An article in the Canadian Medical Association Journal suggests that it is wrong to circumcise male infants, but that the operation could reasonably “be offered” to boys just before puberty. This is the opinion of Dr Noni Macdonald, a professor of pediatrics at Dalhouisie University, who writes that since the “potential benefits” of circumcision kick in only after males become sexually active, it would make more sense to offer circumcision to 11-year olds than to do it to babies. “The [infant] isn’t at risk of HIV and sexually transmitted diseases, because they’re not sexually active, so why are we rushing to do it at that time?” She wonders why people are more likely to accept circumcision of a baby, who cannot give any kind of consent, and for whom the operation is of no benefit at all, than of a pre-teen, who might have at least some chance of understanding his options.
Good questions, but we do not feel that Professor Macdonald has come up with the right answers. She is correct to say that it is unethical to circumcise anybody without informed consent, and also that infants cannot possibly derive any benefit from such an operation, but we cannot agree that it would be acceptable to routinely “offer” to circumcise boys at 11 or 12 years of age. If boys at that age are not considered capable of consenting to sexual relations with other people, they are certainly not competent to consent to having part of their genitals surgically removed – an irreversible step, far more radical than mere sexual activity.
Another objection is that the average 11 year old does not have sufficient maturity, independence or knowledge to agree to such an operation, and is too subject to pressure from parents, relatives and peers to be able to make a free and informed choice. If circumcision provides some degree of protection against sexually transmitted infections (a contentious point), the only logical age at which a male can legally consent to circumcision would be the same as the age of consent for sexual purposes – that is, from 16 to 21 years, depending on the jurisdiction. In other words, if it is wrong to perform circumcision in infancy, it is equally wrong to perform it at any time before legal adulthood.
Full details of the proposal and a critical analysis by CIA follow.
A new study has reignited the ongoing debate over circumcision, with a provocative new suggestion by a leading Canadian researcher: Wait until boys are 11 or 12 before they are circumcised, and allow them a say in the decision. Dr. Noni MacDonald, professor of pediatrics at Halifax’s Dalhousie University, says that since the potential benefits of circumcision only begin to set in once males become sexually active, there may be merit in offering circumcision to young boys “rather than their baby brothers.”
She makes the provocative suggestion in the latest issue of the Canadian Medical Association Journal, in response to new evidence from large trials in Africa concluding the benefits of male circumcision in cutting the risk of HIV in heterosexual men there. “The [infant] isn’t at risk of HIV and sexually transmitted diseases, because they’re not sexually active, so why are we rushing to do it at that time?” Dr. MacDonald said. “If you’re really going to do this, we need to think of the timing. Why aren’t we offering it to peripubertal boys, when it’s going to be relevant?”
The Canadian Paediatric Society is in the process of trying to decide what to say about the topic. Several committees are reviewing the African data, said executive director Marie Adele Davis. The Ottawa-based group’s current position is that the benefits and harms of circumcision are so evenly balanced that it does not support recommending circumcision as a routine procedure for newborns.
Circumcision rates in Canada are falling, but it remains one of the most frequently performed surgical procedures worldwide. Dr. Neil Pollock, a Vancouver-based doctor who has performed more than 30,000 circumcisions, says routinely postponing the decision on the procedure is off the mark. “If it makes sense to do it later in life, it makes sense to do it earlier,” he said in an interview. He adds that having the surgery while in infancy makes it safer and less painful for the baby, and less costly for the medical system.“ Parents are always called upon to make decisions for their children, what they believe to be in their best interest,” he said. “If you explain to any 11-year-old what you were proposing, likely an 11-year-old would never consent to have that done.”
Because Canada has a much lower HIV rate than Africa, it isn’t clear how applicable the African studies are to the North American experience. A recent U.S. analysis estimated that neonatal circumcision would reduce the 1.87% lifetime risk of HIV among men, but only by about 16%. “It’s not a huge decrease,” noted Dr. MacDonald.
To those squeamish about a procedure that is deemed to be too painful and uncomfortable for a pre-teen, she says: “Why are we fine with doing it to a baby but not a young man? “It’s curious that a painful elective procedure of no major benefit to the infant until years later would ever be deemed more acceptable than the same procedure for a peripubertal boy,” Dr. MacDonald writes in the CMAJ. What’s more, unlike infant boys, older boys can give consent. “The baby gets no choice, the parents make the decision,” she said. “An 11-, 12-, or 13-year-old boy could really make a decision on their own about this.”
