ARGUMENTS FOR and AGAINST the
ROUTINE CIRCUMCISION of MALE INFANTS and BOYS

1. Have the advocates of routine male circumcision made a convincing case?

Between the mid-eighteenth and the late nineteenth century, but only in English-speaking countries, the status of the male foreskin fell disastrously. It was transformed from "the best of your property", as a popular rhyme of the period put it, and an adornment which brought pleasure to its owner and his partners, to "a useless bit of flesh", an enemy of man, and a "harbour for filth", as Dr Remondino and other scissors-happy doctors of the late Victorian period asserted. It is hard to think of any body part whose standing fell so far and so rapidly, nor one which came to be treated with such savage hostility; even today in countries with a history of routine circumcision doctors seem to regard the foreskin as guilty until proven innocent. Yet, as the Canadian pathologists Chris Cold and John Taylor point out, the prepuce has been a prominent feature of the external genitals of all primate species for 65 million years, and the species in which it has developed most luxuriantly is precisely the one which has been most successful in the struggle for existence; despite this, since the nineteenth century it has been "the most vilified normal anatomical structure of the human body" (1).

But aside from calling the foreskin nasty names, have the supporters of involuntary circumcision really made much of a case for their favourite surgery? Strictly speaking, it is not the opponents of routine male circumcision who need to make a case against the procedure, but its supporters who must prove its necessity: they need to explain why a natural part of the human body, and one common to all primates, is so dangerous that it must be amputated before a baby can talk, crawl or do anything much except scream.

What has naturally evolved must be presumed to be beneficial or harmless unless there is overwhelming evidence to the contrary. Here we will consider what sort of a case the anti-foreskin lobby has been able to put up.

What is the foreskin?

The penis consists of several major parts, but one useful way of looking at it is to divide it into an erectile portion (the part that gets stiff) and a non-erectile portion (the part that does not). The foreskin is the non-erectile portion. A more conventional definition would be to describe it as the soft, sensitive double-fold of tissue which covers the lower half of the penis shaft, extends in a sleeve over the head (glans) and usually ends in a tapering nozzle or spout. The outer layer is tender skin, the inner layer a sensitive mucous membrane. There is no agreed anatomical definition about where the foreskin ends and the skin of the penis shaft begins, and hence no exact surgical definition of what circumcision is meant to remove. As a consequence, the amount of tissue cut off by the operation is highly variable (some doctors take more, some less), but a typical circumcision carried out in a western hospital will remove about 50 per cent of the surface tissue of the penis.

The foreskin is not just a flap of skin, but a complex web of mucous membrane, muscle fibres, blood vessels and nerves: in fact, it supports one of the densest concentrations of nerves in the whole body. The underside of the penis (just beneath the glans) is called the fraenum, and this carries ridged bands which are densely packed with fine-touch nerve receptors and a very rich blood supply. The main nerve supplying the penis goes down to the end and then doubles back, allowing the foreskin to slide backwards and forwards, and showing that this is exactly what it evolved to be able to do. To operate at its best, the penis is meant to be covered with a mobile sheath of responsive flesh.

Further information:

Development of the normal foreskin
Anatomy of the adult penis

What is routine male circumcision?

Circumcision is the surgical amputation of this tissue. By routine male circumcision we mean the removal of the foreskin from the penis of normal male babies or boys, on the decision of adults (usually parents or guardians), without the boy's consent, and in the absence of any genuine medical indication, and particularly in the absence of the sort of critical injury, malformation or disease which would be required for the amputation of any other part of the body without the subject's consent. In the past the procedure was referred to as Routine Neonatal Circumcision or Routine Infant Circumcision, abbreviated here as RNC.

Strictly speaking, RNC is no longer practised in Australia, since most doctors are opposed to the practice and only do it in response to parental insistence. Each case today is thus an individual decision, not a matter of mere routine. In the heydey of circumcision in the 1950s, doctors pressured parents to agree to have their baby boys circumcised and would automatically do it unless they strenuously objected; sometimes they did it without even parental consent. The essential elements of routine (medically unnecessary) circumcision as practised today are (1) decision by adults; (2) absence of medical indication or need; (3) lack of consent on the part of the boy.

