9 10 240 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Robert Darby Subject The topic of the resource Circumcision history Description An account of the resource Archive of the work published by Robert Darby Creator An entity primarily responsible for making the resource Robert Darby Source A related resource from which the described resource is derived circinfo.org historyofcircumcsion.org Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Text Any textual data included in the document <div class="intro" id="intro"> <h3>Words of up-to-the-minute wisdom from Morris Fishbein MD, editor of JAMA from 1924 to 1949</h3> The quotes are from Morris Fishbein (ed), Modern Home Medical Adviser (New York: Doubleday, 1969) The speed of medical progress continues to be one of the marvels of our scientific century .... Many new and brilliant young authors have kindly associated themselves with me in this work. I express appreciation to them. Sex Hygiene: The Teaching of Sex to The Young Child Within the first few days of life the genital organs of the baby should be carefully examined for evidence of defects or abnormalities. In case such defects are found they should be corrected when possible, as such peculiarities are often responsible for irritations or abnormal stimulations which may greatly complicate the sexual life of the child when he or she is older. The tissues of the infant are still highly plastic, and it frequently happens that corrections made early are surprisingly successful for this reason. The boy baby should be carefully examined to see if he needs circumcision. If the foreskin can be completely and easily retracted most authorities think that circumcision should not be done, but when there is the least doubt about the matter, decision should be made in favor of the operation, which is a trivial one when done within the first week or two of life. Later it is somewhat more serious, but never dangerous when performed by a competent surgeon. When the foreskin is tight or adherent there will accumulate under it secretions which will produce bad odors and cause pain and itching. The girl baby also should be carefully examined for abnormalities. In the washing of the female infant, care must be taken. Sometimes the hymen may be ruptured by rough handling. While it is true that the presence of an intact hymen is by no means proof of virginity, or the absence of it proof of sexual experience, a large percentage of people still believe that such is the case, and so care must be taken to prevent an accident which might later put the baby, grown to womanhood, in an embarrassing position. Washing the parts should be done in such a way that the friction will not cause erotic stimulation and in this way lead the child to the habit of playing with herself. Crying babies, male and female, will nearly invariably hush when the genital organs are manipulated. This old, old trick of careless nurses and ignorant mothers, should never be practiced, as it may lead to masturbation. Masturbation is probably far less harmful than has been supposed. The routine care of a child should never be delegated to someone else when it is physically possible for the mother to see to it herself. pp. 83-84 Sex Hygiene: The School Child Frequently children will get into the habit of playing with or pulling at the genitals. Such children - both boys and girls - may be in need of a thorough examination by a competent physician. Not unlikely circumcision or other special corrective measure is needed. If there is no pathologic basis for the habit, the child should be taught that it is bad manners to behave in such a way and that an ugly habit may be formed. With help, rather than scolding, he may soon correct the ugly practice .... Little boys and girls are occasionally found to have developed the practice of masturbation. Normal children of this age will rarely go into excess unless they are being stimulated by some older person. p. 90 Sex Hygiene: Abnormalities of Sexual Function: Masturbation When children are kept busy with wholesome play, work and planning, and when they are loved and understood in matters such as these, a little masturbation may occur but will be speedily forgotten. Be sure the children are healthily tired when they go to bed. Be sure that there is no need of circumcision, or if there is that it is corrected. Be sure the organs are clean so that they will not be irritated by foul secretions. Be sure that tight underwear does not demand constant pulling at the clothing. p. 115 Sex Hygiene: The Hygiene of the Reproductive System: Cleanliness The first principle in the hygiene of the reproductive system is cleanliness. By this we do not mean to imply that lack of cleanliness will often jeopardize the physical health of the individual. Actually there is more danger that meddlesome methods of attaining cleanliness will cause disease than that lack of cleanliness will cause it. This is particularly true in the case of the woman. The reproductive organs must be clean if they are to be held in high regard; they must be free of odor; they must be wholesome; they must not offend. They are exceedingly important to the welfare of the race, the self-respect of the individual, and the happiness of the family. Washing of the external genitalia is extremely important. The external organs need washing and not the internal. Much harm has been done by the excessive use of antiseptic or even cleansing douches. The normal vagina nearly always contains germs. These germs are not only harmless, but actually beneficial, because