a US study by Sansom et al claiming that US males had a lifetime risk of acquiring HIV of 1.87 per cent (i.e. nearly 1 in 50), that neonatal circumcision (presumably universal) would reduce this risk by 16 per cent, and that it was therefore justified as a measure of public health. To her credit, MacDonald regards this risk reduction as too small to justify circumcision without consent, but she has apparently failed to realise that the paper she cites is fatally flawed in several crucial respects and has been roundly criticised (i.e. torn to shreds) in the same journal in which it originally appeared.

Among other objections, the critics point out:

• the 1.87% lifetime risk was a wild exaggeration; the risk was more likely to be around 0.4%;
• there was no basis for assuming that the risk reduction afforded by circumcision was 60 per cent, and in fact it is certain to be much less than this;
• evidence from Africa (where HIV is a heterosexual epidemic) was not applicable to the USA, where the disease is concentrated among homosexual men;
• the study ignores extra costs arising from complications, as well as giving zero value to the foreskin as a functional element of the genitals.

As the critic points also out, with suitably massaged assumptions, you can “prove” anything you like: or as the computer scientists say, GIGO: garbage in, garbage out.

To read the full critique, go to www.plosone.org, and search for Stephanie L. Sansom et al, Cost-Effectiveness of newborn circumcision in reducing lifetime HIV risk among U.S. males. When you get the article, choose the tab for Comments, and select the first: GIGO, by vanhowe.

Another critic (Hanabi) points out that Sansom’s own data show that the lifetime risk of HIV to Black men was 6.23% while 73% of Black men are circumcised, yet the lifetime risk to Hispanics was only 2.88% with a circumcision rate of 42%. This suggests that there is no connection at all between circumcision and reduced susceptibility to HIV, that circumcision increases the risk of HIV, or that being Black in the USA is a far greater risk factor for HIV than possessing a foreskin. (This last point may be related to the disproportionate number of Black men in American prisons, where unsafe sex is rampant.)

It is interesting to note that Sansom’s article was originally offered to the US journal Pediatrics, which rejected it as unsound, forcing the authors to seek exposure in a far less authoritative on-line journal. Since the authors are associated with the American Centres for Disease Control, known be stacked with pro-circumcision zealots, we may suspect that the paper was little more than a piece of propaganda, cobbled together to support their case for universal neonatal circumcision.

3. References

1. Pang MG, Kim DS. Extraordinarily high rates of male circumcision in South Korea: history and underlying causes. BJU International 2002;89:48-54; also, Romeo B. Lee, Filipino experience of ritual male circumcision: Knowledge and insights for anti-circumcision advocacy. Culture, Health & Sexuality, May–June 2006; 8(3): 225–234; also Boyle GJ. Issues associated with the introduction of circumcision into a non-circumcising society. Sex Trans Inf 2003;79:427-8

2. Joel Feinberg, The Child’s Right to an Open Future, in Freedom and Fulfilment: Philosophical Essays (Princeton University Press, 1992). See also Dena Davis, Genetic Dilemmas: Reproductive Technology, Parental Choices and Children’s Futures (London and New York: Routledge, 2001), and idem, Genetic Dilemmas and the Child’s Right to an Open Future, 28 Rutgers Law Journal 549 (1997)

3. Brian Morris, In Favour of Circumcision (Sydney: NSW University Press, 1999), 61-2