Extenuating Circum Stances, Pt. 3: Science and Tradition

Since the 1970s, routine MGC has seen a steady increase in opposition. According to social anthropologist Kirsten Bell, “the anticircumcision movement began to gain ground in the 1980s, with the publication of Edward Wallerstein’s (1980) respected Circumcision: An American Health Fallacy.” Since Wallerstein’s work, several groups have sprouted in the U.S. dedicated to eradicating unnecessary MGC, such as the National Organization of Circumcision Information Resource Center, or NOCIRC,[1] and the National Organization to Halt the Abuse and Routine Mutilation of Males, or NOHARMM.[2] Both organizations claim that they are aiming to make the world safer for children through education and activism. In more recent years, the word intactivism has been used to represent those in the U.S. who oppose routine neonatal MGC. Many intactivists argue that the procedure is not only unnecessary, but that the practice is child abuse in the form of genital mutilation, and that it denies the child of his inherent right to an intact penis (D’Arcy 2012). Additionally, others may stress the significant physical and emotional trauma that occurs as a result of the procedure (Schwartzman 2013).

MGC presents a unique meeting place for science and tradition. In other fields of medicine, scientific inquiry and research results tend to influence practice. As evidence accrues for a particular outcome, old practices are discarded and new, and hopefully safer, practices take their place. Oddly enough, this model does not fit the history of MGC in the U.S. Instead, the American Association of Pediatrics (AAP) has gone back and forth on their views of circumcision over the years, resulting in confusion both in the medical community and the public at large. MGC became a standard practice for the prevention of disease, included among them the practice of masturbation, starting in the mid to late 19th Century. By 1920, the practice had become so standardized it wasn’t questioned and was considered standard practice without parental consent in many American hospitals (Gollaher 2000:172). Under pressure from opposition in the 1970s, the AAP reviewed what little evidence there was and decided that there was no absolute medical reason to circumcise (Bell 2005: 128). The AAP maintained this position, with some slight variations across the years, until mid-2012, when the group released the following stance: “A recent analysis by the AAP concluded that the medical benefits of circumcision outweigh the risks” (AAP 2013). The group stopped short of actually endorsing the practice of routine neonatal MGC, but its change in position incited fury amongst those who oppose MGC. The change in statement also meant that the AAP’s position now stands in opposition to the positions of national programs in other medically advanced societies including Canada, the U.K., Sweden, and Australia.

Additionally, the AAP’s stance seems to go against the evidence of modern medical research. While there is a positive correlation of MGC with a reduction in penile cancer rates in clinical research, worldwide rates of such cancer are so low, that the results are mixed. The majority of Swedish men, for example, are uncircumcised and have some of the lowest rates of penile cancer in the world. Additionally, penile cancer is so rare, that using it as justification for prepuce removal is a less rational argument than encouraging the removal of breast tissue to prevent breast cancer in females. As medical TV show co-host and pediatrician Jim Sears stated, “More babies die from getting circumcised than men die from getting penile cancer.” To risk not pointing out the obvious: penile cancer is a skin cancer; surely removing one-third to one-half of the total skin of the penis reduces the risk of contracting the disease.

In 1993, Edgar Shoen of the AAP stated the MGC should be considered “analogous to immunization in that side effects and complications are immediate and usually minor, but the benefits accrue for a lifetime” (Shoen 1993). This statement was made in direct relation to “conclusive evidence” that MGC resulted in a reduction of the risk of urinary tract infection (UTI) in males. While this appears to be the case, UTIs are much less common in men than women – “By one year, UTIs become ten times more common in girls… [and between] twenty and fifty years of age, women’s incidence of UTIs is fifty times greater than men’s” (Gollaher 155) – and the AAP does not recommend genital cutting of females for prevention.

Looking at the arguments for MGC and the prevention of other diseases, including HIV, cervical cancer, and gonorrhea, the evidence is problematic at best. Within certain regional or cultural groups, men who have undergone MGC may show lower rates of HIV and other sexually transmitted infections (STIs), but this does not hold looking across or comparing between cultural groups. For instance, the U.S. has higher rates of MGC and STIs compared to European countries such as Germany and the U.K. Additionally, cut men tend to have more partners and perhaps even participate in more adventurous sexual activity, which increase risk the of contracting and spreading STIs. This makes finding a direct causal relationship with MGC tenuous.

MGC’s secular history in the U.S. is rooted in the late Victorian era when a number of doctors and other medical professionals endorsed the practice as a cure for many things, among them masturbation. The inventor of the corn flake, John Harvey Kellogg, is an important player in both MGC and FGC practices in the U.S., as one of the staunchest defenders of both practices for moral hygiene. He also advocated for the surgery to be administered without anesthesia, so the patient associated pain with his or her genitals (Bell 2005; Gollaher 2000). Attitudes about masturbation, and the wide array of mental and emotional disorders that genital cutting was believed to cure, have evolved significantly since the late 19th Century, and while the practice of clitoral cauterization and other forms of FGC have disappeared in the U.S. over time, MGC remains a tradition of birth medicine.