they prevent the growth of other germs which can cause trouble. If they are frequently washed away with cleansing douches or inhibited with antiseptics, abnormal conditions may develop in the vagina, and trouble may ensure. Further more, strong antiseptics frequently irritate the mucous membrane and make it more susceptible to invasion by other bacteria. Sometimes, particularly in the male, it is impossible to hold down odors merely by washing the external genitalia. In some men the foreskin is so tight about the end of the penis that it cannot be retracted and the groove beneath it cleaned of the white secretion - known as smegma - which accumulates there. This secretion is of an oily nature and easily becomes rancid, producing exceedingly bad odors and also irritation of the mucous membrane. At the time of birth every male child should be carefully examined to determine whether or not he is in need of circumcision which consists of removing the foreskin. When done in the early days of life the operation is a trivial one. Later it is somewhat more serious, but never dangerous when performed by a competent surgeon. Even those who are not in need of circumcision should retract the foreskin and clean the groove beneath it carefully at least once a day. A child in need of circumcision is often made nervous by the irritation of the rancid secretions and will be constantly twisting, squirming, and pulling at himself. He may also develop the habit of masturbation as a result of the irritation which induces him to handle his penis. pp. 118-19 Care and Feeding of the Child: Development of the Infant If the baby is a male and has not been circumcised, the foreskin should be gently retracted and cleansed beneath. Several months may pass before this retraction can be completely accomplished and force should never be used. It is easier to care for the penis of a newborn who has been circumcised, but even then, the small amount of foreskin left should also be retracted and the edge of the glans, or head of the penis, cleaned daily. p. 198 <h4>NOTE</h4> Morris Fishbein (1889-1976) was the editor of the Journal of the American Medical Association from 1924 to 1949, the key years in which routine circumcision established itself in American medical culture. He published many popular books on health (unfortunately), and his autobiography (505 pages of it!) in 1969. The continuity of his views on the supposed irritation and smell provoked by preputial moisture with Victorian agonising over secretions and masturbation will be noted. Also striking is the difference in his attitude to the female genitals, which (unlike the penis) must not be washed too much lest the soap cause irritation. This seems rather more plausible than the strange proposition that the body's own natural moisturisers could irritate the skin. Further information <a href="http://xroads.virginia.edu/~1930s/PRINT/time/06_1937.html" rel="noopener" target="_blank">His photo on the cover of Time, 1937</a> <a href="http://www.britannica.com/ebi/article?tocId=9311256" rel="noopener" target="_blank">Encyclopedia Britannica entry</a> <a href="http://www.rense.com/general19/enemy.htm" rel="noopener" target="_blank">Morris Fishbein - AMA Enemy Of American Health</a> There are dozens of web articles along the lines of this one, all more or less claiming (inter alia) that a certain Harry Hoxsey invented a cure for cancer, but that Fishbein, as President of the American Medical Association, tried to buy the formula in order to suppress it. This appears to be a favourite myth of the alternative therapists, <a href="http://www.acahf.org.au/articles/ausscience6.htm" rel="noopener" target="_blank">as Dr Peter Bowditch notes</a>. One can well believe their claim that Fishbein had failed anatomy, however, as his Victorian views on sex and sexuality make all too sadly clear. Interestingly enough, Fishbein was the author of a book called Fads and Quackery in Healing, published in 1932; some sceptics might wonder whether routine circumcision was yet another example of the same. </div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Dr Fishbein's fantasies (1960s) darby Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Robert Darby Subject The topic of the resource Circumcision history Description An account of the resource Archive of the work published by Robert Darby Creator An entity primarily responsible for making the resource Robert Darby Source A related resource from which the described resource is derived circinfo.org historyofcircumcsion.org Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Text Any textual data included in the document <div class="intro" id="intro"> The following article was published in the Village Voice in June 1975. Sub-headings have been added for ease of reading. <h3>The argument over circumcision: The case against</h3> <h4>by Sylvia Topp</h4> Circumcision is the only preventive operation left in <div> American medicine; the automatic removal of tonsils, appendix and adenoids went out of style years ago. </div> If you're the parents of a boy, chances are you had him circumcised â€“ over 80 per cent of American parents do. And chances are you had him circumcised without giving it a second thought. But is there any other part of your child's body you would automatically let a doctor remove? And without an anaesthetic? I decided not to circumcise my son when he was born four years ago, and since then I have wondered why parents are so docile in accepting such a bizarre operation. It amazes me that they think nothing of