Study says wait until age 11 for circumcision, by Sharon Kirkey and Michael Fraiman
National Post (Canada), 5 April 2011
The comment from Simon in Toronto is of particular interest
Quote from Dr Pollock: “If you explain to any 11-year-old what you were proposing, likely an 11-year-old would never consent to have that done.” That’s about as solid an argument against circumcision as anybody should need. Basically, he’s saying that the best reason to cut babies is because they can’t tell you to stop. It neatly – and brutally – clarifies the moral injustice of the practice.
The African studies have already been shown to be unreliable due to lack of controls or proper monitoring of participants. Also, what in the world would any data from there have to do with anything here? Cultural and social practices, economic conditions, health care options and political difference are too large to allow for a legitimate comparison. Correct me if I’m wrong, but I’ve never heard of groups of Western men gang-raping pre-pubescent girls because they think that will cure them of/protect them from HIV/AIDS, as has been reported from parts of Africa.
All of my sons are uncut. They are natural, whole and healthy. Why the heck would somebody want to subject them to the painful cutting-off of a valuable piece of an important body part? It’s time for our society to put the bizarre practice of circumcision into the dustbin of history.
… as is this from Vancouver Sun
Circumcision perpetuated by lack of consent
Re: Circumcision best left for prepubescence, disease expert says, April 4 “Why are we rushing to do it (circumcision) at that time (infancy)?” asks Dr. Noni MacDonald. Although those with a financial or other personal interest in perpetuating routine circumcision [such as Neil Pollock, Terry Russell, Mateen Jabbar, Brian Morris etc] will never admit it, the simple reason is that infants are the most powerless human beings in our society. Circumcision proponents know very well that if restricted to cases where informed consent of the circumcisee were sought, the procedure would vanish overnight.
Greg Depaco, Vancouver Sun, 7 April 2011
Reference: Noni McDonald, Male circumcision: get the timing right, Canada Medical Association Journal 2011;183(7):872. PDF available; send request through Contact form on this site.
Professor MacDonald makes an interesting suggestions, but her comments are marred by several mistakes, an uncritical attitude to recent pro-circumcision literature, and a complete failure to understand the rules of informed consent. To take the last point first, it is simply wrong to say that an 11- or 12-year-old boy can give informed consent to circumcision, an operation that makes dramatic and irreversible changes to both the appearance and function of the organ that probably means more to him than any other. Boys of that age are not considered capable of consenting to sexual relations with other people, and even if they agree to have sex with somebody the other party will be regarded as guilty of sexual assault. Why should circumcision be treated any differently? If “peripubertal” boys at are not considered capable of consenting to sexual relations with others, they are certainly not competent to consent to having part of their genitals surgically removed.
Another consideration is that the average 11 year old does not have the maturity or knowledge to agree to such an operation, and is too subject to pressure and coercion from parents, relatives and peers to be able to make a free and informed choice. If circumcision provides some degree of protection against sexually transmitted infections (a contentious point), the only logical age at which a male can legally consent to circumcision would be the same as the age of consent for sexual purposes – that is, from 16 to 21 years, depending on the jurisdiction. In other words, if it is wrong to perform circumcision in infancy, it is equally wrong to perform it at any time before legal adulthood.
Professor MacDonald’s contention that circumcision at puberty provides “the opportunity for informed choice by the proposed recipient of the procedure. The boy can give assent” is contradicted by the experience of both tribal societies and of modern societies such as South Korea and the Philippines. Tribal societies have been performing initiation rites on “peripubertal” boys and girls, sometimes involving circumcision and other genital mutilations, for thousands of years, but the children have no more opportunity to decline the operation than to fly to the moon. If they object they are subject to violent coercion, and if they run away they are ostracized from the tribe and very likely to die. Circumcision of boys at around 11 years of age is pretty much universal in both South Korea and the Philippines, and in both societies the combination of social expectation, peer pressure and the fact that the boys are still children subject to parental discipline means that they have not the slightest chance of being able to say “No thanks” [1]. But unless they can decline without prejudice to their future social status, there is no possibility of an informed choice. It’s simply coercion with a velvet glove.
