added a research item
The current legal status and medical ethics of routine or religious penile circumcision of minors is a matter of ongoing controversy in many countries. We focus on the United Kingdom as an illustrative example, giving a detailed analysis of the most recent guidance on the subject, from 2019, from the British Medical Association (BMA). We argue that the guidance paints a confused and conflicting portrait of the law and ethics of the procedure in the UK context, reflecting deeper, unresolved moral and legal tensions surrounding child genital cutting practices more generally. Of particular note is a lack of clarity around how to apply the “best interests” standard—ordinarily associated with time-sensitive proxy decision-making regarding therapeutic options for a medically unwell but incompetent patient, such as a young child dealing with disease or disability—to a parental request for a medically unnecessary surgery to be carried out on the genitalia of a well child. Challenges arise in measuring and assigning weights to intended sociocultural or religious/spiritual benefits, and even to health-related prophylactic benefits, and in balancing these against potential physical, functional, and psychosexual risks or harms. Also of concern are apparently inconsistent safeguarding standards applied to children based on their birth sex categorization or gender of rearing. We identify and discuss recent trends in British and international medical ethics and law, finding gradual movement toward a more unified standard for evaluating the permissibility of surgically modifying healthy children’s genitals before they can meaningfully participate in the decision.
The World Health Organization (WHO) condemns all medically unnecessary female genital cutting (FGC) that is primarily associated with people of color and the Global South, claiming that such FGC violates the human right to bodily integrity regardless of harm-level, degree of medicalization, or consent. However, the WHO does not condemn medically unnecessary FGC that is primarily associated with Western culture, such as elective labiaplasty or genital piercing, even when performed by non-medical practitioners (e.g., body artists) or on adolescent girls. Nor does it campaign against any form of medically unnecessary intersex genital cutting (IGC) or male genital cutting (MGC), including forms that are non-consensual or comparably harmful to some types of FGC. These and other apparent inconsistencies risk undermining the perceived authority of the WHO to pronounce on human rights. This paper considers whether the WHO could justify its selective condemnation of non-Western-associated FGC by appealing to the distinctive role of such practices in upholding patriarchal gender systems and furthering sex-based discrimination against women and girls. The paper argues that such a justification would not succeed. To the contrary, dismantling patriarchal power structures and reducing sex-based discrimination in FGC-practicing societies requires principled opposition to medically unnecessary, non-consensual genital cutting of all vulnerable persons, including insufficiently autonomous children, irrespective of their sex traits or socially assigned gender. This conclusion is based, in part, on an assessment of the overlapping and often mutually reinforcing roles of different types of child genital cutting—FGC, MGC, and IGC—in reproducing oppressive gender systems. These systems, in turn, tend to subordinate women and girls as well as non-dominant males and sexual and gender minorities. The selective efforts of the WHO to eliminate only non-Western-associated FGC exposes the organization to credible accusations of racism and cultural imperialism and paradoxically undermines its own stated goals: namely, securing the long-term interests and equal rights of women and girls in FGC-practicing societies.
Femawle Genital Mutilation/Cutting (FGM/C) comprises all procedures that involve partial or total removal of the external female genitalia or injury to the female genital organs that are medically unnecessary (i.e. performed primarily for cultural or religious reasons), especially when done without the consent of the affected person. Such procedures are usually carried out in infancy or childhood and, most often before the age of 15. Although some pictorial and training tools are available, existing literature focuses primarily on adults. The signs of FGM/C particularly in prepubertal girls, can be subtle and depend on the type as well as on the experience of the examiner. The health care provider (HCP) should be trained to be familiar with, and able to identify a wide range of both modified and unmodified genitalia, as well as findings that may superficially look like FGM/C but actually reflect the normal range of genital anatomy. Knowledge of FGM/C types and subtypes, as well as complications and differential diagnoses of physical findings, are critical. We present a reference guide and atlas containing iconographic material of both the pre- and post-pubertal external female genital area with and without genital cutting/alteration. Our purpose is to facilitate training of health care professionals in making accurate diagnoses, providing appropriate clinical management, ensuring culturally informed/sensitive patient–provider communication, and accurate recording and reporting to child welfare/law enforcement agencies, where required.
In many cultures, children with intersex traits are subjected to medically unnecessary genital operations in an attempt to reshape their sexual anatomy to approximate a more stereotypical male or female appearance. In addition to these surgeries, there are three main patterns of medically unnecessary genital operations performed on non-intersex children across the globe. In the first pattern, the dominant culture endorses routine or religious genital cutting only of boys, as in the United States, Israel, Afghanistan, or Saudi Arabia, for instance. In these cultures, girls are ineligible for genital cutting, or may be seen as deserving protection from it. In the second pattern, neither boys nor girls of the dominant culture have their genitals cut unless there is a strict medical indication—which in these contexts is rare. This is the prevailing pattern throughout Europe and indeed most other parts of the world. In the third pattern, both boys and girls of the dominant culture have their genitals cut for non-medical reasons, for example, in the context of a rite of passage or religious initiation. Typically, this occurs around puberty, but the timing ranges from right after birth to before marriage. In this chapter, I present a moral argument in favor of the second, “European” pattern, both as a matter of ethics and gender equality. I do not discuss legal implications. In other words, I argue that, morally speaking, neither boys nor girls who are too young to consent should have their genitals cut—to any extent—unless it is medically necessary to do so, whether or not they have intersex traits. The alternative, from a gender equality perspective, would be to argue that both boys and girls should have their genitals cut on an equal basis, for example, by a doctor using sterile instruments. But from an ethical perspective, I argue, this would not be acceptable.
