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On the Unethical Nature of Routine Infant Circumcision Brenton J. Priest Date: June 8, 2012 David Wendell Moller, Ph.D., Chair and Professor Department of Bioethics Dane R. Sommer, D. Min., M. Div., Faculty Advisor A thesis submitted in partial fulfillment of the requirements for the degree of Masters of Arts in Bioethics in the Department of Bioethics of the College of Biosciences at Kansas City University of Medicine and Biosciences ABSTRACT
ON THE UNETHICAL NATURE OF ROUTINE INFANT CIRCUMCISION BRENTON JAMES PRIEST
Kansas City University of Medicine and Biosciences
Department of Bioethics College of Biosciences 8 June 2012
The practice of infant circumcision is not new, but it is currently undergoing a fiercely contested ethical examination. While the American Medical Association remains neutral on the subject, various groups have taken up positions in the debate. This dispute has culminated in an excessive amount of confusion, founded on a lack of education on the topic. Without clear direction from reputable medical institutions, parents are often compelled by healthcare providers to make unnecessary and uninformed decisions. The purpose of this paper is to argue that routine neonatal circumcision is not ethical. Without disputing entirely the use of circumcision for the treatment of certain diseases, I oppose the use of routine circumcision as a preventative form of medicine. I will begin by discussing the procedure of circumcision, its history, and proposed benefits and risks. This discussion will include the often misunderstood structure and function of the anatomy. I will then examine the ethical dilemmas surrounding routine neonatal circumcision and conclude that it is an unethical practice. TABLE OF CONTENTS
ABSTRACT
TABLE OF CONTENTS
PROCEDURE
HISTORY AND RELIGIOUS SIGNIFICANCE
FEMALE CIRCUMCISION
RISKS AND BENEFITS
ETHICAL FRAMEWORK
ANALYSIS
CASE STUDY: AS NATURE MADE HIM: THE BOY WHO WAS RAISED AS A GIRL
CONCLUSION
OTHER REFERENCES AND RESOURCES
This thesis is the result of a lifetime of impressions from the world and the people around me. I want to thank all of my friends and family for your input over the years on this controversial topic. I believe it is important and relevant to the society in which we live. Whether or not you realized it, you all have been influencing me, and my opinions, for a long time. I was actually listening. So, to my family, thank you for the greatest childhood ever— I love you, always. I especially want to thank my thesis mentor, Dr. Dane Sommer, who is the Director of Chaplaincy Services at Children's Mercy Hospital and adjunct professor at KCUMB, for all of his advice throughout this process. I appreciate that even though he is thoroughly opposed to my position on circumcision, he has given me valuable insight in the completion of this thesis. F. Scott Fitzgerald once said that, "The test of a first rate intelligence is the ability to hold two opposed ideas in the mind at the same time, and still retain the ability to function." It is for this aspect of Dr. Sommer's character and intellect that I deeply respect him and his position on the matter of circumcision. I would also like to thank all of the other faculty and friends that supported me over this year of ethics training and in constructing this thesis project, particularly Drs. Jason Wasserman, Randall Morris, and David Moller, Rebecca Ballard, Steven Fouse, and all of my friends in the KCUMB Bioethics Class of 2012. For my classmates, I am overjoyed by all of the dialogue that this topic engendered. My hope is that as future doctors, you will always question practices that are considered routine and, in the case of neonatal circumcision, remember that your patient is the child, not the parent. I am honored to have spent this past year with you all, and I look forward to spending many more with you as we train to become physicians. Do not do unto others as you would that they should do unto you. Their tastes may not be the same. —George Bernard Shaw The practice of infant circumcision is not new, but it is currently undergoing a fiercely contested ethical examination. While the American Medical Association remains neutral on the subject, various groups have taken up differing clinical and ethical positions in the debate. This dispute has culminated in an excessive amount of confusion, founded on a serious lack of education on the subject. Without clear direction from reputable American medical institutions, parents are often compelled by healthcare providers to make unnecessary and uninformed decisions. The purpose of this paper is to argue that routine neonatal circumcision is not ethical. Without disputing entirely the use of circumcision for the treatment of certain diseases, I oppose the use of routine circumcision as a preventative or prophylactic surgery. I will begin by discussing the procedure of circumcision, its history and religious significance, and proposed benefits and risks. This discussion will, at its inception, include the often misunderstood structure and function of the anatomy of the penis, highlighting the differences in the adult and the child. The mechanics of sexual function will also be examined because they are altered with circumcision. I will then examine the ethical dilemmas surrounding routine neonatal circumcision, including a comparison with and discussion of female circumcision. I will conclude that routine neonatal circumcision is an unethical practice and a violation of individual human rights. Routine infant, or neonatal, circumcision can be defined for this paper as a form of genital alteration performed regularly on male infants without critical analysis of the outcomes associated with such a surgery. Routine is literally defined as a customary or regular course of procedure. Thus, calling the practice "routine" implies that it is normally performed rather than not and leads to the dismissal of risk. Giving a procedure, in this case circumcision, the title of routine allows the decision for the operation to be made without thought, without pause, and without discretion for individuality. Yet, we make a decision one way or another for baby boys every day in this country. My argument against this aspect of routine infant circumcision is that individuals should be afforded the opportunity to make this choice for themselves once they are mature and competent. While infantile circumcision is relatively common in the United States– the rate for newborn males as of 2009 is around thirty-three percent1, 2– in most other parts of the world, it is only performed ritually for religious reasons. The rate in the United States is currently experiencing a steady decline; however, recent studies could likely result in a revival of the practice. I believe that this course of action would constitute a I became interested in this topic around the age of four. I remember hearing a big word on the evening news, and I asked my grandmother what it meant. She explained it to me, and even showed me what circumcision meant for my own body. Even as a young child, I had wondered before this incident why the skin on my penis was 1 Roni Caryn Rabin, "Steep Drop Seen in Circumcisions in U.S." New York Times, August 16, 2010, http://www.nytimes.com/2010/08/17/health/research/17circ.html?_r=1. 2 While this number was given during the 2010 AIDS Conference in Vienna by a CDC official, conflicting surveys put the rate around 56 percent. Later CDC estimates for the year 2010 showed the rate to be greater than 50 percent as well, but even these higher numbers still reflect a decline from 2006. not all the same color. She explained that it was due to the scar that had formed after the surgery, and that the operation had been performed when I was a baby. I did not really ask too many questions about it after that. I was under the impression that the surgery was done to all baby boys, and that it was very important. Since I heard the word come from the pulpit many times after that, I also assumed it was a requirement for my Christian faith. I suppose that conversation has remained within my memory for many years because it was the first time I was informed that some part of my body had been changed at a very young age. I had received surgical alteration, even though I was not sick, and this factor was difficult for me to understand. I could remember my tonsillectomy experience that had occurred at age three, and while my case was severe enough that it was medically indicated, I had found it to be extremely painful. In my childlike mind, I could see a disconnect with those two medical interventions, but I was too young to question the difference between them. As I grew older, however, I did find myself questioning why I had been circumcised. I can remember in junior high and high school wondering what it would have been like if my parents had chosen not to circumcise me. I even recall a feeling of insecurity during those formative years, directly related to the fact that I was circumcised. I always justified this surgery as a requirement for my faith, and I knew that my parents would never do anything they thought would be harmful to me. The truth is, however, that I have never actually been happy with the fact that I did not have a say in this most private part of my body. During my first year of college, I decided to do some research on the topic, and I was shocked to find that most of the world did not practice circumcision.3 Almost immediately, I also learned that it was not a part of the Christian faith. This information disturbed me, and I began to wonder why this surgery was deemed so important by so many people. This questioning led me into the rabbit hole that is the debate on circumcision, and I am still trying to understand how the intact body could ever have become such a contentious matter. I have remained interested in the topic and watched it grow into a major discussion both in and out of the medical field, especially with the publicity of recent legislative measures aimed at limiting its practice. I told that story because it is a reflection of the thesis proper. The story is deeply personal, and I do not share it lightly. My research has forced me to conclude that the issue of circumcision is deeply personal for many men, and as a widespread surgical procedure in the United States, circumcision needs to be discussed. It is often considered either taboo in conversation, or it is only referenced as something meant to evoke giggles. This paradigm is changing as we shall see in this paper. My questioning and personal insecurities specific to this topic are shared by many of the people subjected to the practice of routine infant circumcision. Discrediting so many voices asking for change in current policy would constitute a transgression. 3 W. D. Dunsmuir and E. M. Gordon, "The History of Circumcision," British Journal of Urology International 83, no. S1 (January 1999): 1-12, doi:10.1046/j.1464-410x.1999.0830s1001.x. Therefore, my argument, after careful review of the literature and a considerable amount of the personal testimony available, centers around three main points. First, the evidence surrounding any medical benefit of routine infant circumcision is conflicting at best and, therefore, does not outweigh the risk. Second, circumcising a baby boy infringes on his innate human rights of personhood and liberty. Last, even if it was proven that the benefits outweighed the risks, routine infant circumcision should still not be performed because the breach of autonomy is a matter of justice that should not be violated. My sincere hope with this thesis project is that through education of the normal anatomy, analysis of the alleged benefits, and exposure of the risks that routine circumcision entails, parents will be able to make fully informed decisions. I believe that with this knowledge, parents will be dissuaded from making the decision to circumcise their sons, and that the practice will continue to decline in America. Additionally, I speculate that baby boys who are left uncircumcised will not choose to be circumcised later in life, unless there is a religious reason or pressing medical indication. In parts of the world where circumcision is rare, this trend has become mainstream. To suffer is to be acted upon by an agent or force over which one has —Dr. Dane Sommer The male anatomy, especially the prepuce, is often misunderstood. For this discussion, it will be helpful to include an anatomy tutorial concerning the male genitalia because circumcision removes and affects several parts of it. The penis is a tubular structure that extends from the base of the ischium (pubic bone).4 Below it, the testes are housed in the scrotum. While the scrotum is almost entirely an external structure, holding the testicals away from the body for temperature regulation and sperm production, the penis is only partially external. Actually, only about half of the penile structure can be seen, generally speaking. It originates deep within the perineal region of the body. This aspect of the penis provides greater support, especially during sexual intercourse, since the human penis does not contain a baculum or erectile bone. Most other mammals do actually have this penile bone. Moreover, due to the penis being embedded within the body, there are very few issues of dislocated or dislodged penises. Since the erectile tissue runs the entire length of the penis, both interior to the body and exteriorly, erections can be much stronger. For any natural selection and propagation of the species arguments, these features are rather important. The root of the penis, or the radix, is the attached portion. There are basically three parts of the root connected to the body including the left and right crus of penis and the bulb of penis in the middle. In the main body, or corpus, of the penis, there are three sections, which stem from the root. There are two corpora cavernosa lying next 4 The following is general anatomy information and is largely public domain. It can easily be found and verified by searching WebMD or Wikipedia. to each other on the dorsal (topside) of the penis, and they originate at the two crura of the penis. The corpus spongiosum runs the length of the ventral (underside) of the penis. It originates at the bulb of the penis and then enlarges at the tip of the penis to become the glans (glans penis), or the head as it is commonly referred, which is covered by the prepuce (foreskin). These three cavernous sections of the penis corpus are the erectile tissue. During an erection these three tissues are engorged with blood causing the penis to become stiff. These three interior erectile sections also give the penis its While the actual anatomy of genital structures for males is more complicated than it may appear on the outside, the plumbing on the inside is straightforward. Urine and semen exit the body via the same tube, the urethra. The urethra is the tube that extends from the urinary bladder, through the length of the penis, and ends at the glans. This tube is embedded in the corpus spongiosum, which is why it opens at the tip of the glans in the normal, anatomical male. The urethra is the only tube that urine should enter, under normal circumstances, after leaving the bladder. During sexual activity, sperm must also exit through the urethra, but it must get there first. Sperm is produced in the testes and then stored in the epididymis. Upon ejaculation, it traverses the vas deferens which runs up and out of the scrotum, over the pubic bone and top of the bladder, and into the seminal vesicle. The sperm mixes with secretions from the seminal vesicle and is moved onward to the prostate gland via the ejaculatory duct. The prostate is rather famous, or infamous, for causing cancer in males, but it is required for erections and certain sexual activities. The prostate empties its secretions into the ejaculatory duct5 as well, and they are mixed with the semen. Once the sperm mixes with secretions from the various glands, including fructose sugars to feed the sperm and proteolytic enzymes to protect them, the sperm solution is known as semen. Semen is basically a medium that allows the sperm to "swim." The semen can now enter the urethra and exit the body. This entire process is known as ejaculation. Ejaculation usually occurs in correlation with an orgasm, and requires less than ten seconds to transpire. The pea-sized bulbourethral glands, or Cowper's glands, are located behind the bulb of the penis, on either side of the urethral entry into the corpus spongiosum. They release lubricants during sexual arousal, but their fluid is not part of the semen proper. These glands do not produce any fluid in some males, and some theories suggest that infantile circumcision may exacerbate this deficiency.6 The exterior of the penis, as mentioned earlier, is only a part of the main structure. The exterior basically consists of five main parts. The base is the area where the skin of the penis meets the pubic hair, which is not the beginning of the actual penis. The shaft is the length of the penis, between the base and the glans. The glans, or head, is an extension of the corpus spongiosum, and it is "designed" to be an internal part of the penis. As such, the glans is only exposed during sexual activity. The skin of the shaft 5 The prostate also surrounds the urethra, and its glands can release directly into the urethra. If swelling of the prostate occurs, as in prostatitis, it can occlude the urethra making it difficult and painful to urinate. 