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What Is the Best Age to Circumcise? A Medical and Ethical Analysis

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Abstract

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.
What is the best age to circumcise?
A medical and ethical analysis
by Alex Myers and Brian D. Earp
Abstract
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.
Key words: circumcision, benefits, risks, autonomy, consent, gender
This is the authors’ copy of an accepted
paper, now published. Please cite as:
Myers, A., & Earp, B. D. (2020). What is
the best age to circumcise? A medical and
ethical analysis. Bioethics, 34(7), 645-663.
doi: 10.1111/bioe.12714
2
1. Introduction
Over recent decades, two major trends have emerged in the academic literature concerning penile
circumcision (partial or total removal of the penile prepuce). On the one hand, findings from three
randomized controlled trials (RCTs) conducted in Africa in the 2000s
1
have been taken to show
that clinical circumcision of adult males can reduce their risk of contracting HIV through penile-
vaginal intercourse, at least in settings with a high prevalence of heterosexual HIV transmission
and a low prevalence of such circumcision. Although the quality of the evidence from these trials
has been called into question,
2
with additional concerns raised about the decision pathways by
which this evidence was rushed into policy,
3
and reports of an apparent lack of real-world
effectiveness at the population level now beginning to emerge,
4
a heavily-funded campaign to
1
Auvert, B., Taljaard, D., Lagarde, E., et al. (2005). Randomized, controlled intervention trial of male circumcision
for reduction of HIV infection risk: the ANRS 1265 Trial. PLoS Med, 2(11), e298; Bailey, R. C., Moses, S., Parker,
C. B., et al. (2007). Male circumcision for HIV prevention in young men in Kisumu, Kenya: a randomised
controlled trial. Lancet, 369(9562), 643656; Gray, R.H., Kigozi, G., Serwadda, D., et al. (2007). Male
circumcision for HIV prevention in men in Rakai, Uganda: a randomised trial. Lancet, 369(9562), 657666. A
fourth trial looking at male to female transmission of HIV as a consequence of penile circumcision was stopped
early due to “futility” with female partners of circumcised men becoming infected with HIV at a higher rate than
female partners of genitally intact men; see Wawer, M. J., Makumbi, K., Kigozi, G., et al. (2009). Circumcision in
HIV-infected men and its effect on HIV transmission to female partners in Rakai, Uganda: a randomised controlled
trial. Lancet, 374(9685): 229-237.
2
Van Howe, R. S., & Boyle, G. (2018). Meta-analysis of HIV acquisition studies incomplete and unstable. BJUI
International, e-letter. Available at http://www.bjuinternational.com/letters/meta-analysis-circumcision-
incomplete-unstable/ (accessed November 3, 2019); Boyle, G. J., & Hill, G. (2011). Sub-Saharan African
randomised clinical trials into male circumcision and HIV transmission: methodological, ethical and legal
concerns. Journal of Law and Medicine, 19(2), 316334; Van Howe, R. S., & Storms, M. R. (2011). How the
circumcision solution in Africa will increase HIV infections. Journal of Public Health in Africa, 2(1), 1115;
Garenne, M., Giami, A., & Perrey, C. (2013). Male circumcision and HIV control in Africa: questioning scientific
evidence and the decision-making process. In T. Giles-Vernik & J. Webb (Eds.), Global health in Africa: historical
perspectives on disease control (pp. 185-210). Athens: Ohio University Press. For a contrary view, see, e.g.,
Wamai, R. G. et al. (2012) “Criticisms of African trials fail to withstand scrutiny: male circumcision does prevent
HIV infection,” Journal of Law and Medicine 20(1), 93123.
3
Dowsett, G. W., & Couch, M. (2007). “Male circumcision and HIV prevention: is there really enough of the right
kind of evidence?” Reproductive Health Matters, 15(29): 3344; Bell, K. (2015). HIV prevention: making male
circumcision the ‘right’ tool for the job. Global Public Health, 10(56): 552572; de Camargo, K. R. Jr., de
Oliveira Mondonça, A. L., Perrey, C., & Giami, A. (2013). Male circumcision and HIV: a controversy study on
‘facts’ and ‘values. Global Public Health, 8(7), 769783; de Camargo, K. R., Jr., de Oliveira Mondonça, A. L.,
Perrey, C., & Giami, A. (2015). Making the circumcision controversy controversial: going meta and taking aim at
the messenger(s): reply to Wamai et al. Global Public Health, 10(56), 667671. The dominant policy paradigm
appears to have been driven by a relatively small network of actors with influence at the WHO among other
organizations; see Giami A., Perrey, C., de Oliveria Mendonça, A.L., & de Camargo, K. R. (2015). Hybrid forum
or network? The social and political construction of an international ‘technical consultation’: male circumcision
and HIV prevention. Global Public Health, 10(56), 589606.
4
Or even higher rates of infection among some medically circumcised males: Rosenberg, M. S., Gómez-Olivé, F.
X., Rohr, J. K., Kahn, K., & Bärnighausen, T. W. (2018). Are circumcised men safer sex partners? Findings from
the HAALSI cohort in rural South Africa. PloS one, 13(8), e0201445. See also Garenne, M., & Matthews, A.
(2019). Voluntary medical male circumcision and HIV in Zambia: expectations and observations. Journal of
3
“scale up” mass circumcision of African boys and men as a public health measure is currently
underway.
5
On the other hand, human rights scholars have increasingly objected to the medically
unnecessary genital cutting of any person—whether female, male, or intersex—who either does
not or cannot consent to the cutting. Such objections were recently summarized in an international
consensus statement published in the American Journal of Bioethics, in which the authors argued
that 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 impermissible unless the person
is non-autonomous (incapable of consent) and the cutting is medically necessary” (see Box 1) and
thus “cannot reasonably be deferred.”
6
Biosocial Science, online ahead of print at https://doi.org/10.1017/S0021932019000634. However, see Davis, S.,
Toledo, C., Lewis, L., Maughan-Brown, B., Ayalew, K., & Kharsany, A. B. (2019). Does voluntary medical male
circumcision protect against sexually transmitted infections among men and women in real-world scale-up
settings? Findings of a household survey in KwaZulu-Natal, South Africa. BMJ Global Health, 4(3), e001389. For
preliminary evidence of risk-compensation or behavioral disinhibition as a potential mechanism for increased STI
acquisition in some populations over the long termbased on biomarkers and a randomized designsee Kim, H.
B., Pop-Eleches, C., Jung, J., & Kim, B. (2018). Male circumcision, peer effects and risk compensation. Presented
to the Association of Public Policy Analysis and Management, November 10, 2018. Available at
http://barrett.dyson.cornell.edu/NEUDC/paper_226.pdf (accessed November 3, 2019).
5
Hankins, C., Forsythe, S., & Njeuhmeli, E. (2011). Voluntary medical male circumcision: an introduction to the
cost, impact, and challenges of accelerated scaling up. PLoS Med, 8(11): e1001127; Torres-Rueda, S., Wambura,
M., Weiss, H., et al. (2018). Cost and cost-effectiveness of a demand creation intervention to increase uptake of
voluntary medical male circumcision in Tanzania: spending more to spend less. JAIDS: Journal of Acquired
Immune Deficiency Syndromes, 78(3), 291-299. Originally termed “Voluntary Medical Male Circumcision”
(VMMC) with the aim of recruiting men to be circumcised voluntarily, the scale-up now appears to be targeting
younger and younger males, including until recently infants by way of their mothers, who are presumably much
less capable (or incapable) of refusing the procedure. See, for example, Sgaier, S. K., Sharma, S., Eletskaya, M., et
al. (2017). Attitudes and decision-making about early-infant versus early-adolescent male circumcision: demand-
side insights for sustainable HIV prevention strategies in Zambia and Zimbabwe. PLoS ONE, 12(7), e0181411;
Sidler, D., Earp, B. D., van Niekerk, A. A., Moodley, K., & Kling, S. (2017). Targeting mothers and selling men
what they do not want: a response to ‘missed opportunities for circumcision of boys.’ South African Medical
Journal, 107(4), 281. There are now disturbing indications that many thousands of young boys have been forcibly
circumcised without parental knowledge or consent as a part of this scale-up: Luseno, W. K., Field, S. H., Iritani,
B. J., et al. (2019). Consent challenges and psychosocial distress in the scale-up of Voluntary Medical Male
Circumcision among adolescents in Western Kenya. AIDS and Behavior, online ahead of print at
https://link.springer.com/article/10.1007/s10461-019-02620-7. Further problems include “potentially misleading or
questionable mobilization practices (including possibly undue inducements), problematic uses of social pressure,
and circumcision of children under age ten.” Gilbertson et al. (2019). Voluntary medical male circumcision for
HIV prevention among adolescents in Kenya: unintended consequences of pursuing service delivery targets. PLOS
ONE, 14(11): e0224548. See also the 2019 report of the VMMC Experience Project, an African-led NGO, alleging
widespread human rights abuses associated with the campaign, as submitted to the United Nations Committee on
the Rights of the Child: https://www.vmmcproject.org/un-report/ (accessed November 3, 2019).
6
The Brussels Collaboration on Bodily Integrity (BCBI). (2019). Medically unnecessary genital cutting and the
rights of the child: moving toward consensus. American Journal of Bioethics, 19(10), 17-28. The authors clarify
that the scope of their argument for purposes of the statement is the so-called Western medicolegal context,
especially countries with a strong tradition of individual rights. For arguments and evidence in support of the main
thesis of the “Brussels” statement that go into greater depth, see Lightfoot-Klein, H., Chase, C., Hammond, T., &
Goldman, R. (2000). Genital surgeries on children below an age of consent. In L. T. Szuchman & F. Muscarella
(Eds.), in Psychological perspectives on human sexuality (pp. 440-479). New York: John Wiley & Sons; Svoboda,
4
Building on this perspective, we argue that the best age to circumcise, considering both
empirical/medical and normative/ethical factors, is no earlier than an appropriate age of consent
(depending on the jurisdiction, the age of consent to sexual relations, for instance, is usually
between 14 and 18).
7
At that age, the individual’s own informed consent can at least potentially
be obtained, and indeed must be obtained for the circumcision to be morally permissible.
8
Our proposal is motivated in part by a concern for children’s sexual self-determination. In
modern Western societies, children of all sexes and genders are taught from an early age that
adults should not touch—let alone cut or remove healthy tissue from—their so-called “private
parts” before they are sexually autonomous. The only widely recognized exceptions to this rule
concern (1) the youngest of children, insofar as they are not yet able to wash themselves
adequately and need help with this from a designated caretaker and (2) required medical
examinations or procedures. The emphasis here is on “required.” Under ordinary conditions, if a
doctor or other healthcare provider handles a child’s genitals beyond what is “strictly necessary
for diagnosis or treatment,” this is immediately understood to cross an ethical line. Moreover, if
the child-patient happens to be unconscious or otherwise does not remember the medically
unnecessary genital interference, this does not normally make the action morally permissible.
9
J. S. (2013). Promoting genital autonomy by exploring commonalities between male, female, intersex, and
cosmetic female genital cutting. Global Discourse, 3(2), 237255; Townsend, K. G. (2019). The child’s right to
genital integrity. Philosophy & Social Criticism, online ahead of print at
https://doi.org/10.1177/0191453719854212; Kehrer, I. (2019). Cuts into children’s future: a comparative analysis
between FGM, male circumcision and intersex genital surgeries. Peace Human Rights Governance, 3(3), 333-363.
See also Earp, B. D., & Steinfeld, R. (2017). Gender and genital cutting: a new paradigm. In T. G. Barbat (Ed.),
Gifted women, fragile men. Euromind Monographs 2. Brussels: ALDE Group-EU Parliament; Earp, B. D., &
Steinfeld, R. (2018). Genital autonomy and sexual well-being. Current Sexual Health Reports, 10, 7–17.
7
See https://www.ageofconsent.net/world (accessed November 3, 2019). Please note that although most
jurisdictions have a set age at which capacity to consent to sexual relations is presumed for legal purposes, the
moral capacity to provide valid consent (whether to sex or other activities) in adolescence develops variably and
individually. Some adolescents who have reached the age at which they can legally consent to sex, for example,
might nevertheless not be Gillick competent for purposes of deciding about certain medical procedures (and vice
versa). On Gillick competence, see Larcher, V., & Hutchinson, A. (2010). How should paediatricians assess Gillick
competence? Archives of Disease in Childhood, 95(4), 307-311.
8
For an overview of debates concerning the capacity of legal minors to consent to certain medical treatments see
for example Alderson, P. (2007). Competent children? Minors’ consent to health care treatment and
research. Social Science & Medicine, 65(11), 2272-2283. Note, however, that medically unnecessary circumcision
does not normally constitute treatment (on most common understandings of that term).
9
Quoting and paraphrasing from BCBI, “Medically unnecessary genital cutting,” op cit. note 6. For related
arguments, see Myers, A. (2015). Neonatal male circumcision, if not already commonplace, would be plainly
unacceptable by modern ethical standards. The American Journal of Bioethics, 15(2): 5455.
5
Box 1. Medically necessary versus medically beneficial
10
According to the Brussels Collaboration on Bodily Integrity (BCBI), an intervention to alter a
bodily state is medically necessary when (1) the bodily state poses a serious, time-sensitive threat
to the person’s well-being, typically due to a functional impairment in an associated somatic
process, and (2) the intervention, as performed without delay, is the least harmful feasible means
of changing the bodily state to one that alleviates the threat. Medically necessary” is therefore
different from “medically beneficial,” a weaker standard, which requires only that the expected
health-related benefits outweigh the expected health-related harms.
11
The BCBI states that although
the weaker, “medically beneficial” standard may well be appropriate for certain interventions into
the body, it is not appropriate for cutting or removing healthy tissue from the genitals of a non-
consenting person (given, among other things, the special significance of the body part in question).