Endosex, in contrast to intersex, refers to innate physical sex characteristics judged to fall within the broad range of what is considered “usual for binary female or male bodies by the medical field,” or to persons with such characteristics  (p. 437). In this short contribution, we explain the origins and increasing use of this little-known term and discuss its practical and ethical relevance to medicine as well as to scholarship from a range of disciplines concerned with individuals’ sexed embodiment.
According to the World Health Organization (WHO), customary female genital modification practices common in parts of Africa, South and Southeast Asia, and the Middle East are inherently patriarchal: They reflect deep-rooted inequality between the sexes characterized by male dominance and constitute an extreme form of discrimination against women. However, scholars have noted that while many societies have genital modification rites only for boys, with no equivalent rite for girls, the inverse does not hold. Rather, almost all societies that practice ritual female genital modification also practice ritual male genital modification, often for comparable reasons on children of similar ages, with the female rites led by women and the male rites led by men. In contrast, then, to the situation for boys in various cultures, girls are not singled out for genital modification on account of their sex or gender; nor do the social meanings of the female rites necessarily reflect a lower status. In some cases, the women’s rite serves to promote female within-sex bonding and network building—as the men’s rite typically does for males—thereby counterbalancing gendered asymmetries in political power and weakening male dominance in certain spheres. In such cases, and to that extent, the female rites can be described as counter-patriarchal. Selective efforts to discourage female genital modifications may thus inadvertently undermine women-centered communal networks while leaving male bonding rites intact. Scholars and activists should not rely on misleading generalizations from the WHO about the relationship between genital cutting and the social positioning of women as compared to men. To illustrate the complexity of this relationship, we compare patterns of practice across contemporary societies while also highlighting anthropological data regarding pre-industrial societies. Regarding the latter, we find no association between the presence of a female initiation rite and a key aspect of patriarchy as it is classically understood, namely, social endorsement of a gendered double-standard regarding premarital sexual activity. We situate this finding within the broader literature and discuss potential implications.
Defenders of male circumcision increasingly argue that female ‘circumcision’ (cutting of the clitoral hood or labia) should be legally allowed in Western liberal democracies even when non-consensual. In his target article, Richard Shweder (2022) gives perhaps the most persuasive articulation of this argument to have so far appeared in the literature. In my own work, I argue that no person should be subjected to medically unnecessary genital cutting of any kind without their own informed consent, regardless of the sex characteristics with which they were born or the religious or cultural background of their parents. Professor Shweder and I agree that Western law and policy on child genital cutting is currently beset with cultural, religious and sex-based double standards. We disagree about what should be done about this. In this commentary, I argue that ‘legalising’ childhood FGC so as to bring it into line with current treatment of childhood MGC is not an acceptable solution to these problems. Instead, all medically unnecessary genital cutting of non-consenting persons should be opposed on moral and legal grounds and discouraged by all appropriate means.
The WHO, American Academy of Pediatrics and other Western medical bodies currently maintain that all medically unnecessary female genital cutting of minors is categorically a human rights violation, while either tolerating or actively endorsing medically unnecessary male genital cutting of minors, especially in the form of penile circumcision. Given that some forms of female genital cutting, such as ritual pricking or nicking of the clitoral hood, are less severe than penile circumcision, yet are often performed within the same families for similar (eg, religious) reasons, it may seem that there is an unjust double standard. Against this view, it is sometimes claimed that while female genital cutting has ’no health benefits’, male genital cutting has at least some. Is that really the case? And if it is the case, can it justify the disparate treatment of children with different sex characteristics when it comes to protecting their genital integrity? I argue that, even if one accepts the health claims that are sometimes raised in this context, they cannot justify such disparate treatment. Rather, children of all sexes and genders have an equal right to (future) bodily autonomy. This includes the right to decide whether their own ’private’ anatomy should be exposed to surgical risk, much less permanently altered, for reasons they themselves endorse when they are sufficiently mature.
The American College of Nurse-Midwives (ACNM), American Society for Pain Management Nursing (ASPMN), American Academy of Pediatrics (AAP), and other largely U.S.-based medical organizations have argued that at least some forms of non-therapeutic child genital cutting, including routine penile circumcision, are ethically permissible even when performed on non-consenting minors. In support of this view, these organizations have at times appealed to potential health benefits that may follow from removing sexually sensitive, non-diseased tissue from the genitals of such minors. We argue that these appeals to “health benefits” as a way of justifying medically unnecessary child genital cutting practices may have unintended consequences. For example, it may create a “loophole” through which certain forms of female genital cutting—or female genital mutilation (FGM) as it is defined by the World Health Organization (WHO)—could potentially be legitimized. Moreover, by comparing current dominant Western attitudes toward “FGM” and so-called intersex genital “normalization” surgeries (i.e., surgeries on children with certain differences of sex development), we show that the concept of health invoked in each case is inconsistent and culturally biased. It is time for Western healthcare organizations—including the ACNM, ASPMN, AAP, and WHO—to adopt a more consistent concept of health and a unified ethical stance when it comes to child genital cutting practices.