6 No research has shown solid proof of this. It is a theory that some scientists have purported as a possible cause. transitions into the prepuce, or foreskin, which folds over the glans and generally keeps it covered. The perineal raphe can be seen on the ventral side of the penis, and this is a remnant of embryological development. It extends from the anus, around the scrotum, up the midline of the shaft, and all the way to the meatus (urethral opening). The raphe becomes the frenulum just before reaching the meatus. For years, medical textbooks have omitted virtually all discussion on the structure and function of the foreskin.7 Thus, even doctors are not well educated on the matter, resulting in a range of opinions regarding circumcision. In fact, the foreskin is not just skin. It is quite different from even the skin on the shaft of the penis, and it is not attached to an underlying connective tissue. It can freely move back and forth over the glans penis. The prepuce, while considered to be one functioning unit, is actually two separate parts: the outer foreskin and the inner mucosa of the foreskin. The inner mucosa is in contact with the glans except during sexual activity. Likewise, the glans penis is not covered with skin. Rather, it is a mucosa. After circumcision, the glans will become keratinized and dried out, which can lead to a loss of sensitivity.8 On the ventral side of the penis, the highly erogenous, elastic tissue called the frenulum connects the foreskin to the glans. All parts covered by the foreskin are protected by a mucosal lining.9 7 W. D. Dunsmuir and E. M. Gordon, "The History of Circumcision," British Journal of Urology International 83, no. S1 (January 1999): 1-12, doi:10.1046/j.1464-410x.1999.0830s1001.x. 8 C. J. Cold and J. R. Taylor, "The Prepuce," British Journal of Urology International 83, no. S1 (January 1999): 34-44, doi:10.1046/j.1464-410x.1999.0830s1034.x. Mucosal membranes are found at all openings of the body. Due to the mucous produced by their glands, they provide a moist barrier that protects against infection. Mucosal membranes are typically a non-keratinized epithelium. The epithelium of the vagina is a good example of a mucosa because, while it is stratified (multi-layered) to protect against abrasion, it is moist and non-keratinized. Both of these qualities aid in sexual pleasure and natural childbirth. The mucosa of the glans penis and inner foreskin is, or should be, nearly identical to the vaginal epithelium. If circumcision has occurred, then the body will have transformed the mucosal epithelium of the now exposed glans (the inner foreskin is mostly removed) into a dry and keratinized layer to protect itself. Keratinization is the body's mechanism of protecting underlying tissue from the environment. The skin is the most obvious example of a keratinized epithelium. It must be resistant to the environment, so the body adds keratin into the dying cells, called squames, at the top layers of the epidermis. These layers of microscopic chainmail provide a rigid barrier between the living cells of the dermis and the harsh surroundings in which we live. In the uncircumcised male, the prepuce provides this protection to the glans since the glans is not covered with skin. It is an internal structure of the body before its outer covering, the prepuce, is removed. To be clear, even after the glans has been exposed permanently due to circumcision, skin will not form on it. The mucosa of the glans simply dries up, and the keratinization that occurs thickens the surface epithelium many times over. At the microscopic level, this is tantamount to wearing chainmail armor over the most sensitive part of the body, blunting and mitigating the sensory receptiveness of the nerve endings in the glans. Beyond protecting the glans, the foreskin has a major sexual function as well.10 The tissue is highly innervated, much more so than normal skin and even the glans penis. Circumcision removes what will become around fifty percent, or about fifteen square inches, of the erogenous tissue in the adult,11 and that tissue will contain many specialized free nerve endings.12 This tissue is rich in encapsulated pressure, or pleasure, receptors and mechanoreceptors including fine-touch Meissner's and Pacinian Corpuscles.13 It should be noted that the glans do not contain these encapsulated corpuscles except in exceedingly sparse quantity near the coronal sulcus, just proximal to the glans. This characteristic only leaves the glans capable of protopathic sensitivity which "refers to cruder, poorly localized feelings (including pain, some temperature sensations and certain perceptions of mechanical contact)."14 The ridged band is also removed during circumcision. It is a complex of nerve fibers and dartos muscle that helps the foreskin retract and fold properly.15 The ridged band is sensitive tissue that extends from the frenular delta region (frenulum), so it exhibits an elastic quality. It creates the "pucker" of the folded foreskin when it is not 11 J. R. Taylor, A. P. Lockwood, and A. J. Taylor, "The Prepuce: Specialized Mucosa of the Penis and Its Loss to Circumcision," British Journal of Urology 77, no. 2 (February 1996): 291-295, doi:10.1046/j.1464-410X.1996.85023.x. 12 C. J. Cold and J. R. Taylor, "The Prepuce," British Journal of Urology International 83, no. S1 (January 1999): 34-44, doi:10.1046/j.1464-410x.1999.0830s1034.x. 13 J. R. Taylor, A. P. Lockwood, and A. J. Taylor, "The Prepuce: Specialized Mucosa of the Penis and Its Loss to Circumcision," British Journal of Urology 77, no. 2 (February 1996): 291-295, doi:10.1046/j.1464-410X.1996.85023.x. 14 C. J. Cold and J. R. Taylor, "The Prepuce," British Journal of Urology International 83, no. S1 (January 1999): 37, doi:10.1046/j.1464-410x.1999.0830s1034.x. 15 J. R. Taylor, A. P. Lockwood, and A. J. Taylor, "The Prepuce: Specialized Mucosa of the Penis and Its Loss to Circumcision," British Journal of Urology 77, no. 2 (February 1996): 291-295, doi:10.1046/j.1464-410X.1996.85023.x. fully retracted behind the glans, and the stretching of the ridged band as it moves back and forth around the corona and sulcus has been shown to enhance sexual sensation significantly.16,17 All of these mechanisms provide what is known as the "Gliding Action" during intercourse, reducing the need for lubricants, and adding to sexual pleasure. Basically, after the initial penetration of the intact penis during sex, the penis moves in and out of its own skin rather than across the vaginal wall. Due to the complex inner structure of the clitoris, which will be discussed further in a later section,18 this action seems to deepen the sensation for both partners because the girth of the penis is effectively augmented every time the glans retracts within the foreskin. Moreover, because the penis is not fully withdrawing from the vagina as often, lubricants produced by the female, and in some cases the male too, remain inside the vagina. "This sheath-within- a-sheath alignment allows penile movement, and vaginal and penile stimulation, with minimal friction or loss of secretions."19 The corona (the widest part) of the glans of the circumcised male strips the lubrication from the vagina during each withdrawal, resulting in the need for extra lubricants during sex. 16 K. O'Hara and J. O'Hara, "The Effect of Male Circumcision on the Sexual Enjoyment of the Female Partner," British Journal of Urology International 83, no. S1 (January 1999): 79-84, doi:10.1046/j.1464-410x.1999.0830s1079.x. 17 DaiSik Kim and Myung-Geol Pang, "The Effect of Male Circumcision on Sexuality," British Journal of Urology International 99, no. 3 (March 2007): 619-622, doi:10.1046/j.1464-410x.1999.0830s1052.x. 18 See section titled FEMALE CIRCUMCISION. 19 K. O'Hara and J. O'Hara, "The Effect of Male Circumcision on the Sexual Enjoyment of the Female Partner," British Journal of Urology International 83, no. S1 (January 1999): 81, doi:10.1046/j.1464-410x.1999.0830s1079.x. Furthermore, the five most sensitive regions of the penis are located in tissue that is usually completely removed with circumcision. All five of these sensitive regions are more sensitive than the most sensitive region on the circumcised penis, which is the ventral part of the scar.20 The glans penis, while often thought to be the most sensitive and sexually excitable region of the penis, is in fact, only capable of primitive sensory capability– "on or off" perception– similar to the heel of the foot.21 This type of limited perception is called protopathic sensitivity, which I mentioned earlier. The difference in nervous perception between the glans and the prepuce is considerable and somewhat analogous to the back of the hand versus the palm, respectively. With the analogy of the hand, it is not so much that one side of the hand feels way better than the other. It is simply that with both sets of nerve endings, there is greater sensory response. In the penis, this effect is considerably amplified because the nerves of the prepuce actually receive sensory information in fine detail and function differently than those in the glans. They are much more refined in the prepuce. Not to mention, estimates for the number of nerve endings and sensory receptors lost through circumcision are thought to range in the tens of thousands. Circumcision is the act of excising or amputating all or most of the prepuce, which is the foreskin, and (sometimes) the associated frenular tissue. For the purposes 20 Morris L. Sorrells et al., "Fine-touch Pressure Thresholds in the Adult Penis," British Journal of Urology International 99, no. 4 (April 2007): 864-869, doi:10.1111/j.1464-410X.2006.06685.x. 21 C. J. Cold and J. R. Taylor, "The Prepuce," British Journal of Urology International 83, no. S1 (January 1999): 34-44, doi:10.1046/j.1464-410x.1999.0830s1034.x. of this paper, I will focus on the procedure for infants, which is common in the United States, where it has been practiced on baby boys routinely for about the last seventy years. If the parents give consent for it, the surgery is usually performed at the hospital within one or two days of birth, except in cases of religious ritual, such as with the Jewish Brit Milah. In this case of religious ritual, the practice is not viewed as a medical procedure. So, it is usually not performed at the hospital, but rather, at a welcoming ceremony called a "Bris" or "Brit Milah." I will discuss religious circumcision more in depth at a later point in this paper. In the hospital setting, a sterile environment is used for the procedure, which usually lasts no more than thirty minutes. The baby must be strapped down to a restraining board to keep him from moving his arms and legs. The area around the baby's genitalia is then sanitized for the operation, usually with a povidone-iodine (PVPI) The American Academy of Pediatrics recommends the use of local anesthesia,22 but this typically normal aspect of surgery is often disregarded.23 Until somewhat recently, the use of anesthesia was uncommon due to the erroneous assumption that infants do not feel pain.24 "[Additionally,] some doctors minimize circumcision pain by calling it ‘discomfort' or comparing it to the pain of an injection, although these opinions 22 American Academy of Pediatrics Task Force on Circumcision. Circumcision Policy Statement, Pediatrics 1999;103(3):686-93. 23 R. Goldman, "The Psychological Impact of Circumcision," British Journal of Urology International 83, no. S1 (January 1999): 93-102, doi:10.1046/j.1464-410x.1999.0830s1093.x. have been refuted by empirical studies."25 Conventional wisdom among doctors performing infantile circumcisions has also included the use of a pacifier soaked in sucrose to calm the baby and to ease his pain. A recent study, however, has indicated that oral sucrose is not effective in preventing or relieving pain in neonates based on chemical activity within the brain and spinal cord.26 Therefore, it is not recommended as an adequate analgesic. Nevertheless, if anesthesia is used, doctors have several varieties to choose from. One method is to insert a dorsal nerve block. This technique requires a shot on the upper, dorsal side of the penis. This does not, however, deaden the nerves of the ventral side. Another method that can be used, alone or in conjunction with the dorsal nerve block, is Lidocaine or a similar numbing agent. These also are injected. This method requires the doctor to administer multiple shots in a circumferential pattern, called a ring block, around the area to be excised. A less invasive method of anesthesia comes in the form of EMLA topical cream, which must soak into the skin for at least thirty minutes before it is efficacious. Unfortunately, the cream not only lacks the ability to numb the deeper tissue of the prepuce, but physicians often do not wait the full thirty-minute period before operating.27 In the end, due to the complex nervous 26 Rebeccah Slater et al., "Oral Sucrose as an Analgesic Drug for Procedural Pain in Newborn Infants: A Randomised Controlled Trial," abstract, Lancet 376, no. 9748 (October 2010): 1225-1232, doi:10.1016/S0140-6736(10)61303-7. 27 C. J. Cold and J. R. Taylor, "The Prepuce," British Journal of Urology International 83, no. S1 (January 1999): 34-44, doi:10.1046/j.1464-410x.1999.0830s1034.x. structure of the penile tissues, the use of anesthesia does not eliminate the pain associated with the procedure.28 After the anesthesia is applied, two forceps are attached to the outer rim of the prepuce at the 10:00 and 2:00 positions to open the preputial space. A blunt probe is then used to separate the foreskin forcibly from the glans. In infants, the foreskin is attached to the surface of the glans penis with tissue similar to that tissue which affixes the fingernails to the nail beds.29 After the separation has been completed for the entire circumference of the glans, a hemostat is used to compress a dorsal groove into the prepuce, parallel to the shaft of the penis. After a few seconds, the doctor cuts a slit in the dorsal part of the foreskin that was formerly clamped. By opening the foreskin, space is made for a circumcising clamp to be applied. There are several versions of these clamps, including the most commonly used Gompo, Plastibell, and Mogen varieties. For infants, the type of clamp is chosen by the doctor, and each clamp provides a slightly different outcome. Whichever is chosen, the circumcising clamp is used to apply pressure to the foreskin, causing the blood flow to be cutoff by crushing the tissue. This step requires care because any skin that is clamped must be cut. The doctor then uses a scalpel to ablate the rest of the prepuce that remains on the clamp. On the ventral side, depending on the technique being used, the doctor will choose either to leave the frenulum or remove it. Finally, dissolvable stiches are implanted to unite the skin from the shaft with the mucosa of the residual inner foreskin. The recovery time is about two weeks for neonates, as long as there are no complications involved. Acetaminophen is generally the pain reliever used post-operatively for neonatal circumcision. HISTORY AND RELIGIOUS SIGNIFICANCE The origins of circumcision are not entirely known. Hieroglyphs show that the practice was used by ancient Egyptian priests, and records indicate that ancient Israelites either adopted or developed a form of the practice concomitant to the ritual still widely used by Jews today.30 What we consider to be circumcision today, however, was actually three different rituals for the ancient Israelites. Circumcisions today include the complete removal, more-or-less, of the prepuce. In ancient times, ritual circumcision did not necessarily imply this type of removal. The circumcision that is part of the Abrahamic Covenant was called Milah, hence, the Brit Milah ceremony.31 It only involved the removal of the residual foreskin that extended beyond the glans. During the Hellenistic period and Roman rule, Jewish men that wanted to compete in athletic events or use the gymnasiums and public baths sought to undo their circumcisions by stretching the skin so as to not be ridiculed. Since very little tissue was ever removed in a Milah ritual, these men could easily stretch the skin enough to cover the head of the penis. In an effort to prevent this type of foreskin restoration, the Rabbinate added a far more invasive procedure to the usual ritual circumcision. Peri'ah 30 W. D. Dunsmuir and E. M. Gordon, "The History of Circumcision," British Journal of Urology International 83, no. S1 (January 1999): 1-12, doi:10.1046/j.1464-410x.1999.0830s1001.x. 31 James E. Peron, "Circumcision: Then and Now," Many Blessings, Spring 2000, 41-42, http://www.cirp.org/library/history/peron2/. is the tearing of the skin from the glans and the removal of the inner mucosa.32 This method of circumcision is most similar to routine infant circumcision of today. It was usually performed with an exceptionally sharp fingernail, and yielded a greatly reduced sensitivity. By implementing this extra step in circumcision, the rabbis prevented future foreskin restoration and lessened the sexual pleasure that males could receive. Under the ideal of protecting individuals from immoral actions, this more invasive type of circumcision was defended by the rabbis. In fact, the great rabbi and physician, Moses Maimonides (1135–1204), stated that circumcision was required to "cause man to be moderate" because circumcision "weakens the power of sexual excitement" and "lessens the natural enjoyment."33 The final step to be added to ritual circumcision is called Metzitzah B'peh.34 This last part is the sucking of the wound of the newly cut and torn (Milah and Peri'ah) penis. This procedure was added much later seemingly for reasons of preventing infection. This feature involves the mohel actually sucking the bleeding penis with his mouth to remove the pooling blood. "This was most probably adopted to collapse the major blood vessels to stem bleeding and to extract any induced bacteria from the wound and blood system. In effect, it often introduced infection, such as tuberculosis and venereal diseases, with very serious and tragic consequence, as reported throughout history."35 33 Morten Frisch, Morten Lindholm, and Morten Grønbæk, "Male Circumcision and Sexual Function in Men and Women: A Survey-based, Cross-sectional Study in Denmark," International Journal of Epidemiology 40, no. 5 (June 2011): 1367-1381, doi:10.1093/ije/dyr104. 