Why is it an issue all of a sudden?

Although Australia largely abandoned RNC in the 1980s, and did so with very little fuss, the issue has suddenly become topical and controversial. A few die-hard circumcision enthusiasts and medical researchers, mainly from the USA and other cultures where routine male circumcision is the rule, are making strident claims for the protective effect of circumcision against a number of diseases which defy normal control strategies, and particularly the one for which there is still no cure and of which everybody is afraid: AIDS. They attempt to exploit this fear by demanding widespread (indeed, universal) circumcision of male infants as a public health measure, on the feeble and misleading analogy that it is just like immunisation, and thus the sort of harmless and effective medical intervention which should be made compulsory. The main objective of this propaganda is to halt the decline of RNC in the USA and to revive it in Australia, Canada and Britain.

See pages on cervical cancer and HIV-AIDS.

The aim of this website is to challenge these claims; to show that circumcision is neither effective as a disease control strategy, nor harmless to those who do not seek it; and to bring facts, historical perspective, reason and ethics into the debate over RNC.

The cat which keeps coming back

Circumcision was a Victorian medical fad which should have gone out with neck-to-knee bathing costumes, phrenology and the idea that children should be seen and not heard. Instead, a small band of medical researchers and moral fanatics keep coming up with new reasons for doing it. First there was the claim that it would stop masturbation and the imaginary disease of spermatorrhoea. Then it was suggested that it would protect men from syphilis. Then doctors forgot that all baby boys have a tight and non-retractable foreskin (phimosis) and declared that the natural condition of the infant penis was a pathological abnormality requiring urgent surgical correction. After that it was asserted that circumcision would give immunity to cancer of the penis in men and of the cervix in women. Some doctors seriously believed that circumcision would cure various forms of muscular paralysis, brass poisoning and whooping cough; others claimed it would prevent tuberculosis, polio, epilepsy and wet dreams. Then there was a lot of vague talk about hygiene, as though boys and men were too stupid to wash themselves, and ridiculous references to embarrassment in locker rooms.

At no time did more than a handful men choose to have themselves circumcised; it was always something to done to babies and boys without their agreement or permission.

In the 1990s the myth about syphilis was revived in a new form: that uncircumcised men have a higher risk of catching HIV-AIDS (and that therefore all boys should be circumcised soon after birth). Most recently there has been an attempt to resuscitate the old claim (dating from the 1930s, refuted by studies in the 1960s and 70s) that male circumcision will reduce the incidence of cervical cancer in their female partners.

One by one these claims for the harmfulness of the foreskin and the benefits of its amputation have been proven false or misguided, but new reasons keep being invented.

Circumcision in Australia

Australia inherited circumcision from Britain in the nineteenth century, and by the early 1900s as many as 25 per cent of male infants were already having part of their penis cut off, either soon after birth or in early childhood. Although Britain itself dropped RNC in the late 1940s (and New Zealand in the 1950s), Australia followed United States practice, and the figure rose steadily to a peak of about 90 per cent in 1955, before falling back again: down to 50 per cent by 1975, and only 10 per cent by 1995.

It can be seen from the table that the biggest jump in the rate of RNC occurred in the decade 1910-1920, giving Australia the distinction of being the first modern nation to circumcise half its male babies. This was a period of acute fear of venereal disease, particularly syphilis; the erroneous belief that circumcision would provide protection against syphilis was probably an important reason why more parents were having their boys cut at this time. The year 2000 was a landmark as the first time since 1945 when the total number of uncut males in Australia outnumbered the circumcised. Interestingly, though, despite the hight rate of RNC, the total number of cut males has never exceeded 61 per cent - less than two thirds.

The rate of routine circumcision declined steadily in the 1980s and 90s and looked set to fall below 5 per cent nationally, but there has been a slight rise in the frequency of the procedure since 1999, possibly as a response to recent scares over STDs (especially HIV-AIDS), urinary tract infections (UTIs) and most recently HPV (human papillomavirus -- the wart virus implicated in cancer of the penis and cervix). Long-time advocates of RNC have been doing their best to exploit popular fears of these diseases in order to put pressure on the medical profession to revive the procedure as a public health measure, despite powerful criticism of their claims in the medical literature and increasing warnings that the procedure is unethical and potentially illegal (as the Queensland Law Reform Commission warned in 1993).

