Circumcision in boys and girls: why the double standard?
BMJ 2011; 342 doi: https://doi.org/10.1136/bmj.d978 (Published 16 February 2011) Cite this as: BMJ 2011;342:d978
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The medical aspects have been thoroughly reviewed herein. Perhaps to answer Mihail's original query -'why the double-standard...?', we need to look at cultural and prevailing societal influences.
The overarching question: why would a (logical and fair-minded?) society urgently seek to protect one type of baby (a girl) but not another (a boy)? Why did the FGM legislation not include, or extend further down the track, to males? The answer can only be cultural:
1. Men are conditioned to have the stiff upper lip and not to complain; they have not, yet, in sufficient numbers, raised the issue. The management classes - doctors, politicians, strategy developers - tend to listen to those who are most vocal and camera-hungry. They very much want to be seen to be fair and compassionate - but only as a response to whoever is shouting at them, not as an initiative. (If one man complains, he is a rather odd nuisance; if twenty complain something, miraculously, happens).
2. Of all the advocacy groups, there is not one for men as a group. The ideological arguments are beyond the scope of this response, but given that most workplace injuries happen to men, that they are the predominant group amongst the homeless, their suicide rate is three time higher (they die significantly earlier anyway) and are uniquely coerced into dying young on battlefields (98% in Iraq/Afganistan) - we can say very broadly, that males are the less-valued gender. (Note: in 2011, young American males still have to register for the draft if they wish to vote). Yet rather loud egalitarian politicians over the last three decades have ignored all of the above. Is is because the only advocacy groups of real standing are female, gay or BME?
3. Limits on debate The vast majority of people, I believe, wish any debate to have full expression and as much exposure to differing opinions before reaching their own conclusion. However, the most vocal of advocates against sexism - examples in the UK could be Mses. Harman and Eagle - do not wish to countenance evidence of sexism against men or boys. It appears they only wish to fight the sexism of yesterday with their own sexism e.g. Section 159 of the Equalities Act.
So - given all of the above acting contemporaneously - this is the culture which greatly facilitates baby boys being let down so very badly on the protection so intuitively and logically required.
The remedy is clearly to have a cultural change based on protection where it is most needed. The honest and direct contributions herein from women and men are therefore most welcome in that regard.
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We never found any evidence of so called Psychological problems with fellow male immigrants when we came to this country back in sixtees.
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"The fear and shame that non-circumcised adolescent boys go through in countries were circumcision is common practice are psychological aspects worth remembering. Often tradition and the satisfaction to look like everyone else overtake the psychological stress accompanying a minor surgical procedure that raises so much debate..."
Ah, but is this "fear and shame" considered in regards to non- circumcised adolecent girls in countries where female circumcision is common practice?
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The only difference in male and female circumcision is cultural bias.
Before asserting that "male and female circumcision are not the same," I'd like to ask the religious and/or ethnic background of the person making the claim.
Are you Jewish? Muslim? Or do you otherwise belong to a cultural or ethnic group where circumcision is socially acceptable, or a requirement?
If so, then you could be pre-disposed to accept "evidence" that male circumcision has "medical benefits," and to reject evidence to the contrary.
This exists for whatever cultural procedure that you name. Go to societies where female circumcision is acceptable, even required, and you will hear the same long list of alibis of why female circumicison "should" happen, or that it should be a "parent's choice."
There is a long litany that people give of why male and female circumcision simply "cannot be compared," all of which are myths that can be applied to either procedure.
People will make claims that "female circumcision is meant to subjugate female sexuality." - Check your history; male circumcision began in the commonwealth as a way to curb masturcbation. Rabbi Maimonides has said that "putting the male organ in as quiet a state as possible" was the purpose of male circumcision.
"Female circumcision eliminates a woman's chances for orgasm." Actually, studies have shown that this isn't true. There are actually varieties of female genital cutting, ranging from a prick to draw blood, the excision of the clitoral hood, the excision of the clitoris itself, and then there is the famous "imfibulation," which involves sewing the vagina shut to leave a small hole. (Actually, according to the New York Times, imfibulation is actually the rarest kind of female genital cutting, comprising of 15% of all FGM annually.) Studies have shown that orgasm is not elliminated, not even the worst kind of FGM. WHERE are people making this claim?
"Female circumcision is traumatic because it is performed when a woman can remember." In some cases, yes. Actually, in Islam, boys are circumcised at ages 7 and 13. Any word on these? Are people aware of "sunnat," a procedure performed in baby girls in Indonesia, Malaysia and Singapore? Would people that say argue that "a boy is circumcised in infancy, thus he doesn't remember" advocate "sunnat?"