34 James E. Peron, "Circumcision: Then and Now," Many Blessings, Spring 2000, 41-42, http://www.cirp.org/library/history/peron2/. A glass tube is generally used today for this part of the ritual. Most rabbis claim that it is not acceptable to perform the traditional Metzitzah B'peh. Some Orthodox mohelim, however, still do this ritual with their mouths, even though there are obvious medical risks associated with such an act. A common misconception about Christianity is that, like in Judaism, ritual circumcision is required. This line of thought is only a misunderstanding, however, and has no scriptural or creedal basis. Since Christianity arose out of the Jewish heritage, one major question developed almost immediately for that religion. Do Gentile (pagan) converts have to become Jews before becoming Christians? The answer is no. The question boiled down to whether it was appropriate to force Greek and Roman male converts to be circumcised. In the first of four major debates in early Christianity, it was decided by the Apostle Paul and the other church leaders at the Jerusalem Conference that Gentile converts did not have to convert to Judaism.36 Paul even brought Titus, who was an uncircumcised convert, with him to the conference to ensure that the church leaders were genuine in their support of his message. This decision no doubt helped to bolster the number of willing converts to The Way (Christianity), but it also marked the decisive moment where The Way became Christianity– a separate religion from Judaism. From that point on, Christianity moved further and further from its Jewish roots, with the separation culminating with the destruction of the Jewish temple 36 Acts 15:1-29 (NRSV). Sometime after the Jerusalem Conference, the apostle Paul found out that some people were still emphasizing the importance of The Law and circumcision to potential converts. These missionaries were stirring up problems within the churches that Paul had already founded, and he responded with some of the most colorful writing found in the Bible today. He is exceptionally and repetitively clear when he consoles the concerned church members. He refers to any apostles who promote circumcision for Christians as "false believers" and "dogs who mutilate the flesh!"37 Paul's argument is that Christians are symbolically circumcised, not of the flesh but of the heart. He is not being anti-Semitic here either. Paul was a Jew and remained a Jew even after accepting Christ. His argument in the Letter to the Galatians, moreover, is that Christ is the new Adam. This line of reasoning (for Christians) removes the commandment of circumcision that is given to Abraham in Genesis. Nevertheless, in his frustration, the apostle Paul goes so far as to tell the church at Galatia that "I wish those who unsettle you would castrate themselves!"38 The issue of circumcision in Islam is not as straightforward as it is in Christianity. It is largely practiced as a tradition, from the patriarch Abraham, but it is not required. "The performance of circumcision in the Muslim community is considered one of the rules of cleanliness in Islam and is allowed by the Prophet Mohammad as a continuity of the covenant of Abraham; it is not [however] mentioned in the Quran."39 Interestingly, even though boys are circumcised as part of the Abrahamic Covenant, the procedure is 37 Gal. 2:1-21 (NRSV); Phil. 3:2-7 (NRSV). 38 Gal. 5:12 (NRSV) 39 S. A. H. Rizvi et al., "Religious Circumcision: A Muslim View," British Journal of Urology International 83, no. S1 (January 1999): 15-16, doi:10.1046/j.1464-410x.1999.0830s1013.x. Emphasis is mine. generally postponed until the boy is four to thirteen years old, rather than eight days old. By waiting, the foreskin will have retracted on its own, which makes the circumcision safer and (comparatively) less painful. That age range, however, presents its own issues of bringing fear and memory along with the procedure.40 Muslims are usually associated with female circumcision as well, but it is also not mentioned in the Quran. Some Hadiths, auxiliary Islamic sacred texts, speak in favor of circumcision, both male and female, but female circumcision is generally prohibited by the faith and confined to the African continent.41 There is no history of circumcision in Eastern traditions. Ancient Sanskrit texts, such as the Kāma Sūtra, and the Khajuraho group of temples in India, show that the ancient cultures deeply valued and even worshiped sex of all forms. As circumcision would have been seen as a way to limit the virility of a man, it was never adopted. Hinduism and Buddhism, along with the other cultures considered to be Far East, simply do not practice ritual circumcision. It is also not practiced routinely in those areas of the world for any other reasons, be they medical or cultural. The only exception to this general rule is South Korea, and they have an extremely high rate, near 100 percent, of adult circumcision.42 They have not typically practiced circumcision on infants though. It is interesting that they are so unique in this tradition. It is likely that their interest in circumcision emanates from American involvement in their country since the Korean 40 R. Goldman, "The Psychological Impact of Circumcision," British Journal of Urology International 83, no. S1 (January 1999): 93-102, doi:10.1046/j.1464-410x.1999.0830s1093.x. 41 S. A. H. Rizvi et al., "Religious Circumcision: A Muslim View," British Journal of Urology International 83, no. S1 (January 1999): 13-16, doi:10.1046/j.1464-410x.1999.0830s1013.x. 42 DaiSik Kim and Myung-Geol Pang, "The Effect of Male Circumcision on Sexuality," British Journal of Urology International 99, no. 3 (March 2007): 619-622, 2011, doi:10.1046/j.1464-410x.1999.0830s1052.x. War. It is also plausible that their high rates of adult circumcision are resultant of the spread of Christianity to that country, but as I have shown, the requirement of circumcision in Christianity is misguided. Also, predominately Muslim countries in the south of Asia and the Pacific Rim, such as Indonesia, report high rates of circumcision. While some of the religious and ceremonial origins of routine infant circumcision are unclear, there is a richer account of its medical basis in western medicine. In the 1800's, during the Victorian era, it was thought to help curb masturbation,43 which was considered both an illness and a sin. Europe abandoned this idea fairly quickly, but not before it had grown solid roots in the United States. In the 1930's, Dr. Kellogg (more widely known for inventing cornflakes) said that, "The operation should be performed… without administering an anesthetic… The soreness which continues for several weeks interrupts the practice [of masturbation], and… it may be forgotten."44 While this theory was thoroughly debunked, circumcision has continued to be used as a punishment for sexual intemperance even into the present. Circumcision was also advocated as a means of promoting cleanliness, and proponents of the practice still claim this argument today. The practice peaked in the United States in the 1970's,45 but with a societal transition towards secularism and humanism, the rates have steeply fallen since. This is due to a more general social transition away from the paternalistic model of medicine and focused treatment in such 43 W. D. Dunsmuir and E. M. Gordon, "The History of Circumcision," British Journal of Urology International 83, no. S1 (January 1999): 1-12, doi:10.1046/j.1464-410x.1999.0830s1001.x. 44 John Kellogg, Plain Facts for Old and Young. (Charlottesville: University of Virginia Library, 1995), 295. 45 W. D. Dunsmuir and E. M. Gordon, "The History of Circumcision," British Journal of Urology International 83, no. S1 (January 1999): 1-12, doi:10.1046/j.1464-410x.1999.0830s1001.x. a way that it is more patient-centered and concerned with autonomy. Even religion, which has often been the reason behind circumcision, has grown more secularized along with society. Thus, religious circumcision, while not going away completely, has been much less emphasized. Decreased risks of penile cancer and phimosis, among other conditions, have also been used in promoting prophylactic circumcision, but as we will see, these are no longer empirically supported by the medical and scientific community. Studies linking circumcised persons with lower risks of STD transmissions, however, have resulted in resurging advocacy for routine circumcision. As a result of this continued promotion, an entire movement of activists, cleverly called the Intactavists, has risen up to combat any establishment advocating routine circumcision. Their aim is to educate the public about genital integrity and, ultimately, to get legislation passed that protects all minors– males, females, and the intersexed– from non-autonomous genital alteration, including circumcision. FEMALE CIRCUMCISION It is important to discuss female circumcision with any comprehensive examination of male circumcision. There are many comparable features between the procedures for both genders, yet female circumcision is considered barbaric in our culture. In fact, female circumcision is usually referred to as female genital mutilation. So, that begs the question: Why is male circumcision not referred to as male genital Anatomically, the female genitalia follows the same body plan as that in males. The preputial hood is equivalent to the prepuce. The labia majora and labia minora, or the outer and inner lips, make up the external covering to the vaginal opening, the urethral meatus, and the clitoris. These are correlative to the scrotum in the male. The labia start at the mons pubis and extend to the perineum. The clitoris is the complement to the penis. The part of the clitoris that can be seen externally is the glans clitoris, much like the glans penis. The clitoris, likewise, is mostly a complex inner organ, much the same way that the penis is. This aspect of the clitoris has only recently been shown to have sexual benefit. The Discovery Channel recently aired the show Curiosity: Why Do We Have Orgasms? with host Maggie Gyllenhaal. What was found by the researchers in the show is that the internal clitoris is stretched by the penis laterally, and this feature greatly adds to sexual sensation in the female. It is also the likely reason that women find sex more comfortable and enjoyable with men who own an intact, or uncircumcised, penis. 46, 47 The researchers on the show were actually debating the purpose of the female orgasm. The male orgasm is needed for sperm release, but a female does not need to have an orgasm to become pregnant. This awareness has not escaped those throughout history who have espoused the practice of female circumcision, a procedure which makes it exceedingly difficult (and oftentimes impossible) for a woman to enjoy sex. 46 Morten Frisch, Morten Lindholm, and Morten Grønbæk, "Male Circumcision and Sexual Function in Men and Women: A Survey-based, Cross-sectional Study in Denmark," International Journal of Epidemiology 40, no. 5 (June 2011): 1367-1381, doi:10.1093/ije/dyr104. 47 K. O'Hara and J. O'Hara, "The Effect of Male Circumcision on the Sexual Enjoyment of the Female Partner," British Journal of Urology International 83, no. S1 (January 1999): 79-84, doi:10.1046/j.1464-410x.1999.0830s1079.x. There are four types of both male and female circumcision.48 Each type is generally more invasive and disfiguring than the last. For female circumcision, the World Health Organization (WHO) has listed the classification types.49 "Type one is known as clitoridectomy, which is the partial or total removal of the clitoris and, rarely, the prepuce (the fold of skin surrounding the clitoris) as well. Type two is called excision, which is the partial or total removal of the clitoris and the labia minora, with or without excision of the labia majora. Type three is called infibulation." It is usually the most invasive and traumatizing. "It is the narrowing of the vaginal opening through the creation of a covering seal. The seal is formed by cutting and repositioning the inner, and sometimes outer, labia, with or without removal of the clitoris." The labia are basically sewn together, only leaving a small hole for urine and menstrual blood to pass through. "Type four is simply called other. This last type is considered to be all other harmful procedures to the female genitalia for non-medical purposes, e.g. pricking, piercing, incising, scraping and cauterizing the genital area." Type four is not necessarily invasive at all, and some consenting adult women choose to alter their genitalia. The problems with female circumcision mainly lie in that it is often done to minors under the guise of sexual purity. It can render the girl void of sexual sensation and can increase the rate of genital infections. Female circumcision, somewhat ironically, has been shown to reduce the risk of acquiring HIV, but unlike male circumcision, no medical authority is advocating for mass female circumcisions. For male circumcision, the WHO has not made a categorical list of all the types. With increasing advocacy for education and analytical examination of male circumcision, 48 Available at: http://www.circinfo.org/FGMclassification.html 49 The following categorization is quoted material and taken directly from the WHO Fact Sheet 241, May 2008. Available at: http://www.circinfo.org/FGMclassification.html however, some people have started to attempt the task. Dr. Sami Aldeeb offers the following classification. Type one male genital cutting includes removal of the prepuce. This type consists of "cutting away in part or in totality the skin of the penis that extends beyond the glans." 50 "Type two is [the type] practiced mainly by Jews. The circumciser takes a firm grip of the foreskin with his left hand. Having determined the amount to be removed, he clamps a shield on it to protect the glans from injury. The knife is then taken in the right hand and the foreskin is amputated with one sweep along the shield. This part of the operation is called the Milah. It reveals the mucous membrane (inner lining of the foreskin), the edge of which is then grasped firmly between the thumbnail and index finger of each hand, and is torn down the center as far as the corona. This second part of the operation is called Peri'ah. It is traditionally performed by the circumciser with his sharpened fingernails." Type two is most similar to routine infant circumcision because it includes the forced separation of the prepuce from the glans and the use of a circumcising clamp to amputate the foreskin in its entirety. Type two often includes the removal of the frenulum, known as frenectomy. "Type three involves completely peeling the skin of the penis and sometimes the skin of the scrotum and pubis. It existed (and probably continues to exist) among some tribes of South Arabia. Jacques Lantier describes a similar practice in black Africa, in the Namshi tribe." This process is also known as denuding because it is literally a type of skinning. If the skin of the scrotum is removed, then castration ensues. "Type four consists in a slitting open of the urinary tube from the scrotum to the glans, creating in this way an opening that looks like the female vagina. Called subincision, this type of circumcision is still performed by some Australian aborigines." 50 Quoted material taken directly from Dr. Aldeeb's description that appears on the CircInfo site. Available at: http://www.circinfo.org/FGMclassification.html. Other similar categorizations can be found on the International Coalition for Genital Integrity's website. Subincision is used to prevent a male from reproducing. Rather than a slit, it is often just a piercing through the urethra, creating a hole on the ventral side of the penis near the base. This hole can be covered with a finger to allow for normal urination. During sex and with the force of ejaculation, subincision causes the semen to exit the piercing which is proximal to the meatus. The idea is to prevent pregnancy since it is unlikely that the semen will enter the vagina. In an effort to stop the genital cutting, alteration, and mutilation of female minors, a bill was passed under the Clinton administration that made it a crime to circumcise underage females. Interestingly, that same administration was in favor of male circumcision, even though the United Nations had drafted a resolution asking that the legal protection baby girls enjoy be amended to include baby boys. When side-by- side comparisons are made between the two procedures, they both are highly invasive, painful, and have long-term complications. Perhaps it should be acceptable in our society to refer to both male and female circumcision as genital mutilation. RISKS AND BENEFITS There are many proposed benefits and acknowledged risks with routine infant circumcision. However, while many of the proposed benefits are based more in opinion and cultural tradition than science, they nevertheless are used to justify the procedure. The medical benefits given in favor of circumcision include reduced chances for phimosis and BXO (bilantis), reduced chances of transmitting or possibly acquiring an STD, reduced risk of penile cancer, reduced risk of infection, and (in some cases) greater sexual sensation. It is often assumed that the penis will be cleaner and more hygienic if circumcised, and culturally, some people believe that the circumcised penis looks better and is more attractive. Parents also justify the procedure by claiming that their son should look like his father or brothers and that he will not be teased as much in the locker room or by future sexual partners. As with any surgery, however, there are risks with infant circumcision. Known immediate risks of the operation include loss of blood (together with exsanguination), infection (including sepsis), excessive pain, mental or emotional harm and stress, excising too much skin, buried penis, partial or full loss of the penile tissue, and even death.51,52 While most of these complications are rare, about 100 baby boys die each year in America due to circumcision related problems.53 Additionally, some conditions are contraindicative of circumcision.54 Because the foreskin is firmly attached to the glans at birth, the meatus cannot be examined until the circumcision has begun. If the condition hypospadias is present, then it will need to be fixed. Hypospadias is where the urethral opening is located somewhere besides the tip of the glans. The problem is that most cases of hypospadias or similar 51 E. W. Gerharz and C. Haarmann, "The First Cut Is the Deepest? Medicolegal Aspects of Male Circumcision," British Journal of Urology International 86, no. 3 (August 2000): 332-338, doi:10.1046/j.1464-410x.2000.00103.x. 52 J. Goodman, "Jewish