Circumcision: medical, cultural, and ethical perspectives

circumcision: ETHICAL, RELIGIOUS, MEDICAL AND LEGAL PERSPECTIVE

Circumcision is one of the most common operations performed in the United States. A practice that gained popularity mainly in 1960s-1970s is still quite common considering that six out of every ten male children are circumcised in the country even today.While there has been a wealth of research on the subject, now more leaning towards discrediting of many of its benefits, still law doesn't prohibit the practice. In fact law has actually worked in favor of circumcision over the years and does provide protection to male circumcision.

Circumcision has basically been a religious ritual which gained immense support when medical journals and studies around the country came up with reliable information regarding health benefits of circumcision. For most traditional Christian societies, circumcision was something they viewed neutrally even though Genesis does explicitly refers to circumcision: "And ye shall be circumcised in the flesh of your foreskin; and it shall be a token of a covenant betwixt Me and you."

Prior to late 19th century, male circumcision was not a common practice among Christians and was widely practiced in Jewish and Muslim societies. Christians would usually view it with some suspicion as Christian Church saw it as something not really important. Since most Christians were neutral on the subject, it made it easier to shape their opinion about it later when advocates of circumcision promoted it as something healthy, natural and beneficial.

This change in attitude was marked during the first decades of the 20th century when physicians started advocating circumcision and uncircumcised penis was seen as something unnatural, deformed and basically harmful. This advocacy was so powerful that within a very short period of time, circumcision became a common practice. It was seen both as a remedial measure against potentially harmful diseases and as a preventive procedure. American people quickly adopted this change in attitude towards circumcision and in the year 1977, it was cited as the most commonly performed operation in the country. It is still performed on approximately six out of every ten infant boys in this country. For some inexplicable reason, support for circumcision continued to gain strength even after studies that presented circumcision as a deterrent for masturbation were largely discredited. While it may not act as a deterrent in some cases, some studies later found circumcision to protect against such diseases as penile cancer and urinary tract infections and was even seen as a possible means of reducing the risk of contracting AIDS.

In 1980s and 1990s, a movement against the practice of male circumcision took hold in the country. Some carefully planned lobbying and massive publicity gradually began shifting the attitudes to how they were prior to the 20th century. Uncircumcised penis suddenly became more natural and desirable and popular American opinion was significantly influenced by presenting circumcision as something wrong and bad. While this movement gained momentum in other English speaking countries, America was slow to follow suit. Though rate of circumcision has dropped, the practice is not altogether ruled out. It is still very common and this could be largely due to the influence of Jewish and Muslim communities where circumcision has religious significance.

MALE CIRCUMCISION AND LAW

Legally, there is no law in the country to prohibit or discourage the practice of circumcision. It is in fact quite actively favored by the courts and some states protect circumcision to the point of excluding it from the list of practices seen as ritual abuse. Jewish circumcisers known as mohelim are also protected by the law. Thus circumcision for ritual or medical reasons is provided sufficient support under the American law. Tort law does provide some protection in case of circumcision-related medical problems. However tort cannot guarantee regulation of this medical procedure and is hence rather ineffective. In any case, circumcision rarely ever goes so wrong that it would lead to a lawsuit and for this reason, law doesn't provide for complications resulting from circumcision. In most cases, complications occurring from this procedure can be surgically corrected and thus res ipsa loquitur is not available for this medical practice. However the law does recognize unauthorized circumcisions and provide suitable compensation in such cases. A person can sue a practitioner for circumcising him or his child without informed consent. But since the nature of this procedure is such that it's usually performed on children whose informed consent cannot be sought, the law doesn't really protect the persons circumcised. It is usually the parents who can initiate a lawsuit.

Pro-Circumcision Research:

Support for circumcision started in two distinct stages and the first of which was when physicians changed their stance on the practice and saw it as a remedy for some diseases and medical conditions. In this regard, something that happened in 1870 is worth mentioning. In those days Lewis Sayre, who was a well-known orthopedic surgeon and also enjoyed the coveted position as president of the American Medical Association, was consulted about a case where a five-year-old boy couldn't fully straighten his legs. Sayre felt that this condition could be some form of paralysis but couldn't immediately ascertain the cause. Sayre was informed that there was something wrong with the foreskin on child's penis and upon examination it was found that foreskin had sore which was causing the paralysis: "As excessive venery is a fruitful source of physical prostration and nervous exhaustion, sometimes producing paralysis," Sayre maintained, "I was disposed to look upon this case in the same light, and recommended circumcision as a means of relieving the irritated and imprisoned penis."

This turned out to be just the right procedure as the child was miraculously cured within weeks. Sayre then publicized the use of circumcision to some paralysis conditions and felt that irritation or inflammation of penis could result in conditions of legs and joints During the same year, Sayre delivered a very important paper at a meeting of American Medical Association that recognized the benefits of circumcision and for next 30 years, it was this paper that provided the basis for growing support for this procedure.