The list goes on. Female circumcision is supposed to be "far worse" because "it is performed on older girls, in the bush, with dirty utensils, by an amateur, with no pain killers." Male circumcision is "so much better," we are told, because "it is performed in a hospital, in babies, with sterile equipment, by trained professionals, with pain killers, and the baby doesn't even remember."
Would the same people advocate for "sunnat" performed by a doctor, in a hospital, in babies, with sterile equipment and all the proper pain killers? Watch the same alibis that work for male circumcision fall flat when it comes to female circumcision...
And then there's the all-time favorite alibi of the "potential medical benefit." "A large amount of studies show that circumcision in males could have potential medical benefit."
This is strange; how many "studies" have been performed in female circumcision to see if it has any "benefits?" Would such "studies" ever be deemed acceptable? What if "studies" showed the exact same "benefits?" Would we then argue that it is "acceptable practice" for parents to opt for?
But I think the bigger question is, what is the reason that there are even "studies" on male circumcision? Isn't it a little backwards to be placing primacy on trying to legitimize a surgical procedure as opposed to finding other better, safer, more effective, less invasive means of providing "medical benefit?" Does anybody else not see it strange that "researchers" are seeking ways to legitimize surgical procedure in the healthy?
I propose the following litmus test for those who argue in favor of male circumcision because there are "potential benefits": How far do you actually care for "potential medical benefits?"
If a doctor offered you circumcision, and a newer, better option, say an actual vaccine against HIV, which would you choose? Would you take the vaccine which actually immunizes your child, or would you still want to opt for circumcision? The answer to this will speak volumes.
Here is the bottom line: People can find reasons why male and female genitals are "different," but the principles violated when cutting off parts of genitals of a healthy, non-consenting individual of any sex is exactly the same.
The foreskin is not a birth defect. Nor is it a congenital deformity or a genetic anomaly akin to a 6th finger or a cleft. The foreskin is normal, healthy tissue found in all males at birth.
Circumcision is the cutting off of a part of a person's genitals. It is the destruction of tissue. Unless there is medical or clinical indication for the surgical amputation of flesh, it is by definition, genital mutilation.
Unless there is a clinical or medical indication, what business does a doctor have performing surgery in healthy, non-consenting individuals, much less pandering to a parent's sense of entitlement?
Unless there is clinical or medical necessity, what "choice" do parents actually have? And why are physicians pretending like they could give it?
Instead of "studying" ways to legitimize the deliberate destruction of healthy human flesh, why aren't "researchers" studying ways to cure or prevent disease WITHOUT having to forcefully cut off part of another human's body?
The "study" of circumcision is a modern-day atrocity.
It is a modern-day disgrace that the deliberate genital mutilation of infants and violation of their most basic of human rights is even a question, even something to be "studied."
Let's "study" the "potential medical benefits" of cutting off the labia. Labia-plasties are on the rise even in the west nowadays, and "studies show" that women enjoy sex better without these useless bits of flesh. Who knows! Perhaps it could prevent AIDS. It's all for "science," is it not?
Why is it perfectly acceptable to "study" male genital mutilation, but not female?
These "studies" on genital mutilation must end. They are a blight on modern medicine.
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It was reassuring to read Mihail Evans full and comprehensive piece criticising the practice of neonate male circumcision, and the recent extensive supporting replies by M. Storm/R. van Howe leave nothing to add medically. It seems the medical profession is, finally, able to take on board arguments against the odd, senseless and cruel practice of non- theraputic male circumcision on infants.
Manzoor Mermon's reply seemed to confuse many different areas in a few sentences. The final comment appeared to state that women experience so much trauma in giving birth, neonate male circumcision is 'sort of OK - for a bit of balance'. This argument is best left without further examination.
Eleanor Zimmerman goes down the route of FGM is so much worse. An analogy: the fact that one person is say shot in the chest and the other 'only wounded in the arm' doesn't make the latter OK and make it alright to carry on. Additionally, the reality of two baby twins - a boy and a girl - having unequal protection in law from being attacked by a knife indicates a rudimentary contempt for the male sex.
Janos Baombe promulgates rather dramatically 'the fear and shame of looking different'. Thank heavens he is on hand to help with this awful problem! Most tribes wear some article of clothing, don't have too much interest in the same gender one assumes, and have other more practical concerns on a day-to-day basis.
Harvey Gordon's old text books presumably don't talk about the rate of penile cancer - about 1 in 100,000 by most estimates. At that rate, hardly worth minimising yet further by an invasive and nasty op 'just in case'.
Re: the AIDS/HIV - babies don't have intercourse. At least not for around another 14 years at least, where there may well be advances in medical care.