An opposing view has been advanced by those who advocate for non-voluntary neonatal
male circumcision (NNMC).
12
According to these advocates (Box 2), penile circumcisions
performed in infancy (roughly, the first year of life) and especially in the neonatal period (roughly,
the first month of life) are relevantly different from circumcisions performed later in life.
Specifically, they claim that penile circumcision is technically simpler, safer, and more cost
effective when it is performed on an infant or neonate as opposed to an adolescent or adult, and
that the accumulated health benefits are also greater.
13
Thus, to delay penile circumcision until it
10
This Box is adapted from Box 1 of BCBI, op cit. note 6. Internal references omitted. The definition of medical
necessity is based on Earp, B. D. (2019). The child’s right to bodily integrity. In D. Edmonds (Ed.), Ethics and the
contemporary world (pp. 217-235). Abingdon and New York: Routledge.
11
The BCBI notes that benefit/harm comparisons are often contested as they depend on “the specific weights
assigned to the possible outcomes of the intervention, given among other things a) the subjective value to the
individual of the body parts that may be affected, (b) the individual’s tolerance for different kinds or degrees of risk
to which those body parts may be exposed, and (c) any preferences the individual may have for alternative (e.g.,
less risky or invasive) means of pursuing the intended health-related benefits.” BCBI, op cit. note 6, p. 18. For in-
depth discussions of the contested nature of benefit/harm ratios concerning male circumcision in particular,
emphasizing that evaluations of the primary literature may be shaped by cultural bias or other potentially distorting
factors, see Darby, R. (2015). Risks, benefits, complications and harms: neglected factors in the current debate on
non-therapeutic circumcision. Kennedy Institute of Ethics Journal, 25(1), 1–34; Earp, B. D., & Shaw, D. M.
(2017). Cultural bias in American medicine: the case of infant male circumcision. Journal of Pediatric Ethics 1(1),
8–26; Frisch, M., Aigrain, Y., Barauskas, Y., et al. (2013). Cultural bias in the AAP’s 2012 technical report and
policy statement on male circumcision. Pediatrics, 131(4), 796800. See also Van Howe, R. S. (2018). Response to
Vogelstein: How the 2012 AAP Task Force on circumcision went wrong. Bioethics, 32(1), 77-80; and Svoboda, J.
S., & Van Howe, R. S. (2013). Out of step: fatal flaws in the latest AAP policy report on neonatal circumcision.
Journal of Medical Ethics, 39(7), 434-441 (replies and counter-replies are available at the journal website).
12
In keeping with a familiar distinction in bioethics, we use the term “non-voluntary,” which concerns a moral
patient unable to express their will in relation to a given procedure, rather than “involuntary” which implies a moral
agent able to express their will who refuses the procedure.
13
See for instance Dickson, K. E., Samuelson, J., Ashengo, T. A., Chrouser, K., Curran, K., Otolorin, E.,
Caldamone, A., & Tomlinson, D. (2010). Manual for early infant male circumcision under local anesthesia. World
Health Organization and Jhpeigo. Geneva: WHO Press. According to the Los Angeles Times, one of the main
6
could be undertaken voluntarily, they claim, is to increase the associated risks and costs (both
medical and monetary), as well as to reduce the associated benefits, assuming the procedure will
be performed either way. Whether this latter assumption is an appropriate one will be discussed
later. Nevertheless, for at least some advocates of NNMC, such financial and health-related
considerations are so compelling that they may override the default moral presumption against
medically unnecessary interference with a child’s genitals—not only by touching in this case, but
indeed by cutting into and irreversibly excising healthy and functional tissue.
14
Against this moral presumption, it is often noted that pre-autonomous children are not yet
capable of consenting to any surgical procedure, medically necessary or otherwise. Hence, it is
claimed, the child’s parents must decide about such matters. It is true that parents are normally
(and appropriately) entrusted with many decisions surrounding the care and upbringing of their
children. But in contemporary Western societies, at least, parents are not permitted to authorize
simply whatever encroachments into their child’s bodily integrity they may choose. Rather, there
are clear moral and legal limitations. For example, in addition to encroachments involving genital
contact of any kind, those that involve cutting into the skin, acute tissue damage, or permanent
modification of the external physical features of a child, must normally clear a very high bar to
be considered ethically acceptable. In fact, some encroachments, such as child facial scarification,
foot binding, and medically unnecessary female genital cutting—including “symbolic” forms that
are less invasive than penile circumcision—are categorically forbidden in such societies.
15
Even
authors of this manual, David Tomlinson, was then serving as “the World Health Organization’s chief circumcision
expert.” Hennessy-Fiske, M. (2011, September 2). Injuries linked to circumcision clamps. Los Angeles Times.
Available at https://www.latimes.com/health/la-xpm-2011-sep-26-la-he-circumcision-20110926-story.html
(accessed November 3, 2019). Prior to consulting for the WHO, it appears that Tomlinson had filed for a patent for
a newborn circumcision clamp, claimed to be preferable to those most widely in use:
https://patents.justia.com/patent/20080004631 (accessed November 3, 2019). Notably, Tomlinson’s clamp is touted
in the WHO manual for potential mass adoption in Africa “for the purposes of HIV prevention,” despite no
empirical evidence that newborn circumcision specifically has a protective effect against HIV. Instead, the manual
repeatedly conflates adult and newborn circumcision, citing evidence drawn from studies of the former to justify
claims about the latter. A similar conflation problem can be found in Morris, B. J. et al. (2012). A ‘snip’ in time:
What is the best age to circumcise? BMC Pediatrics, 12(20), 1-15. It should be noted that these authors appear to
assume that the circumcision will be performed at some point or another. However, if an adult decides stay
genitally intact, as most do when given the opportunity, the hypothetical circumcision will be even “simpler, safer
and more cost-effective” because it will not occur.
14
That is, the penile prepuce. Cold, C. J., & Taylor, J. R. (1999). The prepuce. BJU International, 83(S1), 3444.
15
One such “symbolic” form is so-called ritual nicking of the clitoral hood/foreskin, which does not remove tissue
and often leaves no visible mark on the vulva. According to a recent ruling from Australia’s highest court, for legal
purposes, (1) the clitoral foreskin is part of the clitoris, and (2) any medically unnecessary cutting of this tissue, no
matter how slight, constitutes illegal mutilation, irrespective of whether there is any lasting damage or functional
impairment. Australian Associated Press. (2019, October 16). High Court upholds NSW genital mutilation
convictions. Sydney Morning Herald. Available at https://www.smh.com.au/national/nsw/high-court-upholds-nsw-
genital-mutilation-convictions-20191016-p53197.html (accessed November 3, 2019). For further discussion of
ritual nicking and different Western legal standards for male versus female genital cutting, see Davis, D. S. (2001).
7
slapping or spanking a child for their own supposed good (i.e., as a means of discipline) is banned
in more than 50 countries.
16
When a child faces a medical emergency such that a bodily encroachment cannot be
delayed without significantly increasing the risk of death or disability, this creates a special
situation. In such an emergency situation, the permission of the child’s parents or other
appropriate caregiver must be relied upon as the closest available proxy for the child’s consent,
assuming the child is not yet in a position to consent on their own behalf.
17
By contrast, when
there is no disease or deformity present for which immediate medical intervention is required, it
is normally understood that the permission for a surgery must come from the individual whose
body will be altered and/or exposed to the associated risk. As Hutson argues:
The most fundamental principle of surgery is that no operation should be done if there is no disease, as it
cannot be justified if the risk of the procedure is not balanced by the risk of a disease. Even when patients
have significant disease, potentially dangerous operations can hardly be justified if their risks are much
greater than the disease itself. The problem for routine circumcision is that since there is no disease, no
complication whatsoever can be tolerated, since the risks of the procedure are not being balanced against
the risks of any present disease.
18
Against this view, NNMC advocates (Box 2) argue that future diseases must also be
considered; that is, potential future diseases to which the individual might be exposed, depending
largely on their own choices, and for which there are both less risky and more effective modes of
prevention that do not involve genital cutting. We address this argument in the present paper. In
doing so, we carefully examine some of the main empirical and conceptual claims put forward by
advocates of NNMC. We argue, first, drawing on recent evidence, that the strictly medical case
for NNMC is not as compelling as its advocates maintain. But going beyond this, we suggest that
the narrow parameters of a medical cost-benefit analysis are insufficient to draw meaningful
moral conclusions about the acceptability of NNMC.
19
Instead, what is required is more
Male and female genital alteration: a collision course with the law. Health Matrix, 11(1), 487570; Davis, D. S.
(2003). Cultural bias in responses to male and female genital surgeries. The American Journal of Bioethics, 3(2),
W15-W16; Earp, B. D., Hendry, J., & Thomson, M. (2017). Reason and paradox in medical and family law:
shaping children's bodies. Medical Law Review, 25(4), 604-627; and Earp, B. D. (2020). Protecting children from
medically unnecessary genital cutting without stigmatizing women’s bodies: implications for sexual pleasure and
pain. Archives of Sexual Behavior, available online ahead of print at https://doi.org/10.1007/s10508-020-01633-x.
16
Cole, D. (2019, September 3). Whatever happened to the campaign to banspanking? NPR. Available at
https://www.npr.org/sections/goatsandsoda/2019/09/03/755136377/whatever-happened-to-the-campaign-to-ban-
spanking (accessed November 3, 2019).
17
See Alderson, op cit. note 8.
18
Hutson, J. M. (2004). Circumcision: a surgeon’s perspective. Journal of Medical Ethics, 30(3), 238240.
19
See also Darby, op cit. note 11.
8
thoroughgoing engagement with the particular ethical issues posed by medically unnecessary
genital cutting of minor children.
Box 2. Who advocates for non-voluntary neonatal male circumcision (NNMC)?
Throughout this article, we refer to the arguments of NNMC advocates, who have been described as
falling into two main camps: (1) strong advocates, who argue that the health benefits of NNMC are so
great and the risks so trivial that boys should be “circumcised as a matter of routine, or even that the
operation should be compulsory,” and (2) weak advocates, who believe that “while the benefits
outweigh the risks they are not so great that doctors should recommend the operation, but great enough
to authorize parental discretion.”
20
The “strong” position is associated primarily with a grouping
around Brian J. Morris, a former professor of molecular medical sciences at the University of Sydney
and a driving force behind the Circumcision Academy of Australia (CAA), a network of circumcision
proponents and financially-interested providers.
21
The “weak” position is associated primarily with
certain actors within the US medical establishment, including, most notably, the eight-member Task
Force behind the now-expired 2012 circumcision policy statement of the American Academy of
Pediatrics (AAP).
22
Rejecting both positionsthat is, failing to conclude that the benefits of NNMC
outweigh the risks, or reaching the opposite conclusion, that the risks outweigh the benefitsare most
child health authorities outside the United States, including all comparable national-level medical
bodies to have issued formal statements on NNMC (see later discussion).
20
These quotes are from Darby, op cit. note 11, pp. 1-2, summarizing the position of NNMC advocates. Some of
the material in this Box is lightly adapted from Darby’s discussion.
21
See https://www.circumcisionaustralia.org (accessed November 3, 2019). The CAA lobbies for government
health insurance coverage for medically unnecessary newborn circumcisions; billing for such circumcisions
appears to be a primary source of income for several CAA board members, including some whose private practices
are centered around offering the procedure. For details, see Frisch, M., & Earp, B. D. (2018). Circumcision of male
infants and children as a public health measure in developed countries: a critical assessment of recent evidence.
Global Public Health, 13(5), 626641, especially note 4.
22
AAP Task Force on Circumcision. (2012). Circumcision policy statement. Pediatrics, 130(3), 585-586. Although
the AAP policy formally expired in 2017, an anonymous working group at the US Centers for Disease Control and
Prevention (CDC) subsequently released a similar policy, in 2018, which remains online:
https://www.cdc.gov/hiv/risk/male-circumcision.html (accessed November 3, 2019). This release came in the face
of extensive criticism from international medical authorities and at least one invited peer reviewer, many of whose
substantive objections to an earlier draft of the CDC policy were effectively ignored during the process of revision.
See Kupferschmid, C., et al. (2015). Commentary on the CDC "Recommendations for providers counseling male
patients and parents regarding male circumcision and the prevention of HIV infection, STIs, and other health
outcomes.” CDC Public Submission. Available at https://www.regulations.gov/document?D=CDC-2014-0012-
2455 (accessed November 3, 2019); and Van Howe, R. S. (2015). A CDC-requested, evidence-based critique of the
Centers for Disease Control and Prevention 2014 draft on male circumcision: How ideology and selective science
lead to superficial, culturally-biased recommendations by the CDC. CDC Peer Review Report. DOI:
10.13140/2.1.1148.4964. For additional articulations of the “weak” position on NNMC as described above, see
Benatar, M., & Benatar, D. (2003). Between prophylaxis and child abuse: the ethics of neonatal male circumcision.
American Journal of Bioethics, 3(2), 35-48; Mazor, J. (2013). The child’s interests and the case for the
permissibility of male infant circumcision. Journal of Medical Ethics, 39(7), 421428; and Jacobs, A. J., & Arora,
K. S. (2015). Ritual male infant circumcision and human rights. The American Journal of Bioethics, 15(2), 30-39.
9
In the end, we argue that children’s interest in future bodily autonomy, especially over those
parts of the body that have special psychosexual significance—such as the penis, vulva, or
breasts—is sufficiently weighty to render NNMC morally impermissible in most cases.
23
Even
taking health considerations into account, that is, we find that the best age to circumcise is the age
at which the individual is developmentally capable of providing informed consent to the
permanent alteration of their own genitals.
As a final note, we will be using gender-neutral language (as in the previous sentence) as far
as possible in this paper while staying true to particular empirical findings. This is because we
recognize that some people with penises may not identify as boys or men, such as trans women
or some genderqueer individuals.