Burden of proof

Strictly speaking, it is not the opponents of routine male circumcision who need to make a case against the procedure, but its supporters who must prove its necessity: they need to explain why a natural part of the human body, and one common to all primates, is so dangerous that it must be amputated before a baby can talk, crawl or do anything much except scream. But since the operation has become entrenched in the medical culture of English-speaking countries over the past 120 years, it has come to be seen as reasonable, customary or even normal. As the sorcerer's apprentice found to his cost, starting a practice ("seemed a good idea at the time …") is often much easier than stopping it.

Advocates of RNC particularly have to

• demonstrate (1) that the benefits of the operation significantly outweigh the injury inflicted, the risks of the procedure and the disadvantages of living without the normal covering of the penis; and (2) that the operation must be done before the child is able to give legal consent;

• explain how a part of the body which has evolved over millions of years could be pathogenic (disease-producing) and must be removed to ensure a normal level of health.

Human evolution

Advocates of RNC have never been able to explain why all primates (monkeys, chimps etc) have foreskins, or how humans became the most successful mammal on the planet while carrying this supposedly pathogenic burden. For 99 per cent of the million or so years during which modern humans have prospered, males have lived and died with their foreskins intact, and in that time our species managed to colonise just about every corner of the earth. Perhaps the foreskin was a factor in that triumph. There is good evidence that the human foreskin became longer, more luxuriant and more richly networked with sensory nerves than those of our near relatives, suggesting that it must have conferred a selective advantage: the more foreskin you had, the more offspring you left behind, and the more your extra-foreskin genes spread through the population. (Ref. 1) This could not have happened if the foreskin had been as troublesome as its enemies claim: what has naturally evolved must be presumed to be beneficial or harmless unless there is overwhelming evidence to the contrary. (Ref. 2)

Trying to come up with the goods

It is this proof that circumcision advocates are obliged to provide, and which they have been struggling unsuccessfully to manufacture since the 1850s (when Jonathan Hutchinson announced that his statistics showed that circumcised men were all but immune to syphilis). The world is still waiting for them to make a convincing case. Although there have been mountains of reports and studies (more than anybody could read in a lifetime), the issue is still inconclusive. The most that even a scaremongering evangelist like the Queensland GP Terry Russell can say is that RNC "may reduce the risk of STDs (syphilis, gonorrhoea, herpes and candida) and carcinoma of the cervix in female partners", as well as phimosis, paraphimosis, HIV-AIDS, neonatal UTIs and carcinoma of the penis. (Ref. 3) This is not good enough: "may" is not much different from "may not".

Australia's other prominent crusader for RNC, Professor Brian Morris, cites several studies which purport to show a higher incidence of gonorrhoea and syphilis among uncut males and reaches the dithering conclusions that (1) "based on the bulk of evidence it would seem that at least some STDs could be more common in uncircumcised males under some circumstances"; but that (2) "there may be little difference in most STDs between those with and those without a foreskin". (Ref. 4) That's really helpful.

Can these guys be serious? They want to circumcise all boys at birth because retention of the foreskin "may" increase the risk of their getting a few diseases they most likely would not get anyway; most of which are curable; and which, even if they did get them, do not strike until many years later. Except for infantile UTIs (which are usually cured easily by antibiotics), there is plenty of time for a boy to reach maturity and make his own assessment of the risks and choose the best means, for him, of managing them. To make a convincing case for RNC Russell, Morris and Co must do much better than they have done so far: we need proof that that if the foreskin is not cut off urgently the child will get seriously ill or die before he is old enough to make his own health decisions. Nothing like this has ever been achieved by the circumcision lobby, or even seriously attempted. Statistics are not available, but it is quite likely that more boys under the age of eighteen die as a result of circumcision, or its complications, than from any of the diseases circumcision is supposed to protect them against. Certainly this is true in South Africa, where several hundred boys ach year die as a result of tribal circumcision.