Campaigns to circumcise millions of boys and men to reduce HIV transmission are being conducted throughout eastern and southern Africa, recommended by the World Health Organization and implemented by the United States government and Western NGOs. In the United States, proposals to mass-circumcise African and African American men are long standing, and have historically relied on racist beliefs and stereotypes. The present campaigns were started in haste, without adequate contextual research, and the manner in which they have been carried out implies troubling assumptions about culture, health, and sexuality in Africa, as well as a failure to properly consider the economic determinants of HIV prevalence. This critical appraisal examines the history and politics of these circumcision campaigns while highlighting the relevance of race and colonialism. It argues that the "circumcision solution" to African HIV epidemics has more to do with cultural imperialism than with sound health policy, and concludes that African communities need a means of robust representation within the regime.
Purpose of Review To summarize and critically evaluate the moral principles invoked in support of zero tolerance laws and policies for medically unnecessary female genital cutting (FGC). Recent Findings Most of the moral reasons that are typically invoked to justify such laws and policies appear to lead to a dilemma. Either these reasons entail that several common Western practices that are widely regarded to be morally permissible and are currently treated as legal—such as intersex “normalization” surgery, female genital “cosmetic” surgery performed on adolescent girls, or infant male circumcision—are in fact morally impermissible and should be discouraged if not legally forbidden; or the reasons are being applied in a biased and prejudicial manner that is itself unethical, as well as inconsistent with Western constitutional requirements of equal treatment of individuals before the law. Summary In the recent literature, only one principle has been defended that appears capable of justifying a zero tolerance stance toward medically unnecessary FGC without relying on, exhibiting, or perpetuating unjust cultural or moral double standards. This principle holds that, in countries whose ethicolegal traditions are shaped by a foundational concern for individual rights, respect for bodily integrity, and personal autonomy over sexual boundaries, all non-consenting persons have an inviolable moral right against any medically unnecessary (or medically deferrable) interference with their genitals or other private anatomy. In such countries, therefore, all non-consenting persons, regardless of age, race, ethnicity, parental religion, assigned sex, gender identity, or other individual or group-based features, should be protected from medically unnecessary genital cutting, regardless of the severity of the cutting or the expected level of benefit or harm.
Imagine an article describing “newborn labiaplasty techniques” for girls. Regardless of any statistical health benefits that might follow from this procedure (such as a reduced risk of labial cancer or UTIs) the surgery could not ethically be performed. This is because it removes anatomically normal, non-diseased, functional tissue—from a psychosexually significant part of the body—with no urgent medical need and without the consent of the affected person. Even if labiaplasty were less expensive, healed faster, and had fewer complications in the neonatal period compared to after an age of consent, it would still be unethical—indeed illegal—to perform such an operation on a healthy newborn
There are now legally prohibited forms of medically unnecessary female genital cutting—including the so-called ritual nick—that are less severe than permitted forms of medically unnecessary male and intersex genital cutting. Attempts to discursively quarantine the male and female forms of cutting (MGC, FGC) from one another based on appeals to health outcomes, symbolic meanings, and religious versus cultural status have been undermined by a large body of recent scholarship. Recognizing that a zero-tolerance policy toward ritual FGC may lead to restrictions on ritual MGC, prominent defenders of the latter practice have begun to argue that what they regard as “minor” forms of ritual FGC should in fact be seen as morally permissible—even when non-consensual—and should be legally allowed in Western societies. In a striking development in late 2018, a federal judge ruled that the longstanding U.S. law prohibiting “female genital mutilation” (FGM) was unconstitutional on federalist grounds, while separately acknowledging the logical relevance of arguments concerning non-discrimination on the basis of sex or gender. In light of such developments, feminist scholars and advocates of children’s rights now increasingly argue that efforts to protect girls from non-consensual FGC must be rooted in a sex and gender-neutral (that is, human) right to bodily integrity, if these efforts are to be successful in the long-run.
In recent years, the dominant Western discourse on “female genital mutilation” (FGM) has increasingly been challenged by scholars. Numerous researchers contest both the terminology used and the empirical claims made in what has come to be called “the standard tale” of FGM, also termed “female genital cutting” (FGC). The World Health Organization (WHO), a major player in setting the global agenda on this issue, maintains that all medically unnecessary cutting of the external female genitalia, no matter how slight, should be banned as torture and a violation of the human right to bodily integrity. However, the WHO targets only non-Western forms of female-only genital cutting, raising concerns about gender bias and cultural imperialism. Here, we summarize ongoing critiques of the WHO’s terminology, ethicolegal assumptions, and empirical claims, including the claim that non-Western FGC as such constitutes an extreme form of discrimination against women. To this end, we highlight recent comparative studies of medically unnecessary genital cutting of all types, including those affecting adult women and teenagers in Western societies, individuals with differences of sex development (DSD), transgender persons, and males. In so doing, we attempt to clarify the grounds for a growing critical consensus that current anti-FGM laws and policies may be ethically incoherent, empirically unsupportable, and legally unsustainable.