This paper was so sensational and so widely accepted that it completely molded public opinion regarding circumcision and for 30 years after that, this practice was viewed as a cure for anything from epilepsy, gout, spine-related problem, and even alcoholism. Some doctors went as far as recommending circumcision for curing neurasthenia, a serious condition with signs such as "morbid fears, fear of society, of solitude, or traveling, of places, of disease, or morbid impulses, to kill one's self or others, mental depression, wakefulness, headache, impaired memory, [or] deficient mental control." It was also seen as a cure for masturbation and spermatorrhoea (i.e. wet dreams) and this was where circumcision gained the most support as people found it easier to get their children circumcised instead of watching over them. This form of support resulted from a paper entitled "Circumcision as Preventative of Masturbation by Jonathan Hutchinson, a well-known British physician and President of the Royal College of Surgeons. In this paper, Hutchinson argued in favor of circumcision maintaining that since it treated irritation, it could also act as a deterrent for masturbation. He hoped that this practice "may often accomplish much, both in breaking the habit as an immediate result, and in diminishing the temptation to it subsequently."

This theory by Hutchison was widely accepted and gained even greater support when in 1898, W.M. Donald, of Detroit College of Medicine, confirmed these findings writing that a "comfortable minority" of cases concerning masturbation resulted from "preputial irritation, due to adhesions or undue length of the foreskin, or both, quite sufficient to account for the vice." It was also reported that such cases of masturbation could be effectively cured if the child undergoes this surgery early in his life. Donald's research was based on three cases where three boys under the age of ten from Detroit orphan asylum were found masturbating. It was seen that all these boys were uncircumcised. Circumcision was recommended and when performed, it produced the following results:

The youngest was in the grasp of the vice to such an extent that he attempted to masturbate the day following the operation, but succeeded in inducing only a vast amount of swelling and soreness, with tearing of the stitches. Since that time to the present writing, three months later, his nurse reports that he has been absolutely free of the trouble. The second boy was cured by the operation, and has since remained cured. The third boy, aged ten, was such an incorrigible case, having probably masturbated for several years, that after the operation, despite the fact that during the day he showed no sign of indulgence in his vice, yet when soundly asleep at night his nurse would discover him practicing it unconsciously. I thereupon ordered rough mits [sic] placed on his hands at night, so that the rough friction would awaken him from his sound sleep. After a few nights of this treatment he gave us no further trouble.

Donald then concluded that when a child is found suffering from genital irritation, it was best to have circumcision performed on him "during the first year of life, so that to a degree at least danger of future moral contamination may be avoided."

The obvious and well-documented benefits of circumcision led to a sudden increase in its popularity and by 1889, it was getting circumcised was in fashion. Circumcision gained even greater support when it was presented not as a cure but also as a prophylactic. Since the benefits were well-known and circumcision was widely advocated, people decided that it was better to get their children circumcised as soon as it was possible. Thus, instead of waiting for diseases to develop or other signs of discomfort to emerge, it was thought best to have circumcision done before it was too late and thus neonatal circumcision became popular. By 1910 and in the early decades of the 20th century, it was noted that "the uncircumcised male, particularly one born in an urban area, indeed, is becoming a rarity in our society."

ANTI-CIRCUMCISION Research

Circumcision is a popular practice and many still have faith in its medical benefits. But opponents of this practice are now growing more vocal maintaining that the procedure doesn't really merit as much attention or credit as a cure for some genital diseases or other medical problems. While even today, 60% of all boys are circumcised in the United States but the rate is slowing dropping with more studies discrediting old claims about various benefits of circumcision. Among Muslims and Jews, the practice is still common with Muslims treating it as a religious obligation and do not in any case accept researches opposing circumcision. In Britain however, rate of circumcision is very low, falling around 5 to 6%.

Anti-circumcision movement gained momentum with various studies publicizing its alleged demerits. American Academy of Pediatrics played a key role in changing people's attitude towards circumcision when in 1971 and again in 1975, it claimed that "there is no absolute medical indication for routine circumcision of the newborn," and maintained that proper hygienic practices could offer the same advantages. But the Academy received a rude shock when it was found in 1989 that there existed a correlation between urinary tract infections and absence of circumcision. A decade later, the Academy adopted its stance of 1970s once again but this time, more tactfully, claimed that there was no need for circumcision to become a "routine" procedure and anesthesia would have to be used when circumcising boys.

The campaign against routine neonatal circumcision is rather different in nature when compared with researches and studies that first promoted the practice. The campaigners were a whole different breed namely physicians who were genuinely interested in promoting a practice that could prove remedial and beneficial to majority of males. However this new group that is opposing circumcision is driven by social anxieties and do not necessarily know a great deal about medical benefits or the lack of the same thereof. They are actively suggesting that circumcision is a painful practice that may or may not have any medical benefits. They are also motivated by gender issues since only males are subjected to circumcision. Somehow this practice hurts the traditional image of man as the stronger sex.

The campaign actually lacks good medical support and appears to be grounded in social issues of gender and human rights. They claim that a child might undergo emotional and physical trauma when circumcised and this may impact his adult life.Apart from this, they also appear to have gender related concerns and anti-circumcision is largely seen as a "men's movement."