24
In fact, the potential harms of neonatal or early-childhood
circumcision for trans women who elect a penile inversion surgery—as a part of gender-affirming
care, for example—has yet to receive much attention.
25
However, the preemptive removal of a
large proportion of sensitive, elastic genital tissue from the penis that could otherwise have been
used in the construction of a neovagina—i.e., the penile foreskin—is undoubtedly of relevance to
the welfare interests of such women.
26
2. Empirical issues
A. Benefits
Let us begin by looking at the issue of health benefits, a number of which have been claimed to
follow from penile circumcision, although their likelihood, magnitude, and causal relationship to
23
See the discussion by Munzer, who refers to the physical and symbolic “salience” of the genitals as a relevant
moral consideration. Munzer, S. R. (2018). Examining nontherapeutic circumcision. Health Matrix, 28(1), 1-78.
24
See, e.g., Dembroff, R. (2019). Beyond binary: genderqueer as critical gender kind. Philosopher's Imprint, online
ahead of print at http://philsci-archive.pitt.edu/16317/; Vogler, S. (2019). Determining transgender: adjudicating
gender identity in US asylum law. Gender & Society, 33(3), 439-462.
25
As the authors of a recent review state: “The inner layer of the foreskin, the neurovascular bundle, and the glans
are used as a pedicled island flap. This flap is used to construct the inner part of the labia minora, the neoclitoris,
and its prepuce.” They note that in cases where “more tissue might be required (e.g., because of circumcision or a
small penis), further full-thickness skin grafts (e.g., from the proximal medial thigh)” will likely have to be
transplanted. Papadopulos, N. A., Lellé, J. D., Zavlin, D., Herschbach, P., Henrich, G., Kovacs, L., ... & Schaff, J.
(2017). Quality of life and patient satisfaction following male-to-female sex reassignment surgery. The Journal of
Sexual Medicine, 14(5), 721-730.
26
For an intriguing discussion of certain tensions in this area, see Levy, I. (2017, June 23). Transgender and
Jewish. Tablet Magazine. Available at https://www.tabletmag.com/jewish-life-and-religion/237080/transgender-
and-jewish (accessed November 3, 2019).
10
NNMC in particular remain in dispute.
27
This dispute can be illustrated by comparing the
disparate conclusions of otherwise similar medical bodies that have assessed the vast and often
contradictory body of evidence on penile circumcision.
Consider first the position of the American Academy of Pediatrics (AAP). In 2012, an
eight-member AAP Task Force
28
asserted that the health benefits of NNMC outweigh the risk of
surgical complications—albeit not to such an extent that the procedure could be recommended
on medical grounds alone.
29
However, no recognized procedure for assigning weights, whether
to benefits or risks, was used by the Task Force, so the basis for its conclusion was unclear. In a
subsequent publication, Task Force members clarified that the benefits of NNMC were only “felt
to outweigh the risks,” and urged readers to “draw their own conclusions.”
30
(Testifying at a
government hearing on behalf of Germany’s pediatric associations in late 2012, Dr. Wolfram
Hartmann reported that the AAP statement has been graded by almost all other pediatric societies
and associations worldwide as being scientifically untenable.”)
31
In 2015, the Canadian Paediatric Society weighed in, concluding that the medical benefits
and risks of NNMC were “closely balanced,”
32
while the Royal Dutch Medical Association
27
For a discussion of some of the controversy, see Jansen, M. (2016). Routine circumcision of infant boys: It's time
to make progress through the common ground. Journal of Paediatrics & Child Health, 52(5), 477-479.
28
It is concerning that there appears to have been financial, religious, and political conflicts of interest among the
AAP Task Force members, though none were disclosed in the original statement. Task Force member Waldemar
Carlo is a director of Mednax, the publicly-traded medical services company; although he failed to declare this
financial conflict of interest in the original AAP policy statement, it was added to an AAP response to international
critics: AAP Task Force on Circumcision (2013). Cultural bias and circumcision: the AAP Task Force on
Circumcision responds. Pediatrics, 131(4), 801-804. Task Force member Andrew Freedman stated in an interview,
“I circumcised [my son] myself on my parents’ kitchen table on the eighth day of his life. But I did it for religious,
not medical reasons. I did it because I had 3,000 years of ancestors looking over my shoulder.” Merwin, T. (2012,
September 19). Fleshing out change on circumcision. Jewish Week. Available at
https://jewishweek.timesofisrael.com/fleshing-out-change-on-circumcision/ (accessed November 3, 2019). In a
subsequent editorial, Freedman stated that “protecting” this parental option to circumcise “was not an idle concern”
for the AAP Task Force members “at a time when there are serious efforts in both the United States and Europe to
ban the procedure outright.” Freedman, A. (2016). The circumcision debate: beyond benefits and risks. Pediatrics,
137 (5), e20160594. For extensive discussion of these matters, including analysis of the AAP response to its mostly
European critics, see Earp & Shaw, op cit. note 11.
29
AAP Task Force on Circumcision. (2012). Male circumcision. Pediatrics, 130(3), e756785. For extensive
critiques of the AAP analysis and further context, see note 11. See also Earp, B. D. (2015). Do the benefits of male
circumcision outweigh the risks? A critique of the proposed CDC guidelines. Frontiers in Pediatrics, 3(18), 1–6.
30
AAP Task Force on Circumcision. (2013). The AAP Task Force on Neonatal Circumcision: a call for respectful
dialogue. Journal of Medical Ethics, 39(7), 442-443, 442.
31
Hartmann, W. (2012). Expert Statement: Dr med. Wolfram Hartmann, President of Berufsverband der Kinder-
und Jugendärzte, “for the hearing on the 26th of November 2012 concerning the drafting of a federal government
bill.” Cologne, Germany: Berufsverband der Kinder- und Jugendärzte (BVKJ. e.V.). Available at http://www.rz-
etelsen.net/Hartmann%20-%20German%20Statement.pdf (accessed November 3, 2019).
32
Canadian Paediatric Society. (2015). Newborn male circumcision. Paediatrics & Child Health, 20(6), 311320.
For further discussion, see Earp, B.D. (2015). Letter to the editor: strengths and weaknesses in the 2015 Canadian
Paediatric Society statement regarding newborn male circumcision. Paediatrics & Child Health, 20(8), 433;
Morris, B. J., Klausner, J. D., Krieger, J. N., Willcox, B. J., Crouse, P.D., & Pollock, N. (2016). Canadian
11
maintained that there “is no convincing evidence that [NNMC] is useful or necessary in terms of
prevention or hygiene.”
33
Meanwhile, the Royal Australasian College of Physicians, upon
revisiting its 2010 policy in light of the AAP statement, affirmed that “the frequency of diseases
modifiable by circumcision, the level of protection offered by circumcision and the complication
rates of circumcision do not warrant routine infant circumcision in Australia and New Zealand.”
34
Finally, the Danish Medical Association declared in 2016 that NNMC is “ethically unacceptable”
on account of the known surgical risks, the lack of sufficient evidence of a “clear health benefit,”
and the permanency of the anatomical change.
35
What these various positions suggest is that insofar as NNMC does confer some kind or
degree of health-related benefit, it is far from clear that this benefit offsets even the strictly health-
related risks, let alone in a decisive manner. Thus, even the AAP, whose policy among
comparable organizations is the most favorable toward circumcision, does not actually
recommend NNMC on grounds of health. But even if there were universal agreement among
qualified medical authorities that the net health benefits of circumcision were as impressive as its
strongest advocates claim (see Box 2),
36
this would not entail that NNMC—specifically—was
medically, much less all-things-considered morally, justified.
This is because the strongest evidence of health benefit is derived from studies of adult,
not newborn, circumcision; and this evidence primarily concerns risks pertaining to sexually
Pediatrics Society position statement on newborn circumcision: a risk-benefit analysis revisited. The Canadian
Journal of Urology, 23(5), 84958502; Robinson, J. L., Ann Jefferies, A., & Lacaze, T. (2017). Letter to the editor
Re: Canadian Pediatrics Society position statement on newborn circumcision: a risk-benefit analysis revisited.
The Canadian Journal of Urology, 24(1), 86848687.
33
The Royal Dutch Medical Association. (2010). Nontherapeutic circumcision of male minors. KNMG, 1–17.
Available at https://www.knmg.nl/circumcision/ (accessed November 3, 2019).
34
Royal Australasian College of Physicians, Paediatrics & Child Health Division. (2010). Circumcision of infant
males. RACP. Available at https://www.racp.edu.au/docs/default-source/advocacy-library/circumcision-of-infant-
males.pdf (accessed November 3, 2019); see also Pringle, K. (2014, April 4). Circumcision health risks and
benefits - experts respond. Science Media Center. Available at
http://www.sciencemediacentre.co.nz/2014/04/04/circumcision-health-risks-and-benefits-experts-respond/
(accessed November 3, 2019).
35
Danish Medical Association. (2016). Lægeforeningens politik vedrørende omskæring af drengebørn uden
medicinsk indication. Available at https://www.laeger.dk/laegeforeningens-politik-vedroerende-omskaering-af-
drengeboern-uden-medicinsk-indikation (accessed November 3, 2019).
36
See for instance Morris, B. J. (2007). Why circumcision is a biomedical imperative for the 21st century.
Bioessays, 29(11), 1147-1158. Morris’s typical claim, which has not been substantiated by anyone outside his
research group, is that the benefits of circumcision outweigh the risks by a ratio of 100:1. But as Svoboda, Adler,
and Van Howe recently noted, “no recognized procedure for objectively assigning weights to individual benefit or
risks is used by Morris in his calculations [so] the ratio should not be taken seriously. For example, with no sound
justification for how the higher number was obtained, in 2017 Morris et al. increased the ratio to 200 to 1,
suggesting that the ratio is not scientifically meaningful.” Svoboda, J. S., Adler, P. W., & Van Howe, R. S. (2019).
Is circumcision unethical and unlawful? A response to Morris et al. The Journal of Medical Law and Ethics 7(1),
7292; 84. The 200 to 1 assertion is made in Morris, B. J., Kennedy, S.E., Wodak, A.D., et al. (2017). Early infant
male circumcision: systematic review, risk-benefit analysis, and progress in policy. World Journal of Clinical
Pediatrics, 6(1), 89-102.
12
active persons, which does not include most children. Yet by the time a person does become
sexually active, they will most likely be capable of consenting to circumcision if that is what they
choose. They will also be capable of withholding their consent if they determine that circumcision
is not in their medical (or other) best interests, and they can make this judgment on the basis of
their actual—rather than hypothetical/future—health-related context and behavior.
In short, when a potential health benefit can be achieved either via (1) a non-voluntary
surgical procedure performed on an individual to whom the benefit does not currently apply, and
likely will not apply for many years (if at all); or (2) a similar surgical procedure undertaken
voluntarily by the same individual when that individual is in a position to decide whether the
benefit is actually applicable (and if it is, whether it is worth the medical and non-medical risks
given their known values/preferences and the available non-surgical alternatives); it is not
normally justified, even on medical grounds, to proceed with option (1).
37
As we noted in the Introduction, one potential health benefit that has received much
attention in the recent literature is a partial reduction in the risk of female-to-male, heterosexually
transmitted HIV as a result of voluntary medical male circumcision (VMMC). The main support
for this claimed benefit stems from studies conducted in sub-Saharan Africa and published in the
latter half of the 2000s.
38
At present, it is scientifically irresponsible to extrapolate from the
findings of these studies on adult circumcisions performed in one epidemiological environment,
to neonatal circumcisions performed in a dissimilar epidemiological environment.
39
Nevertheless, both “strong” and “weak” advocates of NNMC (Box 2) have appealed to the
African RCTs in recent years to promote (in the case of strong advocates) or defend (in the case
of weak advocates) non-voluntary circumcision of newborn males: not only in sub-Saharan
Africa, where heterosexually transmitted HIV remains at epidemic levels, but also in the United
States and other developed countries, where heterosexually transmitted HIV is relatively rare.
40
In the African context, a plausible motivation for the shift to infancy is the failure of VMMC
programs to attract the number of men set by target quotas, despite the enormous effort and
37
A counterargument to this view is that the surgical procedure in (1) is less medically risky than the similar
surgical procedure in (2). We discuss this claim in a later section.
38
Auvert et al., op cit. note 1; Bailey et al., op cit. note 1; Gray et al., op cit. note 1.
39
For a discussion of why, see Bossio, J. A., Pukall, C. F., & Steele, S. S. (2014). A review of the current state of
the male circumcision literature. The Journal of Sexual Medicine, 11(12), 28472864.
40
Morris, B. J., & Krieger, J. N. (2015). The literature supports policies promoting neonatal male circumcision in
North America. The Journal of Sexual Medicine, 12(5), 1305. But see Bossio, J. A., Caroline F. Pukall, C. F., &
Steele, S. S. (2015). Response to: the literature supports policies promoting neonatal male circumcision in N.
America. The Journal of Sexual Medicine 12(5), 13061307.
13
expense directed at supply-side “demand creation.”
41
This shift is concerning from an ethical
perspective, as infants, in contrast to unwilling adolescents or adults, are unable to refuse to the
procedure.
Most other claimed health benefits similarly accrue after sexual debut. As a group of
mostly European pediatricians and other medical authorities argued in response to the 2012 AAP
policy statement on NNMC, there is only one potentially substantial health benefit that has
“theoretical relevance in relation to infant male circumcision; namely, the possible protection
against urinary tract infections in infant boys.”
42
This potential benefit has never been studied via
RCT, but observational and cohort studies cited by the AAP suggest that UTIs are anywhere
between three and ten times more likely to occur in genitally intact male infants under 2 years of
age than in circumcised ones.
43
A problem with interpreting such figures is that the rate of false
positives may be higher for diagnoses among the former group than the latter.