Despite the lack of conclusive evidence that MGC has any medical benefits that would justify its persistence, the U.S. stance on circumcision emphasizes placing trust in the hands of the medical establishment. This becomes an issue when doctors and surgeons are seen as having authoritative knowledge, yet when discussing this surgery, they stress the benefits and not the risks. Where scientific authority has failed to confirm the benefits, they place the onus on the parents, who turn back to the medical establishment for guidance. This vicious cycle benefits no one and may result in the continuation of an unnecessary surgical practice.

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[1] http://www.nocirc.org/
[2] http://www.noharmm.org/

Extenuating Circum Stances, Pt. 2: Male Genital Cutting

MGC is a medical enigma. It is the oldest known surgery in recorded history, with the oldest depictions of priests cutting the foreskins of young men being found on the walls of the necropolis of Saqqara in Egypt. These reliefs date back to 2400 B.C.E. and while they are the oldest known images of the practice, the surgery certainly dates back further in time. It remains unknown what the impetus for the practice was, but it certainly began before medical science and religious ideology were distinctly separate fields. While many may ponder on the originating factor – whether it was for cleanliness, hygiene, aesthetics, chastity, therapy, or something else entirely is the matter of an entirely different debate – perhaps the more puzzling element of the practice is its long history of pervasiveness, particularly into modern, medically advanced societies. This is particularly true considering that for much of its existence, the practice has been confusing, unnecessary, and even offensive to those who don’t practice it: the Romans forbade it; the Greeks jeered at it (they emphasized the beauty of a long prepuce in much of their art and found the exposure of the glans to signify sexual arousal); modern day ‘intactivists’ claim that it is a sex crime.

It is important to note that MGC goes far beyond the traditional notions of routine neonatal circumcision that are withheld in the U.S. The typical American idea of MGC is a removal of the prepuce only, which is often thought of as being just a little bit of skin at the end of the penis. In truth, the procedure removes a third to one half of the entire skin on the penis. In other forms of MGC practiced around the world, such as in parts of Africa, Australia, and the Pacific islands, cutting can involve making slits in the prepuce, piercing the foreskin, or even slitting the urethra in part or in whole along the ventral shaft of the penis (Bell 2005:126). Because these forms of MGC are not as common or as widely known or discussed, many people have difficulty drawing a connection between MGC and FGC. However, one commonality is clear: a variety of genital cutting forms are practiced that range in severity of cuts and medical complications.

‘A COVENANT WITH GOD’

It is estimated that 30% of men worldwide today are circumcised. Two-thirds of the total population is Muslim. The remaining one-third is comprised of men in specific geographic locations where MGC exists as a social norm: the United States, Canada, Israel, and New Zealand. It is no secret that Islam and Judaism call for MGC. As both are Abrahamic religions, the originating scripture in Genesis is interpreted literally and expressed in present day as a symbol for one’s sacrificial covenant with the Hebrew God: “Every male among you shall be circumcised, You shall be circumcised in the flesh of your foreskins, and it shall be a sign of the covenant between me and you.”[1]

Without doubt, this tradition is seen as carrying over into the third Abrahamic religion, Christianity, particularly among Protestant groups in the United States and Great Britain. Keeping the covenant, however, is not a requirement for Christians, according to the apostle Paul as written in the New Testament. Paul clearly states, “In Christ, neither circumcision nor uncircumcision counts for anything.”[2] According to the New Testament book of Luke, Jesus was circumcised, which is not a surprise to most, considering that Jesus was Jewish. For this reason, he would have kept with many, if not all, of the laws of old. What is more surprising, perhaps, is that genital cutting never appeared in any of Jesus’ teachings. This is important in understanding the drivers behind the practice as it spread in Western Europe, Australia, the United States, and Canada in the 19th and 20th centuries. It is worthy to also point out the gender bias in the Old Testament: women were left out of the covenant of genital cutting. Jesus, Paul, or the authors of the books of the New Testament may have specifically left out discussion of MGC in Christianity to include women in the new covenant, which focused largely on baptism, a gender inclusive practice.

Metzitzah b’peh, or oral suction, is the Jewish tradition whereby the mohel, or ceremonial circumciser, places the cut penis in his mouth and sucks the blood to prevent infection. This practice continues today in some Orthodox Jewish groups, including those in the U.S., and has been the source of much controversy in recent years. Opponents of the practice claim that there is an increased risk of spreading herpes and other sexually transmitted infections to the infants. Furthermore, some claim the act is sexually exploitative and is, in fact, a sex crime. Proponents argue that the practice “lowers the internal pressure in the tissues” of the penis, allowing for the wound to heal more quickly and with decreased risk of infection. In addition to these medical benefits, they claim that the practice has “deep religious significance” (Halperin 2012).