One hopes that those politicians and leaders who purport to be 'equalists' and 'champions of the oppressed' can get round to this issue of also protecting male babies - as every other group seems to have active and forceful representation. Bravo Mr Evans et al.
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Thank you for publishing this insightful article, which points out the obvious: removal of genital tissue from either gender is wrong and should be made illegal. All people should be allowed to make their own decisions regarding genital modification, but only after reaching majority age. No society or religion or culture should impose such a trauma on helpless children. As Christopher Hitchens says: do not hurt children. Only bad things happen when you hurt children, and circumcision hurts. There are certain rights that supercede religions or cultural groups: the right to bodily integrity is one of those. Children deserve protection from bodily harm. Laws are already in place to protect from abuse, torture, mutilation, starvation, neglect, and so on. These laws need to be enforced. We would not as a society tolerate someone saying they wanted to amputate their child's fifth finger as part of some new religion, so why do we tolerate amputating the foreskin/prepuce as part of an outdated ritual from thousands of years ago?
Few adult males will agree to the surgery once they have lived their lives intact. Many young men in the U.S. have told me they wish they had been left alone as babies. They envy those left intact.
Those who do not believe there is harm in infant male circumcisions need to witness one to hear the screaming and see the writhing of the boys as they are cut. It sickened me as a medical student and resident physician. It continues to sicken me as an attending physician (who stopped circumcising over 20 years ago) when I see the harmful after- effects of circumcision: the incredible loss of skin, the bleeding, the stenosis, skin bridges, buried penises, curvatures, loss of sensation, and worse. But what most strikes me is the affect of the babies I see in the office after being circumcised (by others); they seem depressed, defeated, resigned, irritable-unlike the intact babies who are calm, smiling and interactive. To not be affected by this indicates a cultural desensitization to abuse and torture and to accept as natural that which is unnatural. Circumcision for either gender is about controlling sexuality and exerting power over societal members.
For those who believe in the powers of prevention extolled by the African RCT's, you need to look into the data more deeply. Because some of those men obtained HIV through non-sexual means (probably the health care system with contaminated needles and syringes). Do not be misled by the pro-circumcision lobby who have an agenda. These studies have many flaws. Furthermore, HIV transmission to females was increased by male circumcision. HIV transmission may actually be decreased by female circumcision, but why would anyone support that? The same issues apply to male circumcision. Certainly infants are not at risk for STD's, sexually transmitted HIV, etc.
Male circumcision does not prevent anything but normal sexual function. European countries, Japan, Australia, etc. have lower rates of HIV, STD's, UTI's and they are intact. The U.S. has high rates and they are predominantly circumcised. Does not add up to what the pro- circumcision lobbyists want us to believe. Leave male babies and female babies alone. When we know better, we do better.
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Congratulations to the editors of BMJ for having the courage to publish an article on this topic. This is a topic that even Oprah Winfrey is afraid to address. The comments in the article are directly on target and hopefully a serious discussion can begin. Unfortunately, some of the comments in the rapid responses indicate there are still some obstacle to be overcome.
The answer to Dr. Gordon's question is "no." Two recent studies have found that when controlled for phimosis (presumably from balanitis xerotica obliterans) circumcision as an infant has no impact on penile cancer risk.
The protections from HIV that circumcision provides are dubious. In the randomized clinical trials suggesting protections from heterosexually transmitted HIV infection, it is quite likely that half of the men in the studies did not get HIV through heterosexual sexual contact (most likely iatrogenic spread). Moreover, there appears to be a lack of external validity. If you look across Africa, in many countries circumcised men have a higher prevalence of HIV than men who are not circumcised. Finally, these studies were of circumcision performed on adult men. There has been no studies that have shown that circumcision in infants has any impact on HIV-infection risk.
Ms. Zimmerman puts forth a false comparison and then fails to make a comparison between male genital cutting and female genital cutting. The false comparison is that she compares the most invasive forms of female genital cutting to the moderately invasive, more commonly performed, form of male genital cutting. For the comparison to valid, anatomically similar procedures would need to compared. In the case of female genital cutting, this would be removal of the clitoral hood. Ms. Zimmerman needs to look into the complications of male genital cutting more carefully. All of the complications she listed for female genital cutting, other than blood trapped in vagina and obstetrical complications that are impossible for a male to experience, also are complication for the male. One study found that female genital cutting was associated with a lower risk of HIV infection. There is plenty of material in the medical for proponent of both forms of cutting to justify their cultural practices. If you believe that the Langerhans cells are the gateway for HIV into the body, then cutting the outside of the female genitals is the wrong approach, it should be the cervix that should be remove. Of course this is absurd. The only differences between female and male genital cutting is that female genital cutting is performed on females, it is performed by females in Africa (male cutting is primarily performed by men), and it includes a wider array of practices and amounts of tissue damage.