Circumcision: An Alternative Perspective," British Journal of Urology 83, no. S1 (January 1999): 93-102, doi:10.1046/j.1464-410x.1999.0830s1022.x. 53 D. Bollinger, "Death and the New Penis: Circumcision Related Death Estimate for the United States," International Coalition for Genital Integrity, 2006. Available at: http://www.icgi.org/articles/bollinger4.pdf. 54 E. W. Gerharz and C. Haarmann, "The First Cut Is the Deepest? Medicolegal Aspects of Male Circumcision," British Journal of Urology International 86, no. 3 (August 2000): 332-338, doi:10.1046/j.1464-410x.2000.00103.x. conditions do not prevent urination and can be fixed by using some of the foreskin tissue once the prepuce has retracted on its own. If an infant presents with hypospadias, and the circumciser does not notice or realize it, then the circumcision may proceed anyway. This action results in there not being enough tissue to fix the condition. As hypospadias is somewhat common in boys, circumcising infants routinely can have disastrous effects for the child. There is also a growing body of literature that acknowledges future complications from routine infant circumcision. These risks comprise meatal stenosis, partial or full loss of sensation and sensitivity, hypersensitivity, tight erections, excessive scarring, skin bridging, curvature of the penis, neuromas, urethral fistulas, and psychological distress. Moreover, studies have shown that sexual satisfaction is diminished in circumcised individuals. For instance, while masturbation is not prevented by circumcision, it is made less pleasurable.55 A recent Danish study also found that circumcised men were three times more likely than uncircumcised men to experience "frequent orgasm difficulties;" their female partners, when compared to the female partners of uncircumcised men, were four times more likely to report dyspareunia (painful intercourse).56 This study confirmed the findings of a prior study 55 DaiSik Kim and Myung-Geol Pang, "The Effect of Male Circumcision on Sexuality," British Journal of Urology International 99, no. 3 (March 2007): 619-622, doi:10.1046/j.1464-410x.1999.0830s1052.x. 56 Morten Frisch, Morten Lindholm, and Morten Grønbæk, "Male Circumcision and Sexual Function in Men and Women: A Survey-based, Cross-sectional Study in Denmark," International Journal of Epidemiology 40, no. 5 (June 2011): 1367-1381, doi:10.1093/ije/dyr104. that concluded women enjoyed sex more with an uncircumcised man, rather than one who had been circumcised.57 57 K. O'Hara and J. O'Hara, "The Effect of Male Circumcision on the Sexual Enjoyment of the Female Partner," British Journal of Urology International 83, no. S1 (January 1999): 79-84, doi:10.1046/j.1464-410x.1999.0830s1079.x. Each is the proper guardian of his own health, whether bodily, or mental or spiritual. Mankind are greater gainers by suffering each other to live as seems good themselves, than by compelling each to live as seems good to the rest. —John Stuart Mill, On Liberty ETHICAL FRAMEWORK In order to evaluate the ethicality of routine infant circumcision, it is prudent to qualify any bioethical philosophies that may be appropriate. This practice is not only a medical issue; it is a matter of human rights. John Stuart Mill's Rule Utilitarian perspective offers the most applicable philosophy for this inspection of the practice. He evaluates the ideas of autonomy, beneficence, and rights. Then, he puts them into a framework of duty and justice that is based in social liberty. Mill is against Paternalism in favor of one sort of autonomy. He is interested in social liberty, not free will. Paternalism, then, is the idea that the state can coerce you for your own good. This ideal can be, and often has been, applied to the medical arena. He believes that society can interfere in many ways, but he wonders whether they should. "He who lets the world, or his own portion of it, choose his plan of life for him, has no need of any other faculty than the ape-like one of imitation. He, who chooses his plan for himself, employs all his faculties."58 This idea is perhaps one reason that Mill spoke against paternalism. With Utilitarianism, the goal is to promote the good, but what counts as good is an additionally difficult matter. Mill chooses to define the good as happiness, that is, the development of our distinctly human capabilities. Social liberty, he claims, promotes the growth of humanity better than paternalism. Rights make our personal liberties possible. A right is a claim that is grounded in a fundamental interest. Furthermore, all rights are matters of justice which makes 58 John Stuart Mill, comp., On Liberty and Other Essays, Edited by John Gray. (New York: Oxford University Press, 2008), 65. them, by definition, protected by society. Very few interests are actually rights, which mean that most interests can be legally harmed. Rights, therefore, being protected by law, are useful because they maximize the good. With liberty, there is an assumed right to autonomy. "The human faculties of perception, judgment, discriminative feeling, mental activity, and even moral preference, are exercised only in making a choice."59 Beneficence is a moral duty, however, not based on justice like the duty to respect autonomy. It therefore does not have to be protected by society. Mill says that the only purpose for which a power can exercise its will over a citizen's will is to prevent harm to others. "His own good, either physical or moral, is not a sufficient warrant."60 A person cannot be made to do something because it is in his best interest. The question at hand, then, is whether the harms associated with routine infant circumcision are risky enough that society should interfere. Since there is no operative risk to a healthy baby who does not undergo surgery, imposing the risks of a surgery when there is no medical indication for one in the hope of gaining future benefit for the child is overly risky. Even though beneficence is morally laudable, in the case of infant circumcision, it is not acceptable because it denigrates the justice associated with and the right to autonomy. Mill goes on to say that "To have a right, then, is to have something which society ought to defend me in the possession of… this being for reason of general utility."61 Justice, therefore, is more imperative than beneficence, and by extension as a form of justice, autonomy is also more imperative than beneficence because it is a right. Thus, "Over himself, over his own body and mind, the individual is I am not attempting to assert that beneficence is not important. We force children to be educated. While he was not exactly in favor of public education, Mill was a strong advocate for all children to be educated because it promotes general utility. This notion is an act of beneficence, however; so, how can society force us into being educated? By educating our children, we are protecting their open future. This statement can be reworded to say that we are protecting their future autonomy. Because infant circumcision engenders risk to the child and limits the right to future autonomy, circumcision is not justifiable from this philosophical perspective. Then, prospective fathers who are defending future circumcision on their boys will say things like "He'll be teased in the locker rooms." Why? For having all his body parts intact? Or, my personal favorite: "I want him to look like me!" Is this a part of American culture I have not been enlightened about yet? Do you all go home at Thanksgiving and get your wangs out in front of your fathers and compare notes? I mean, really. —Alan Cumming, Actor, Author, and Intactavist There are many reasons why parents choose to circumcise their sons. The most commonly cited motives are due to religious reasons and the medical and social benefits that circumcision may provide. My argument against this line of reasoning begins with the idea that any benefit promoted as justification for circumcising falls short when comparing it to the immediate risk imposed upon the child. When we fail to recognize that circumcision, even on babies, is surgery, then we fail to divine the purpose of preventative medicine. Preventative medicine is based in healthy lifestyles and good hygiene, not prophylactic surgery. Preventative medicine tries to mitigate the need for surgery, not embrace the use of amputations and surgical alterations to the body. All surgeries have risk, whether it is from the invasive nature of the operation, the long term physiological and psychological effects, or simply the anesthesia used, and at some point, prophylactic and non-autonomous circumcisions will cause the very problems they were supposed to prevent. A surgeon or urologist should be the one to perform circumcisions as they are surgery. Routine infant circumcisions, however, are oftentimes performed by [possibly] inexperienced family physicians and OB/GYN's.63 They can also be performed by ritual circumcisers in America, but in some countries, circumcisions must be done by a licensed physician. Moreover, the variability in method for infant circumcision is problematic. The Mogen clamp, for instance, gives the best cosmetic result and usually 63 E. W. Gerharz and C. Haarmann, "The First Cut Is the Deepest? Medicolegal Aspects of Male Circumcision," British Journal of Urology International 86, no. 3 (August 2000): 332-338, doi:10.1046/j.1464-410x.2000.00103.x. leaves the sensitive frenulum intact, but it does not fully protect the glans from amputation like the Gompo clamp. The Plastibell has a record of causing necrotizing fasciitis because it relies on the skin tissue to die before it can fall off. The Gompo clamp shields the glans well enough, but it oftentimes crushes the frenulum, increasing the chances of hemorrhage and requiring the surgeon to remove the frenulum as well. In adults, circumcising clamps are usually not preferred because they do not leave a good cosmetic result. With the developed penis and retractable prepuce, the circumcision can be done free-handed. Here again, the adult gets to choose how he wants to be circumcised, if he needs or wants to be circumcised for whatever reason. The main reason that clamps are used in the infant is because the area is small and difficult to work with, and the clamps greatly reduce the chance of blood loss. Infants have an extremely finite amount of blood, so this aspect of routine circumcision is important to Routine infant circumcision has an added danger that is commonly overlooked. When it is not indicated and performed anyway, the operation can result in dire complications for any baby with the condition hypospadias. Hypospadias is actually considered an intersexed condition by the Intersex Society of North America. Because routine genital alterations are absolutely not the best option when a newborn patient presents as intersex, for many reasons including those listed above, they are against modifying the patient without the patient having a choice in the matter. I am of the opinion that hypospadias is a birth defect, rather than an intersex condition. I understand, however, why they would choose to list it as such. Beneficence based genital conformity surgeries, while historically accepted by the medical community, are being challenged. This argument can apply to routine infant circumcision fairly easily. Under the guise of prevention, hygiene or cleanliness is perhaps the most common reason that infant boys are circumcised. "A review of the scientific literature, however, reveals that the actual effect of circumcision is the destruction of the clinically demonstrated hygienic and immunological properties of the prepuce and intact penis."64 Under the assumption that the uncircumcised penis is dirtier, smellier, and impossibly difficult to keep clean, proponents canvass that infant circumcision is the easiest way to correct for this "mistake of nature."65 Nature does not make mistakes nearly as often as doctors do. The foreskin, like the tonsils and appendix, has historically been seen as an extra part– something we do not need. Whether you believe that God created us with an inherent "imperfection," even though we are supposedly "created in His perfect image," or you believe that we are the flawed product of millions of years of evolution, any argument that the foreskin is a mistake falls short. In only the last few decades did scientists discover that the tonsils and appendix protect us from disease, and so it is the same with the prepuce. As I outlined earlier in this paper, the prepuce has many functions. One of those functions happens to be a mechanism that keeps us 64 P. M. Fleiss, F. M. Hodges, and R. S. Van Howe, "Immunological Functions of the Human Prepuce," Sexually Transmitted Infections 75, no. 5 (October 1998): 364, http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1758142/pdf/v074p00364.pdf. 65 R. Goldman, "The Psychological Impact of Circumcision," British Journal of Urology International 83, no. S1 (January 1999): 96, doi:10.1046/j.1464-410x.1999.0830s1093.x. In the infant, the foreskin is fused to the glans, and this fusion creates a sterile environment within the preputial space.66 The only requirement as far as cleaning is concerned is washing the outside of the penis with soap and water. Compared to the open wound resultant from circumcision, the intact penis is relatively very easy to keep clean. Since babies wear diapers, which inadvertently hold urine and feces in contact with the body, the chance for the circumcision wound becoming infected is quite high. Urine is sterile, but feces contain all sorts of bacteria and flora including E. coli, which is a notorious cause of infection. For the adult male who is uncircumcised, his parents most likely taught him that personal cleanliness is important for the health of the body and for societal interaction. As for the argument of preventing unwanted odors via routine infant circumcision, most people generally just take a shower. Theoretically, I could potentially understand this argument if access to showers or bathtubs was rare. Since that is not the case, circumcising to prevent odors "down there" is preposterous at best. We teach our kids to wash their ears, their armpits, their teeth, and we can just as easily teach them how to clean and care for their genitals. Ironically enough, I still smell if I do not clean myself fairly frequently. I say that with every bit of the intended sarcasm because I am circumcised as I mentioned, but seriously, personal hygiene is just a part of life. Even once the foreskin is able to be retracted, the boy or man only need pull back the foreskin and clean it with water and perhaps a moisturizer. Soap is not needed or 66 C. J. Cold and J. R. Taylor, "The Prepuce," British Journal of Urology International 83, no. S1 (January 1999): 34-44, doi:10.1046/j.1464-410x.1999.0830s1034.x. recommended. "Washing the human prepuce with soap is a common cause of balanoposthitis."67 Balanoposthitis is an irritation of the skin and mucosa of the Additionally, smegma seems to be a major concern among parents and doctors regarding cleanliness of the penis. The claim is that the uncircumcised penis will commonly produce this substance within the preputial space, giving an unsightly and unclean penis. Smegma is produced by both uncircumcised and circumcised penises.68 The substance is actually an emollient made up of shed epithelial cells, secretions from the mucosal lining of the prepuce and glans, and bacterial flora.69 It has an immunological purpose and a sexual one. The flora help the body protect against genitourinary infections. The emollient properties of the mixture actually help with lubrication during sexual intercourse. Moreover, it is not common in most men who bathe or shower regularly and who practice good personal hygiene. Men with confirmed clinical phimosis have the highest occurrence of smegma, but even then, the rate is only at about six percent.70 On a side note, smegma and odors are also produced by women, yet men, for thousands of years, have not seemed to mind so much. 67 P. M. Fleiss, F. M. Hodges, and R. S. Van Howe, "Immunological Functions of the Human Prepuce," Sexually Transmitted Infections 75, no. 5 (October 1998): 364, http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1758142/pdf/v074p00364.pdf. 68 C. J. Cold and J. R. Taylor, "The Prepuce," British Journal of Urology International 83, no. S1 (January 1999): 34-44, doi:10.1046/j.1464-410x.1999.0830s1034.x. 69 P. M. Fleiss, F. M. Hodges, and R. S. Van Howe, "Immunological Functions of the Human Prepuce," Sexually Transmitted Infections 75, no. 5 (October 1998): 364-367, http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1758142/pdf/v074p00364.pdf. 70 C. J. Cold and J. R. Taylor, "The Prepuce," British Journal of Urology International 83, no. S1 (January 1999): 34-44, doi:10.1046/j.1464-410x.1999.0830s1034.x. The idea that routine infant circumcision prevents infection is flawed. The clinical evidence is very straightforward in that the prepuce serves the body by protecting against infection. Urinary tract infections (UTI's) have been the most common type of infection listed that circumcision prevents. Multiple studies have been done on the correlation between this type of infection and the status of circumcision, and they are all conflicting.71,72 Although, "an 8 year prospective study that controlled for genitourinary abnormalities found no difference in the rate of upper urinary tract infections between circumcised and intact boys."73 I am inclined to trust this finding more than the other popularly cited study by Wiswell and Geschke that the Gerharz article speaks of.74 The Wiswell study did find greater numbers of proportionate UTI's in newborns left uncircumcised, but that was the only complication for those patients. They reported many other types of complications, however, for circumcised patients. So, in the circumcised group, the proportionate rate of UTI's was indeed lower. The Gerharz article also quotes from Niku et al that "Compared with circumcised children, uncircumcised boys have a 5-89-fold higher risk of acquiring UTI with the possibility of subsequent development of bacteraemia and meningitis."75 Without doing further 71 P. M. Fleiss, F. M. Hodges, and R. S. Van Howe, "Immunological