As recently as May 2013, controversies involving the practice of metzitzah b’peh (MBP) have populated the news in the U.S. and Germany. A rabbi in Berlin has been sued for performing the ceremony on his own son (Goldman, et. al. 2013) immediately on the tails of a recent court case from Cologne that nearly banned the practice of MGC for non-medical reasons entirely (Huffington Post 2012). Putting the risks associated with MGC in general aside, the New York City Department of Health has specifically linked 2 deaths and 13 cases of infant infection with herpes since 2000 with the practice of MBP (Goldman; Brady 2013). According to CNN, infant males who underwent MGC with MBP “between April 2006 and December 2011 had an estimated risk of contracting neonatal HSV-1 infection of 24.4 per 100,000 cases, [which is] 3.4 times greater than other infants” (Brady).

The aforementioned Cologne court case had nothing to do with MBP. In fact, the case involved a Muslim family that had a Muslim doctor perform the operation on their 4 year old son strictly for religious reasons. The boy’s penis began bleeding severely two days after the surgery and an investigation was launched when the admitting hospital contacted authorities. The court ruled that MGC was a violation of the child’s rights and, taking the rights of the parents and the right to religious freedom into context, decided that “the procedure was not in the best interests of the child” (Connolly 2012). Specifically, the court stated that the child’s body was “permanently and irreparably changed.” The ruling brought both Jewish and Muslim groups together to criticize the court, claiming that the court violated their religious authority and that it was “an attack on centuries of religious affiliation.”

Outside of these recent cases, MGC has been staunchly defended by religious groups, particularly Jewish and Muslim groups, for thousands of years. Dating back to early Roman, Greek, and Babylonian control over the Middle East, laws have been enacted that both ban and protect the practice. Some historians believe that the prevalence of MGC and the increased invasiveness of the procedure – initial practices only required a removal of part of and did not require the removal of the entire prepuce along with the practice of MBP – expanded to differentiate Jews from others during periods of exile.

Whatever the case, any arguments made for the medical benefits of MGC, are deeply rooted in religious and social practices dating back thousands of years. Many studies of medical benefits of MGC focused on the frequency of certain diseases and infections in Jewish populations.[3] The problem with these studies, however, is that they ignore the cultural factors that may influence the prevalence of certain medical problems more than circumcision. For example, Jewish men traditionally have fewer partners than non-Jewish European and men, who also tend to be uncircumcised. Still, it is important to understand the cultural factors at play and recognize that no discussion of circumcision is free from the influence of these complex dynamics. It is important to note, however, that even within Jewish communities, a spiritual ritual, brit shalom, has been founded that takes the place of ritual MGC, replacing it with a new ceremony complete with a naming ritual and prayers (Rosenblum 2009). Brit shalom is a way for Jews to adhere to the covenant without cutting the flesh of their children.

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[1] Genesis 17:10-11. The HarperCollins Study Bible, New Revised Standard Version. San Francisco: HarperCollins San Francisco, 1993.
[2] Galatians 5:6. The HarperCollins Study Bible, New Revised Standard Version. San Francisco: HarperCollins San Francisco, 1993
[3] See Weiss 1977; Poland 1990; Fleiss and Hodges 1996; and Laumann, Masi, and Zuckerman 1997, among others.

Extenuating Circum Stances, Pt. 1: Introduction

As the father to both a daughter and a son, I was struck by the oddity that, while I was asked by several people, including medical personnel and non-medical, interested parties, whether or not I was going to have my son circumcised, not a single person asked if I was going to have my daughter circumcised. Indeed, some people assumed that I was having my son circumcised without asking, as if leaving him uncircumcised was not an option. What is the basis for this assumption? Is it based on social, political, economic, religious, medical, or a combination of factors? And why is there not a similar assumption, or even a question, regarding circumcising our daughters? In order to answer these questions, an examination of circumcision must account for social, economic, religious, cultural, and other factors that have shaped the history and development of the practice, and the controversies that ensue, along the binary lines of gender.