I argue against the use of 'mutilation' in certain contexts, as there is evidence that such stigmatizing language may have adverse effects on the very people who are meant to be helped. Since it is not necessary to stigmatize women's bodies in order to ground the ethical claim that cutting children's genitals is morally wrong if not medically necessary, I choose to use non-stigmatizing language.
I elaborate on one of the key psychosocial considerations raised by Connor et al. (2019), namely the potentially stigmatizing nature of much current activist, academic, and social-policy discourse surrounding non-Western forms of FGC. I explore how this discourse may, at least along certain dimensions, inadvertently harm the very people it is intended to help, focusing on possible implications for sexual experience. Mindful of this concern, I conclude with some suggestions for how ethical opposition to FGC can be grounded in a principled way that does not further stigmatize individuals who have already been affected by non-consensual, medically unnecessary genital cutting.
Introduction: Clitoral reconstruction (CR) is a controversial surgical procedure performed for women who have undergone medically unnecessary, often ritualistic genital cutting involving the clitoris. Such cutting is known by several terms; we will use female genital mutilation/cutting (FGM/C). Treatments offered to women affected by complications of FGM/C include defibulation (releasing the scar of infibulation to allow penetrative intercourse, urinary flow, physiological delivery, and menstruation) and CR to decrease pain, improve sexual response, and create a pre-FGM/C genital appearance. Aim: In this study, our aim is to summarize the medical literature regarding CR techniques and outcomes, and stimulate ethical discussion surrounding potential adverse impacts on women who undergo the procedure. Methods: A broad literature review was carried out to search any previous peer-reviewed publications regarding the techniques and ethical considerations for CR. Main outcome measure: The main outcome measure includes benefits, risks, and ethical analysis of CR. Results: While we discuss the limited evidence regarding the risks and efficacy of CR, we did not find any peer-reviewed reports focused on ethical implications to date. Clinical implications: CR can be indicated as a treatment for pain and potential improvement of associated sexual dysfunction when these have not responded to more conservative measures. Women must be appropriately informed about the risks of CR and the lack of strong evidence regarding potential benefits. They must be educated about their genital anatomy and disabused of any myths surrounding female sexual function as well as assessed and treated in accordance with the current scientific evidence and best clinical practices. Strength & limitations: This is the first formal ethical discussion surrounding CR. This is not a systematic review, and the ethical discussion of CR has only just begun. Conclusion: We present a preliminary ethical analysis of the procedure and its potential impact on women with FGM/C. Sharif Mohamed F, Wild V, Earp BD, et al. Clitoral Reconstruction After Female Genital Mutilation/Cutting: A Review of Surgical Techniques and Ethical Debate. J Sex Med 2020;17:531-542.
Penile circumcision is often claimed to be simpler, safer, and more cost-effective when performed in the neonatal period as opposed to later in life, with a greater benefit-to-risk ratio. In the first part of this paper, we critically examine the evidence base for these claims, and find that it is not as robust as is commonly assumed. In the second part, we demonstrate that, even if one simply grants these claims for the sake of argument, it still does not follow that neonatal circumcision is ethically permissible - absent urgent medical necessity. Based on a careful consideration of the relevant evidence, arguments, and counterarguments, we conclude that medically unnecessary penile circumcision—like other medically unnecessary genital procedures, such as ‘cosmetic’ labiaplasty—should not be performed on an individual who is too young (or otherwise unable) to provide meaningful consent to the procedure.
How did Alan Dershowitz help strike down the U.S. ban on "female genital mutilation" and what does this have to do with male circumcision? This is a video of the talk, "Religious freedom, equal protection, and the child’s (gender neutral) right to bodily integrity," delivered by children's right scholar Brian D. Earp of Yale and Oxford universities to the UK National Secular Society in London on May 18, 2019.
We seek to clarify and assess the underlying moral reasons for opposing all medically unnecessary genital cutting of female minors, no matter how severe. We find that within a Western medicolegal framework, these reasons are compelling. However, they do not only apply to female minors, but rather to non-consenting persons of any age irrespective of sex or gender. Keeping our focus exclusively on a Western context for the purposes of this article, we argue as follows: Under most conditions, cutting any person’s genitals without their informed consent is a serious violation of their right to bodily integrity. As such, it is ethically impermissible unless the person is non-autonomous (incapable of consent) and the cutting is medically necessary.
When a US federal judge ruled recently that a 1996 law prohibiting "female genital mutilation" (FGM) was unconstitutional, it prompted shock and dismay across the political spectrum: how could it be unconstitutional to protect little girls from this form of violence? I have followed the legal developments surrounding FGM in the US for some time and have warned that a ruling like this was bound to happen. In fact, I gave a speech only a few weeks earlier explaining why the US anti-FGM law might have to be struck down. Other Western countries could soon follow suit. Legal scholars have argued for decades that a collision course with the US Constitution was set the moment the 1996 FGM law was passed. I'll explain why and suggest a more stable way to protect potential victims going forward.