Further information on complications and on deaths and recent news items

Medical scaremongering

Both Dr Russell and Professor Morris are frequently seen in the media urging parents to have their boys circumcised, and much of their routine is just a long list of nasty diseases, designed to terrify people into seeking urgent medical aid. How different it is from the rantings of a Victorian quack is a matter of personal judgement. In 1891 Dr Peter Charles Remondino wrote:

"The prepuce seems to exercise a malign influence in the most distant and apparently unconnected manner; where, like some of the evil genii or sprites in the Arabian tales, it can reach from afar the object of its malignity, striking him down unawares in the most unaccountable manner; making him a victim to all manner of ills, sufferings and tribulations; unfitting him for marriage or the cares of business; making him miserable and an object of continual scolding and punishment in childhood, through its worriments and nocturnal enuresis; later on, beginning to affect him with all kinds of physical distortions and ailments, nocturnal pollutions, and other conditions calculated to weaken him physically, mentally, and morally; to land him, perchance, in jail or even in a lunatic asylum." (Ref. 5)

How could Drs Russell or Morris disagree with him when he writes:

"Circumcision is like a substantial and well-secured life annuity; every year of life you draw the benefit, and it has not any drawbacks …. Parents cannot make a better paying investment for their little boys, as it insures them better health, greater capacity for labor, longer life, less nervousness, sickness, loss of time, and less doctor-bills, as well as increases their chances for an euthanasian death." (Ref. 6)

Drs Russell and Morris are radicals and extremists: most Australian doctors are opposed to RNC or undecided on the issue, and the Royal Australasian College of Physicians has recently issued yet another statement against the practice . The truth is that RNC has never been supported by more than a small fraction of the world's medical establishment and remains a controversial and unproven therapy. Back in the 1890s an early opponent of RNC noted this confusion and uncertainty, not only over the risks and touted benefits of the operation but when and how to do it, how much tissue to excise, how to stop bleeding etc, and asked: "Where doctors differ, who shall decide?" (Ref. 7)

There can be only one answer to that question: the owner of the organ in question.

References

1. 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, Vol. 77,1996, pp. 291-295; C.J. Cold and J.R. Taylor, "The prepuce", BJU International, Vol. 83, Supplement 1 (January) 1999, pp. 34-44; C.J. Cold and K.A. McGrath, "Anatomy and histology of the penile and clitoral prepuce in primates: Evolutionary perspective of specialised sensory tissue in the external genitalia", in George C. Denniston, Frederick Hodges and Marilyn Milos (eds), Male and female circumcision: Medical, legal and ethical considerations in pediatric practice (New York and London, Kluwer Academic/Plenum Publishers, 1999), pp. 19-30

2. The argument holds even if you believe in the creationist account of human origins. If God created men with a foreskin it must be presumed that He intended them to have one.

3. Terry Russell, "Debate: Male circumcision remains a valid procedure - Yes", Australian Doctor, 24 May 1996, p. 54

4. Brian Morris, In favour of circumcision (Sydney 1999), pp. 38 and 39. See the scathing review by Basil Donovan in Venereology, Vol. 12 (1999), pp. 68-9. Professor Donovan describes Morris as "a man on a mission to rid the world of the male foreskin" and some of his claims as "so dangerous" that the publishers ought to withdraw the book.

5. P.C. Remondino, History of circumcision from the earliest times to the present: Moral and physical reasons for its performance (Philadelphia and London 1891), pp. 54-5

6. Remondino, p. 186

7. Herbert Snow, The barbarity of circumcision as a remedy for congenital phimosis (London 1890), p. 32

2. Circumcision is not vaccination

Advocates of RNC as a public health measure are fond of likening the operation to vaccination. In this comparison they are treading in the footsteps of Dr Remondino and the enthusiasts of the 1890s, who claimed that universal circumcision would control syphilis (and many other diseases) in the same way as compulsory vaccination defeated smallpox. Unfortunately, only the second of these measures had scientific validity. A moment's thought will reveal the absurdity of the vaccination analogy - to mention a few obvious differences:

• Vaccination confers immunity against specific diseases; even if the extravagant claims of its advocates were correct, circumcision could do no more than reduce risk (and not by much). Nobody will become immune to any disease by virtue of circumcision.