Functions of the Human Prepuce," Sexually Transmitted Infections 75, no. 5 (October 1998): 364-367, http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1758142/pdf/v074p00364.pdf. 72 See: E. W. Gerharz and C. Haarmann, "The First Cut Is the Deepest? Medicolegal Aspects of Male Circumcision," British Journal of Urology International 86, no. 3 (August 2000): 332-338, doi:10.1046/j.1464-410x.2000.00103.x. 73 P. M. Fleiss, F. M. Hodges, and R. S. Van Howe, "Immunological Functions of the Human Prepuce," Sexually Transmitted Infections 75, no. 5 (October 1998): 364, http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1758142/pdf/v074p00364.pdf. 74 E. W. Gerharz and C. Haarmann, "The First Cut Is the Deepest? Medicolegal Aspects of Male Circumcision," British Journal of Urology International 86, no. 3 (August 2000): 332-338, doi:10.1046/j.1464-410x.2000.00103.x. research into these particular numbers, and given the spacious range of possible acquisition risk, I am suspicious of them. All other evidence that I have seen, barring these two exceptions, would indicate that these numbers do not make sense and that typically, there is little difference in UTI occurrence between circumcised and uncircumcised boys. Nevertheless, the bigger problem with promoting circumcision as a way of preventing infection lies in the simple fact that, in modern medicine, we have antibiotics. It is true that antibiotics can sometimes cause mild problems and even allergic reactions, but by and large, they are the single most effective technique we have for fighting bacterial infections. The risks associated with antibiotics are also less problematic than risks associated with surgery. As such, it is considerably more logical to treat a UTI when one is present with an antibiotic, than to amputate healthy tissue as part of a campaign that can only hope for– not guarantee– a lower chance of acquiring an easily diagnosed and imminently treatable infection. Given the research available, I would speculate that the risk of acquiring an infection as a result of the circumcision operation is probably greater than the risk of acquiring a UTI. More research, however, would need to be done to test the empirical validity of this hypothesis. Not to mention, any infection acquired post-circumcision would probably be more dangerous to the health of the child than a UTI. Phimosis and paraphimosis are conditions of the penis that involve the prepuce. As a result, they have been cited as reasons to circumcise. Pathological phimosis is where the foreskin cannot be fully retracted behind the glans, and it is often caused or associated with bilantis xerotica obliterans (BXO).76 It is oftentimes misdiagnosed because the foreskin is usually not retractable in children. A non-retractable prepuce is not pathological phimosis but can be termed physiological phimosis.77 A non- retractable prepuce constitutes normal anatomy, but many (too many) post-natal circumcisions are performed because of the misdiagnosis of phimosis.78 Today, mild cases of physiological phimosis are treated with a topical steroid cream, such as hydrocortisone, because these creams can encourage the separation of the prepuce from the glans.79 If the symptoms are severe or repetitive, circumcision might be encouraged by the doctor, but it cannot be performed until the symptoms subside. Additionally, most European countries prefer a preputioplasty operation, also called the "dorsal slit," over circumcision.80 The surgery is much less invasive, less painful, and leaves most of the foreskin intact.81 Of the many conditions that routine infant circumcision is promoted to prevent, pathological phimosis caused from BXO is the only condition that absolutely indicates 76 A. M. K. Rickwood, "Medical Indications for Circumcision," British Journal of Urology International 83, no. S1 (January 1999):45-51, doi:10.1046/j.1464-410x.1999.0830s1045.x. 77 Ibid. Emphasis is mine. 78 A. M. K. Rickwood, S. E. Kenny, and S. C. Donnell, "Towards Evidence Based Circumcision of English Boys: Survey of Trends in Practice," British Medical Journal 321, no. 1 (September 2000): 792-793, doi:10.1136/bmj.321.7264.792. 79 A. M. K. Rickwood, "Medical Indications for Circumcision," British Journal of Urology International 83, no. S1 (January 1999):45-51, doi:10.1046/j.1464-410x.1999.0830s1045.x. 81 International Coalition for Genital Integrity, Position Paper on Neonatal Circumcision and Genital Integrity, ed. Dan Bollinger et al. Available at: http://www.icgi.org/Downloads/ICGIoverview.pdf. circumcision.82 Studies showing alternatives to this procedure, such as potent topical steroids, suggest that there could be adequate response to the less invasive treatment.83 Regardless, these conditions present in fewer than 2.5 percent of boys,84 which is not sufficient cause to warrant mass routine circumcision. Paraphimosis, conversely, is not caused by a disease. Rather, it is a form of abuse, albeit, usually done unknowingly.85 It is a condition that results from the foreskin remaining retracted behind the glans. Severe edema can gather in the distal penis and cause the foreskin to be trapped proximal to the coral sulcus. Paraphimosis is only prevented by proper education of the caregivers and parents of the child, and can usually be corrected without circumcision. While circumcision would indeed prevent paraphimosis, which is exceedingly rare anyway, it is not appropriate to consider it a preventable pathology in the same way a disease could be prevented. The argument for cutting off pinky toes so that they cannot run into doorframes later in life would be similar. We can hurt many parts of our body throughout life, but that is no reason to start pruning our limbs. The prevention of penile cancer is an interesting case for promoting circumcision. I acknowledge that some research suggests that infant circumcision does seem to be associated with lower rates of some types of penile cancer. For instance, it 82 A. M. K. Rickwood, "Medical Indications for Circumcision," British Journal of Urology International 83, no. S1 (January 1999):45-51, doi:10.1046/j.1464-410x.1999.0830s1045.x. 83 International Coalition for Genital Integrity, Position Paper on Neonatal Circumcision and Genital Integrity, ed. Dan Bollinger et al. Available at: http://www.icgi.org/Downloads/ICGIoverview.pdf. 84 A. M. K. Rickwood, "Medical Indications for Circumcision," British Journal of Urology International 83, no. S1 (January 1999):45-51, doi:10.1046/j.1464-410x.1999.0830s1045.x. is certainly impossible to get cancer of the foreskin when there is no foreskin, but this argument alone is not sufficient because penile cancer can infect all parts of the penis. While there is no proof, it is speculated that pathological phimosis with BXO is a risk factor for developing penile cancer. The etiology of BXO, however, remains unknown because individuals presenting with the condition are almost always circumcised for treatment.86 BXO is theorized to be the pre-malignant state.87 Since people with phimosis usually have other compounding issues– such as lack of personal hygiene and smoking– it is not clear if the phimosis is the actual risk factor.88 Smokers, especially those who also have or have had HPV, are at the greatest risk of developing penile It is problematic, though, to circumcise infants in the hope of preventing cancer. For one, penile cancer is extremely rare, easily discovered, and has a high success of treatment.90 It is rarer than male breast cancer. Also, the rates of penile cancer in the United States, where circumcision is common, are similar or higher when compared to the developed countries of Western Europe, where circumcision is very rare.91 This fact suggests that healthy lifestyle choices probably affect the risk for penile cancer more than circumcision does. Second, there seems to be a misconception that circumcised penises are not capable of becoming cancerous. This assertion is not founded in 89 The American Cancer Society. http://www.cancer.org/Cancer/PenileCancer/DetailedGuide/penile-cancer-risk-factors research, and ample evidence of penile carcinoma in circumcised individuals is available. Last, the American Cancer Society says that, "In weighing the risks and benefits of circumcision, doctors consider the fact that penile cancer is very uncommon in the United States, even among uncircumcised men. Neither the American Academy of Pediatrics nor the Canadian Academy of Paediatrics recommends routine circumcision The premise that routine infant circumcision may also prevent cervical cancer in the female is no longer substantiated because there is now an accepted vaccine for this prevention. With the development of the Gardasil vaccine, which is substantially cheaper and much less invasive than circumcision, lower risk of HPV infections should correlate with a reduction in cervical cancer. Moreover, since the vaccine has an imminently greater effect on the rates of new HPV infections and transmissions, resources should be allocated to promote it, rather than routine circumcision. Additionally, recent suggestions by proponents suggesting that routine infant circumcision could prevent prostate cancer are, in my opinion, ridiculous. Prostate cancer is the most common cancer found in males all over the world, including the United States, and it is also the second leading cancer killer in men, just behind lung cancer. Focusing on the prevention of prostate cancer through an unproven prophylactic surgery, rather than working to develop a cure, is a gross misuse of research funding and a flagrant disregard of common sense. The promoted list of benefits of circumcision in centuries past has included quite literally everything under the sun at one point or another, and it appears that we are coming full circle. Due to three highly publicized studies regarding circumcision and the AIDS epidemic in Africa,93,94,95 the rush to implement a mass circumcision campaign has ensued as a way to end AIDS in Africa and, by extension, the world. I could have written my thesis on this one aspect of circumcision, so I will be general in saying that the studies are flawed. Several articles appearing in major medical journals have contested the findings of those three studies. In fact, the first study was done in South Africa, but nearly five years later, South Africa is proposing legal bans on routine infant circumcision, citing the unethical nature of the surgery and the steeply increased AIDS rates among newly circumcised, sexually active adults. The realization that the "Randomly Controlled Clinical Trials" in Africa are not having the promised effects should come as no surprise. I suggest reading the excellent article by Oxford research professor, Brian Earp, titled, When bad science kills, or how to spread AIDS.96 He gives an analysis, based on several of the important contesting articles, of why the studies were never going to deliver with the promises they made. Boyle and Hill exhaustively show the methodological flaws inherent within the studies, 93 Bertran Auvert et al., "Randomized, Controlled Intervention Trial of Male Circumcision for Reduction of HIV Infection Risk: The ANRS 1265 Trial," PLoS Medicine, E298 ser., 2, no. 11 (October 2005): 1112-1122, doi:10.1371/journal.pmed.0020298. 94 Robert C. Bailey et al., "Male Circumcision for HIV Prevention in Young Men in Kisumu, Kenya: A Randomised Controlled Trial," Lancet 369, no. 9562 (February 2007): 643-656, doi:10.1016/S0140-6736(07)60312-2. 95 Ronald H. Gray et al., "Male Circumcision for HIV Prevention in Men in Rakai, Uganda: A Randomised Trial," Lancet 369, no. 9562 (February 2007): 657-666, doi:10.1016/S0140-6736(07)60313-4. and there is an extensive list of them, by the way. The most important may be that the sixty percent reduction in HIV acquisition by the intervention (circumcised) group is just misleading. The sixty percent is relative to the rates seen in the two groups. "What does the frequently cited ‘60% relative reduction' in HIV infections actually mean? Across all three female-to-male trials, of the 5,411 men subjected to male circumcision, 64 (1.18%) became HIV-positive. Among the 5,497 controls, 137 (2.49%) became HIV- positive, so the absolute decrease in HIV infection was only 1.31%."97 This really does not provide enough significance to suggest mass clinical practicality. Not to mention, when the rest of the flaws are considered and accounted for, the significance may disappear anyway. Additionally, beyond the problems of internal validity that Boyle and Hill reveal, Green et al. suggest that due to external validity, the real world situation will not produce as great of an outcome as the clinical trials did. As a result, they argue that, "Before circumcising millions of men in regions with high prevalences of HIV infection, it is important to consider alternatives. A comparison of male circumcision to condom use concluded that supplying free condoms is 95 times more cost effective."98 Last, Van Howe and Storms argue that due to risk compensation, the rates of HIV infections will actually increase. 97 Gregory J. Boyle and George Hill, "Sub-Saharan African Randomised Clinical Trials into Male Circumcision and HIV Transmission: Methodological, Ethical and Legal Concerns," abstract, Journal of Law and Medicine, Thomson Reuters 19, no. 2 (December 2011): 316-334, http://www.ncbi.nlm.nih.gov/pubmed/22320006. Full article, available at: http://www.salem-news.com/fms/pdf/2011-12_JLM-Boyle-Hill.pdf. 98 Lawrence W. Green et al., "Male Circumcision and HIV Prevention: Insufficient Evidence and Neglected External Validity," American Journal of Preventative Medicine 39, no. 5 (November 2010): 479-482, doi:10.1016/j.amepre.2010.07.010. Emphasis is mine. "Risk compensation occurs when people believe they have been provided additional protection (wearing safety belts) [such that] they will engage in higher risk behavior (driving faster). As a consequence of the increase in higher risk behavior, the number of targeted events (traffic fatalities) either remains unchanged or [actually] increases."99 So will be the same with African men who are circumcised and believe that they no longer require the need and protection of condoms. According to the Fleiss et al. article and the Cold and Taylor article that I have cited throughout, the prepuce provides an immunological protection to the penis and the body. Fleiss et al. state that, "Amputation of the prepuce neither inhibits risky sexual behavior nor confers immunity after exposure to pathogens. This is demonstrated by the fact that the United States has both the highest number of sexually active circumcised males and the highest rates of genital cancers, STDs, and AIDS of any first world nation."100 Cold and Taylor support this assertion from the histological perspective. Langerhans Cells, while often erroneously thought to be removed completely with circumcision, are not HIV receptors. Rather they are immunological cells designed to fight infections. Regardless, "surgical removal of the Langerhans cells in all mucosa and skin to prevent infections is not feasible, nor rational."101 We have vaccines for HPV and anti-retroviral drugs for HIV and AIDS that are far more effective than circumcision. Consequently, the campaign to circumcise the masses in order to prevent sexually transmitted disease and infections has been called a 99 Robert S. Van Howe and Michelle R. Storms, "How the Circumcision Solution in Africa Will Increase HIV Infections," Journal of Public Health in Africa 2, no. 1 (February 2011): 11-15, doi:10.4081/jphia.2011.e4. 100 P. M. Fleiss, F. M. Hodges, and R. S. Van Howe, "Immunological Functions of the Human Prepuce," Sexually Transmitted Infections 75, no. 5 (October 1998): 366, http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1758142/pdf/v074p00364.pdf. 101 C. J. Cold and J. R. Taylor, "The Prepuce," British Journal of Urology International 83, no. S1 (January 1999): 40, doi:10.1046/j.1464-410x.1999.0830s1034.x. "deadly distraction." With funding for the mass circumcision campaign in Africa emanating from rich and powerful sources, such as the Bill and Melinda Gates Foundation, the WHO and UNAIDS are likely at a major conflict of interest between trying to end AIDS and trying to retain monetary support. This enigma raises ethical concerns about the validity of the campaign as well. Even if we were to assume that infant circumcision prevents the spread of AIDS, no advantage would be seen for almost twenty years. It is plausible to imagine that a vaccine or cure for AIDS will have been found by that point. Therefore, circumcising infants as part of a mass circumcision campaign is employing seriously flawed medical judgment. Furthermore, studies show that less than one percent of boys will need to be circumcised post-natally.102 So, the familiar mantra "Do it now, or he'll need it later!" does not hold up empirically. Moreover, it is now recognized that eight to twenty percent of boys who undergo infant circumcision will develop meatal stenosis, a narrowing of the urethral opening, before adolescence.103 "The removal of the prepuce exposes the glans to ammoniacal substances present in urine-soaked nappies. This may lead to irritation and injury of the external urethral meatus. Subsequent scarring of the meatus may result in meatal stenosis predisposing to UTI."104 This complication is the result of scar tissue that builds up from the circumcision and drying of the mucosa from 102 A. M. K. Rickwood, S. E. Kenny, and S. C. Donnell, "Towards Evidence Based Circumcision of English Boys: Survey of Trends in Practice," British Medical Journal 321, no. 1 (September 2000): 792-793, doi:10.1136/bmj.321.7264.792. 