44
But even if one
takes such figures at face value, the difference between absolute and relative risk needs to be
highlighted. According to the AAP’s own estimates, UTIs affect roughly 1% of boys in the first
two years of life regardless of circumcision status, suggesting that “the number needed to
circumcise to prevent [one] UTI is approximately 100.”
45
However, rather than permanently
excising a sensitive genital structure from 100—or even far fewer—healthy boys to prevent one
of them from acquiring a UTI, the same hypothetical UTI could be safely, successfully, and non-
41
See Van Howe, R.S. (2018). Expertise or ideology? A response to Morris et al. 2016, “Circumcision is a primary
preventive against HIV infection: critique of a contrary meta-regression analysis by Van Howe.” Global Public
Health, 13(12),1900-1918; Sidler et al., op cit. note 5.
42
Frisch et al., op cit. note 11, p. 796.
43
AAP Task Force on Circumcision, op cit. note 29, p. e756.
44
As the authors of the Canadian Paediatric Society statement on NNMC note, “urines obtained via a midstream or
catheter specimen from an uncircumcised male are commonly contaminated by organisms under the foreskin.
Evidence for this is that 9% of uncircumcised and 0.5% of circumcised asymptomatic males had bacteruria later
verified by suprapubic urine collection to be falsely positive.” Robinson et al., op cit. note 32, p. 8684, referring to
Simforoosh, N., Tabibi, A., Khalili, S. A. et al (2012). Neonatal circumcision reduces the incidence of
asymptomatic urinary tract infection: a large prospective study with long-term follow up using Plastibell. Journal
of Pediatric Urology, 8(3), 320-323. See also Van Howe, R. S. (2005). Effect of confounding in the association
between circumcision status and urinary tract infection. Journal of Infection, 51(1), 59-68.
45
AAP Task Force on Circumcision, op cit. note 29, p. e767. Other credible estimates of the number-needed-to-
prevent range from 25 to 100see Eisenberg, M. L., Galusha, D., Kennedy, W. A., & Cullen, M. R. (2018). The
relationship between neonatal circumcision, urinary tract infection, and health. The World Journal of Men's Health,
36(3), 176-182to as many as 195; see To, T., Agha, M., Dick P. T., Feldman W. (1998). Cohort study on
circumcision of newborn boys and subsequent risk of urinary-tract infection. Lancet, 352, 18131816. Some
“lifetime” estimates have been published including UTIs potentially acquired between sexual debut and death, but
these fall outside the scope of our analysis.
14
invasively treated with antibiotics in most cases.
46
This is the standard of care for girls, who are
about 4 to 8 times more likely than boys to acquire a UTI by age 5 years, according to the AAP.
47
Balanitis (or inflammation of the glans penis) is also thought to occur less often in
circumcised males, although it may actually be more common in such males while they are still
in diapers.
48
According to the UK National Health Service, balanitis is “not usually serious” and
“most cases [are] easily treated with good hygiene and creams [or] ointments.”
49
Again, it is not
clear why indiscriminately removing genital tissue from healthy infants to reduce—potentially—
the risk of a typically non-serious and easily treatable source of temporary discomfort should even
be entertained. Phimosis, the inability to fully retract the prepuce over the glans of the penis,
necessarily occurs less frequently in circumcised males who lack a prepuce.
50
However, in young
boys, a non-retractile foreskin is normal as the foreskin is fused to the glans at birth, after which
the two structures gradually separate during early childhood. In approximately 50% of cases, this
process will be complete by ten years of age, but it can continue until after the onset of puberty.
51
For this reason, phimosis, as such, is difficult to diagnose accurately before adolescence.
Moreover, if a lack of ability to retract the foreskin does create problems for a child, this can
usually be treated in a less invasive way than by excising the foreskin altogether: topical creams
and gentle stretching will resolve the majority of problematic cases with no cutting of tissue
46
Fisher, D. J. (2019). Pediatric urinary tract infection treatment & management. Medscape. Available at
https://emedicine.medscape.com/article/969643-treatment (accessed November 3, 2019): “Most cases of
uncomplicated UTI respond readily to outpatient antibiotic treatments without further sequelae.”
47
What is more, “most children who have one UTI will not have another.” American Academy of Pediatrics.
(2018). Recurrent urinary tract infections (UTIs) in children. From the AAP Section on Urology. Available at
https://www.healthychildren.org/English/health-issues/conditions/genitourinary-tract/Pages/Urinary-Tract-
Infections-in-Teens.aspx (accessed November 3, 2019).
48
Van Howe, R. S. (2007). Neonatal circumcision and penile inflammation in young boys. Clinical Pediatrics, 46,
329-333. See also Escala, J. M., & Rickwood, A. M. K. (1989). Balanitis. British Journal of Urology, 63(2), 196-
197. According to these authors, balanitis “is usually associated with a prepuce which is partly or completely non-
retractable. It does not cause phimosis and no single pathogen is involved. Most boys suffer a single episode and
circumcision is indicated only for those with recurrent, troublesome attacks.”
49
NHS. (2017). Balanitis. UK National Health Service. Available at https://www.nhs.uk/conditions/balanitis/
(accessed November 3, 2019).
50
The incidence of pathologic phimosis in intact males (0.5% to 1%) appears to be similar to the incidence of
preputial stenosis/phimosis following circumcision (0.3-1.7%). See Shankar, K. R., & Rickwood, A. M. K. (1999).
The incidence of phimosis in boys. BJU International, 84, 101-102; Kaweblum, Y. A., Press, S., Kogan, L.,
Levine, M., & Kaweblum, M. (1984). Circumcision using the Mogen clamp. Clinical Pediatrics, 23, 679-682;
Stenram, A., Malmfors, G., & Okmian, L. (1986). Circumcision for phimosisindications and results. Acta
Paediatrica Scandinavia, 75, 321-323; Van Howe, R. S. (1997). Variability in penile appearance and penile
findings: a prospective study. British Journal of Urology, 80, 776-782.
51
Kayaba, H., Tamura, H., Kitajima, S., Fujiwara, Y., Kato, T., & Kato, T. (1996). Analysis of shape and
retractibility of the prepuce in 603 Japanese boys. Journal of Urology, 156, 1813-1815; Øster, J. (1968). Further
fate of the foreskin. Incidence of preputial adhesions, phimosis, and smegma among Danish schoolboys. Archives
of Disease in Childhood, 43, 200-203.
15
required, and most of the remainder can be addressed with foreskin-preserving preputioplasty (for
instance, a limited dorsal slit with transverse closure).
52
Recurrent pathological phimosis is thought to be a risk factor for penile cancer, which
may explain why (especially early) circumcision has been associated with a lower relative risk of
contracting this rare cancer.
53
According to recent estimates, “penile cancer is one of the rarest
malignancies for which site-specific data are available in cancer registries. In 2003–2007, penile
cancers accounted for 0.15% of all incident cancers in the United States, thus ranking 43rd in
incidence among all site-specific cancers in US males.”
54
In fact, penile cancer “is not among the
10 most common malignancies in males in any national cancer registry; even in high-incidence
regions of South America, Africa, and Asia, the risk of developing penile cancer before age 75
years is below 0.4%.”
55
In line with this, the AAP estimates that between 909 and 322,000
circumcisions would be required to prevent a single case.
56
A similar analysis applies to most of the health benefits commonly cited by NNMC
advocates. We do not have room to cover them all here. Instead, we refer the reader to more
exhaustive critical surveys of the claimed health benefits of NNMC that have recently been
performed by others.
57
Our point in this section has not been to imply that NNMC has no
statistical health-related benefits. Rather, it has been to emphasize that (1) the likelihood and
52
In a large prospective study, a total of 1185 boys with a diagnosis of pathological phimosis were treated with
fluticasone proprionate. Successful results with no side effects were achieved in 1079 (91.1%) patients including
those diagnosed with mild balanitis xerotica obliterans. Zavras, N., Christianakis, E., Mpourikas, D., & Ereikat, K.
(2009). Conservative treatment of phimosis with fluticasone proprionate 0.05%: a clinical study in 1185 boys.
Journal of Pediatric Urology, 5(3), 181-185. Regarding preputioplasty, see, e.g., Hotonu, S., Mohamed, A.,
Rajimwale, A., & Gopal, M. (2019). Save the foreskin: outcomes of preputioplasty in the treatment of childhood
phimosis. The Surgeon, in press.
53
See, e.g., Larke, N. L., Thomas, S. L., dos Santos Silva, I., & Weiss, H. A. (2011). Male circumcision and penile
cancer: a systematic review and meta-analysis. Cancer Causes & Control, 22(8), 1097-1110. These authors note,
however, that in 2 of the 8 studies included in their analysis, “the protective effect of childhood/adolescent
circumcision on invasive cancer no longer persisted when analyses were restricted to boys with no history of
phimosis.”
54
Frisch, M. (2017). Penile cancer. In M. Thun et al. (Eds.), Cancer epidemiology and prevention (ch. 55), Oxford:
Oxford University Press.
55
Ibid, note 54.
56
AAP Task Force on Circumcision, op cit. note 29, p. e768.
57
See for example Dave, S., Afshar, K., Braga, L. H., & Anderson, P. (2018). Canadian Urological Association
guideline on the care of the normal foreskin and neonatal circumcision in Canadian infants (full version). Canadian
Urological Association Journal, 12(2), E76-E99. The authors fail to find that the health benefits of NNMC
outweigh the medical risks, concluding that from an “overall societal perspective, given our healthcare system and
the socioeconomic and educational status of our population, universal neonatal circumcision is not justified based
on the evidence available.” The most recent evidence-based review from any non-partisan group or organization of
which are aware is the one from Evidence Based Birth: Dekker, R., & Bertone, A. (2019). Evidence and ethics on:
circumcision. Evidence Based Birth. Available at https://evidencebasedbirth.com/evidence-and-ethics-on-
circumcision/ (accessed November 3, 2019). These authors state: “After an extensive review of the literature,
we’ve concluded that there is no compelling evidence to justify routine male infant circumcision on medical
grounds.”
16
magnitude of these benefits is scientifically controversial; (2) most medical bodies that have
studied NNMC have failed to conclude that the health-related benefits outweigh even the strictly
health-related risks or harms; (3) most of the benefits cited by NNMC advocates do not apply
until sexual debut, which is typically at, near, or after the time at which the vast majority of
individuals could consent to circumcision if that is what they wanted; (4) the main health benefits
said to apply before sexual debut have a low absolute risk of occurring, are typically non-serious,
and can usually be effectively treated without tissue loss; and (5) nearly all of the health benefits
attributed to circumcision can be achieved in less invasive ways that do not involve non-voluntary
genital cutting.
B. Costs
We turn next to the question of costs or drawbacks to NNMC, which we have divided into three
categories: general harms, medical complications, and financial costs. These costs are discussed
separately because in Anglophone Western countries, even those with low or declining rates of
NNMC, it is commonplace to discuss circumcision solely in terms of its medical benefits and
surgical risks. The prima facie value of the prepuce itself (see Box 3), the state of being genitally
intact, and/or the ability to decide for oneself about whether to undergo an elective genital
procedure—all of which are necessarily lost to NNMC—are not typically given as much attention.
But insofar as an individual does place a positive value on any of those factors (the prepuce,
genital intactness, or having a choice), NNMC is a harm to them even if there are no surgical
complications.
58
The magnitude of the harm, in turn, depends on the degree of value placed on
the factors, which cannot be known in infancy or early childhood and is likely to be highly
individually variant.
Another problem with current conceptions of harm relating to NNMC is that anatomically
normal and benign attributes of the foreskin are sometimes implied to have negative value. For
example, according to the 2012 AAP statement, “Penile wetness (defined as the observation of a
diffuse homogeneous film of moisture on the surface of the glans and coronal sulcus) is
considered a marker for poor penile hygiene and is more prevalent in uncircumcised than in
circumcised men.”
59
In support of this view, the AAP Task Force cites a study finding a higher
58
Svoboda, J. S. (2017). Nontherapeutic circumcision of minors as an ethically problematic form of iatrogenic
injury. AMA Journal of Ethics, 19(8), 815-824.
59
AAP Task Force on Circumcision, op cit. note 29, p. e763.
17
rate of “penile wetness” among intact than circumcised men.
60
The study does not explain how
penile wetness constitutes “poor penile hygiene,” nor does it define what is meant by the latter
concept. It merely notes, as does the AAP Task Force, that other authors have used “penile
wetness” as a proxy for “poor penile hygiene.” Neither the authors of the study nor the AAP Task
Force seem aware that penile wetness in genitally intact males is normal, just as labial wetness in
genitally intact females is normal. The glans penis, like the glans clitoris, evolved though natural
selection to be an internal organ that is protected and lubricated by a prepuce, akin to the
relationship of the eye to the eyelid.
61
Box 3. A brief overview of the human prepuce
The prepuce is a “common anatomical structure of the male and female external genitalia of all
human and non-human primates.” In humans, the penile and clitoral prepuces are identical in early
fetal development and remain indistinguishable in some intersex individuals. The prepuce is an
“integral, normal part of the external genitalia that forms the anatomical covering of the glans
penis and clitoris,” thereby internalizing each and “decreasing external irritation and
contamination.” In the case of the penile prepuce, an additional function is to protect the urinary
opening from abrasion, as this runs through the penile, but not the clitoral glans. In both cases, the
prepuce is “a specialized, junctional mucocutaneous tissue which marks the boundary between
mucosa and skinsimilar to the eyelids, labia minora, anus and lips.” The “unique innervation
of the prepuce establishes its function as an erogenous tissue.”
62
General harms
Circumcision removes one-third to one-half of the motile skin system of the penis.
63
This is tissue
that many individuals consider to be erogenous, as it provides a range of specific sensations that
can contribute to the subjective experience of sexual enjoyment.