• Vaccination adds to the body's natural immune system; circumcision amputates a large and visually prominent part of the penis.

• Vaccination leaves at most a small spot or lump; circumcision disfigures and scars a man in his most sensitive region for life.

• Vaccination is an injection; circumcision is major surgery, accurately described as pre-emptive amputation.

• Vaccination does not diminish the functionality of any body part; circumcision has documented adverse effects on the function of the genitals.

• Vaccination is scientific medicine, with proven protective value; circumcision is a relic of Victorian quackery.

3. Is male circumcision genital mutilation?

This is a controversial question on which there is much disagreement. Many men are quite happy with their circumcised condition and would not for one moment consider that they had been mutilated. Others are sorry that they had been circumcised without having a say in the matter and would prefer to have been left alone; while they would not regard themselves as mutilated they do have sense of being incomplete. Others still are angry and resentful at what was done to them and do have a strong sense of having been deprived of an important part of their body, certainly amounting to mutilation. A smaller number who have suffered additional injury or complications carry such badly disfigured penises that even doctors have to concede that they have been mutilated. Some men have themselves circumcised in adulthood and are pleased with the result, though others regret it as a terrible mistake. No male wishes to admit that he has been wounded, much less impaired, in his most vital bits, and we would be the last to accuse anybody of being mutilated if that is not how he sees himself.

Yet the fact remains that many men who do not agree that male circumcision is mutilation are vehemently opposed to any form of female circumcision because they believe that it is mutilation. Although Amnesty International has never said a word against male circumcision, it has taken a strong stand against female genital mutilation (FGM), which it defines as the removal of any part of the female genitalia; by this definition the removal of any part of the male genitalia must similarly be defined as male genital mutilation. Most of the tribal cultures which practise FGM also practise male circumcision, and they obviously see the operations as similar in nature, and the clitoris especially as the female equivalent of the foreskin. In the nineteenth century, when doctors were going all out to stop masturbation, the "heroic" remedy and preventive they recommended was clitoridectomy in girls and circumcision in boys; in each case they denied it was mutilation because the reproductive function was not damaged. Whether male circumcision is a mutilation or not, there is a striking visual difference between cut and uncut men.

Unlike the circumcision of boys, comparable procedures on women did not take off in English-speaking countries, with the result that people in the western world have been culturally conditioned to regard the first as an acceptable option and the latter as an unspeakable barbarity. Among the Islamic cultures which do practise various forms of FGM, the operations are also considered normal and proper, and they are now justified with the same sort of medical rationalisations with which supporters of male circumcision defend their own surgical rituals. A cool look at the two operations, and the arguments used to justify them, will show that they have more in common than many people assume.

A recent United Nations report on the implementation of the Convention on the Rights of the Child in Guinea-Bissau states: "Traditional practices and customs are causing serious problems for children and women. The circumcision of boys aged 9 to 13 years and female genital mutilation in girls aged between 7 and 12 years among the Fula and Mandinga ethnic groups are the most cruel and harmful practices. There are no effective measures at the national level to eliminate them."

(United Nations press release, 22 May 2002)

Some people object to the description of circumcision as male genital mutilation because they believe that a procedure performed with therapeutic, disease-prevention or even just benevolent intent cannot be a mutilation, or that the injury is too minor to qualify as a mutilation. But this opinion rests on a misunderstanding of the plain meaning of English words. The Oxford English Dictionary defines mutilate as "deprive (a person or animal) of a limb or bodily organ; cut off … maim", and maim as "disable, wound, cause bodily hurt or disfigurement to; render … incomplete". Cutting off the foreskin is thus mutilation by the ordinary meaning of words.