103 E. W. Gerharz and C. Haarmann, "The First Cut Is the Deepest? Medicolegal Aspects of Male Circumcision," British Journal of Urology International 86, no. 3 (August 2000): 332-338, doi:10.1046/j.1464-410x.2000.00103.x. having the glans constantly exposed. It is exquisitely painful to correct if dilation (expansion of the urethra) or meatotomy (surgical splitting or sub-incision of the ventral part of the glans) is required. Not to mention, this condition–usually a resultant problem of circumcision– predisposes urinary tract infections, which hypothetically occur less often with circumcision. Empirically, with circumcision rarely required, yet often causing a painful condition, it is nonsensical to perform circumcision routinely on infants from any medical basis. The issue of the pain involved must also be counted as a risk factor with routine infant circumcision. There can be no doubt that circumcision is painful. Because the prepuce is fused to the glans in the infant, forcefully separating the two tissues is often considered torturous. "Peadiatrician Paul Fleiss, writing in the Lancet, considers these cortisol levels [in the blood] and heart rates to be ‘consistent with torture.'"105 Considering that the tissue that fuses the prepuce to the glans is nearly the same as that tissue which affixes the fingernails to the nail beds, I am inclined to consider the procedure torture as well. I cannot think of many things that would be more painful than the common torture practice of jamming bamboo shoots under the fingernails seen in movies and third-world countries. Since the local anesthesia is either not allowed to or does not have the capacity to work completely, then it is obvious that the babies are still going to be in pain during the procedure. Considering that the healing 105 J. Goodman, "Jewish Circumcision: An Alternative Perspective," British Journal of Urology 83, no. S1 (January 1999): 93-102, doi:10.1046/j.1464-410x.1999.0830s1022.x. time is around two weeks, the anesthesia, if it was even used, will quit working before the pain resulting from the procedure returns.106 Additionally, due to the pain and psychiatric concerns involved, routine infant circumcision is consistent with the definition of trauma as seen on the DSM-IV sheet published by the American Psychiatric Association.107 Evidence shows that infants have similar or greater neural responses than adults, and due to the persistent pain of the procedure, many babies enter into a state of shock to try and escape the pain.108 A newborn baby should not have to undergo this sort of trauma– it does not seem fair. Compounding the trauma of the operation, the post-operative period can be difficult as well. Ample testimony from mothers [and fathers] witnessing their son's circumcision suggests that it negatively impacted the critical bonding between them.109 When the traumatic experience of pain is combined with the other needless risks of infection, hemorrhage, scaring, excessive loss of erogenous tissue, and even death, then the practice of routine infant circumcision should be reexamined and ended. Social reasons often dictate the justification for infant circumcision as well. Parents want to protect their babies from future harm– even in the face of the immediate harm presented with circumcision. There are typically three non-medical or social reasons that parents give as legitimate cause when choosing to circumcise. The first is that "It will look better." This assertion is dependent upon personal choice and is 106 R. Goldman, "The Psychological Impact of Circumcision," British Journal of Urology International 83, no. S1 (January 1999): 93-102, doi:10.1046/j.1464-410x.1999.0830s1093.x. largely based in cultural upbringing. It is a value judgment that should be left to the owner of the penis. Personally, I think it looks odd and completely unnatural for a man to have a scar all the way around his penis rather than to have an intact prepuce. As far as the looking better argument is concerned, and to quote the term coined by Dan Bollinger, how quickly would the rate of routine infant circumcision drop if doctors changed the informed consent to read "Parental Elected Penile Reduction Surgery?" The second social reason often given in support of circumcision is that "He needs to look like his father (or brothers or cousins or other community members)." Well, the problem with this argument is that, barring identical twins, no two people look that much alike. What if the boy takes after his mother? Is it then acceptable to alter his genitals to match hers? I realize that the last comment is preposterous, but it is the same argument as the first. Penises come in many shapes, colors, and sizes, and there is really no reason to alter a boy's genitals to match someone else's. This is cosmetic surgery. Cosmetic surgery is not allowed on non-consenting minors, even with parental consent. In fact, circumcision is the only procedure that can be performed on a male minor at a time when there is no medical indication. Perhaps we allow a few too many tonsillectomies, appendectomies, and tubes to be placed in the ear canals, but at least those types of surgeries require some medical reason or indication for the intervention. A parent is not allowed to have a child's tonsils removed so that the child will match the parent who also received a childhood tonsillectomy. When we look at these social arguments through the lens of other operations, the inherent problems with them become more obvious. The last, and possibly most common, argument given in favor of routine infant circumcision is the famed Locker Room argument. Parents claim that "He'll be teased in the locker room." My only question here is that considering how much more erogenous tissue the intact and whole penis contains, why would the child not be bragging in the locker room? In all seriousness though, bullying is a terrible problem. If it is happening in the locker room, then the coaches need to take a proactive approach in stopping it. Circumcising individuals at birth is just simply not an efficient way of preventing bullying. With circumcision rates dropping some twenty percent over the last few years, the chances for newborn boys to be teased in the locker room are greatly decreased. It very well may be that by the time the child is old enough to play sports, circumcised individuals will make up the minority of boys in their schools. There is also the possibility that the boy will choose not to play sports, so this argument is then null. For example, I did not play sports, but I was still teased plenty of times, usually for being in band and choir. The only times I entered the locker room were for tornado drills. For this reason, it is important to let the child decide this aspect of his body on his own. When parents assume that their son is going to be teased in the locker room for being uncircumcised, they are also assuming that he is going to play sports. That is a lot of assuming being done on behalf of somebody who is only an infant. The right to choose one's own fate should be acknowledged with neonates. It may be that children are non-autonomous individuals, but one day, they will have their own autonomy. The protection of their open future and creativity needs to be upheld, otherwise, we risk violating their innately human rights to their own bodies. This freedom to live as each should choose, rather than as each should be chosen for guarantees that all children have the opportunity to experience their best life possible. If that means consensually altering their genitals after becoming an adult, so be it. The expression of creativity can only happen in the face of a choice. Parents strip this choice from their sons if they choose to circumcise them at birth. This argument affects the practice as it relates to ritual or religious circumcision as well. When baby boys are circumcised as part of a religious ritual, that religion is being forced upon them. I do not mean to sound anti-religious here, quite the contrary, I want the baby to have the opportunity to choose his religion when he is old enough to make that choice for himself. It is all the more powerful a decision when he chooses for himself what god to worship or what faith he will follow. Religious freedom has its limits; our legal system just chooses to overlook these limits in the matter of circumcision. The first amendment guarantees freedom of religion, but it also guarantees freedom from religion. Raising a child within a faith is not really problematic. If the child does not like it or believe it, he can move on. If his body, however, has been altered to accommodate a religious ritual, it can make the transition much more difficult. Additionally, the legal system has checkpoints in place to protect children. If the parents belong to a faith that does not allow medical intervention, the parents are still required to have their children treated by medical professionals. In the case of circumcision, the children need to be protected from the undo risk that is imposed by the surgery so that their open future is accommodated. According to the research at hand, routine infant circumcision limits sexual response and function as well. Here lies another reason why the practice must be reconsidered. Our sexuality is a deeply personal, and usually, private matter. The ways in which sexuality is expressed are certainly altered by circumcision, and this limit placed on creativity should be stopped. Recent evidence has once again brought to light the effects of circumcision on sexual response and sensation. Circumcision basically turns the penis wrong-side-out, at least in the way that is designed to function during sex. The result is a penis that is greatly reduced in sensory capabilities and sexual enjoyment. O'Hara and O'Hara found that females preferred intercourse with an intact male over a circumcised one. A shorter thrusting style was reported by many of the females with uncircumcised partners, and this technique was found to be more desirable and satisfying to the woman.110 So much was this the case that the authors of that study advise that informed consent forms be changed to reflect the changes in sexual function caused by circumcision and the greater sexual enjoyment of the female with an uncircumcised Reduced pleasure resulting from circumcision is probable, and should be taken into account when discussing circumcision. Frisch et al. also found that women were not as taken with the circumcised penis as popular media in America would have us 110 K. O'Hara and J. O'Hara, "The Effect of Male Circumcision on the Sexual Enjoyment of the Female Partner," British Journal of Urology International 83, no. S1 (January 1999): 79-84, doi:10.1046/j.1464-410x.1999.0830s1079.x. believe. Their study, undertaken in Denmark, found that women with uncircumcised partners reported a more fulfilling sex life significantly more often than women with circumcised partners. Women with circumcised partners were more likely to report that their sex needs were incompletely fulfilled. They "consistently" reported more often that they had overall sexual function difficulties, orgasm difficulties, lubrication insufficiency, dyspareunia, and vaginisms. Circumcised men were also more likely to report "frequent orgasm difficulties" when compared with uncircumcised men. Furthermore, the study ran sixteen robustness analyses which confirmed that circumcised men are at about three times greater odds of experiencing frequent orgasm difficulties. Similarly, these analyses found that women with circumcised partners experienced four times greater odds of frequent dyspareunia. They also found no association for the impact of age at the time of circumcision.112 It is likely that the change in sexual function and response account for the need of changes in sexual practice. Dissenting voices here argue that sensitivity is not altered. This assertion, however, is based on only one study by Masters and Johnson.113 This study was not peer-reviewed, and there is some anecdotal evidence (hearsay) to suggest that the results were falsely presented by an editor of the study. Also, the study did not take into consideration the sensitivity of the prepuce as it was always retracted in the few uncircumcised men enrolled in the study. "No clinically significant difference 112 Morten Frisch, Morten Lindholm, and Morten Grønbæk, "Male Circumcision and Sexual Function in Men and Women: A Survey-based, Cross-sectional Study in Denmark," International Journal of Epidemiology 40, no. 5 (June 2011): 1367-1381, doi:10.1093/ije/dyr104. 113 W. H. Masters and V. E. Johnson, Human Sexual Response (Boston: Little, Brown, & Company, 1966), 189-191. could be established between the circumcised and the uncircumcised glans during these examinations."114 Validity aside, their findings are not all that surprising. The glans, after all, is only capable of protopathic sensitivity. Some circumcised men claim that they could not handle it if they had any more sensitivity. Marilyn Milos, the founder of NOCIRC and considered the Mother of the Intactavist Movement, writes: "I have dealt, time and again, with talk show hosts who say ‘If I had any more sensitivity, I couldn't stand it.' I think the reason for this is that, without the Meissner's corpuscles in the ridged band of the foreskin to provide sensory feedback, a man doesn't know where he is in relation to the orgasmic threshold. Many men think their inability to control orgasmic timing is due to over-sensitivity rather than the fact they lack tens of thousands of important nerve endings that provide essential feedback." With respect to what is lost with circumcision, the best analogy I can come up with is cell phone reception. When there is bad reception, the call is garbled and does not come through properly, but loudness usually is not the issue. When there is good reception, the person at the other end is not really any louder. Rather, it is just clearer and better. So it is with the sensitivity issue between the glans and the prepuce. The two are designed to work together to provide ultimate sexual response in the male, not exactly hypersensitivity. It is also documented that circumcised males who are sexually active in the United States have more varied techniques for intercourse and masturbation.115 114 Ibid., emphasis in mine. 115 Edward O. Laumann, Christopher M. Masi, and Ezra W. Zuckerman, "Circumcision in the United States: Prevalence, Prophylactic Effects, and Sexual Practice," Journal of the American Medical Association 277, no. 13 (April 1997): 1052-1057, doi:10.1001/jama.1997.03540370042034. Sometimes, these include sexual practices considered less safe, which would support the earlier assertion made by Fleiss et al. It is for these reasons that I would recommend leaving infant boys uncircumcised. Proponents of routine circumcision argue that it is an act of beneficence to circumcise baby boys. They make the argument that by doing this surgery when the child is an infant, the baby will grow up without the harsh memory of the pain involved. They advocate that the baby will have a lower risk of infection and disease, which is absolutely correct in some instances. They fail, however, to acknowledge the drastically increased immediate risk imposed on the baby by the procedure. While the proposed benefits may offer some statistical relevance, they are not practically relevant. Not only do the benefits fail to outweigh the risks, many of the proposed benefits are listed as known risks. Compounding these factors is that the baby cannot choose his fate. This enigma raises the issue of autonomy. Autonomy is a recognized right of all patients. However, autonomy is compromised when we circumcise an infant as a preventative measure. It is the baby's body, and he should have the right to choose for himself once he is an adult. I accept that we let parents make all sorts of decisions for their children– sometimes at great risk to the child– but it is debatable whether this surgery should even be legal. At the time it is performed, there is no medical indication present, making routine circumcision little more than a cosmetic surgery. These types of surgeries are usually not allowed on children unless the child wants the operation and is deemed by an independent party (the Court) to be competent enough to make such a decision. Circumcision is an amputation by definition, and it cannot be truly undone. It irreversibly changes the most private part of the baby's body– a part that only he should be allowed to have a say in. Unless there is an imminent need for medical intervention, we should not infringe upon the autonomy of the child. Furthermore, nearly every benefit used to justify routine infant circumcision will not manifest until adulthood, and at that point, the boy will be an autonomous adult who can freely decide to be circumcised if he wills it. For instance, if the reason given for the surgery is to lower the risk of an STD, we are assuming that the child will be promiscuous later in life. It is problematic to make such an assumption about someone who is so very young. We have a moral duty to respect for persons. It is unjust to override the inherent autonomy that guarantees our right to liberty of one's self. This problem then becomes a matter of justice, and, drawing on Mill's philosophical approach, beneficence should not be allowed to override issues of justice, including autonomy. Even though it is more expedient to circumcise someone at birth, rather than to have to do it later, it is an injustice to the personhood and future autonomy of the baby. Moreover, physicians have an obligation to non-maleficence. Performing an elective surgery that imposes risk on a non-consenting individual is the opposite of "Do no harm." It is hard to justify this procedure in light of current policies that protect patients who are children because medically unnecessary procedures on children are forbidden. While the American Academy of Pediatrics has avoided taking a firm position on routine circumcision, they do officially consider it non-therapeutic.116 As an elective procedure then, routine infant circumcision, if standards were applied consistently, would not be ethically permissible. Indeed, baby girls are absolutely protected against any form of circumcision or genital cutting, which is commonly referred to as female genital mutilation. The very discrepancy in naming these two procedures illustrates the disconnect between them in our society. Our country has been struggling for ages to promote gender equality, yet the law protecting baby girls from something considered barbaric– indeed some forms of female genital mutilation remove less tissue than male circumcision117– remains to be expanded to protect boys. Because it is rooted in traditions tied to religion and culture, routine circumcision is a complex topic. However, while commonly connected to religion, it is not required in either Christianity or Islam.118,119 In Judaism, however, circumcision has a special role, but it is not part of the Mosaic Law, and as a result, many Jews today are reconsidering whether it is necessary. In the Creation story in Genesis, God saw man, and God said "He is very good." Thus, routine infant circumcision would not seem to follow logically for any of the three Abrahamic faiths. Circumcision also is not germane in most eastern religions. Therefore, due to its irreversibility, electivity, painfulness, risk, and lack of 116 American Academy of Pediatrics Task Force on Circumcision. Circumcision Policy Statement, Pediatrics 1999;103(3):686-93. 