letting their child experience, as one of his first sensations in life, what must be the horrible pain and traumatic shock of being held down and having apiece of his penis cut off. And they don't even ask why. In preparation for this article I read all the current journal literature on circumcision. I interviewed by telephone, at random, 10 per cent of Manhattan's obstetricians; I questioned many recent mothers of boys; and I talked to every man I could find who had either not been circumcised at all or had been circumcised later than infancy. <h4>The blame game</h4> What shocked me most was that over half Manhattan's obstetricians consider circumcision unnecessary. Yet they continue to circumcise over 90 per cent of the boys they deliver because they believe it's useless to try to convince the parents not to. In fact, most of them don't even try. Yet two-thirds of the mothers I interviewed said they would not have had their sons circumcised if their doctor had advised against it, and the others were not sure. <h4>Origins of circumcision</h4> The theories of the origin of circumcision are numerous and confusing. The practice is firmly based in history, which is one of the reasons no questions are asked. A practical theory is that the original people practising circumcision lived in arid conditions where the operation had appeal as a prophylactic measure against balanitis (inflammation of the head of the penis), since sand might collect under the foreskin and be hard to get out, given the scarcity of water (<a href="http://www.cirp.org/library/general/leitch1/" rel="noopener" target="_blank">Leitch 1970</a>). Some think circumcision stems from the primitive custom of carrying off parts of the body â€“ the Indians took skulls, others took genitals â€“ of a defeated enemy as a trophy or testimony of manly prowess in battle. It may also have roots in the ritual castration practised in ancient matriarchal religions, but since castration inherently (and sharply) limits the perpetuation and growth of a people, a token mutilation, such as circumcision, was found far more practical (Bolande 1969). Freud also viewed circumcision as a symbol of castration, but as an act perpetrated by the father out of fear and jealousy of the son. Others claim that circumcision represents a subconscious wish on the part of the male to become female. In some societies circumcision is performed to reduce what is considered excess sexual energy, thus having a civilizing effect; in others it proves an adolescent's ability to endure pain and thereby be accepted as an adult (<a href="http://www.cirp.org/library/general/morgan/" rel="noopener" target="_blank">Morgan 1965</a>). Circumcision is practised by only one sixth of the world's population â€“ throughout the near east and parts of Africa, among the Moslems of India and south-east Asia, by the Australian Aboriginals and some Polynesians, and by some Indians of north and south America (<a href="http://www.cirp.org/library/general/gairdner/" rel="noopener" target="_blank">Gairdner 1949</a>). <h4>Circumcision in the United States</h4> The American practice was taken from the Jews, who began arriving here in large numbers from eastern Europe at the end of the nineteenth century. Christians had not practised circumcision since the teachings of St Paul actually dissuaded them from it. And it wasn't until the twentieth century that doctors started developing theories that circumcision was medically beneficial. Although it caught on to some extent in England, Australia and Canada, the United States was the only western country where circumcision became really popular. It never became the prevailing custom in any European country but England. Its popularity has been decreasing in England, Australia and Canada for some years now, and I hope that America will soon join that trend. Although the <a href="http://www.cirp.org/library/statements/aap/" rel="noopener" target="_blank">American Academy of Pediatrics</a> issued a statement of policy in October 1972 which began: "Neonatal circumcision should not be considered a routine procedure", there has been little noticeable change in the circumcision policy in this country so far. <h4>Functions of the foreskin</h4> Because hardly anyone in this country has ever seen a foreskin, it might be well to describe its function. The foreskin protects the head of the penis, or glans, keeping it moist and sensitive at all times. It is drawn back during an erection or sexual intercourse (and for cleaning purposes), so the otherwise unexposed glans, which is provided with special sensory receptors for appreciating pleasurable sensations, is stimulated only during these times. During intercourse the foreskin is pushed back and forth, at times forming a wide ring at the base of the penis â€“ a sort of natural French tickler. When the foreskin has been removed, the head of the penis is constantly stimulated and loses much of its sensitivity; it dries out, and the skin becomes tough by necessity because it is constantly rubbing against clothing. Since, according to most people I asked, an uncircumcised penis affords more pleasure for both parties during sex, perhaps circumcision is part of a Puritan conspiracy to make sex ess enjoyable. Or, because the moistness of the uncircumcised penis acts as a natural lubricant during intercourse, perhaps circumcision is simply a vast Vaseline conspiracy! In a young child the foreskin protects he head of the penis from irritation by the ammonia in urine. Sometimes this irritation results in a meatal ulcer, a condition