While routine male circumcision is not seen as medically necessary by most medical associations in the world – more on this to come – routine, non-medical circumcision rates in the United States remain high. In fact, routine male circumcision remains the most common surgery in the United States[1] with over 1 million boys being circumcised each year. There is a decline in routine neonatal circumcision; the Centers for Disease Control and Prevention released a report in 2011 that showed a drop in newborn male circumcision from 62.5% in 1999 to 56.9% in 2008 using data from the National Hospital Discharge Survey.[2] Still, the United States stands alone as the last medically advanced nation to routinely perform this surgery on infants. In this sense, male circumcision is a uniquely American phenomenon with a complex history that intersects religious, social, political, economic, and scientific domains. The primary arguments for the widespread continuation of circumcision today tend to come from religious and social points of view, while the arguments against come primarily from scientific views, but economics also finds itself playing a unique part in the reduction of circumcision, particularly in the Western U.S., where immigration of Mexican and other Latin American individuals is high and some states have removed Medicaid coverage of the surgery.[3]

When it comes to the female genitals, however, the United States stands nearly as a whole at the opposite side of the spectrum. The majority of the world’s female circumcision occurs in Africa and several countries in Asia and the Middle East. The World Health Organization has estimated that about 101 million girls aged 10 and older have undergone female genital cutting (abbreviated FGC) in Africa alone.[4] The practice is largely encouraged for religious and social reasons, including ensuring chastity and proving the sexual purity of a girl to her husband. In the West, most opponents of FGC belie any notion of social benefits, insisting that the consequences for FGC far outweigh any possible benefits. And this is the essence of the controversy, what I refer to as “The West versus the Rest,” though, admittedly, this may not be the most accurate description. The debate over FGC is not simple by any means; on its surface it is a about female genitals, but deep down it is about culture, ideology, social status, and, indeed, gender relations.

For the purposes of remaining as neutral as possible while discussing the practices, controversies, and analysis of both male and female genital modification surgery, I have chosen to refer to both practices with the phrase “genital cutting.” While male circumcision is rarely referred to as male genital cutting (MGC), this phrase will be used to avoid confusion and to better compare it to the genital cutting practices of FGC. FGC, meanwhile, will be used to avoid underrepresenting the risks, procedures, or complications resulting from cutting female genitals (i.e., female circumcision) or overstating the horrors typically only associated with the more sever forms of FGC (i.e., female genital mutilation, or FGM). As will be discussed below, different groups prefer different terms depending on the specific cutting practice and its significance to their ideology or tradition.

[1] http://academicdepartments.musc.edu/surgery/divisions/pediatric/procedures/circumcisionhttp://academicdepartments.musc.edu/surgery/divisions/pediatric/procedures/circumcision

[2] http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6034a4.htm?s_cid=mm6034a4_w

[3] Bell 2005:129

[4] http://www.who.int/mediacentre/factsheets/fs241/en/index.html

Extenuating Circum Stances

I'm in the process of conducting some new anthropological research on the controversies surrounding male and female genital cutting. Note, I am choosing not to use the term circumcision where avoidable, instead relying on the more neutral phrase "genital cutting" as circumcision tends to denote only male foreskin removal and does not account for the wide range of surgical procedures performed on female genitals worldwide. Additionally, the phrase "genital mutilation," which is commonly used in the West to refer to female genital cutting (FGC) draws attention to the horrors of FGC, while not accounting for the less drastic acts of clitoral and clitoral hood "shaving" or "clipping" and FGC that only involves piercing. Not all FGC is as drastic as some groups make it out to be, which involves total infibulation, or the complete removal of the clitoris, outer and inner labia, and is followed up by the sewing shut of the vaginal opening leaving only a small hole for menstrual fluids and urine. While this does occur, if you read the posts to come, you will no doubt see that this is not the only form of FGC.

As a brief intro, I will include the abstract from my research here. I will be posting my introductory section within the next two weeks, followed, hopefully, by a section per week.

Abstract: To cut, or not to cut? That is the question. The arguments for circumcision, both male and female, while often coming from religious or ethical groups, state medical benefits that arise from removing the foreskin, clitoris, or labia. For many years, however, arguments have been made against circumcision denying those same benefits. Opponents of male circumcision often cite its barbaric nature and argue that the medical benefits are largely overstated. A common argument is that while the American Academy of Pediatrics (AAP) stated in 2012 that a decline in male circumcision could result in higher rates of urinary tract infections, HIV, and HPV in men, the AAP neglects to account for the lower overall rates of such issues in European and Asian countries with larger populations of uncircumcised men. Regardless of such arguments, the cultural and religious views of many individuals in the United States and many third world countries, particularly those with significant Abrahamic religious influence, continue to result in traditional infant male circumcisions. At the same time, in the United States, female circumcision and clitoridectomy are rare and may be considered by many to be heinous acts. This begs the question, then: what is the difference between male and female genital mutilation and why is one considered to be more cultural acceptable than the other? Additionally, what are the cultural beliefs that allow one group to not only largely accept genital mutilation but encourage it? The controversy surrounds the notion that genital circumcision, both male and female, particularly when concerning children and infants, is a human rights issue. This notion, however, is deeply divided along gender lines, along with economic, social, and religious lines.