117 C. J. Cold and J. R. Taylor, "The Prepuce," British Journal of Urology International 83, no. S1 (January 1999): 34-44, doi:10.1046/j.1464-410x.1999.0830s1034.x. 118 Gal. 2:1-21 (NRSV). The apostle Paul speaking against circumcision for Christians because it is done as an act of the Jewish Law, which he claims Christ fulfilled. Thus, it is unnecessary. 119 S. A. H. Rizvi et al., "Religious Circumcision: A Muslim View," British Journal of Urology International 83, no. S1 (January 1999): 13-16, doi:10.1046/j.1464-410x.1999.0830s1013.x. patient consent, routine infant circumcision should not be performed- even for religious CASE STUDY: AS NATURE MADE HIM: THE BOY WHO WAS RAISED AS A GIRL The case of David Reimer is perhaps the most well-known case of a botched circumcision. What makes his case so important, however, revolves around the events that transpired after his circumcision. Due to the time period of the accident and a psychiatrist's dream opportunity for a gender identity experiment, the "Twins Case," as it is known, is also one of the most important medical cases involving gender reassignment. Thanks to John Colapinto's account, As Nature Made Him: The Boy Who Was Raised as a Girl, and the TLC interview that followed, this case has famously become the cornerstone for almost any debate involving gender identity and Nature versus Nurture. The story of David Reimer enforces the idea that "the genitals of unconsenting minors should not be needlessly modified,"120 be it through gender reassignment or even routine circumcision. While this case does not specifically involve routine infant circumcision, it is nevertheless an important case to review with any in-depth study on the topic. As I have elucidated earlier in this paper, circumcision is oftentimes used when it is not medically indicated. Additionally, since the actual techniques for the surgery vary, the outcomes are also variable. This case provides an extreme situation of the possible outcomes of a failed circumcision, yet such an outcome is not extinct. The ethics at 120 The Intersex Society of North America stake in this case are remarkably similar to routine circumcision, and while the experiment exacted upon the Reimer twins would be considered unnecessary and unethical today, gender reassignments are still used to "repair" disastrous circumcisions. Many themes found in this case exist in problematic infant circumcision cases, and since botched circumcisions still occur quite frequently, I will provide a discussion of these themes after presenting the case study. On August 22, 1965, in Winnipeg, Manitoba, Ron and Janet Reimer became the happy parents of identical twin boys whom they named Bruce and Brian. To set the stage, as it were, this is a time period when the modern episteme of medicine is in full swing. Doctors have a tremendous amount of power over the patient, and technology is used to the fullest extent possible. This method of medical care, while common in the 1960's, is almost foreign to us today where autonomy of the patient often reigns supreme. Compounding the paternalistic atmosphere of the doctor-patient relationship is the fact that Ron and Janet are young parents, only twenty-one and twenty years old respectively, and they are relatively poor with limited educations. They would be in a position to rely heavily on the advice of their physicians. When the boys were about eight months old, Janet noticed that they would both cry during urination and even after diaper changes. Their pediatrician diagnosed Bruce and Brian as each having a mild case of phimosis, and he concluded that the twins should be brought in to be circumcised. Being compliant parents, they left their two babies at the hospital one evening soon after, and the two boys were scheduled for their operations the following morning on April 27, 1966. No one would have guessed that this surgery was going to be anything other than routine. It would prove, however, to be a dramatic and life shattering event for Bruce and his family. For reasons unknown, the attending physician was not available the morning of the operation. Rather, a general practitioner, Doctor Jean-Marie Huot, was sent in to perform the two surgeries. Bruce was brought back first. He was put to sleep by the anesthesiologist, Doctor Max Cham. For non-infantile patients, the practice of the time was to perform circumcisions under general anesthesia. According to Colapinto, what happened next is not fully known. Court papers filed with the hospital say that an artery clamp was used on the foreskin. This is an odd choice and would have been outside of the standard of care. When interviewed, Dr. Cham remembered that a Gompo clamp had been used, which makes much more sense. It is possible that the court documents had mislabeled the type of clamp used in the circumcision. For some reason, rather from inexperience or simply a whim, Dr. Huot decided to use a Bovie cautery machine in lieu of a scalpel.121 Dr. Huot's decision would prove to be detrimental. A Bovie cautery machine uses a generator to run an electric current through a needle. It is designed to cut and cauterize at the same time. It literally burns the skin away. The use of a cautery tool was wholly unnecessary given the use of a Gompo clamp. Not to mention, the clamp is made of conductive metal, and the needle is carrying an electric current. If they come 121 John Colapinto, As Nature Made Him: The Boy Who Was Raised as a Girl (New York: Harper Perennial, 2001), 12. into contact with each other, the patient could easily be electrocuted. In Bruce's case, the doctor tried twice to cut the skin, but the needle did not work. So, the current was turned up, and on the third try, there was a sizzling sound. Dr. Cham remembers seeing a wisp of smoke wafting up to reveal a burnt and disfigured penis.122 Dr. Earl K. Vann, the urology specialist, was called. He immediately performed an emergency suprapubic cystotomy to allow a way for urine to be passed. This surgery creates an opening under the belly button where a tube passes out of the abdomen and into a urine collection bag. Ron and Janet were then called and asked to come to the hospital. The doctors chose not to attempt circumcising Brian.123 Over the next few days, the tissue of Bruce's penis dried and fell off. His parents were horrified at this turn of events. They were told that nothing could be done to fix Bruce's penis. The best hope that the hospital could offer was to perform a phalloplasty when Bruce started pre-school. They were told that, "Such a penis would not, of course, resemble a normal organ in color, texture, or erectile capability."124 They went to the Mayo Clinic as well, but were told a similar story. So, they returned home, distraught As fate would have it, Ron and Janet saw an interview on TV with Dr. John Money. He was from New Zealand, and he was widely regarded as the world expert on gender identity. He had a patient with him who had undergone a sex-change operation. While he pandered on about how we really become boys or girls based on the way we are nurtured during the first two years of life, Ron and Janet found a new hope for their injured child. After receiving Janet's letter, Dr. Money was excited to help the Reimer Dr. Money, who worked for Johns Hopkins Hospital in Baltimore, immediately suggested that Bruce undergo a surgical castration so that he could become a girl. Time was of the essence because Bruce would soon be approaching two years of age. After that, Dr. Money said that the sex-change operation would fail on the psychological level. After thinking it through, the Reimers felt that this was the best option for their child. They were in exquisite need for hope, and Dr. Money was positive and reassuring that everything would work out for the best this way. Unfortunately for Dr. Money's theory, Bruce was not a baby that had been born with ambiguous genitalia or hermaphroditism. He was a boy- a male- through and through. Growing up, Brenda– the name given to Bruce after the operation– was forced to wear cute dresses and play with dolls. She preferred to play with Brian's toys though. Once a year, both Brenda and Brian had to see Dr. Money. He would ask them provocative questions about which one was the boy and which one was the girl. His methods have been roundly castigated by the medical community. Neither the American Medical Association nor the Canadian Paediatric Society thought that this surgery was in Bruce's best interest, but it is often difficult to confront the undisputed leader of a particular field. The sex-change did not work, at any rate. Brenda continued to display rebellious, tomboyish behavior and became deeply depressed around the age of thirteen. Dr. Money wanted her to undergo another operation, but she refused. After threatening suicide, her parents finally disclosed the events that had made her Brenda chose to become David. At the age of fourteen, David Reimer underwent corrective surgery– including phalloplasty– to become a man again. He would never be able to have children of his own, but he was happy. He married Jane Fontaine on September 22, 1990 and became stepfather to her three kids. Sadly, Brian never recovered from the news that his sister was actually his brother. Brian began to spiral into a psychosis that culminated in schizophrenia. Brian died of an accidental medication overdose in July of 2002. Not long after, David became depressed as well. Tragically, on May 5, 2004, he shot and killed himself. The 1960's are markedly an era of paternalistic medicine. Generally, this should not have affected the standard of care given to patients. In accidental or problematic cases like Bruce's circumcision, however, paternalistic medicine can be problematic. An experiment such as Dr. Money's would be very difficult to get through an IRB (Institutional Review Board) today, but these did not exist or were not regulated as they are now. There were many times throughout the process that the Reimer parents were not involved in the care of their boys. At least, they were not involved in the sense that they left the boys at the hospital for the surgeries, and they were not present in the sessions with Dr. Money. These occurrences would not have happened in today's medical environment. Given the allegations by the twins about the provocative and perverted nature of the sessions with Dr. Money, this aspect of the experiment might not have happened if the parents had been more closely involved. For the experiment itself, Dr. Money needed a patient just like Bruce in order to prove his Theory of Gender Neutrality. Dr. Money's theory that nurture trumps nature was only accepted for hermaphroditic babies. He believed that all humans were socialized this way, and he needed to prove it. Basically, he thought that if a person is born with a penis, society nurtures "him" into being a male, and the same would be true for individuals born with a vagina. The only way to prove this was to have a control case where there were two identical twin boys, in which one of them was surgically altered to become a girl before the age of two, and observe them until adulthood. Nobody with healthy twins would have submitted to this, but the Reimers were desperate for help. Additionally, given a paper that was published by Milton Diamond, Dr. Money needed to confirm his theory quickly. Diamond's paper directly challenged Money. It said that a lab had found that hormonal levels in utero cause the fetus to differentiate in Guinea Pigs. This knowledge confirmed that nature– not nurture– decided the sex and gender identity of an individual. Dr. Money needed to do an experiment before this theory was tested on human fetuses, or he would risk losing the chance to prove his theory. Dr. Money persuaded the Reimers that they must do this for their baby. In breaking down the ethics of this case, it is easy to see that the experiment failed on many levels. Given the standard of care at the time, the sex reassignment may have been viewed as the best treatment by some doctors, yet it was certainly opposed by others. Autonomy is lacking on almost every level. I have already mentioned the paternalistic attitudes of the doctors, but this led to obvious coercion from Dr. Money. There was a lack of informed consent all around. In the TLC interview made shortly before David's death, Janet Reimer says that she did not know that they would be using electricity during the surgery, and therefore, could not understand why Bruce had been burned. She thought the doctors would be using a knife. So, informed consent was not obtained. After the surgery, there was added coercion from Dr. Money. The family was desperate and vulnerable, Money was a very powerful and charismatic doctor, the family did not believe that they had any other option, and Dr. Money made the surgery sound much less experimental than it actually was. The autonomy of the child is also usurped in this case. If the family had listened to the Canadian doctors, they would have waited to do any castration surgery. If Bruce decided to remain a male, then he could have retained the ability to have children. As the phalloplasty operation improved over time, he might have been able to have corrective surgery. In the end, he chose to be a male anyway, and this would have saved him some hardship. It can be argued that beneficence is not a strong enough case to reassign the gender of a child who is hermaphroditic. In Bruce's case, he was actually born a boy, so the idea that this operation would help him was misguided. The Intersex Society of America states that reassignments should not be performed for the parent's wellbeing, either. Understandably, the Reimers were horrified and wanted to help their son. They needed help to understand the fallout of the failed circumcision. This issue is actually highly relevant today, because gender reassignment is still promoted if a routine infant circumcision does not go properly, especially in cases where the entire penis is lost.125 Non-maleficence was not on Dr. Money's radar. He caused irreparable harm to both twins. He apparently photographed them naked to show them how they were different. He also asked them sexually provocative questions, and he was even alleged to have made them get into sexual positions to show the differences of sexual behavior between males and females. The exact course and extent of these events will never be fully known, but he said he tried to make Brenda believe that she was a girl. Regardless, Dr. Money forgot the first rule of being a doctor– "Do no harm." For the baby Bruce, he was subjected to an unneeded circumcision that was performed by an inexperienced physician. That is disturbing and tragic, but unfortunately, he was not the first and will not be the last. The doctors chose not to circumcise Brian given the events that had transpired. His phimosis cleared up within a couple of weeks on its own, and this could have only exasperated the family's guilt and sorrow for what had happened to Bruce. The doctor's choice to vary the technique, by using a Bovie machine rather than a scalpel, for Bruce was simply dangerous. It is not uncommon for circumcisions to be botched126, but in Bruce's case, it was deemed by the 125 Several journal articles abound, detailing the sex change operations and the outcomes. 