found only in circumcised boys. In addition, Ritter's disease (a staphylococcal skin infection) and meatal stenosis (a narrowing and obstruction of the opening of the urethra at the head of the penis) also occur only in the circumcised. <h4>Arguments for circumcision</h4> But what are the arguments most commonly advanced for circumcision? The diseases associated with an uncircumcised penis are phimosis, cancer of the cervix, and cancer foreskin the penis. But many doctors now think that these fears are based on false premises. Phimosis Phimosis, the inability to retract the foreskin, was found to be normal in infants; in four out of five six-month-old males, half of the one-year-olds and 10 per cent of the three-year-olds, the foreskin is still attached to the head of the penis (<a href="http://www.cirp.org/library/general/gairdner/" rel="noopener" target="_blank">Gairdner 1949</a>). At the age of four or five, separation can be completed, if necessary by gently manipulation or with a probe. Cervical cancer Cancer of the cervix was thought to be caused by an uncircumcised penis, since Jewish women rarely got the disease and nearly all Jewish men are circumcised. Many doctors have discredited this theory, however, In Germany, Scandinavia, Switzerland and Japan, where circumcision is the exception, the incidence of cervical cancer is the same or less than in the United States, where circumcision is the rule. A study in India showed that although Muslim women, whose men are usually circumcised in youth, did get less cancer of the cervix than the Hindus, the Parsee women and the Indian Christian women, who attach great importance to cleanliness, got even less cancer of the cervix than the Moslems, and their men are never circumcised (Khanolkar 1950). In England a study showed no difference in the circumcision status of the husbands of 54 cervical cancer patients and 54 controls (<a href="http://www.cirp.org/library/disease/cancer/aitken-swan1/" rel="noopener" target="_blank">Aitken-Swan and Baird 1965</a>), and an American study had similar results (Terris et al 1973). An investigation in Kenya revealed no significant differences in the number of cases of cervical cancer in women of tribes whose men were or were not circumcised (<a href="http://www.cirp.org/library/general/preston/" rel="noopener" target="_blank">Preston 1970</a>). In Ethiopia the incidence of cancer of the cervix is higher than or comparable to that of Europe and the United states, even though 90 per cent of Ethiopian males are ritually circumcised (<a href="http://www.cirp.org/library/general/leitch1/" rel="noopener" target="_blank">Leitch 1970</a>). Other variables, besides the absence of circumcision, have been associated with a high risk of developing cervical cancer. These include low socio-economic status, early marriage, multiple marriages, extramarital relations, coitus at an early age, frequent coitus, non-use of contraceptives, syphilis and multiparity [i.e. having many children] (<a href="http://www.cirp.org/library/general/preston/" rel="noopener" target="_blank">Preston 1970</a>). The assumption is that smegma, present under the foreskin, is cancer-producing. However, this disease was unaffected by the use of a condom, which should protect the women from smegma (<a href="http://www.cirp.org/library/general/leitch1/" rel="noopener" target="_blank">Leitch 1970</a>). At any rate, having a circumcised husband is no insurance against cervical cancer, since even virgins get it, as do women who only have sexual relations with circumcised men. Also, Jewish women are more susceptible mow than they were at the beginning of the century, a difficult fact to explain (Wynder et al 1954). Cancer of the penis Cancer of the penis, a rare condition, is the only serious disease related to lack of circumcision. Only seven cases of penile cancer have been reported in western countries in men circumcised in infancy (<a href="http://www.cirp.org/library/general/leitch1/" rel="noopener" target="_blank">Leitch 1970</a>). However, the Zulus have a high rate, even though they practise routine circumcision (Klauber 1973). [NOTE: In South Africa it is the <a href="http://www.historyofcircumcision.net./templates/pages/ritual_circumcision_in_south_africa.html" rel="noopener" target="_blank">Xhosa who practise circumcision</a>, traditionally on boys in their late teens, not the Zulus.] Again, attempts have been made to implicate smegma, an obvious approach, since it is secreted under the foreskin, and thus only by uncircumcised men. However, these researchers have always reported negative results (Weiss 1964; Heins et al 1958; Fishman 1942). It is seldom mentioned than women also have foreskins and smegma-producing glands, and face a more difficult problem keeping the clitoral region free from smegma (if indeed any women considers she is dong this at all), since the clitoris is such a small organ compared to the penis of the male. Yet, cancer of the clitoris is extremely rare. More likely other factors are more important in causing penile cancer: a noon-retractable foreskin, which is the case in over half the males having cancer of the penis (Hanash et al 1970); a congenitally tight or long redundant foreskin (<a href="http://www.cirp.org/library/general/leitch1/" rel="noopener" target="_blank">Leitch 1970</a>; Lenowitz and Graham 1946; Dean 1935; Wolbarst 1932); poor hygiene, promiscuity, lack of prophylaxis, and failure to obtain treatment for minor inflammatory penile lesions (Schrek and Lenowitz 1947). It would seem that if a man can retract