In this chapter, an infringement of bodily integrity (BI) is defined as any penetration into a bodily orifice, breaking of the skin, or alteration of a person’s physical form. A violation of a person’s right to BI is any infringement of their BI that wrongs them. An autonomous person is wronged by an infringement of their BI if they did not consent to it. If a person is incapable of consenting because they are temporarily non-autonomous – as in the case of an intoxicated adult or a pre-autonomous child – the infringement should be delayed until the individual becomes autonomous and can make their own decision. It is only when the infringement cannot be delayed without putting the person into a situation they would be even less likely to consent to (if they were autonomous) that the infringement does not wrong them. Given the seriousness of violating anyone's right to BI, and especially that of the most vulnerable persons, the appropriate likelihood-of-consent for proceeding with a BI infringement on a child is argued to be at or near the ‘medically necessary’ threshold.
We sought to quantify early deaths following neonatal circumcision (same hospital admission) and to identify factors associated with such mortality. We performed a retrospective analysis of all patients who underwent circumcision while hospitalized during the first 30 days of life from 2001-2010 using the National Inpatient Sample (NIS). Over 10 years, 200 early deaths were recorded among 9,833,110 subjects (1 death per 49,166 circumcisions). Note: this figure should not be interpreted as causal but correlational: it may include both under-counting and over-counting of deaths attributable to circumcision. Compared to survivors, subjects who died following newborn circumcision were more likely to have associated co-morbid conditions, such as cardiac disease (OR: 697.8 [378.5-1286.6] p<0.001), coagulopathy (OR: 159.6 [95.6-266.2] p<0.001), fluid and electrolyte disorders (OR: 68.2 [49.1-94.6] p<0.001), or pulmonary circulatory disorders (OR: 169.5 [69.7-412.5] p<0.001). Recognizing these factors could inform clinical and parental decisions, potentially reducing associated risks.
Iceland is considering a bill that would ban male circumcision performed for non-medical reasons before an age of consent. What are the legal and ethical issues that are at stake?
Purpose of Review The purpose of this study is to survey recent arguments in favor of preserving the genital autonomy of children—female, male, and intersex—by protecting them from medically unnecessary genital cutting practices. Recent Findings Nontherapeutic female, male, and intersex genital cutting practices each fall on a wide spectrum, with far more in common than is generally understood. When looking across cultures and comparing like cases, one finds physical, psychosexual, and symbolic overlaps among the three types of cutting, suggesting that a shared ethical framework is needed. Summary All children have an interest in genital autonomy, regardless of their sex or gender.
In this chapter, we contrast legal and ethical perspectives on two forms of nontherapeutic female genital cutting: those commonly known as “female genital mutilation” and those commonly known as “female genital cosmetic surgeries.” We begin by questioning the usefulness of these categories—and the presumed distinctions upon which they rest— stressing the shared features of the two sets of practices. Taking UK legislation as a case study, we show that there are troubling inconsistencies in the way in which female genital cutting is understood in Western contexts. Specifically: (a) all nontherapeutic genital alterations to female minors are criminalised, typically with harsh penalties for transgressing the law, while even more invasive nontherapeutic genital alterations to male and intersex minors are permitted and almost entirely unregulated; and (b) genital alterations of adult women regarded as “cosmetic” in nature are treated as legal, while in some jurisdictions, anatomically identical procedures classified as “mutilation” are illegal. This chapter highlights these and other inconsistencies, speculates as to why they arise in Western contexts, and explores the scope for more consistent and constructive attitudes and legislation.
In 2012, the American Academy of Pediatrics (AAP) updated its policy on infant male circumcision, arguing that the benefits of the procedure outweigh the risks. In response, medical authorities from Europe and Canada argued that the AAP report exhibited cultural bias in favor of circumcision. In this commentary, originally published at the University of Oxford’s Practical Ethics website, I argue that the AAP is on less secure footing than it seems to think. Taking into consideration both scientific and ethical perspectives, I conclude that circumcision before an age of consent is not an appropriate health-promotion strategy.
This is a rough draft of a lecture delivered on October 1st, 2012, at the 12th Annual International Symposium on Law, Genital Autonomy, and Children’s Rights (Helsinki, Finland). It will appear in a substantially revised form—as a completed paper—at a later date. If you quote or use any part of this article, please include the following citation and notice: Earp, B. D. (forthcoming, pre-publication draft). Assessing a religious practice from secular-ethical grounds: Competing metaphysics in the circumcision debate, and a note about discursive respect. To appear in Proceedings of the 12th Annual International Symposium on Law, Genital Autonomy, and Children’s Rights, published by Springer. * Note, this is not the finished version of this document, and changes may be made before final publication.
McMath (2105) argues that while a child’s interest in future autonomy should generally be respected in relation to his own interests, the well-being of other parties may require that his autonomy be overridden in the interests of public health. At the same time, McMath seems conflicted about whether the seriousness of the threat of HIV, especially in developed countries, can in fact justify the sacrifice of individual freedom that is entailed by circumcision in infancy or early childhood (that is, the freedom to make one’s own decision about whether to undergo an elective genital surgery at an age of understanding). In this context, McMath’s discussion about the child’s interest in making decisions that reflect his mature preferences and values when he is older is compelling. But when considering arguments for paternalism in the name of public health, we suggest that McMath moves too quickly from certain empirical premises to associated policy proposals, skipping over gaps in evidence as well as important questions of value.