There is no contradiction between something being both of therapeutic benefit and a mutilation. If you are unlucky enough to need your arm or leg amputated because of incurable injury or disease, the operation is therapeutic (saves your life), but the result is still a mutilation: you become a maimed and imperfect person. Circumcision is thus always a mutilation: the argument is over whether it is a justifiable or unjustifiable mutilation. If the benefits of circumcision were as great as its champions claimed, losing your foreskin might be considered a worthwhile sacrifice; but if the benefits are not as great as claimed, it would be a pointless sacrifice.

Whether anybody has the right to force a child to make such a sacrifice, even if it did offer benefits, before he is capable of giving informed consent is a separate question.

Because circumcision has been around in English-speaking countries for about 100 years, most people have grown accustomed to seeing men with circumcised penises and regard them as a perfectly normal option ("Cavalier or roundhead?" as schoolboys use to ask). It was not so before the 1850s, when Richard Burton (the famous explorer) could write that "Christendom practically holds circumcision in horror", Edward Gibbon referred to it as a "singular mutilation", and the average eighteenth century fellow regarded his foreskin as "the best of your property". (Ref. 1) It would be a very good thing if the western world returned to this sensible perspective. Dr Sami Aldeeb has a through discussion of this issue in his study, The legitimisation of male and female circumcision.

Few people outside the Islamic cultures which practise female circumcision would hesitate to call any of those procedures female genital mutilation, but why is the case of boys any different? As Thomas Szasz remarked a few years ago: "Why is routine neonatal circumcision legal? Because it is defined as preventive medicine. Why is it defined as preventive medicine? To avoid having to ban it as male genital mutilation". (Ref. 2) The great German biologist August Weisman had no doubt that any distortion or removal of any body part was mutilation, no matter what the rationale:

"Cases of habitual mutilation which have been continuously repeated for numerous generations … have not produced any hereditary consequences. … The mutilation of certain parts of the human body, as practised by different nations … have not led to malformation or reduction of the parts in question. Such hereditary effects have been produced neither by circumcision, nor the removal of the front teeth, nor the boring of holes in the lips or nose, nor the … crippling of the feet of Chinese women." (Ref. 3)

Anybody who agrees that knocking out teeth, piercing the septum (or anywhere else), or footbinding is mutilation must think very carefully before denying that circumcision is in the same category.

References

1. Roy S. Wolper, "Circumcision as polemic in the Jew Bill of 1753: The cutter cut?", Eighteenth Century Life, Vol. VII, 1982, pp. 24-36

2. "Routine neonatal circumcision: Symbol of the birth of the therapeutic state", Journal of Medicine and Philosophy, Vol. 21, 1996, p. 143.

3. (1869), quoted in Ernst Mayr, The growth of biological thought: Diversity, evolution and inheritance (Cambridge, Mass. 1982), p. 698

4. Summary: Why CIA opposes routine male circumcision

CIA is opposed to the circumcision of infants or young boys in the absence of definite, serious and health-threatening medical indications for three important reasons:

1. The penis is a delicate sensory organ which is permanently damaged by circumcision, especially if performed before the natural separation of the glans and foreskin has occurred. Circumcision is associated with bodily disfigurement, an unacceptable incidence of complications, and long-term detrimental effects on sexual function which have been consistently under-reported in the medical literature.

2. Circumcision is not an effective method for the prevention of sexually transmitted diseases or exposure to HIV-AIDS or the human papilloma viruses (HPV) implicated in penile and cervical cancer. Only condoms are an effective method of preventing exposure to infectious pathogens during sexual intercourse. However, with the reduction in the sensitivity of the penis which is inevitably caused by circumcision, and in the false belief that they are less at risk of sexually transmitted infections, circumcised men are less likely to remain satisfied with safer sex practices.

3. Australian and other western societies have recognised that parents and other adults do not have an absolute right to use surgery to impose their sexual, cosmetic or religious preferences on children. Although he is dependent and voiceless, the child is the end consumer or client of the operation. Regardless of the impact on his body, his sexuality, and whatever personal beliefs he may develop later, he has no choice but to live with the results of the procedure for the rest of his life. Children should have the right to make their own decisions about non-therapeutic and irreversible procedures on their bodies when they reach the legal age of consent.