his foreskin and does keep it clean, the risk of cancer is virtually removed (Jolly 1964; <a href="http://www.cirp.org/library/general/gairdner/" rel="noopener" target="_blank">Gairdner 1949</a>). In Scandinavia and Puerto Rico, where very few men are circumcised, the incidence of cancer of the penis is very low. Cancer of the penis can be treated if a doctor is seen right away. Most severe cases are not seen by any doctor until the disease is so far developed that it is too late to do anything. <h4>Preventive surgery an old fashioned fad</h4> Circumcision is the only preventive operation left in American medicine; the automatic removal of tonsils, appendix and adenoids went out of style years ago â€“ though more lives could be saved by routine appendectomy (advocated by nobody) than by routine circumcision. Also, bilateral simple mastectomy (removal of the breasts) in young girls would prevent far more breast cancer in later years than the penile cancer prevented by circumcision. "If a surgeon should perform one circumcision every 10 minutes, eight hours a day, five days a week, he would seem to be able to prevent one penile cancer by working steadily for between six and 29 years. Since a significant number of penile cancers are curable, still more time and labour might be required to prevent a fatality from this disease" (Marshall 1954). How many smokers pay any attention to the warnings about lung cancer? Most of them believe that the pleasure they get outweighs the higher risk of lung cancer â€“ a cancer far more deadly and non-treatable than cancer of the penis. Infection of the foreskin is another problem supposedly associated with non-circumcision. These infections are usually not serious, however, and not one of the uncircumcised men I interviewed mentioned any such problem. "Hygiene" is the most bizarre reason given for circumcision. What other part of your body would you consent to have surgically removed so that you would not have to wash it? Would you have all your fingernails and toenails pulled out so that dirt could not collect under them? Would you have your ear or your nose cut off so that you would not have to clan inside them? Surely the penis is an equally important part of the body, yet parents permit part of it to be cut off so that their sons will not have so much trouble cleaning it! <h4>Risks and complications</h4> The circumcision operation itself can result in infection and other complications; some complication occurred in 55 per cent of the babies in one study (<a href="http://www.cirp.org/library/procedure/patel/" rel="noopener" target="_blank">Patel 1966</a>). The infections following circumcision are usually mild, but thy can result in serious and sometimes fatal conditions, such as diphtheric infection of the wound, staphylococcal bronchopneumonia, staphylococcal septiceaemia resulting in osteomyelitis of the femur, tetanus, tuberculosis or urethritis (Byars and Trier 1958), and necrosis of the penis (Gallagher 1972). Other complications of circumcision arise from mistakes made by the doctor. They an result in deformity or dysfunction of the penis itself, and often require surgical repair. These include accidental amputation, cautery burns, bivalving of the glans, urethral fistula, concealed penis and erysipeloid infections (Burger 1974). Circumcision is often performed by inexperienced physicians or interns. One doctor says that on his daily hospital rounds in New York he frequently finds babies with ugly granulating wounds and others requiring surgical treatment to stop the bleeding. Many of these results are (more or less) remedied by the hospital staff without ever bringing them to the attention of the babies' parents. And then the pain and trauma of the operation should not be ignored. Although parents want to believe that the child will feel no pain, many doctors who have done circumcision operations vehemently deny this myth. It is normal for a boy to have an erection following the circumcision, which can separate the wound (Gottlieb). So on top of everything else, his first erection would be a painful one â€“ more trauma. Beside this, the head of the penis is at first so sensitive that it may bleed from rubbing on the diaper. <h4>Care of the uncircumcised penis</h4> An uncircumcised child must be properly cared for. First, it's not necessary (in fact, it's dangerous), to pull back the foreskin of a baby, no matter what your doctor tells you. The child does not need to be cleaned under the foreskin at this age. If his urine is coming out in a stream and not under pressure, then he is normal. If you forcibly retract the foreskin of a baby you can cause the head of the penis to be strangulated, a condition called paraphimosis, since the hole at that time is only large enough to allow urine to come through. It may be impossible to return the foreskin to its natural position, and the baby will have to be rushed to hospital for an operation. You can also tear the tissue that joins the foreskin to the head of the penis. When this tear heals the condition is called acquired phimosis: the foreskin and penis join together in scar tissue, making the foreskin non-retractable. After the age of four or five the area under the foreskin may be washed whenever the child bathes. No more attention has to be paid to cleaning this area than to cleaning other parts of the body. If someone suggested that you have your daughter circumcised, a custom practised fairly extensively throughout the world, with some medical backing even here, you would not say, "OK, why not?", but