Experience in South Korea, where circumcision was introduced in the 1950s as a result of US influence following the Korean War, and has since become an entrenched “tradition”, shows that once circumcision becomes an unavoidable social custom it is likely to persist long after the temporary medical emergency that gave rise to it has disappeared. Medical treatments can be introduced and abandoned quite easily; social traditions are far more intractable.
The principle of the child’s right to an open future, as developed by the legal philosopher Joel Feinberg and the medical ethicist Dena Davis, holds that children are adults-to be, and that it is the duty of parents to preserve and protect their options so that they can make choices for themselves in adulthood. This applies not only to affection, food, shelter and education, but also to freedom from irrevocable parental decisions, of which circumcision is a permanent, palpable and unnecessary example [2]. Some children might be able to make an informed choice about circumcision as early as age 11, but by that token it is probably also true that they could consent to sexual relations with other people –a proposition that neither law nor custom is willing to accept. In order to protect the majority from exploitation and coercion, all children must be protected from unnecessary genital surgeries and restricted from the free exercise of sexual choices until the age of consent. The practice with respect to genital surgeries should be no less strict than the rules governing sexual activity.
There are two tests that may be applied when decisions have to be made on behalf of those incompetent to make them for themselves, whether minors or disabled adults. The first is the best interests test. These are the long term interests of the person as a person, taking account of the society in which he/she lives, interests, skills, hopes, wishes etc, and if a minor the person’s interests in the future, as an adult. In the case of Re J, for example, an English court determined that it would not be in his best interests for a 6-year old boy to be circumcised merely because his Muslim father wanted him to be. It would, however, be in the child’s best interests to be given necessary therapeutic medical treatment, such as a life-saving blood transfusion, even if his parents were Jehovahs Witnesses, whose religion prohibited such procedures. It would also be in his best interests to be vaccinated against serious diseases, such as hepatitis B, if he was at risk of infection (say from a parent with the disease), even if the parents were philosophically opposed to vaccination. In both cases the child’s welfare trumps the parents’ wishes. When medical treatment is either necessary to save a person’s life, or provides proven and substantial benefits (such as immunity to serious diseases) without harm, loss of body parts or function, and without a significant risk of complications, it is acceptable to provide it without the informed consent of the recipient.
The other test is the imputed judgement test – the option that an incompetent person would, or would be most likely to, choose for himself if he were competent to make and express an opinion. One way of establishing the answer in relation to medical issues is to ask what competent adults choose when faced with the same question. Most adults would agree to a blood transfusion if it meant the difference between life and death, and most would agree to get vaccinated against a serious disease if they were likely to be exposed to it and at risk of infection. The case of circumcision is even more clear-cut: since a negligible number of adult men in western societies elect circumcision for themselves, we may reasonably infer that if the average minor were asked whether he wanted to get circumcised he would say NO.
In fact, proponents of infant circumcision recognise this perfectly well. It is precisely because they know that the average adult , or indeed any male old enough to be conscious of his body and aware of what circumcision entailed, would also say NO, that they insist that the operation must be done in infancy or early childhood, when the boy has no power to resist. In the news report printed in the National Post above, Dr Pollock stated quite openly: “If you explain to any 11-year-old what you were proposing, likely an 11-year-old would never consent to have that done.” Australia’s leading circumcision crusader, Brian Morris, similarly admits that if the circumcision choice were left to them, many boys would make the “wrong” decision. “Parental responsibility must override arguments based on the rights of the child”, he writes, “parents have the legal right to authorise surgical procedures in the best interests of their children”. When they are old enough to give legal consent males “are reluctant to confront such issues” and are neither “mature nor well-informed enough” to make the right decision for themselves. In other words, Morris concedes that if doctors waited until boys were old enough to make up their own mind, most would not consent to the operation [3].
But from an ethical point of view, as “Simon of Toronto pointed out, the fact that the average vocal adult does not wish to be circumcised is proof that it is wrong to do it to voiceless minors. Those who fail to see this can only be described as morally and ethically disabled. Indeed, when it comes to sexual activity, both law and custom regard assaults on minors far more seriously than assaults on adults, and regard interference with babies as one of the vilest of all possible crimes. But if fiddling with a child’s genitals deserves a stiff gaol sentence, what sort of punishment should be inflicted to those who cut part of them off?