Critics of non-therapeutic male and female childhood genital cutting claim that such cutting is harmful. It is therefore puzzling that ‘circumcised’ women and men do not typically regard themselves as having been harmed by the cutting, notwithstanding the loss of sensitive, prima facie valuable tissue. For female genital cutting (FGC), a commonly proposed solution to this puzzle is that women who had part(s) of their vulvae removed before sexual debut ‘do not know what they are missing’ and may ‘justify’ their genitally altered state by adopting false beliefs about the benefits of FGC, while simultaneously stigmatising unmodified genitalia as unattractive or unclean. Might a similar phenomenon apply to neonatally circumcised men? In this survey of 999 US American men, we find that greater endorsement of false beliefs concerning circumcision and penile anatomy predicts greater satisfaction with being circumcised, while among genitally intact men, a trend in the opposite direction occurs: greater endorsement of false beliefs predicts less satisfaction with being genitally intact. These findings provide tentative support for the hypothesis that the lack of harm reported by many circumcised men, like the lack of harm reported by their female counterparts in societies that practice FGC, may be related to holding inaccurate beliefs concerning unaltered genitalia and the consequences of childhood genital modification.
In 2012, a German court ruled that religious circumcision of male minors constitutes criminal bodily assault. Muslim and Jewish groups responded with outrage, with some commentators pegging the ruling to Islamophobic and anti-Semitic motivations. In doing so, these commentators failed to engage with any of the legal and ethical arguments actually given by the court in its landmark decision. In this brief commentary, I argue that a firm distinction must be drawn between criticisms of religious practices that stem from irrational prejudice and bigoted attitudes and those that are grounded in sound moral reasoning. Given that ritual circumcision is a pre-Enlightenment custom that elevates the inclinations of the community over the rights of the individual, it is hardly surprising that a growing number of post-Enlightenment philosophers and legal scholars are taking an ethical stand against it. As the "circumcision debate" continues, parties on all sides of the issue must take care to reason through the relevant considerations with care and respect. [NOTE: this article appears online as "Islamophobia or fair critique?" at http://philosophypress.co.uk/?p=1182.]
Four members of the Dawoodi Bohra sect of Islam living in Detroit, Michigan have recently been indicted on charges of female genital mutilation (FGM). This is the first time the US government has prosecuted an “FGM” case since a federal law was passed in 1996. The world is watching to see how the case turns out. A lot is at stake here. Multiculturalism, religious freedom, the limits of tolerance; the scope of children’s—and minority group—rights; the credibility of scientific research; even the very concept of “harm.” To see how these pieces fit together, I need to describe the alleged crime.
Is the non-therapeutic circumcision of infant males morally permissible? The most recent major developments in this long-simmering debate were (a) the 2012 release of a policy statement and technical report on circumcision by the American Academy of Pediatrics (AAP), and (b) the decision of a German court that ritual circumcision is an unconstitutional form of bodily injury. In this editorial I address the AAP's claims as well as evaluate religious motivations more specifically. I suggest that the AAP's "health benefits" arguments are weak, and that religious circumcision is in tension with post-Enlightenment ethical and legal norms--the root of much of the current controversy. I conclude by asking how this tension might begin to be resolved.
It is sometimes argued that the non-therapeutic, non-consensual alteration of children's genitals should be discussed in two separate ethical discourses: one for girls (in which such alterations should be termed 'female genital mutilation' or FGM), and one for boys (in which such alterations should be termed 'male circumcision'). In this article, I call into question the moral and empirical basis for such a distinction, and argue that all children—whether female, male, or intersex—should be free from having parts of their genitals removed unless there is a pressing medical indication.
In January 2015, Sir James Munby, President of the Family Division, reached a landmark decision about female genital mutilation ("FGM") in the context of British law. Munby argued that the least severe forms of FGM as defined by the World Health Organization constituted "significant harms" in the eyes of the law. Since the most common forms of male circumcision are physically more invasive than the most minor forms of FGM, then, according to Munby, male circumcision must also constitute "significant harm." In order to rescue the legal distinction between these two types of non-therapeutic genital alteration carried out on minors, however, Munby appealed to (among other things) the fact that male circumcision is regarded as a "religious practice" for some groups, whereas FGM is "merely" a "cultural practice," and thus deserving of less legal protection. In this commentary, drawing on the recent work of other scholars, I argue that the supposed distinction between "religious" and "cultural" cannot be used to justify differential legal treatment of male and female forms of non-therapeutic genital alteration, nor can the supposed difference regarding "health benefits" that are sometimes attributed to male circumcision.
What are the effects of circumcision on sexual function and experience? And what does sex—in the sense related to gender—have to do with the ethics of circumcision? Jacobs and Arora (in press) give short shrift to the first of these questions; and they do not seem to have considered the second. In this commentary, I explore the relationship between sex (in both senses) and infant male circumcision, and draw some conclusions about the ongoing debate regarding this controversial practice.