64
The “gliding” motion of the
60
O’Farrell, N., Morison, L., & Chung, C. K. (2007). Low prevalence of penile wetness among male sexually
transmitted infection clinic attendees in London. Sexually Transmitted Diseases, 34(6), 408409.
61
Cold & Taylor, op cit. note 14.
62
Quotations from Cold & Taylor, op cit. note 14.
63
Taylor, J.R., Lockwood, A.P., & Taylor, A.J. (1996). The prepuce: specialized mucosa of the penis and its loss to
circumcision. British Journal of Urology, 77, 291-295.
64
Ibid. See also Martín-Alguacil, N., Cooper, R. S., Aardsma, N., Mayoglou, L., Pfaff, D., & Schober, J. (2015).
Terminal innervation of the male genitalia, cutaneous sensory receptors of the male foreskin. Clinical Anatomy,
28(3), 385-391; Ball, P. J. (2006) A survey of subjective foreskin sensation in 600 intact men. In Bodily integrity
and the politics of circumcision (pp. 177188). New York: Springer; Wong, D. P., Morrison, B. F., Mayhew, R. G.,
Reid, G. A., & Aiken, W. D. (2015). A delayed foreskin-sparing approach to the management of penile fractures in
uncircumcised Jamaican men. International Journal of Surgery Case Reports, 17, 65-68; Kim, D., & Pang, M. G.
(2007). The effect of male circumcision on sexuality. BJU International, 99(3), 619-622.
18
foreskin back and forth over the glans during sexual intercourse or masturbation is permanently
disabled by NNMC, changing the very mechanics of penile stimulation;
65
and part or all of the
frenulum is often removed.
66
Studies employing objective measures consistently show that the
foreskin is the most sensitive part of the organ to light touch.
67
Moreover, scar tissue may form
around the circumference of the penis following circumcision, which apart from being unsightly
in some cases, may also be less capable of supplying varied sensation.
68
Finally, pain is an
unavoidable consequence of circumcision, not only during the procedure itself but also
throughout the healing process. Because general anesthesia is considered too risky for neonates,
the most effective form of pain control is not available to them (whereas it is available for adults).
Instead, local anesthetics must be used. However, the best of these approved for use in neonates
still requires making injections into the base of the penis prior to circumcision, which can itself
be painful.
69
As Bellieni et al. noted after a review of the literature, “there is no such thing as a
pain-free circumcision.”
70
A further consideration is that adults can communicate their pain levels
65
For a demonstration, see MFN24. (2015). Gliding motion of the foreskin. Wikimedia Commons. Available at
https://commons.wikimedia.org/wiki/File:Foreskin_in_motion.gif (accessed November 3, 2019).
66
See Shenoy, S. P., Marla, P. K., Sharma, P., Bhat, N., & Rao, A. R. (2015). Frenulum sparing circumcision: step-
by-step approach of a novel technique. Journal of Clinical and Diagnostic Research, 9(12), PC01PC03.
67
Sorrells, M. L., Snyder, J. L., Reiss, M.D., Eden, C., Milos, M. F., Wilcox, N., & Van Howe, R.S. (2007). Fine-
touch pressure thresholds in the adult penis. BJU International, 99(4), 864-869; Bossio J. A., Pukall, C. F., &
Steele, S. S. (2016). Examining penile sensitivity in neonatally circumcised and intact men using quantitative
sensory testing. The Journal of Urology, 195(6), 18481853. For critical discussion and contextualization of these
findings, see Earp, B. D. (2016). Infant circumcision and adult penile sensitivity: implications for sexual
experience. Trends in Urology & Men’s Health, 7(4), 1721; Van Howe, R. S., Sorrells, M. L., Snyder, J. L., Reiss,
M. D., & Milos, M. F. (2016). Re: Examining penile sensitivity in neonatally circumcised and intact men using
quantitative sensory testing. The Journal of Urology, 196(6), 1824; Rotta, A. T. (2016). Re: "Examining penile
sensitivity in neonatally circumcised and intact men using quantitative sensory testing.” The Journal of Urology,
196(6), 1822-1823.
68
Cold & Taylor, op cit. note 14. See also Fahmy, M. A. B. (2019). Nonaesthetic circumcision scarring. In Fahmy,
M. A. B. (ed)., Complications in male circumcision (pp. 99-134). Amsterdam: Elsevier.
69
Banieghbal, B. (2009). Optimal time for neonatal circumcision: an observation-based study. Journal of Pediatric
Urology, 5(5), 359-362. The ring block injections administered prior to circumcision in this study resulted in
observable pain responses above a pre-defined threshold in 31% of <1 week-old infants and 85% of 1–5 week-old
infants. That is, simply being administered the anesthesia was painful for many infants at a clinically significant
level. Moreover, among 1–5 week-old infants, 71% experienced above-threshold pain during the actual
circumcision. Some research suggests that infants experience pain, if anything, more acutely than adults: “The
newborn is inexperienced in filtering noxious stimuli, so the full impact of pain, without adaptive measures, is
delivered. In older children and adults, pain is attenuated by filters developed with experience by the nervous
system. This difference in our perception may be explained by older [individuals] who can articulate their level of
pain, whereas infants are reduced to screams that the circumcising physician may ignore” Van Howe, R. S., &
Svoboda, J. S. (2008). Neonatal pain relief and the Helsinki Declaration. The Journal of Law, Medicine &
Ethics, 36(4), 803-823. See also Fitzgerald, M. (2015). What do we really know about newborn infant pain?
Experimental Physiology, 100(12), 1451-1457.
70
Bellieni, C. V., Alagna, M. G., & Buonocore, G. (2013). Analgesia for infants’ circumcision. Italian Journal of
Pediatrics, 39(38),1-7. It is notable that a separate AAP Task Force, charged with assessing the literature on infant
pain rather than circumcision, concluded that: “exposure to repeated painful stimuli early in life is known to have
short- and long-term adverse sequelae [including] physiologic instability, altered brain development, and abnormal
19
clearly and manage their own pain control needs as the circumcision wound heals. Pre-verbal
infants, by contrast, whose wound—unlike that of an adult—will be exposed to urine and feces
in a diaper, cannot as effectively communicate their discomfort and must rely on others to change
their bandaging, administer analgesic drugs, and so on, in a timely and appropriate manner.
Most of the above outcomes, which may reasonably be judged to constitute harms,
71
could
apply to circumcisions performed at any stage of life. However, as with the pain issue, some
potential harms of circumcision may be greater in infancy or early childhood compared to after
an age of consent. First, on a psychological level, there is the sheer removal of choice concerning
how an intimate part of one’s body should look or function. Some individuals regard this aspect
of NNMC as harmful in and of itself.
72
Second, on a more physical level, because the infant penis
is so small, the physician performing the circumcision may remove too much tissue, possibly
contributing to tight or painful erections in adulthood, without being able to anticipate or fully
account for this adverse outcome.
73
It may also be more likely that the frenulum would be cut
away with those devices most commonly used to perform a neonatal or infant circumcisions (e.g.,
neurodevelopment, somatosensory, and stress response systems, which can persist into childhood,” and
recommended that “every health care facility caring for neonates should implement [a] pain-prevention program
that includes strategies for minimizing the number of painful procedures performed.” AAP Committee on Fetus
and Newborn and Section on Anesthesiology and Pain Medicine (2016). Prevention and management of procedural
pain in the neonate: an update. Pediatrics, 137(2): e20154271.
71
Of course, one and the same outcome may be judged to beor experienced as—a harm for one individual,
while, for another individual with different preferences, it could be judged to be a benefit. Once again, such
disagreement weighs in favor of allowing the individual to decide about their own genitals in terms of whether they
should be permanently modified. For extensive discussions, see Earp, B. D, & Darby, R. (2017). Circumcision,
sexual experience, and harm. University of Pennsylvania Journal of International Law, 37(2-online), 1–57; Earp,
B. D. (2017). Gender, genital alteration, and beliefs about bodily harm. Journal of Sexual Medicine. 14(5), Supp. 4,
e225 (associated video presentation titled “Circumcision – a sexual harm?” is available at
https://www.youtube.com/watch?v=SB-2aQoTQeA).
72
Hammond, T. & Carmack, A. (2017). Long-term adverse outcomes from neonatal circumcision reported in a
survey of 1,008 men: an overview of health and human rights implications. International Journal of Human Rights,
21(02), 189-218. Bossio J.A., & Pukall C.F. (2018). Attitude toward one's circumcision status is more important
than actual circumcision status for men’s body image and sexual functioning. Archives of Sexual Behavior, 47(3),
771-781.
73
Hammond & Carmack. op cit. note 72, pp. 199-200. See also Kaplan, G. W. (1983). Complications of
circumcision. Urologic Clinics of North America, 10(3), 543-549, referring to skin bridges as further potential
complication of NNMC that may cause tight or painful erections. The size of the infant penis also may also explain
why “partial glans amputation, buried penis and total penectomiesare complications that are primarily limited to
early circumcisions. Ungar-Sargon, E. (2015). On the impermissibility of infant male circumcision: a response to
Mazor (2013). Journal of Medical Ethics, 41, 186-190. For supportive data, see PEPFAR (2019). PEPFAR 2020
country operational plan guidance for all PEPFAR countries. PEPFAR. Available at https://www.state.gov/wp-
content/uploads/2019/11/2019-11-25-COP20-Guidance-Full-Consolidated_Public-2-1.pdf (accessed November 3,
2019). Likewise, deaths following circumcision performed on infants are reported on occasion, including in
developed countries, whereas deaths following the procedure performed under similar conditions on adults are
virtually unheard of. See Earp, B. D., Allareddy, V., Allareddy, V., & Rotta, A.T. (2018). Factors associated with
early deaths following neonatal male circumcision in the United States, 2001- 2010. Clinical Pediatrics, 57(13),
15321540; Paediatric Death Review Committee: Office of the Chief Coroner of Ontario. (2007). Circumcision: a
minor procedure? Paediatrics & Child Health, 12, 311-312.
20
the Gomco clamp, Mogen clamp, or Plastibell), which less discriminately remove tissue around
the diminutive infant glans. In voluntary circumcisions, by contrast—that is, when the penis has
reached its full size—it is easier for the physician to cut around the frenulum, leaving it mostly or
entirely intact.
74
In terms of data collection and estimation of complications, problems associated with
NNMC may be less likely to be recognized or reported: some individuals may go their entire lives
thinking that a negative outcome is normal, or fail to associate the problem with their
circumcision, since this occurred prior to their ability to make a conscious before-and-after
comparison. Finally, the infant foreskin is normally fused to the head of the penis by a membrane,
whereas the foreskin of a fully developed penis is more likely to be detached. The authors of a
study comparing neonatal circumcision with that of older boys—to be discussed further below—
explain the surgical significance of this distinction:
In the neonatal period, irrespective of the applied method of circumcision, a forced and traumatic degloving
of the foreskin from the meatus, glans, and sulcus cannot be avoidedInitially, the inner surface of the
prepuce and the epithelium of the glans are fused, and separation of these two surfaces develops
progressively [which] explains the need for forceful and traumatic degloving in neonatal circumcision.
Degloving leads to a perimeatal inflammation, which can result in meatal deformity with eventual stenosis.
Development of scar tissue with meatal deformity and stenosis [in our study] was secondary to the traumatic
excoriation and was not merely due to exposure and irritation by the diaper of the fragile and under-
keratinized glans epithelium.
75
Even from a purely technical perspective, then, there are at least some costs to performing
circumcision on a small and underdeveloped penis that do not apply to circumcision performed
on a penis that has reached its full size and final configuration. Moreover, any long-term
complications that are incurred in infancy or early childhood will affect the individual for a longer
period of time and hence a greater proportion of their life compared to the same complication
incurred in adolescence or adulthood.
74
On the importance of allowing the penis to reach its full size more generally, consider the analogous case of
elective labiaplasty in females. According to the Royal College of Obstetricians and Gynaecologists (RCOG),
“Even though children aged 16 or over can consent to surgical procedures,” medically unnecessary female genital
cutting procedures “should not normally be carried out on women and girls under 18 years of age, irrespective of
consent, because full genital development is not normally achieved before the age of 18.” RCOG Ethics
Committee. (2013). Ethical opinion paper: Ethical considerations in relation to female genital cosmetic surgery
(FGCS). RCOG. Available at https://www.rcog.org.uk/globalassets/documents/guidelines/ethics-issues-and-
resources/rcog-fgcs-ethical-opinion-paper.pdf (accessed November 3, 2019).
75
Machmouchi, M., & Alkhotani, A. (2007). Is neonatal circumcision judicious? European Journal of Pediatric
Surgery, 17(04), 266-269, 268.
21
Medical Complications
The strictly medical complications of circumcision are often said to be fewer and less serious in
infancy, especially the neonatal period, than at any other stage of life. As “strong” NNMC
advocates (see Box 2) Brian Morris et al. state in a review, “Evidence clearly shows that
circumcision in infancy carries fewer risks of complications than circumcisions performed in
childhood or later in life.”
76
Somewhat incongruously, however, they go on to argue (emphasis
added):
A recent systematic review found a median complication frequency of 1.5% among studies of neonatal
or infant circumcision, compared to 6% among studies of children aged one year or olderIn the large
RCTs of adult MC, complications were seen in 1.7-3.8%; these were virtually all mild or moderate and
were effectively treated.