MacDonald deserves credit for shifting the debate on circumcision away from irrelevant quibbles about the balance of risks and benefits (the so-called pros and cons rubbish), but her own suggestion as to the key question is not much better. The “medically important question” is not at all whether circumcision should be “routinely offered to young male adolescents rather than their baby brothers”, but how we can find an effective method of giving male minors some fraction of the protection against genital cutting currently enjoyed by their sisters.
Another significant weakness in Professor MacDonald’s essay is her acceptance of a very dubious piece of research on the effectiveness of circumcision as a means of reducing a male’s risk of infection with HIV. She cites a US study by Sansom et al claiming that US males had a lifetime risk of acquiring HIV of 1.87 per cent (i.e. nearly 1 in 50), that neonatal circumcision (presumably universal) would reduce this risk by 16 per cent, and that it was therefore justified as a measure of public health. To her credit, MacDonald regards this risk reduction as too small to justify circumcision without consent, but she has apparently failed to realise that the paper she cites is fatally flawed in several crucial respects and has been roundly criticised (i.e. torn to shreds) in the same journal in which it originally appeared.
Among other objections, the critics point out:
As the critic points also out, with suitably massaged assumptions, you can “prove” anything you like: or as the computer scientists say, GIGO: garbage in, garbage out.
To read the full critique, go to www.plosone.org, and search for Stephanie L. Sansom et al, Cost-Effectiveness of newborn circumcision in reducing lifetime HIV risk among U.S. males. When you get the article, choose the tab for Comments, and select the first: GIGO, by vanhowe.
Another critic (Hanabi) points out that Sansom’s own data show that the lifetime risk of HIV to Black men was 6.23% while 73% of Black men are circumcised, yet the lifetime risk to Hispanics was only 2.88% with a circumcision rate of 42%. This suggests that there is no connection at all between circumcision and reduced susceptibility to HIV, that circumcision increases the risk of HIV, or that being Black in the USA is a far greater risk factor for HIV than possessing a foreskin. (This last point may be related to the disproportionate number of Black men in American prisons, where unsafe sex is rampant.)
It is interesting to note that Sansom’s article was originally offered to the US journal Pediatrics, which rejected it as unsound, forcing the authors to seek exposure in a far less authoritative on-line journal. Since the authors are associated with the American Centres for Disease Control, known be stacked with pro-circumcision zealots, we may suspect that the paper was little more than a piece of propaganda, cobbled together to support their case for universal neonatal circumcision.
1. Pang MG, Kim DS. Extraordinarily high rates of male circumcision in South Korea: history and underlying causes. BJU International 2002;89:48-54; also, Romeo B. Lee, Filipino experience of ritual male circumcision: Knowledge and insights for anti-circumcision advocacy. Culture, Health & Sexuality, May–June 2006; 8(3): 225–234; also Boyle GJ. Issues associated with the introduction of circumcision into a non-circumcising society. Sex Trans Inf 2003;79:427-8
2. Joel Feinberg, The Child’s Right to an Open Future, in Freedom and Fulfilment: Philosophical Essays (Princeton University Press, 1992). See also Dena Davis, Genetic Dilemmas: Reproductive Technology, Parental Choices and Children’s Futures (London and New York: Routledge, 2001), and idem, Genetic Dilemmas and the Child’s Right to an Open Future, 28 Rutgers Law Journal 549 (1997)
3. Brian Morris, In Favour of Circumcision (Sydney: NSW University Press, 1999), 61-2
In a landmark judgement, the High Court of England and Wales has ruled that children should not be circumcised until they are old enough to decide for themselves. The case arose when the Muslim father of the boy wanted him to be circumcised in accordance with his own religious beliefs, but the English mother disagreed. Top female Family Division judge Mrs Justice Roberts agreed with their mother’s wish to leave it for the boys, aged six and four, to make up their own minds when they are older whether they wish to have it done. The father, 36, was born in Algeria but is now separated from the 34-year-old mother. The couple met in 2006, lived together in a North London flat, and went through an Islamic ceremony of marriage in 2009 before the boys were born. In July 2012 the mother fled the flat with the boys following violent attacks on her by the father. The judge said the father came to England in 2001 on false documents, but had now been given British passport.