rather, "Why?" and expect a pretty good answer before you went ahead. Your son should be given as much consideration. The onus is on those who believe in circumcision to prove their case to you. Source: Sylvia Topp, "The argument over circumcision: The case against", Village Voice (New York), 16 June 1975, pp. 8-9 <h3>NOTE</h3> This article is interesting as one of the first protests against circumcision to appear in the popular press by a non-professional â€“ a New York journalist and mother who had been shocked at the idea of mutilating her child and who decided to look into the matter. The article is very much a product of its time, demonstrating how deeply decades of misinformation about the structure of the genitals and the causes of disease had seeped into popular understanding; even while rejecting the myth that circumcision was beneficial, the author accepted other myths â€“ that the origins of ritual circumcision lay in hygienic concerns (<a href="http://www.historyofcircumcision.net/templates/pages/the_riddle_of_the_sands.html" rel="noopener" target="_blank">the sand myth</a>), that the glans of the penis was particularly rich in pleasure sensing nerves, that the function of the foreskin was to preserve this sensitivity, that the foreskin had to be retractable by the time the boy was four or five, that sub-preputial moisture ("smegma") possibly was in some way harmful. (The reference to using a probe to separate foreskin from glans in a five-year-old boy is particularly unfortunate.) Today we would stress the ethical and human rights aspects of the problem â€“ the child's right to a whole body and to make his own decisions about his health, and the inherent value of the foreskin itself â€“ as paramount; yet Topp makes no more mention of these issues than the various medicos she diligently cites. Although the article cannot be taken as a reliable source of information about circumcision or advice on the care of the penis today, it is of great historical interest for three main reasons. First, it shows the poor state of 1970s medical knowledge about both the structure and function of the penis and the origins of diseases such as genital cancers (now known to be caused by a virus), and the extent to which doctors were still in the grip of Victorian myths. Second, it marks the point where the debate over the validity of routine circumcision moves out of the pages of the medical journals and into the popular media, no longer the exclusive preserve of the medically sanctified, but the property of an increasingly informed and critical public. Third, it indicates just how far, and in what ways, the debate over circumcision has advanced in the past quarter century; if there has been disappointingly little progress on the "pros and cons" side (enthusiasts still harp on about such hoary myths as cancer, venereal disease, phimosis) at least there is increasing awareness of the ethical issues and a willingness in major journals (such as the <a href="http://jme.bmjjournals.com/cgi/content/full/31/8/463">Journal of Medical Ethics</a>) to challenge the practice. </div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource A New York mother questions the doctors (1975) darby Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Robert Darby Subject The topic of the resource Circumcision history Description An account of the resource Archive of the work published by Robert Darby Creator An entity primarily responsible for making the resource Robert Darby Source A related resource from which the described resource is derived circinfo.org historyofcircumcsion.org Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Text Any textual data included in the document <div class="intro" id="intro"> <h3>US Doctor: No need to circumcise most boys</h3> The following article by Dr Roxanne Allegretti was published in the Freelance Star, Fredericksburg, Virginia, USA, in November last year. It shows that even in the USA, where circumcision of baby boys is still common, doctors are very critical of the custom and recommend that boys be left as nature made them. <h4>American doctor says routine circumcision of baby boys is wrong</h4> FOR THOSE OF YOU who read my last column and the letters to the editor that followed, you already know that my comments about anti-circumcision demonstrators at the recent American Academy of Pediatrics meeting in Washington D.C. were not well received. My column was about SIDS prevention, but I slipped in a little joke about the demonstrators being mostly "graying hippies" and having bumper stickers like, "Not Circumcised? You Lucky Stiff!" While I was trying to be funny, and make light of the controversy at our conference, I apparently offended people all over the U.S.A. and Canada. And all this for a column that wasn't even about circumcision. Obviously, people feel very strongly about this issue. The funny thing is, I agree with the demonstrators. I don't think circumcision should be routinely performed on newborns. I don't do circumcisions. I was trained to, and had to do them while still in the Navy. But in our area, unlike where I trained in California, Ob/Gyn doctors perform most circumcisions. Even if they didn't, I still would not perform them. Like the demonstrators, I believe that removing a healthy body part for cosmetic reasons is not appropriate. Well, let me rephrase that, because I have no problem at all with liposuction in a consenting adult. But in most cases of neonatal circumcision, we're talking about a helpless newborn losing a very sensitive part of the body