The Centers for Disease Control and Prevention (CDC) have announced a set of provisional guidelines concerning male circumcision, in which they suggest that the benefits of the surgery outweigh the risks. I offer a critique of the CDC position. Among other concerns, I suggest that the CDC relies more heavily than is warranted on studies from Sub-Saharan Africa that neither translate well to North American populations nor to circumcisions performed before an age of sexual debut; that it employs an inadequate conception of risk in its benefit vs. risk analysis; that it fails to consider the anatomy and functions of the penile prepuce (i.e., the part of the penis that is removed by circumcision); that it underestimates the adverse consequences associated with circumcision by focusing on short-term surgical complications rather than long-term harms; that it portrays both the risks and benefits of circumcision in a misleading manner, thereby undermining the possibility of obtaining informed consent; that it evinces a superficial and selective analysis of the literature on sexual outcomes associated with circumcision; and that it gives less attention than is desirable to ethical issues surrounding autonomy and bodily integrity. I conclude that circumcision before an age of consent is not an appropriate health-promotion strategy.
According to Brian Morris (2013), "Science supports infant circumcision" and "so should skeptics." It would be more accurate to say that 'Brian Morris supports infant circumcision,' and that skeptics can think for themselves. In this paper, we critically assess the arguments and evidence presented by Morris in his recent article, and draw some general lessons for the ongoing debate about the science and ethics of infant male circumcision. ** Note that the online and print versions of this article have been edited for length; the present document is the original, full-length version, and should be referred to in case of any discrepancies.
In 2015, a senior British judge, Sir James Munby, stated that nontherapeutic childhood male circumcision must be a “significant harm”. His reasoning was that the law currently treats all forms of nontherapeutic cutting or alteration of female genitalia as significantly harmful, including forms that are less invasive than male circumcision (such as “pricking” of the clitoral hood). In his words, “to dispute that the more invasive procedure [i.e., male circumcision] involves the significant harm involved in the less invasive [female] procedures would seem almost irratio- nal”. Against this view, one could note that most men who were circumcised in infancy do not appear to regard themselves as “significantly harmed” by the pro- cedure, seeing it instead as “normal” in their culture or community. However, most women who have undergone even “extreme” forms of nontherapeutic female genital cutting similarly do not regard themselves as harmed, since such cutting is normative in their culture(s) viewed as a means to bodily enhancement. In the latter case, it is often argued that the typical lack of self-perceived harm may be due to a paucity of relevant information (i.e., “they do not know what they are missing”), as well as a greater likelihood of believing various myths about un- modified female genitalia (e.g., the myth that the clitoris, if not cut, will grow to the size of a penis). Might a similar explanation apply to the case of men who do not regard themselves as harmed by circumcision? In this talk, I report the results of a new empirical study exploring the association between American men’s satisfaction with being circumcised and their endorsement of false beliefs con- cerning natural penile anatomy and the effects of circumcision.
Critics of non-therapeutic genital altering procedures, such as male and female “circumcision” as well as medically unnecessary intersex “normalization” surgeries, often appeal to a child’s right to bodily integrity and to the notion of sexual harm to explain why such interventions should be seen as morally (and perhaps also legally) impermissible. While I agree that such interventions are normally impermissible, I contend that the concepts of bodily integrity and sexual harm being appealed to are often insufficiently specified to adequately ground the moral claims they are meant to justify. In this talk, I shall try to identify some of the weaknesses in current justifications of a child’s right to bodily integrity, and point the way toward a more robust defense of genital and sexual autonomy for minors.
Feldblum et al. (2015) argue that voluntary medical male circumcision (VMMC) using the ShangRing device leads to increased sexual pleasure, universally satisfying cosmetic outcome, and virtually no delayed complications in a 2-3 year follow-up study. In this commentary, I suggest that socially desirable responding (SDR) is a likely candidate explanation for at least some of these reported findings, and I argue that this should have been controlled for using available measures. I also highlight evidence from the authors' own study for risk compensation as a result of circumcision (including decreased condom use and an increase in number of sexual partners) and ask why this adverse outcome was not emphasized as a cause for concern. I conclude by providing 6 concrete suggestions for improving future studies on circumcision.
In 2012 the American Academy of Pediatrics (AAP) released a policy statement and technical report stating that the health benefits of newborn male circumcision outweigh the risks. In response, a group of mostly European doctors suggested that this conclusion may have been due to cultural bias among the AAP Task Force on Circumcision, since their conclusion differed from that of international peer organizations despite relying on a similar evidence base. In this article, we evaluate the charge of cultural bias as well as the response to it by the AAP Task Force. Along the way, we discuss ongoing disagreements about the ethical status of nontherapeutic infant male circumcision, and draw some more general lessons about the problem of cultural bias in medicine.
Moral and legal opposition to the non-therapeutic cutting of children's genitals has traditionally focused on female children. In recent years, however, a growing movement of scholars, activists, and individuals affected by childhood genital cutting have argued that all children, regardless of sex or gender, should be protected from such intimate violations. By drawing attention to the overlapping harms to which female, male, and intersex children may be exposed as a result of having their genitals cut, this movement posits a sex and gender neutral—that is, human—right to bodily integrity and genital autonomy. This article introduces and outlines some of the main arguments supporting this perspective.