The question that needs to be asked is whether the infant has a right to bodily integrity that all other humans enjoy. Parental preference and cultural practices are insufficient justifications to override this basic right.
There is no harm in waiting until adulthood to make a decision regarding circumcision. The adult male can consider his options. He can keep his foreskin, choose his partners wisely, use condoms when indicated and be nearly completely protected from STIs and HIV infection. He can get circumcised, choose his partners wisely, use condoms when indicated and be nearly completely protected from STIs and HIV infection. Most adult males will have figured out what the foreskin does and how it feels and that with the other precautions in place circumcision does not have any additive value. The only role for circumcision is for the male who wants to engage in high risk behaviors with high risk partners and doesn't want to use a condom. For these men, circumcision may, at best, delay infection. There are better choices to avoid infection that do not involve cutting off the most sensitive portion of the penis, so when presented with accurate informaion it is unlikely that circumcision will be chosen.
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As a medical student in a muslim country, I never heard from peers or as a GP in East London any request for reversal of circumcision. The obsessive disorder with size and shapes of different parts of the body is a medical rather than ethical issue. The young boys with phimosis as a result of poor hygiene were referred for circumcision. Evans has ignored the scientific proof in BMJs (8th and 15th jan.2011) printed under short cuts or Guardian (21.6.2010) reporting 4 year study confirming male circumcision reduces HIV by 60%, hence 80% of Zimbabwean men aged between 15 and 29 are targeted in circumcision (painful stage) scheme aimed at reducing HIV infections. To outlaw circumcision in the USA (70% male circumcision) or stop vaccinations in third world is unscientific and young children should be covered by existing UN regulations on prevention of disease. Islam and Judaism recommend male circumcisions (Jesus peace be upon him was circumcised on the 8th day too). The female mutilation is cultural in some parts of Africa which predates Islam, Christianity and Judaism. Finally when woman goes in labour parity of sexes disappears.
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Evans courageously questions the ethical justification for male circumcision. As a GP I have often seen the raw lesions left by the surgery, the infections sometimes caused, the clear distress, and, on more than one occasion, a worrying mutilation of the penis whereby more than the foreskin had been removed. I find it odd that this practice is permitted in countries where there are no significant clinical benefits to the procedure. People cite the reduced risk of cervical cancer, but this has been addressed with the introduction of the HPV vaccine, or they cite the higher incidence of rare diseases, such as penile cancer. HIV protection is not relevant in developed countries with low incidence. But even, if for the sake of argument, it were to provide significant protection to some diseases, do we conduct other elective procedures, such as appendicectomy, on children, in case they later on develop appendicitis (the risk of appendicitis in the USA is cited as being 0.25%)? The site of the wound is also relevant: an area that is particularly sensitive, exposed to urine and faeces, and in the context of an infant who cannot make sense of his distress and who cannot give consent.
Evans is quite right to refer to the fact that many men seek to restore their foreskins by drastic means in order to enjoy more satisfying sexual lives or simply to restore their bodily integrity. Googling 'Restoring foreskin' yields 703,000 entries. The issue is sensitive because of the religious context, but arguably we need to consider the differences in hygiene and medicine as well as attitudes to children that existed at the time of the religious injunction as compared to the modern day, when we now have (finally!) the Convention of the Rights of the Child. The great religions promote compassion as a fundamental tenet - where is compassion in all of this? At least it should be done when the individual is autonomous and can make the choice authentically and freely, even if the surgery is more complicated. Some fathers justify it on the grounds of wanting their sons to be 'like them'. But do we insist that our children have to have the same anatomical defects that we have? And finally is the issue of cleanliness and purity not something to do with a disgust towards our 'animal' bodies rather than being based on sound scientific evidence?
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Consent, and necessity are the questions
The issue of whether circumcision might, or might not, confer any advantage isn't really the important one. Any adult, or adolescent, with the consent of their parents, can decide to have a tattoo, body piercing or genital mutilation. If they are of sound mind and properly informed of the dangers of the procedure and implications, then it's their decision.
If an operation is necessary on an infant, then who can object to parents consenting for it to be done?
Where a procedure is not necessary, and can be agreed to later, there is no excuse for parents consenting to it and none for a doctor performing it. There is no need for a change in the law, it is an assault and battery. All that would be necessary to change the practice would be for children who have been assaulted and mutilated to prosecute their parents and the doctor for battery. Enough prosecutions and the medical defence fund would probably start requiring their members to show actual medical necessity.
Competing interests: I was not mutilated by my parents
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