for no good medical reason. Certainly there are religious reasons for some families -- more on that later. In the U.S.A., most people who choose to circumcise their newborns do because they think that that the penis looks "normal" that way and so that it will be cleaner. Neither of these reasons is valid. Isn't the "normal" penis the one that God created? Whatever happened to, "If it ain't broke, don't fix it?" In fact, 80 percent to 85 percent of the world's male population is not circumcised. So that is more "normal." I hear fathers say they worry that if their son does not have it done, he'll wonder why he doesn't look like his dad. Well, that is just as easy to explain as questions like, "Dad, why do you have hair there and I don't?" Or, "Dad, why do you have blue eyes and I have brown eyes?" Hygiene is also a non-issue for most people. There are rare cases, like soldiers out in the field for days and days without bathing, in which the uncircumcised penis is more prone to infection. [Ed: Unlikely â€“ <a href="http://www.historyofcircumcision.net/templates/pages/the_riddle_of_the_sands.html" rel="noopener" target="_blank">see The Sand Myth</a>.] But in most cases, boys who are "uncut" learn to care for their penises just like they learn to brush and floss their teeth, and it's no big deal. Let me mention that there are religious reasons for circumcision in the Jewish and Islamic faiths. I consider that to be very different than the routine circumcision done just because everybody else is doing it. In the Old Testament, circumcision is described as a symbolic act by which a Jewish male enters into a covenant with God. This is a long-standing tradition, and the bris ceremony is very important in the Jewish faith. However, I have learned that the practice is beginning to be questioned by many Jews (See <a href="http://www.jewishcircumcision.org/" rel="noopener" target="_blank">Jewish Circumcision Resource Centre</a>). It is unclear why Christians in Britain and the USA took up the practice, or why it occurs more in the U.S.A. than any other country in the world. There are Christian organizations such as <a href="http://www.catholicsagainstcircumcision.org/" rel="noopener" target="_blank">Catholics Against Circumcision</a> which state that the New Testament has passages that recommend against the practice. Several resources I read mentioned that the practice became more widespread in the late nineteenth century in the U.S.A., and was touted as a way to cure masturbation (which was thought at the time to cause insanity, blindness and all sorts of horrible things). The circumcised penis is certainly less sensitive, due to the loss of a ring of tissue near the tip of the foreskin, which is the most sensitive part of the penis. But, I'm not really seeing that this was a cure Anyway, routine circumcision goes on in many areas, despite the fact that the American Academy of Pediatrics, American Academy of Family Practitioners, and the American Medical Association have all published statements that do not support routine neonatal circumcision. These are echoed by medical organizations all over the world, including the Australian Association of Paediatric Surgeons, which put it like this: "We do not support the removal of a normal part of the body, unless there are definite indications to justify the complications and risks which may arise." As the American Academy of Pediatrics notes in its position statement, there are potential medical benefits, but they are minimal and do not outweigh the risks. (<a href="http://www.cirp.org/library/statements/" rel="noopener" target="_blank">You can read the statement online</a>.) There are definitely fewer urinary tract infections in male infants under 1 year of age who are circumcised. However, fewer than 1 percent of uncircumcised baby boys get UTIs, so the increased risk is still pretty minimal. The same goes for the increased risk of penile cancer in uncircumcised men. There is a slightly increased risk, but this cancer is quite rare. [Ed: The risk is increased <a href="http://www.cirp.org/library/disease/cancer/" rel="noopener" target="_blank">only if hygiene is badly negected and phimosis is present</a>.] Potential <a href="http://www.cirp.org/library/complications/" rel="noopener" target="_blank">complications of circumcision</a> are more likely and include bleeding, poor cosmetic results, adhesions (I see a lot of those), scarring of the urethral opening, infection, and very rarely, penile amputation or death. Then there is another issue I never thought about until I started researching this article. In the U.S.A., 1.2 million circumcisions are performed each year, yet this is considered a medically unnecessary procedure. The cost adds up to somewhere between $150 million to $270 million per year. Just think of how that money could be better spent! In Virginia, Medicaid still pays for circumcisions. If that money was saved, it could pay for many of the infant's immunizations, for example. Several states, including California, Arizona, Florida, Washington and Oregon, already have disallowed <a href="http://www.icgi.org/" rel="noopener" target="_blank">Medicaid coverage of circumcision</a>. Having to pay $100 upfront to be circumcised was certainly a big deterrent at my last practice in California. In California, circumcision is in the minority -- approximately 33 percent of newborns are having it done. In Virginia, it is still more widespread than that, but seems to be decreasing in popularity. (Exact numbers are difficult to come by, but I think we are in