126 J. Goodman, "Jewish Circumcision: An Alternative Perspective," British Journal of Urology 83, no. S1 (January 1999): 93-102, doi:10.1046/j.1464-410x.1999.0830s1022.x. Also see citation #17: Kaplan GW. Complications of circumcision. Urol Clin North Am 1983; 10: 543–9. courts to be malpractice. Anesthesia was almost never used during that time period either, but since Bruce was not an infant, he was put to sleep for the procedure. David Reimer's story is sad. Medical ethics failed miserably in this situation, yet the reasoning and justification at work in Bruce/Brenda's life is the same reasoning and justification that is used today for routine infant circumcision. It is easy to look at this now forty year old case and think that medicine would never allow this sort of thing to Unfortunately, the United States does still allow doctors and parents to force their will onto neonatal males under the guise of protecting the baby's best interest in the form of routine circumcision. The fallacy of this reasoning lies in Dr. Money's assertion that he was protecting Bruce/Brenda's best interest. Ultimately, David chose a different path for himself. What David realized to be in his best interest was far removed from Dr. Money's idea of best interest. The best conclusion that one can draw from this case and cases like it is that the notion of best interest is indeed a value judgment, one that should be determined by the individual whose health is in question. As we look to the future, we can only hope that these sorts of paternalistic decisions will become extinct. Our society gives a certain amount of implied autonomy to children now, and hopefully, this will provide enough hesitation to prevent radical operations– like unnecessary gender reassignments– in the future. Holiness is in right action, and courage on behalf of those who cannot defend themselves, and goodness. —Hospitaller, from Kingdom of Heaven The purpose of this paper has been to argue that routine infant circumcision is not ethical. While there are some proposed benefits to routine infant circumcision, the risks outweigh them. Because the data is conflicting at best, current practice needs to be reconsidered. Further, the breach of autonomy to the child must be considered because autonomy trumps beneficence. While I used Mill's Rule Utilitarian approach, even Immanuel Kant calls respect, the categorical imperative, an extension of autonomy. Even if it was proven that the benefits of routine circumcision outweighed the risks, autonomy should nonetheless be upheld. Georganne Chapin, executive director of Intact America writes: "My argument against circumcision of children and infants is no more and no less than that it's a human rights issue. All people, male as well as female, are entitled to bodily integrity, and nobody — for any reason — has the right to cut off part of another person's body when that person is too young to understand and to consent." Her work has forced the issue of routine infant circumcision into the spotlight. Now, the paradigm of silence is finally shifting. Recent legislative measures, like the proposed ban on the circumcision of minors in San Francisco, have gained national attention. Along with that proposal, many states are considering dropping routine infant circumcision from their Medicaid covered procedures. Colorado was the most recent state to do this, becoming the eighteenth in the nation to adopt the policy. Why should tax dollars be used to cover a non-medically indicated procedure that imposes risk onto otherwise healthy children? The Colorado legislature decided that those monies should be spent on more worthwhile, lifesaving treatments. Celebrities have even taken to discussing their position against circumcision, something that would not have happened in the past, except probably to make fun of the foreskin. Cameron Diaz, while promoting her new movie, What to Expect When You're Expecting, has been bringing up the topic with talk show hosts and audiences around the country. Russell Crowe was also recorded as having quite the outburst against the practice of infant circumcision a couple of years ago. I only mention these celebrities to emphasize the fact that circumcision is finally coming to the forefront of popular debate. There are inherent issues with the procedure, and people are waking up to this knowledge. Most medical associations around the world have also decided that routine infant circumcision is an extreme violation of human rights, and some of them– the Royal Dutch Medical Association for example– are even actively campaigning to get doctors to stop the practice.127 In some countries, like Sweden, the practice is somewhat more limited because the circumciser must be a licensed physician, and anesthesia must be used. While the American Academy of Pediatrics and the American Medical Association remain officially neutral on the subject, they have tacitly agreed by designating the operation as non-therapeutic. The Royal Australian College of Physicians, the Canadian Paediatric Society, the Finnish Medical Association, and the British Medical Association have all agreed and recently reaffirmed, however, that routine infant circumcision should not be performed without medical indication 127 The Non-Therapeutic Circumcision of Male Minors, KNMG, May 2010. The American Academy of Pediatrics is, nevertheless, apparently at the threshold of releasing a new policy statement regarding circumcision. The organization announced that a new policy statement would be made several years back, but they have yet to release it. It has been hinted that the statement will be more strongly in favor of circumcision, based on the "overwhelming empirical evidence of its benefits." I have argued throughout this thesis– which is designed as a comprehensive survey of all the major and relevant literature– that the evidence would point otherwise. Dr. Douglass Diekema, who is a member of the AAP's ad hoc task force on circumcision,128 has suggested that "reasonable people" understand the benefit of circumcision.129 I like to think that I am a reasonable person, but if disagreeing with the AAP's committee makes me unreasonable, then so be it. I can easily understand the benefit of circumcision when it is performed as a medically necessary treatment for the elimination of a condition that threatens the health of an individual. I just do not accept the premise that it is ethically permissible to amputate erogenous (or any other) tissue from a healthy child who lacks the ability to consent. A surgical alteration of the body that has no medical benefit at the time it is performed is little more than cosmetic surgery. Not to mention, given that the Academy is designed to support its members and that its members (i.e.- pediatricians) make lots of money from performing circumcisions, they are not likely to discourage it too strongly. 128 I am making the assumption that he is speaking on behalf of the entire task force. I have no intention of personally attacking him. His statements imply that he is speaking the mind of the whole group of doctors on the committee. 129 For the interview with Dr. Diekema and all quoted statements, please see the Choose Intact blog. Available at: http://www.chooseintact.com/2012/02/19/quoting-dr-doug-diekema-against-the-aaps-position/ While Dr. Diekema acknowledges that not every man would trade his foreskin for better health and could be angered because it was taken from him, he claims that "parents need to be the decision makers here." His statement assumes medical benefit from circumcision, which as I have shown, is debatable and likely false. Furthermore, how in the world are parents with little or no medical training going to make fully informed decisions when the task force has obviously overlooked some rather important data regarding the risk? The risk to individuals extends farther than just operative risk. There is absolutely no way for the parents or any other person to know what the baby would prefer when he grows up. All things considered, an uncircumcised adult retains the ability to choose to be circumcised. Dr. Diekema claims that the evidence of risk involved in the surgery has not changed much since the 1995 policy statement. The internet, however, is teaming with the testimonies of men who are not happy about being circumcised. To dismiss these stories as "lacking scientific data" constitutes a blatant disregard for primary evidence. Personal testimony, especially when found in great quantities, is usually considered the best type of evidence. Circumcision can do serious harm to a baby– physically, mentally, and emotionally– and that harm can remain present into adulthood.130 Long-term physical debilitation and sexual dysfunction caused by circumcision at birth are troubling. The side effects, though rare, are wholly avoidable. Botched circumcisions can lead to a life of humiliation, stress, resentment, and questions. Research is now finally being done to 130 Goldman, R. "The Psychological Impact of Circumcision." British Journal of Urology International 83, no. S1 (January 1999): 93-102, doi:10.1046/j.1464-410x.1999.0830s1093.x. bring these mental and emotional aspects into the picture. More and more, men want to know why their parents and their doctors chose to do this to them, even those who had few or no adverse side effects.131 There is evidence that supports wide spread feelings of penile deficiency among those circumcised at birth, and regret, insecurity, and even post-traumatic stress disorder directly linked to circumcision status or trauma have been reported.132 As a result, many men have turned to the rising trend of non-surgical foreskin restoration. The practice of foreskin restoration is not new. As I mentioned earlier, ancient Jews did it to fit in with their Hellenized neighbors. Largely due to the internet, this latest form of the practice is quite popular. Taping methods or devices such as the TLC Tugger and the DTR are employed to stretch the shaft skin of the penis. Over time, a period of two to three years, the shaft skin is encouraged to actually grow. The result looks similar to an uncircumcised penis. The process, however, is not true restoration of the foreskin. The dartos muscle of the prepuce does not grow back, and likewise, all of the specialized corpuscular neural receptors lost to circumcision remain lost. The coverage of the glans by the new "foreskin" causes it to return automatically to its mucosal state, and this part of restoration along with the psychological aspect of "being whole" is therapeutic for some men.133 Additionally, organizations such as Foregen are working to provide true foreskin restoration through the new field of regenerative medicine. It will be incredibly interesting to see the results of their clinical trial, and the 133 Jim Bigelow, The Joy of Uncircumcising, Exploring Circumcision: History, Myths, Psychology, Restoration, Sexual Pleasure, and Human Rights, 2nd ed. (1992; repr., Kearney, NE: Morris, 2002). societal response to the possibility of regaining the foreskin. When the company first announced its plan and asked for volunteers in the clinical trial, literally thousands responded within the first month which shows that many men want a choice in this most private matter. My goal with this thesis has been to provide a comprehensive examination of the clinical and ethical considerations revolving around routine infant circumcision. There are, however, other challenges that exist. For instance, one of these issues involves the selling (by physicians) of amputated prepuces. Biotechnology companies are extracting the fibroblasts from the infantile foreskins, and using these cells to create cosmetic products. This latest fad in women's cosmetics involves foreskin enriched make-up. The fibroblasts, being a stem-cell of sorts, help remove wrinkles. Talk show hosts, including Oprah, have touted the effectiveness of these cosmetics. Additionally, these companies can also create new skin to use in grafting. While the idea of creating donor skin for trauma victims is appealing, there are strict rules against involuntary, live tissue and organ donations. Therefore, the manufacture of these products is not ethical. For a procedure that is so common in this country, relatively little research has been done on routine infant circumcision. Most of the world's people remain intact, or uncircumcised, and very few of them are sick or dying due to foreskin associated illnesses. Further, the American cultural stigma surrounding the intact penis– basically, that it looks funny or that it is gross– is nothing more than a stigma, founded in a lack of education on the matter. I acknowledge that any change in societal view for this procedure will take time, but in the near future, I expect that the operation will diminish in popularity. Given the trend of other nations on this topic and backlash from the Intactavist community, it might very well be that the protection of genital integrity provided to females will be extended to males. The anatomy of the foreskin plays a role in the function of normal human life, and its value should be considered for what it is rather than what it is not. Auvert, Bertran, Dirk Taljaard, Emmanuel Lagarde, Joëlle Sobngwi-Tambekou, Rémi Sitta, and Adrian Puren. "Randomized, Controlled Intervention Trial of Male Circumcision for Reduction of HIV Infection Risk: The ANRS 1265 Trial." PLoS Medicine, E298 ser., 2, no. 11 (October 2005): 1112-1122. doi:10.1371/journal.pmed.0020298. Bailey, Robert C., Stephen Moses, Corette B. Parker, Kawango Agot, Ian Maclean, John N. Krieger, Carolyn F. M. Williams, Richard T. Campbell, and Jeckoniah O. Ndinya- Achola. "Male Circumcision for HIV Prevention in Young Men in Kisumu, Kenya: A Randomised Controlled Trial." Lancet 369, no. 9562 (February 2007): 643-656. doi:10.1016/S0140-6736(07)60312-2. Bigelow, Jim. The Joy of Uncircumcising, Exploring Circumcision: History, Myths, Psychology, Restoration, Sexual Pleasure, and Human Rights. 2nd ed. 1992. Reprint, Kearney, NE: Morris, 2002. Bollinger D. "Death and the New Penis: Circumcision Related Death Estimate for the United States." International Coalition for Genital Integrity, 2006. Available at: http://www.icgi.org/articles/bollinger4.pdf. Boyle, Gregory J., and George Hill. "Sub-Saharan African Randomised Clinical Trials into Male Circumcision and HIV Transmission: Methodological, Ethical and Legal Concerns." Abstract, Journal of Law and Medicine, Thomson Reuters 19, no. 2 (December 2011): 316-334. http://www.ncbi.nlm.nih.gov/pubmed/22320006. Full Article, available at: http://www.salem-news.com/fms/pdf/ 2011-12_JLM- Boyle-Hill.pdf. Colapinto, John. As Nature Made Him: The Boy Who Was Raised as a Girl. New York: Harper Perennial, 2001. Cold, C. J., and J. R. Taylor. "The Prepuce." British Journal of Urology International 83, no. S1 (January 1999): 34-44. doi:10.1046/j.1464-410x.1999.0830s1034.x. Dunsmuir, W. D., and E. M. Gordon. "The History of Circumcision." British Journal of Urology International 83, no. S1 (January 1999): 1-12. doi:10.1046/j.1464410x.1999.0830s1001.x. Fleiss, P. M., F. M. Hodges, and R. S. Van Howe. "Immunological Functions of the Human Prepuce." Sexually Transmitted Infections 75, no. 5 (October 1998): 364-367. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1758142/pdf/v074p00364.pdf. Frisch, Morten, Morten Lindholm, and Morten Grønbæk. "Male Circumcision and Sexual Function in Men and Women: A Survey-based, Cross-sectional Study in Denmark." International Journal of Epidemiology 40, no. 5 (June 2011): 1367- 1381. doi:10.1093/ije/dyr104. Gerharz, E. W., and C. Haarmann. "The First Cut Is the Deepest? Medicolegal Aspects of Male Circumcision." British Journal of Urology International 86, no. 3 (August 2000): 332-338. doi:10.1046/j.1464-410x.2000.00103.x. Goldman, R. "The Psychological Impact of Circumcision." British Journal of Urology International 83, no. S1 (January 1999): 93-102. doi:10.1046/j.1464-410x.1999.0830s1093.x. Goodman, J. "Jewish Circumcision: An Alternative Perspective." British Journal of Urology 83, no. S1 (January 1999): 22-27. doi:10.1046/j.1464-410x.1999.0830s1022.x. Gray, Ronald H., Godfrey Kigozi, David Serwadda, Frederick Makumbi, Stephen Watya, Fred Nalugoda, Noah Kiwanuka, Lawrence H. Moulton, Mohammad A. Chaudhary, Michael Z. Chen, Nelson K. Sewankambo, Fred Wabwire-Mangen, Melanie C. Bacon, Carolyn F. M. Williams, Pius Opendi, Stephen J. Reynolds, Oliver Laeyendecker, Thomas C. Quinn, and Maria J. Wawer. "Male Circumcision for HIV Prevention in Men in Rakai, Uganda: A Randomised Trial." Lancet 369, no. 9562 (February 2007): 657-666. doi:10.1016/S0140-6736(07)60313-4. Green, Lawrence W., John W. Travis, Ryan G. McAllister, Kent W. Peterson, Astrik N. Vardanyan, and Amber Craig. "Male Circumcision and HIV Prevention: Insufficient Evidence and Neglected External Validity." American Journal of Preventative Medicine 39, no. 5 (November 2010): 479-482. doi:10.1016/j.amepre.2010.07.010. International Coalition for Genital Integrity. Position Paper on Neonatal Circumcision and Genital Integrity. Edited by Dan Bollinger, John W. Travis, Kent W. Peterson, and George Hill. Available at: http://www.icgi.org/Downloads/ICGIoverview.pdf. Kellogg, John. Plain Facts for Old and Young. Charlottesville: University of Virginia Kim, DaiSik, and Myung-Geol Pang. "The Effect of Male Circumcision on Sexuality." British Journal of Urology International 99, no. 3 (March 2007): 619-622. doi:10.1046/j.1464410x.1999.0830s1052.x. Laumann, Edward O., Christopher M. Masi, and Ezra W. Zuckerman. "Circumcision in the United States: Prevalence, Prophylactic Effects, and Sexual Practice." Journal of the American Medical Association 277, no. 13 (April 1997): 1052-1057. doi:10.1001/jama.1997.03540370042034. Masters, W. H., and V. E. Johnson. Human Sexual Response. Boston: Little, Brown, & Mill, John Stuart, comp. On Liberty and Other Essays. Edited by John Gray. New York: Oxford University Press, 2008. O'Hara, K., and J. O'Hara. "The Effect of Male Circumcision on the Sexual Enjoyment of the Female Partner." British Journal of Urology International 83, no. S1 (January 1999): 79-84. doi:10.1046/j.1464-410x.1999.0830s1079.x. Peron, James E. "Circumcision: Then and Now." Many Blessings, Spring 2000, 41-42. Rabin, Roni Caryn. "Steep Drop Seen in Circumcisions in U.S." New York Times, August Rickwood, A. M. K. "Medical Indications for Circumcision." British Journal of Urology International 83, no. S1 (January 1999): 45-51. doi:10.1046/j.1464410x.1999.0830s1045.x. Rickwood, A. M. K., S. E. Kenny, and S. C. Donnell. "Towards Evidence Based Circumcision of English Boys: Survey of Trends in Practice." British Medical Journal 321, no. 1 (September 2000): 792-793. doi:10.1136/bmj.321.7264.792. Rizvi, S. A. H., S. A. A. Naqvi, M. Hussain, and A. S. Hasan. "Religious Circumcision: A Muslim View." British Journal of Urology International 83, no. S1 (January 1999): 13-16. doi:10.1046/j.1464-410x.1999.0830s1013.x. Slater, Rebeccah, Laura Cornelissen, Lorenzo Fabrizi, Debbie Patten, Jan Yoxen, Alan Worley, Stewart Boyd, Judith Meek, and Maria Fitzgerald. "Oral Sucrose as an Analgesic Drug for Procedural Pain in Newborn Infants: A Randomised Controlled Trial." Abstract, Lancet 376, no. 9748 (October 2010): 1225 - 1232. doi:10.1016/S0140-6736(10)61303-7. Sorrells, Morris L., James L. Snyder, Mark D. Reiss, Christopher Eden, Marilyn F. Milos, Norma Wilcox, and Robert S. Van Howe. "Fine-touch Pressure Thresholds in the Adult Penis." British Journal of Urology International 99, no. 4 (April 2007): 864- 869. doi:10.1111/j.1464410X.2006.06685.x. Taylor, J. R., A. P. Lockwood, and A. J. Taylor. "The Prepuce: Specialized Mucosa of the Penis and Its Loss to Circumcision." British Journal of Urology 77, no. 2 (February 1996): 291-295. doi:10.1046/j.1464-410X.1996.85023.x. Van Howe, Robert S., and Michelle R. Storms. "How the Circumcision Solution in Africa Will Increase HIV Infections." Journal of Public Health in Africa 2, no. 1 (February 2011): 11-15. doi:10.4081/jphia.2011.e4. OTHER REFERENCES AND RESOURCES

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Mal. J. Anim. Sci. 14:61-66 (2011) Malaysian Society of Animal Production Production of polyclonal antibody against tetracycline using KLH as a carrier protein Siti Noraini, B.* and Nur Azura, M.S. Biotechnology Research Centre, Malaysian Agricultural Research and Development Institute, P.O. Box 12301, 50747 Kuala Lumpur, Malaysia *Corresponding author