77
In other words, according to these authors, while complications from circumcision in early
childhood (ages 1 year and older) occur about 4 times as frequently as in the neonatal or infant
period—assuming that the cited data are correct; more on this below—there does not appear to
be a very large absolute difference between complications arising from such neonatal or infant
circumcision and adult circumcision, which is the more ethically relevant comparison in terms of
the capacity to consent. In fact, even the relative difference in complication rates appears to be
modest: the complication rate for adult circumcision, according to the authors, is between 1.13
and 2.53 times that of NNMC, with “virtually all” of the complications associated with the adult
form being “mild or moderate” and “effectively treated.” If that is the case, then the marginally
greater alleged complication rate in adults (in absolute terms, between 0.2% and 2.3%) is arguably
of little medical or ethical significance; whereas the capacity of the adult, compared to the infant,
to consent to the procedure is of enormous ethical significance.
76
Morris et al., op cit. note 13.
77
Ibid. Apart from this article by Morris et al., one of the most common sources of the claim that circumcision is
more risky after infancy is the study by El Bcheraoui, C., Zhang, X., Cooper, C. S., Rose, C. E., Kilmarx, P. H., &
Chen, R. T. (2014). Rates of adverse events associated with male circumcision in US medical settings, 2001 to
2010. JAMA Pediatrics, 168(7), 625-634. These authors claim that compared with boys circumcised at <1 year, the
incidences of probable adverse events were "approximately 20-fold and 10-fold greater for males circumcised at
age 1 to 9 years and at 10 years or older, respectively." However, these estimates were indirectly inferred from a
retrospective comparison of hospital billing claims that did not distinguish between voluntary/non-voluntary or
therapeutic/non-therapeutic circumcisions nor adjust for potential confounding with concurrent procedures.
Moreover, the window of analysis employed was likely too short to capture one of the most common late-occurring
complications associated with newborn circumcision, namely, meatal stenosis, such that "the observed low
frequency of urethral strictures (0.01%)and therefore the low overall frequency of complications for boys
circumcised in infancy (0.4%)most likely reflects a combination of insensitive research data and insufficient
follow-up" (Frisch & Earp, op cit. note 21, p. 633).
22
Even so, the evidence cited by Morris et al. in support of their claims regarding an
increased risk for adults does not come from well-controlled studies. Instead, it comes from
studies of non-concurrent populations circumcised with different techniques and evaluated with
disparate methodologies, using inconsistent definitions and thresholds for identifying
complications. Very few studies have made a direct comparison between the complication rates
of neonatal versus later circumcision within a single population, and those that have have yielded
mixed results. One study from Iran, for example, found no statistically significant difference in
late complications (defined as excessive residual foreskin, excessive foreskin removal, meatal
stenosis, granuloma, penile rotation, and secondary chordee) when comparing circumcisions
performed by medically untrained personnel in the neonatal period (5.68%) with those performed
in later childhood (7.44%). However, more than 70% of the latter circumcisions took place
between the ages of 2 and 12, with 12 being the maximum age of any child included in the study.
Since this is below the age of consent in most jurisdictions, it is also below the age-range of the
relevant comparison class for our purposes.
78
Two other studies from Pakistan found a lower overall complication rate in neonates
compared to older children, but similarly failed to make the ethically relevant comparison: the
maximum age at which the circumcisions took place across both studies was 5 years old.
79
Nevertheless, in one of the studies, the authors reported a greater percentage of buried glans cases
78
Yegane, R.-A., Kheirollahi, A.-R., Salehi, N.-A., Bashashati, M., Khoshdel, J.-A., & Ahmadi, M. (2006). Late
complications of circumcision in Iran. Pediatric Surgery International, 22, 442-425. A similar limitation applies to
a later Turkish study, which had a maximum age of 14 years: Bicer, S., Kuyrukluyildiz, U., Akyol, F., Sahin, M.,
Binici, O., & Onk, D. (2015). At what age range should children be circumcised? Iran Red Crescent Medical
Journal, 17(3), e26258. These authors found no statistically significant difference in surgical complication rates
between children circumcised at ages <1 year, 1-7 years, and 7-14 years. There were, however, fewer recorded
complications due to anaesthesia in the <1 year group, but these children were circumcised with local anaethesia
only, whereas general anaesthesia was used among the older children, with the majority complication being the
temporary experience of double vision. We discuss the ethical significance of the use of local versus general
anaesthesia elsewhere in the paper.
79
Moosa, F. A., Khan, F. W., & Rao, M. H. (2010). Comparison of complications of circumcision by ‘Plastibell
device technique’ in male neonates and infants. Journal of the Pakistan Medical Association, 60, 664-667. Razzaq,
S. et al. (2018). Safety of the Plastibell circumcision in neonates, infants, and older children,” International Journal
of Health Sciences 12(5) 1013. Similar findings, with similar limitations (e.g., maximum age of 8.5 months in the
non-newborn comparison group) were reported in a retrospective study of 130 circumcisions performed by a single
pediatric urologist based in the United States: Horowitz, M., & Gershbein, A. B. (2001). Gomco circumcision:
When is it safe? Journal of Pediatric Surgery, 36(7), 1047-1049. More recently, a complication rate of 1.5% was
reported for neonates over a five-year period compared to 2.9% in non-neonates; but again, the study was
retrospective and poorly controlled, and the non-neonate group was not old enough to consent (max age < 5 years):
Hung, Y. C., Chang, D. C., Westfal, M. L., Marks, I. H., Masiakos, P. T., & Kelleher, C. M. (2019). A longitudinal
population analysis of cumulative risks of circumcision. Journal of Surgical Research, 233, 111-117. A prospective
Indian study reported a 4.16% complication rate in neonates circumcised with the Plastibell device compared to
20% in infants, with the same wrong-comparison-group problem (max age 1 year): Shinde, N. D., Moinuddin, M.,
& Danish, A. O. (2018). Plastibell circumcision in neonates and infants at tertiary care centre. International Surgery
Journal, 5(4), 1488-1491. And so on.
23
(3.21%) in neonates (mean age 15 days) than in infants (mean age 3 months) or older children
(mean age 2.3 years) (1.24% and 1.92% respectively), “which may be due to the small size of
[the neonatal] penis and adhesions.”
80
Again, these findings suggest that different kinds of
complications may occur at different rates depending on the age of the individual, with some
being higher (or more serious) at a given age and others being lower (or less serious).
A final study, from Saudi Arabia, had a relatively well controlled prospective cohort
design, and found a significantly higher rate of “serious complications” for neonatal circumcision
compared to circumcision of older infants, regardless of the method used (bone cutter, Gomco
clamp, Plastibell device). The authors concluded from this that “neonatal circumcision should not
be recommended.”
81
However this study, too, did not compare neonatal (or infant) circumcision
with circumcision after an age of consent: the maximum age in the comparison group was 5
months old.
No studies to our knowledge have yet been performed comparing the circumcision of
neonates or infants with that of consenting older adolescents or adults in the same population,
properly controlling for the experience of the surgeon, the method used, the setting, and the reason
for circumcision. This last factor is perhaps the most important. Since it is unusual, especially in
the developed world, for adults to request a circumcision unless they already have a pre-existing
medical condition relating to their penis, some of the greater apparent burden of complications in
adults (on average) may be related to this factor. NNMC, by contrast, is usually performed on a
normal, healthy penis. Some complications that do occur may be missed by the parents, and the
infant will be in no position to recognize or to report these. The only other party who might report
any complications arising from NNMC is the medical practitioner (who has an interest in not
doing so).
That being said, recent findings from a relatively controlled comparison based on millions
of cases, with all circumcisions performed as part of the ongoing VMMC program described
above, suggest the very opposite of the conclusion drawn by Morris et al. in their review.
According to the U.S President's Emergency Plan for AIDS Relief (PEPFAR), “Complications
continue to be reported more commonly among those under age 15 at VMMC, especially in
infants.” In particular, fully 100% of glans injuries and 90% of fistulas reported through their
Notable Adverse Events (NAE) reporting system occurred in children circumcised at ages 14 and
younger. And the overall ratio NAEs to circumcisions performed was five times higher in infants
80
Ibid, p. 12.
81
Machmouch & Alkhotani, op cit. note 75, p. 266.
24
(15.3 per 100,000) than in young adolescents (2.9 per 100,000), which in turn was about twice
the ratio for individuals circumcised at ages 15 years and above (1.6 per 100,000). As a result of
these findings, PEPFAR announced in late 2019 that it will no longer fund infant circumcisions
as a part of the VMMC program, citing the “NAE review, the severity of glans injuries and fistulas
when they occur, and expected timing of pubertal development.” The minimum eligibility criteria
for VMMC have been updated to 15 years of age or Tanner Stage 3 sexual development.
82
Even in developed countries, severe complications associated with NNMC may be more
common than suggested by its proponents’ conservative estimates. At a single children’s hospital
in Birmingham, England, for instance, cases of “life threatening hemorrhage, shock or sepsis”
resulting from infant circumcision ranged from 0 to 11 per year between 2002 and 2011.
83
Since
these figures were obtained due to a special freedom of information request and otherwise would
not have been made public, it is unclear whether the complication rates in the published literature
reflect the full scope of the problem. Finally, it has been suggested that “the severity of
complications is far more important than the rate. Although necrotizing fasciitis, amputation of
the penis and death are incredibly rare,” they may be more common in infancy than in adulthood
(assuming a similar clinical context and a healthy organ); and “some would consider it unethical
[to] advocate for an elective procedure that may or may not benefit an individual [non-consenting]
patient yet has any potential to result in such devastating outcomes.”
84
Financial costs
Morris et al. point to a lower financial cost of performing circumcision in infancy, estimating in
2012 a cost of between $165 and $257 in infancy, compared to $1,800-2,000 for circumcision in
adolescence or adulthood. They acknowledge, however, that the cost for older males can be
reduced by insisting on a local anesthetic, since a general anesthesiologist’s fees can be
considerable.”
85
As noted, general anesthesia is typically contra-indicated in neonates, which
appears to be the main reason why neonatal circumcisions are generally less expensive overall.
82
PEPFAR, op cit. note 73, pp. 171-2, emphasis added. For further discussion, see Earp & Darby, op cit. note 71.
83
Checketts, R. (2012). Response to freedom of information request, FOI/0742. Birmingham Children’s Hospital,
NHS Foundation Trust. Available at http://www.secularism.org.uk/uploads/foi-bch-response-received-260612.pdf
(accessed November 3, 2019). For a recent discussion of some of the challenges obtaining FOI data on
circumcision complications, see Fox, M., Thomson, M., & Warburton, J. (2018). Non-therapeutic male genital
cutting and harm: law, policy and evidence from UK hospitals. Bioethics, 33(4), 467-474.
84
Robinson et al., op cit. note 32, p. 8684, emphasis added. Against this view, it could be argued that certain risks
associated with a lack of circumcision, such penile cancer, may also be devastating. However, these typically
already-low risks can almost always be reduced or eliminated without genital surgery, which carries its own risks,
whereas the most devastating injuries that may be caused by circumcision (e.g., partial or complete amputation of
the glans) are typically more directly attributable to the surgery itself.
85
Morris et al., op cit. note 13, p. 8.
25
Morris et al. state that if adolescent and adult males opted for circumcision under local anesthesia,
the discrepancy in cost would not be as great. Consistent with this, a more recent, informal
estimate suggests that when the procedure is not covered by health insurance, “circumcision for
a newborn infant typically costs $150-$400 for the doctor fee, and possibly an additional facility
fee, which can increase the total to $800 or more,” whereas “circumcision for an older child or
adult male typically costs $800-$3,000 or more.” As a characteristic example, the fees from one
circumcision clinic are listed as “$850 for children 1 to 17 years, $1,500 for adults if local
anesthesia is used and $3,000 for adults if general anesthesia is used.”
86
Assuming for the sake of
argument that these figures are in the right ballpark, the difference in cost between a medically
unnecessary newborn circumcision ($800+ on the high end, including a facilities fee) and that of
an older adolescent who could at least potentially consent ($850 up to age 17), could be $50 or
less in at least some contexts. But even if the comparison is between newborn and adult (age 18+)
elective circumcisions, the difference could be as little as $700 if local anesthesia is used. For a
point of comparison, the US national average cost of adult (elective) labiaplasty is $2,924
according to the American Society of Plastic Surgeons.
87
In either case, the cost of the adult
procedure would be borne exclusively by the small minority of individuals who had an explicit,
robust desire to undergo a genital-altering procedure, whereas those who did not have such a
desire would pay nothing.
Morris et al. also argue that individuals circumcised as adults may need to take time off
work. Any lost earnings that result from this would need to be taken into account as well.
However, similar to the labiaplasty example, this financial loss would be moderated by the fact
that it was voluntarily incurred to achieve a desired outcome, except in those rare cases where the
procedure was medically necessary.
88
We discuss the ethical implications of these observations
in a later section.
3. Ethical Issues
86
See https://health.costhelper.com/circumcision.html (accessed November 3, 2019). We do not suggest that the
estimates from this source are reliable or nationally representative; we use them purely for the sake of illustration.
Please note that the most recent fees listed at the example clinic, Gentle Circumcision of California, are $900 for
teens up to age 17 and $1600 for adults (18+). See http://www.gentlecircumcision.com/ (accessed November 3,
2019).
87
See American Society of Plastic Surgeons (ASPS). (2019). Vaginal rejuvenation surgical options. ASPS.
Available at https://www.plasticsurgery.org/cosmetic-procedures/vaginal-rejuvenation/labiaplasty (accessed
November 3, 2019). The data cited are from 2018.
88
Ungar-Sargon, op cit. note 73.
26
In the previous sections, we explored a range of empirical questions relating to the potential
benefits and risks of circumcision before versus after an age of consent. We argued that the
evidence for the medical benefits of circumcision is much less compelling than its strongest
advocates claim. We also noted that only a few of these alleged benefits would apply to children
below the age of consent. We then highlighted a number of problems with the arguments that
neonatal circumcision carries fewer costs or disadvantages, whether general, medical, or
financial. In the following section, however, we will simply grant for the sake of argument the
claim of NNMC proponents that the greatest balance of medical benefits over risks applies to
circumcisions performed in infancy, and especially the neonatal period, compared to
circumcisions performed later in life. We argue that even if one grants this claim despite the
contrary evidence surveyed above, it does not follow that NNMC is a morally acceptable practice.