In reaching her decision, Justice Roberts said: "First and foremost, this is a once and for all, irreversible procedure. There is no guarantee that these boys will wish to continue to observe the Muslim faith with the devotion demonstrated by their father although that may very well be their choice. They are still very young and there is no way of anticipating at this stage how the different influences in their respective parental homes will shape and guide their development over the coming years. There are risks, albeit small, associated with the surgery regardless of the expertise with which the operation is performed.
There must be clear benefits which outweigh these risks which point towards circumcision at this point in time being in their best interests before I can sanction it as an appropriate course at this stage of their young lives."
She added: "Taking all these matters into account, my conclusion is that it would be better for the children that the court make no order at this stage in relation to circumcision. I am simply deferring that decision to the point where each of the boys themselves will make their individual choices”
Circumcision choice should be left until children are old enough to decide for themselves. The Telegraph, 19 April 2016
Jonathan Wells, Should religious circumcision be banned? The Telegraph, 19 April 2016
The decision of Justice Roberts in the case of L & B in the High Court of England and Wales has important implications for child rights and protection of children against genital surgeries desired by their parents or other adults. In a landmark judgement, the court ruled that children should not be circumcised until they are old enough to decide for themselves. The case arose when the Muslim father of the boy wanted him to be circumcised in accordance with his own religious beliefs, but the English mother disagreed. Top female Family Division judge Mrs Justice Roberts agreed with their mother’s wish to leave it for the boys, aged six and four, to make up their own minds when they are older whether they wish to have it done. The father, 36, was born in Algeria but is now separated from the 34-year-old mother. The couple met in 2006, lived together in a North London flat, and went through an Islamic ceremony of marriage in 2009 before the boys were born. In July 2012 the mother fled the flat with the boys following violent attacks on her by the father. The judge said the father came to England in 2001 on false documents, but had now been given British passport.
The importance of the court’s judgement is that it confirms and extends earlier rulings that where parents disagree about whether a child should be circumcised, he or she should not be circumcised, but protected until he or she is old enough to make an informed decision. It further implies that for circumcision of a child t be lawful, both parents must give consent. This confirms the earlier ruling in the case of Re J that where the parents disagree, the best interests and possible future wishes of the child will need to be considered, which will normally dictate that the child should be free to decide for itself when older).
The case represents a perceptible change towards giving priority to the child’s rights and possible future wishes, thus abandoning the old legal view of children as little more than objects in the possession of their parents. More obviously than in the case of Re J, the Court was receptive to the real risk of harm resulting from circumcision, largely owing to the evidence presented by the mother’s counsel, who was well versed in the recent medical literature. While noting them, Justice Roberts did not give priority to the prophylactic health benefit arguments, but rather correctly evaluated the risks and harms involved as the key factor.
The vital thing is that the court accepted the primacy of the children’s right to make their own decisions about their lives. A key statement from the central argument of the judge (para 142-3): “First and foremost, [circumcision] is a once and for all, irreversible procedure. There is no guarantee that these boys will wish to continue to observe the Muslim faith ... although that may very well be their choice. They are still very young and there is no way of anticipating at this stage how the different influences in their respective parental homes will shape and guide their development over the coming years. ... I am ... deferring that decision to the point where each of the boys themselves will make their individual choices once they have the maturity and insight to appreciate the consequences and longer term effects of the decisions which they reach.”
These comments are essentially consistent with the principle of the child’s right to an open future.
Justice Roberts also referred to Lord Justice Munby’s comment from the Re B & G case last year: that when considering the legal questions around non-therapeutic circumcision, particularly the question of “significant harm” and comparisons with FGM, is to wade into “deep waters” - a suggestion that there is some wider concern about the tenability of this area of the law.
Perhaps the most useful element of the case will turn out to be the factual findings. After hearing at length from an expert of Islamic Studies, the judge was quite satisfied that nothing in Islam requires Muslim parents to circumcise their boys or that a boy’s circumcision is obligatory at any particular age. On the contrary, she found that that even if not uncircumcised they will still be able to participate fully in their father’s Muslim culture. Given that most circumcision cases now involve Islam more than any other faiths, this finding is an important one on which subsequent cases will probably rely.