Legal outcomes often depend on the adjudication of what may appear to be straightforward distinctions. In this article, we consider two such distinctions that appear in medical and family law deliberations: the distinction between religion and culture, and between therapeutic and non-therapeutic. These distinctions can impact what constitutes 'reasonable parenting' or a child's 'best interests' and thus the limitations that may be placed on parental actions. Such distinctions are often imagined to be asocial facts, there for the judge to discover. We challenge this view, however, by examining the controversial case of B and G . In this case, Sir James Munby stated that the cutting of both male and female children's genitals for non-therapeutic reasons constituted 'significant harm' for the purposes of the Children Act 1989. He went on to conclude, however, that while it can never be reasonable parenting to inflict any form of non-therapeutic genital cutting on a female child, such cutting on male children was currently tolerated. We argue that the distinctions between religion/culture and therapeutic/non-therapeutic upon which Munby LJ relied in making this judgment cannot in fact ground categorically differential legal treatment of female and male children. We analyse these distinctions from a systems theoretical perspective-specifically with reference to local paradoxes-to call into question the current legal position. Our analysis suggests that conventional distinctions drawn between religion/culture and the therapeutic/non-therapeutic in other legal contexts require much greater scrutiny than they are usually afforded.
The non-therapeutic alteration of children's genitals is typically discussed in two separate ethical discourses: one for girls, in which such alteration is conventionally referred to as "female genital mutilation" (or FGM), and one for boys, in which it is conventionally referred to as "male circumcision." The former is typically regarded as objectionable or even barbaric; the latter, benign or beneficial. In this paper, however, I call into question the moral and empirical basis for such a distinction, and I argue that it is untenable. As an alternative, I propose an ethical framework for evaluating such alterations that is based upon considerations of bodily autonomy and informed consent, rather than sex or gender.
Millard et al. state in their editorial in the SAMJ January issue that medical male circumcision (MC) in South Africa (SA) peaked in 2013, only to decline in subsequent years despite improved surgical infrastructure and ‘high-level marketing’. They attach great hope to ‘demand creation’, which they state is supported by the Bill and Melinda Gates Foundation and the Clearinghouse on Male Circumcision. ‘Demand creation is trying to sell something that many men don’t want’, they state.
Surgically modifying the genitals of children—female, male, and intersex—has drawn increased scrutiny in recent years. In Western societies, it is illegal to modify the healthy genitals of female children in any way or to any extent in the absence of a strict medical indication. By contrast, modifying the healthy genitals of male children and intersex children is currently permitted. In this journal in 2015, Stephen R. Munzer discussed a controversial German court case from 2012 (and its aftermath) that called into question the legal status of nontherapeutic male circumcision (NTC), particularly as it is carried out in infancy or early childhood. Whether NTC is legal before an age of consent depends partly upon abstract principles relating to the best interpretation of the relevant laws, and partly upon empirical and conceptual questions concerning the degree to which, and ways in which, such circumcision can reasonably be understood as a harm. In this article, we explore some of these latter questions in light of Professor Munzer’s analysis, paying special attention to the subjective, personal, and individually and culturally variable dimensions of judgments about benefit versus harm. We also highlight some of the inconsistencies in the current legal treatment of male versus female forms of nontherapeutic childhood genital alteration, and suggest that problematically gendered assumptions about the sexual body may play a role in bringing about and sustaining such inconsistencies.
In a recent editorial, Dr. Andrew L. Freedman, a member of the 2012 AAP task-force on circumcision, argues that “health issues” are only a “small piece of the puzzle” when it comes to this procedure. “Although parents may use the conflicting medical literature to buttress their own beliefs and desires,” he writes, “for the most part parents choose what they want for a wide variety of nonmedical reasons,” including “religion, culture, aesthetic preference, familial identity, and personal experience.”[1, p. e20160594] Dr. Freedman is correct that nonmedical factors may reasonably factor into a person’s decision about circumcision. But one may question his assumption that this person should be someone other than the individual who would be affected by the surgery were it to take place.
A recent study (Bossio, Pukall, & Steele, 2016) reported that neonatal circumcision is not associated with changes in adult penile sensitivity, leading to viral coverage in both traditional and online media. In this commentary the author questions the conclusions drawn from the study and explores the relationship between objective assessments of penile sensitivity and subjective sexual experience and satisfaction. The author concludes with suggestions for improving future research.
The spectrum of practices termed “Female Genital Mutilation” (or FGM) by the World Health Organization is sometimes held up as a counterexample to moral relativism. Those who advance this line of thought suggest the practices are so harmful in terms of their physical and emotional consequences, as well as so problematic in terms of their sexist or oppressive implications, that they provide sufficient, rational grounds for the assertion of a universal moral claim—namely, that all forms of FGM are wrong, regardless of the cultural context. However, others point to cultural bias and moral double standards on the part of those who espouse this argument, and have begun to question the received interpretation of the relevant empirical data concerning FGM as well. In this article I assess the merits of these competing perspectives. I argue that each of them involves valid moral concerns that should be taken seriously in order to move the discussion forward. In doing so, I draw on the biomedical “enhancement” literature in order to develop a novel ethical framework for evaluating FGM (and related interventions—such as female genital “cosmetic” surgery and non-therapeutic male circumcision) that takes into account the genuine harms that are at stake in these procedures, but which does not suffer from being based on cultural or moral double standards.
What are the similarities and differences between male and female forms of non-therapeutic genital cutting practices?