A. Benefits
Circumcision Before Sexual Debut
The AAP was prompted to update its policy statement on NNMC in light of the three
aforementioned RCTs in sub-Saharan Africa that reported a reduced risk of female-to-male HIV
transmission following VMMC. Based on the inadequately supported assumption that this
reported benefit can be meaningfully extrapolated to NNMC in the US, the AAP 2012 Task Force
claimed that waiting until an age of consent to offer circumcision may be medically
disadvantageous insofar as a certain percentage of US adolescents become sexually active before
they can legally consent to sex.
89
But this claim needs to be put in context. Using data from the
US Centers for Disease Control and Prevention (CDC) concerning female-to-male HIV
transmission—and assuming for the sake of argument that the African data could be directly
applied to the US—the researcher Sarah Bundick has argued as follows:
If we assume that all 5,250 men who get HIV from a female sexual partner [per year] are not circumcised
(though this is certainly not the case), the data suggest that about half of these infectionsaround 2,625
infections or ~5% of new infectionsmay have been prevented if the men had been circumcised. If we
then factor in the number of men who are circumcised when they are infected (approximately 70-80% of
American men are already circumcised), the number of infections that could have been prevented by
89
AAP Task Force on Circumcision,Cultural bias and circumcision,” op cit. note 28, p. 803. The Task Force cites
CDC data from 2011 showing that sexual debut had already occurred by the age of 13 in 6.2% of high school
students.
27
circumcision drops considerably. Taken together, the data suggest that the number of HIV infections that
could be prevented in the US by promoting infant male circumcision is likely to be only in the hundreds per
year — a tiny fraction of the estimated 50,000 new HIV infections.
90
With respect to the specific claim of the AAP Task Force, it should be emphasized that
the sub-population of males that is both (1) sexually active before a legal age of sexual consent
and (2) at a meaningful risk of becoming infected with HIV (i.e., from either a similarly underage
female sexual partner or an older female committing statutory rape), is much smaller than the
sub-population analyzed by Bundick: a CDC study cited by the AAP Task Force shows that only
84 males ages 13-19 were infected with HIV via heterosexual contact in the entire US in 2010.
91
Indeed, the main driver of the HIV epidemic in the US is still homosexual sex between males
(63% of all new infections),
92
and there is no consistent evidence that circumcision—at any age—
prevents HIV in this subset of the population.
93
It is thus very different from the epidemic in sub-
Saharan Africa.
94
90
Bundick, S. (2009). Promoting male circumcision to reduce transmission of HIV: a flawed policy for the US.
Harvard Health and Human Rights Journal (online). Available at https://www.hhrjournal.org/2009/08/promoting-
infant-male-circumcision-to-reduce-transmission-of-hiv-a-flawed-policy-for-the-us/ (accessed November 3, 2019).
91
Centers for Disease Control and Prevention. HIV surveillance in adolescents and young adults, p. 7. Available at
https://web.archive.org/web/20120724001848/www.cdc.gov/hiv/topics/surveillance/resources/slides/adolescents/sli
des/Adolescents.pdf (accessed November 3, 2019). The AAP Task Force (op cit. note 28, p. 803) misleadingly
cites the total number of HIV infections for this age group (2,266), which comprises data for both sexes and all
vectors of infection.
92
Centers for Disease Control and Prevention. HIV in the United States: at a glance. Available at
http://www.cdc.gov/hiv/statistics/basics/ataglance.html (accessed November 3, 2019).
93
A 2008 meta-analysis performed by the CDC and the five largest studies exploring whether there was a link
between circumcision status and HIV prevalence or incidence in men engaging in homosexual activities failed to
find an association that was statistically significant. Millett, G. A., Flores, S.A., Marks, G., Reed, J.B., & Herbst, J.
H. (2008). Circumcision status and risk of HIV and sexually transmitted infections among men who have sex with
men. Journal of the American Medical Association, 300, 1674-1684, (Errata JAMA 2009; 301, 1126-9); Solomon,
S., Mehta, S., Srikrishnan, A., et al. (2015). High HIV prevalence and incidence among MSM across 12 cities in
India. AIDS, 29, 723731; Gust, D. A., Wiegand, R. E., Kretsinger, K., et al. (2010). Circumcision status and HIV
infection among MSM: reanalysis of a Phase III HIV vaccine clinical trial. AIDS, 24, 1135-1143; Jozkowski, K.,
Rosenberger, J. G., Schick, V., Herbenick, D., Novak, D.S., & Reece, M. (2010). Relations between circumcision
status, sexually transmitted infection history, and HIV serostatus among a national sample of men who have sex
with men in the United States. AIDS Patient Care & STD, 24, 465-470. Oster, A. M., Wiegand, R. E., Sionean, C.,
et al. (2011). Understanding disparities in HIV infection between black and white MSM in the United States. AIDS,
25, 1103-1112. Subsequently, a 2019 meta-analysis calculated that circumcised men were at lower risk, but their
findings are of questionable value considering the analysis also found evidence of between-study heterogeneity and
significant publication bias. Yuan, T., Fitzpatrick, T., Ko, N.-Y., et al. (2019). Circumcision to prevent HIV and
other sexually transmitted infections in men who have sex with men: a systematic review and meta-analysis of
global data. Lancet Global Health, 7, e436-47. When adjusted for these two factors, the difference was no longer
seen: Van Howe, R.S. (2019). Is circumcision an answer for HIV prevention in men having sex with men? Lancet
Global Health, 7(8):e1011.
94
For reasons already discussed, this is not to say that NNMC would necessarily be justified in those settings
(where the circumcision programs were originally framed as being voluntary); only that it may be particularly
unjustified in the United States and epidemiologically similar countries.
28
Even granting, therefore, that a tiny fraction of the annual cases of female-to-male
transmission of HIV in the US (and relevantly similar contexts) may occur in adolescents under
the age of 15, likely engaged in unprotected sex, it is unclear how this could justify the non-
voluntary removal of a psychosexually significant part of an individual’s body long before sexual
debut. Neonatally circumcised homosexual males—or heterosexual males who practice safe
sexwill receive virtually no HIV-related benefit whilst bearing the burden of unsafe choices
made by others. It is also worth remembering that circumcision is not a failsafe intervention: it
does not prevent HIV (or any other sexually transmitted infection). Rather, it may merely reduce
one’s risk of contracting the virus by around half per coital act, assuming (for the sake of
argument) that the African findings are both accurate and generalizable.
A more appropriate solution, then, would be to allow individuals to decide for themselves
whether or not to undergo circumcision when they are old enough to understand what is at stake.
If most decline to undergo the procedure even after being informed of its purported benefits, it is
not safe to assume, as some circumcision proponents do, that this is only because they want to
avoid the pain and disruption that accompany the procedure in later life.
95
Rather, these
individuals may place a positive value on their foreskins or on the state of being genitally intact,
or prefer alternative, less invasive, more effective means of preventing sexually transmitted
infections (STIs). Consider that if adult men were forcibly circumcised to lower their risk of STIs,
even on the paternalistic assumption that this was best for them, this would be seen as an
impermissibly coercive public health strategy, amounting to state-sanctioned assault and battery.
On the other hand, when infants—who are unable to offer any effective resistance—are forcibly
circumcised, this is framed as a legitimate means of promoting personal and/or public health by
advocates of NNMC.
96
Let us turn finally to the question of the legal age of consent. NNMC proponents seem to
assume that the age of consent for circumcision must be the same as the age of legal majority (18
years in most jurisdictions). By contrast, we argue that the age of consent for circumcision should
be no earlier than the age of consent to sexual relations, which ranges from 16 to 18 across US
states, often with close-in-age exemptions (so-called “Romeo and Juliet laws”). Such exemptions
allow for even lower age limits when, for example, both partners are minors.
97
Alternatively, in
discussing the age at which a child might be expected to provide their own fully informed consent
95
Morris et al., op cit. note 13, p. 10.
96
Morris, op cit. note 36.
97
See https://www.ageofconsent.net/states (accessed November 3, 2019).
29
for certain medical or surgical interventions, the AAP’s Committee on Bioethics suggested 14
years as a reasonable age.
98
Depending on the maturity, or perhaps the degree of sexual
experience of the minor (if any), something approximating this age might well be appropriate as
a lower limit for consenting to circumcision, consistent with the recent change in eligibility
criteria for VMMC set by PEPFAR. The underlying point is simply that the person whose sexual
or reproductive organ would be permanently affected by the procedure should have at least some
reasonably well-informed say in whether or not they want to undergo the procedure. This is
impossible in the neonatal period.
Cultural Benefits
Not all claimed benefits of circumcision before an age of consent relate to the medical aspects of
the practice. Some have pointed to potential cultural or even spiritual benefits: in some cultures,
for example, circumcision is commonly embraced as means of initiation that allows individuals
to be regarded as full members of the group in which they are raised.
99
Such sociocultural benefits,
it is proposed, are denied to those children who are not circumcised as early as possible: although
they will be able to choose circumcision for themselves—later on—if that is what they desire,
they will first have to go through childhood wondering why they look different to their peers,
possibly being subject to ridicule in the proverbial locker room, and so on.
However, this argument is problematic, even if it is simply stipulated that the underlying
empirical assumptions (about ridicule, etc.) are sound.
100
First, an argument of this form could be
98
Committee on Bioethics. (1995). Informed consent, parental permission, and assent in pediatric practice.
Pediatrics, 95, 314-317.
99
Benatar & Benatar, op cit. note 22, pp. 43-45. See also Schlegel, A., & Barry III, H. (2017). Pain, fear, and
circumcision in boys’ adolescent initiation ceremonies. Cross-Cultural Research, 51(5), 435-463. Note that
circumcision performed as a rite of passage into adulthoodi.e., around pubertycould in principle conform to
our proposed consent threshold, i.e., if the child were mature enough to appreciate what was at stake in the
initiation.
100
It is not clear that such a stipulation would be justified. Advocates of NNMC do not typically cite any evidence
that a child will in fact psychologically suffer if they end up being different from their peers in this particular
respect. There is also a question about who the relevant peers are, depending on the context. In most Western
countries where penile circumcision occurs, for example, it is usually limited to a minority sub-group, whereas
most individuals in the larger society (of which the circumcised child is ostensibly also a part) are not circumcised.
Assuming that the child is not entirely isolated from their non-circumcised peers, then, it could just as easily be
predicted that they will be teased for being circumcised. In short, the teasing argument only works under an
assumption of cultural homogeneity with high rates of circumcision; yet this is not the situation in most multi-
cultural Western societies where the ethical debate about NNMC is primarily taking place. Even in the US state of
Iowa, which has a relatively high rate of circumcision even for the USand where the only empirical study on
“locker room” teasing that we are aware of has been conductedthe data suggest that (1) penile size, not
circumcision status, is the main source of teasing, and (2) even if a boy is teased for not being circumcised, this
does not seem to cause much distress. In fact, “experiencing teasing or witnessing others being teased about penile
appearance did not have an effect on the desire for a different penile appearance [and] being uncircumcised did not
30
applied to any cultural practice—no matter how unjust or harmful—upheld by social norms that
stigmatize noncompliance. Second, whether NNMC really does confer a (net) cultural benefit
depends on how the affected individual personally relates to the culture or sub-culture of their
birth. Some may only identify with certain aspects of that culture; others may wish to reform it or
leave it altogether. Even if one accepts (which seems unlikely in the modern world) that most
individuals will not question the cultural commitments of their parents’ generation, it is far from
clear that the remainder will have been socially benefited by NNMC.
101
B. Costs
Impact on sexual function
As discussed earlier, proponents of circumcision are generally dismissive of claims that removing
the sensitive foreskin may affect sexual experience in a negative way or in a way that an individual
might reasonably resent. For example, in a review paper cited frequently by these proponents,
102
Morris and Krieger rate studies purporting to show that circumcision has no effect on sexual
pleasure (or even a positive effect) as being of higher quality, whilst they deem studies suggesting
otherwise to be of lower quality.
103
But as Bossio et al. point out, the coding scheme employed
by Morris and Krieger can be used in a questionable manner: for example, Morris and Krieger
assigned the highest possible quality rating to a study of which one of them (Krieger) was the
lead author,
104
despite the seemingly clear conflict of interest involved in assessing one’s own
increase the rate of personally experienced teasing.” Alexander, S. E., Storm, D. W., & Cooper, C. S. (2015).
Teasing in school locker rooms regarding penile appearance. The Journal of Urology, 193(3), 983-988, at 985.
101
Ungar-Sargon, op cit. note 73; The Pew Forum on Religion & Public Life. (2008). US religious landscape
survey religious affiliation: diverse and dynamic. Washington, DC: Pew Forum on Religion & Public Life.
102
Morris, B. J., & Krieger, J.N. (2013). Does male circumcision affect sexual function, sensitivity, or satisfaction?
— a systematic review. Journal of Sexual Medicine, 10(11), 2644-2657.
103
Boyle, G. J. (2015). Does male circumcision adversely affect sexual sensation, function, or satisfaction? Critical
comment on Morris and Krieger (2013). Advances in Sexual Medicine, 5(2), 7-12. The author reply is available at
the journal website.
104
Krieger, J. N., Mehta, S. D., Bailey, R. C., Agot, K., Ndinya-Achola, J. O., Parker, C., & Moses, S. (2008).
Adult male circumcision: effects on sexual function and sexual satisfaction in Kisumu, Kenya. Journal of Sexual
Medicine, 5, 26102622. According to Frisch (2011),it should be recalled that a strong study design, such as a
randomized controlled trial, does not offset the need for high-quality questionnaires. Having obtained the
questionnaires from the authors … I am not surprised that these studies provided little evidence of a link between
circumcision and various sexual difficulties. Several questions were too vague to capture possible differences
between circumcised and not-yet circumcised participants (e.g. lack of a clear distinction between intercourse and
masturbation-related sexual problems and no distinction between premature ejaculation and trouble or inability to
reach orgasm). Thus, non-differential misclassification of sexual outcomes in these African trials probably favored
the null hypothesis of no difference, whether an association was truly present or not.” Frisch (2012). Author's
Response to: Does sexual function survey in Denmark offer any support for male circumcision having an adverse
effect? International Journal of Epidemiology, 41(1), 2012, 312314.
31
work, while also failing to engage with or even mention the published criticisms of the study’s
materials.
105
Even more questionably, they assigned the highest possible quality rating for a study
of its kind to a single paragraph in a popular book by Masters and Johnson, referring to an
experiment purporting to show no difference in penile glans sensitivity between circumcised and
non-circumcised individuals.
106
Yet the study was never subjected to peer review, and the
paragraph provided no details of the tools, methodology, or statistical procedures used, when this
information is absolutely required for properly evaluating claims of a “null effect.”
107
But even if one simply accepts the ratings assigned by Morris and Krieger, their own
interpretation of the evidence does not support NNMC. This is because the studies they judge to
be of the highest quality, which according to them “suggest that medical male circumcision has
no adverse effect on sexual function, sensitivity, sexual sensation, or satisfaction,” concern
consensual, adult circumcision, not circumcision of newborns. If anything, then, the review by
Morris and Krieger supports the performance of voluntary circumcision after an age of consent:
for it is circumcision of this kind for which the evidence against adverse sexual outcomes is, by
their own account, the strongest.
Of course, comprehensively assessing both the objective and subjective sexual outcomes
of NNMC in a nuanced, scientific way is exceedingly difficult, and as such has never been
done.
108
So the question might best be put in terms of the burden of proof. Arguably, this lies with
those who propose to excise healthy tissue from the penis, especially when the person who would
undergo this procedure is unable to provide their own consent.
109
We suggest that the arguments
and evidence of NNMC advocates fall far short of meeting this burden. For one thing, proving a
negative claim about adverse sexual outcomes is practically impossible: an absence of evidence
105
Krieger also appears to have a patent pending for a circumcision device of which he is the lead inventor:
https://patents.google.com/patent/WO2013173804A1/ko (accessed November 3, 2019).
106
Masters, W., & Johnson, V. (1966). Human sexual response. Boston, MA: Little Brown & Co, 189-91. The only
study information provided is as follows: “A limited number of the male study-subject population was exposed to a
brief clinical experiment designed to disprove the false premise of excessive sensitivity of the circumcised
glans. The 35 uncircumcised males were matched at random with circumcised study subjects of similar ages.
Routine neurologic testing for both exteroceptive and light tactile discrimination were conducted on the ventral and
dorsal surfaces of the penile body, with particular attention directed toward the glans. No clinically significant
difference could be established between the circumcised and the uncircumcised glans during these examinations.”
107
See Harms, C., & Lakens, D. (2018). Making 'null effects' informative: statistical techniques and inferential
frameworks. Journal of Clinical and Translational Research, 3(Suppl 2), 382-393.
108
Johnsdotter, S. (2013). Discourses on sexual pleasure after genital modifications: the fallacy of genital
determinism (a response to J. Steven Svoboda). Global Discourse, 3(2), 256265. See also Darby, R., & Cox, L.
(2008). Objections of a sentimental character: the subjective dimensions of foreskin loss. Matatu, (37), 145-168.
109
Adler, P. (March 30, 2016). Resolving circumcision controversies: the burden of proof and the benefit of the
doubt. Circumcision and the Law Blog (blog). Available at
https://circumcisionandthelawblog.wordpress.com/2016/03/30/resolving-circumcision-controversies-the-burden-of-
proof-and-the-benefit-of-the-doubt/ (accessed November 3, 2019).
32
is not the same thing as evidence of absence unless one has accurately, robustly, and
systematically measured all such possible outcomes with sufficient statistical power to detect
them, should they exist.
110
Obviously this has not occurred. Moreover, there are many aspects of
the foreskin that are not yet fully understood,
111
and increasing evidence that circumcision likely
does alter subjective sexual experience in a variety of ways.
112
These alterations might not always
be judged negatively: some men circumcised as adults, for instance, have indeed reported no
difference or even an increase in sexual satisfaction, while other men have noted a clear
decrease.
113
The point is that no one other than the owner of the penis is better positioned to
determine whether they wish to assume the risk that circumcision might permanently compromise
their sexual enjoyment. A person who seeks circumcision in adulthood also has the advantage of
being able to explain to the surgeon exactly how they want the procedure performed. They are
able to choose the “style” of cut that conforms to their own aesthetic preferences (e.g., “high and
tight” or “low and loose”),
114
and because their penis is fully grown, the surgeon will be able to
determine with precision its final or stable anatomy, vasculature and innervation.
115
In infancy,
the penis is very small and the surgeon cannot know how big the organ will grow or exactly where
to do the cutting in order to obtain the desired cosmetic result. Because this is essentially a guess,
too much tissue is sometimes removed, as we noted earlier; or indeed too little tissue, such that
re-operation may be pursued.
116
Ignoring consent
NNMC proponents, both “strong” and “weak” (Box 2), argue that the requirement for consent
should not apply to the person being circumcised, but instead to their parents. Parents are regularly
required to make decisions for their children, this argument holds; why should circumcision not
be one of them? As noted, we agree that parents should (or may) make many decisions on behalf
of their children, but there are also certain decisions parents may not make on their behalf. The
110
Boyle, G. J. (2018). Proving a negative? Methodological, statistical, and psychometric flaws in Ullmann et al.
(2017) PTSD study. Journal of Clinical and Translational Research, 3(Suppl 2), 375-381.
111
Martín-Alguacil et al., op cit. note 64.
112
See for instance Sorrells et al., op cit. note 67., cited above. See also Frisch, M., Lindholm, M., & Grønbæk, M.
(2011). Male circumcision and sexual function in men and women: a survey-based, cross-sectional study in
Denmark. International Journal of Epidemiology, 40(5), 13671381; Earp, op cit. note 67, and Martín-Alguacil et
al., op cit. note 64.
113
Kim, D., & Pang, M. G. (2007). The effect of male circumcision on sexuality. BJUI,, 99(3), 619-622.
114
Savulescu, J. (2013). Male circumcision and the enhancement debate: harm reduction, not prohibition. Journal
of Medical Ethics, 39, 416-417.
115
Earp & Darby, op cit. note 71.
116
Krill, A. J., Palmer, L. S., & Palmer, J. S. (2011). Complications of circumcision. The Scientific World Journal,
11, 24582468.
33
question is: to which category does the circumcision decision belong? One might attempt to
answer this question by considering other kinds of bodily alterations that are already seen as off-
limits in Western societies, and then triangulating between these cases and circumcision to see
where the latter falls. Consider the example of tattooing. In many Western jurisdictions, it is
illegal to tattoo a child’s body, presumably because this permanently alters their body in a way
the child may later reasonably regret or resent, before they are able to offer any meaningful
consent.
117
In such jurisdictions, therefore, it would be illegal to tattoo a child’s foreskin. Yet if a
parent wanted to cut off the foreskin entirely, and then tattoo it, this would be permitted under
current norms and standards. NNMC therefore seems anomalous when compared to other
medically unnecessary child body modifications.
Against this view, it might be argued that NNMC, but not tattooing, carries at least some
medical benefits (even if it is not clear that these benefits outweigh even the strictly medical risks,
as previously discussed). This, then, could explain why the former is forbidden but the latter is
not. So let us consider a different example, that of labiaplasty. Labiaplasty is similar to
circumcision in that it removes genital tissue that is not necessary for sexual enjoyment but which
nevertheless has certain properties—sensitivity to touch, elasticity, independent manipulability,
and so forth—that allow for particular subjective sensations, during sex or foreplay, for example,
that many people value positively. It is also similar to circumcision in that the genital tissue it
removes is often warm and moist and may trap bacteria, can become infected or even cancerous,
may be injured or torn during sexual activity, and requires regular washing to maintain good
hygiene. Removing the labia, therefore, likely does confer at least some statistical health benefits
in that it reduces the surface area of genital tissue that is not essential for sexual function (in some
narrow sense) but which may on occasion pose a problem of one kind or another for its owner. In
addition, it may plausibly confer at least some psychological or social benefits for some women,
insofar as they prefer the aesthetics of a vulva that has been subjected to labiaplasty, or if it helps
them avoid negative judgments from potential sexual partners (however inappropriate such
judgments may be). Indeed, the World Health Organization (WHO) includes such broader
psychosocial factors in its definition of health, so perhaps these potential outcomes should be
counted as “health benefits” as well.
Now, let us assume for the sake of argument that performing labiaplasty in infancy is
technically simpler, safer, and more cost effective—with a shorter healing time, and so on—than
117
Chegwidden, J. (2009). Response: Tasmanian Law Reform Institute Issues Paper No. 14: Non-therapeutic male
circumcision, 1-79.
34
labiaplasty performed on a consenting adult. Would any of these considerations, alone or together,
make non-voluntary neonatal labiaplasty permissible, either morally or legally, in Western
societies? It seems unlikely. As one of us has argued elsewhere, even if health benefits of some
kind or degree do one day become reliably associated with neonatal labiaplasty, it is almost certain
that opponents of the practice (which includes the WHO, the United Nations, all Western
democracies, and the present authors) would continue to see clear moral problems:
First, they would argue that healthy tissue is valuable in-and-of-itself, so should be counted in the “harm
column simply by virtue of being damaged or removed. Second, they would point to non-surgical means of
preventing or treating infections, and suggest that these should be favored over more invasive methods. And
third, they would bring up the language of rights: a girl has a right to grow up with her genitals intact, they
would say, and decide for herself at an age of understanding whether she would like to have parts of them
cut into or cut off.
118
The same arguments, we suggest, apply to NNMC.
Irreversibility
What about non-physical ways of shaping of a child? Eldar Sarajlic has contrasted circumcision
with religious indoctrination. He notes that while parents are permitted to raise their children
within a particular religion, there is nothing inherently irreversible about religious indoctrination
(he argues, however, that religious indoctrination is only acceptable if certain efforts are made to
expose children to other ways of thinking outside the home).
119
In any event, a great many people
raised within a particular religious or cultural tradition later abandon certain associated beliefs
and practices.
120
With circumcision, however, no such abandonment is possible. As an analogy,
imagine that Christian parents wanted to tattoo “a Christian cross on their child’s body; the fact
that the child can later distance himself from Christianity does not make the tattoo legitimate and
we could understand his upset about having to carry this religiously imposed, permanent mark,
which [he] might understandably perceive as overstepping a boundary (and therefore as
abuse).”
121
118
Earp, B. D. (2017). Does female genital mutilation have health benefits? The problem with medicalizing
morality. Journal of Medical Ethics Blog. Available at https://blogs.bmj.com/medical-ethics/2017/08/15/does-
female-genital-mutilation-have-health-benefits-the-problem-with-medicalizing-morality/ (accessed November 3,
2019).
119
Sarajlic, E. (2014). Can culture justify infant circumcision? Res Publica, 20(4), 327-343.
120
The Pew Forum, op cit. note 101.
121
Möller, K. (2017). Ritual male circumcision and parental authority. Jurisprudence, 8(3), 461-479, p. 472.
35
This irreversibility is a cost that must be taken seriously. Some NNMC proponents
compare this with the cost that a genitally intact person must bear if they decide to undergo
circumcision later in life,
122
but a fundamental asymmetry remains. Any person who was not
circumcised, but wishes to be, can undertake the surgery voluntarily. A person who was
circumcised without their consent and who resents what was done to their body, by contrast, has
no ethically comparable recourse.
123
It is true, as discussed earlier, that choosing circumcision in later life is not cost-free: one
must take time off school or work and refrain from sexual activity for a number of weeks.
However, older children and adults currently seem willing to take time off work for other valued
projects (e.g., going on a vacation) or to refrain from sexual activity after other elective surgeries
(e.g., a vasectomy or a labiaplasty). It is unclear why circumcision should be treated as a special
kind of burden. Moreover, NNMC proponents do not account for comparable disruptions in the
neonatal period. The developmental needs of an infant are very different to those of an adult.
However, since the infant cannot report on these needs, there is an epistemic asymmetry. Adults
are in a position of being much more aware of—or more easily able to imagine—the kinds of
disruptions they would incur. Such disruptions are therefore easier to identify and perhaps to
measure. But this does not entail that disruptions for the infant are any less significant; there is
simply not enough quality research into the question.
Vaccination analogy
NNMC proponents often liken the procedure to a vaccination, which as Morris et al. point out, is
“similarly performed before the child is old enough to consent and which carr[ies] similar risks
of complications.”
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However, even if the likelihood of complications is similar between the two
procedures (we are not suggesting this is actually the case), the kind of complications will often
be dissimilar—for example, an allergic skin reaction versus a genital laceration—and different
people may assign different weights to such variable complications. Moreover, in the case of
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Benatar & Benatar, op cit. note 22, p. 37.
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They may attempt one the various techniques of so-called foreskin restoration (whereby weights, tapes, or other
devices are attached to the remaining penile shaft skin over several months or years to attempt to stretch it forward)
but this is really misnomer. The foreskin is not actually restored; nor are the specialized nerve endings that were
excised with it. Rather, a pseudo-foreskin is at best created, which some individuals evidently judge to be better
than no foreskin at all. See Schultheiss, D., Truss, M. C., Stief, C. G., & Jonas, U. (1998). Uncircumcision: a
historical review of preputial restoration. Plastic and Reconstructive Surgery, 101(7), 1990-1998. For