the range of 75 percent). It seems like I end almost every column this way: Be informed. Know the risks and benefits before you decide. If you choose to have the surgery performed on your newborn, be sure that analgesia is used. Lidocaine injected into the base of the penis is very helpful in reducing pain during the procedure. Also, giving the baby sugar on a pacifier decreases their pain response. Hard to believe, but even a few years ago it was routine practice not to use any analgesia or anesthesia for newborns being circumcised. Now, it's considered the standard of care. [Ed: It is difficult to avoid the pain, since it is not safe to give babies effective anaesthetics. Pain control is far easier in adults, as they can be given general anaesthetics and effective painkillers after the surgery. <a href="http://www.cirp.org/library/pain/" rel="noopener" target="_blank">Further information here.</a>] If you choose not to circumcise your son, you don't need to do anything special to care for the penis -- just normal bathing. Do not try to retract the foreskin! This should not be done until years later, and will happen naturally with time. For more information on care of the intact penis, see <a href="http://www.nocirc.org/" rel="noopener" target="_blank">Nocirc USA</a> <a href="http://www.cirp.org/pages/parents/" rel="noopener" target="_blank">Circumcision Information and Resource Pages</a> <a href="http://www.doctorsopposingcircumcision.org/" rel="noopener" target="_blank">Doctors Opposing Circumcision</a> Dr Roxanne Allegretti welcomes reader comments and questions. Write to her at Free Lance Star 616 Amelia St Fredericksburg, Virginia, 22401 USA email: <a class="__cf_email__" data-cfemail="3b555e4c48495454567b5d495e5e575a55585e484f5a4915585456" href="/cdn-cgi/l/email-protection">[email protected]</a>. <a href="http://fredericksburg.com/News/FLS/2005/112005/11132005/143815" rel="noopener" target="_blank">Free Lance Star</a> Fredericksburg, Virginia, USA 13 November 2005 <h2>Other American doctors agree with Dr Allegretti</h2> The following rather forthright letter was sent by Dr Chris Fletcher, a doctor in Santa Fe, New Mexico, to parents who sent him the following inquiry: Dr. Fletcher, My wife Lycia is the daughter of Tom and Julie ..., who are friends of yours, I believe. They mentioned that you are a strong opponent of circumcision. We have a baby boy due at the end of March and are debating that very issue. If you have a minute or two, would you mind giving us your arguments? Thanks very much in advance. Regards, Eric ... Portland, OR <h4>Dr Fletcher replied:</h4> The issues regarding circumcision are both quite simple (just leave it alone) and very complex (why do American parents persist in "needing it", since it is basically a rare or unknown procedure most other places in the world). I would be happy, in order to save your son's natural or God-given genitals from a mutilator and real/potentially nasty side-effects, to spend a lot of time discussing this. In fact, when I got Tom and Julie's Xmas card mentioning that Lycia was pregnant and expecting in March (and a boy at that) I actually wondered whether circumcision would be an issue, and whether someone might contact me. Washington and Oregon states wisely restricted Medicaid monies, along with many other Western states (and a total of 16 at present), for unnecessary procedures, including newborn male genital mutilation (circumcision), so the kids from poorer families actually now get a better deal than the ones with private insurance! First, pick up the latest issue (September-October) of <a href="http://www.mothering.com/" rel="noopener" target="_blank">Mothering Magazine</a> -- two good articles, one by a mother of an intact 3 year old boy who very simply and persuasively argues the case against it, and the other, an article on legal issues which is partly an interview conducted by a reporter with me as the reportee. I am attaching a paper which I presented at Oxford several years ago exploring the issues of what American doctors actually tell their patients, charge, do for their own sons, believe, etc. That paper makes up part of the above article in Mothering. Then I would go to the best all-inclusive website (<a href="http://www.cirp.org/" rel="noopener" target="_blank">CIRP.org</a>) which has everything you would ever need to really understand the issues, the cons and whatever pros people have dreamed up, and which has won many important national and international awards for websites. After that, if you have any lingering issues or doubts, call me or email me again. Believe me, it is only a prowess and money issue for doctors. Only child molesters, perverts, or really uneducated physicians would in any way argue that it is a good thing. Still the two most common arguments are the 1950s one -- "Isn't it cleaner doctor?" -- what we call the cleaner wiener argument. And "I want my son to look like me". Both are really stupid and simplistic when you think about it: how can a cut/wounded/mutilated tissue be cleaner than the one all baby boys are born with, especially when you put the bleeding and now smaller penis stump in a diaper (full of clean things like urine and stool). What if your son has different eye color or looks like his mother or has dark hair instead of blond, etc... ? Do you remove eyes and put different colored ones in? Do fathers and their sons ever actually stand side by side (when they are old enough to speak and think rationally!), and compare their penises? Mine never did -- not my father, not my brothers, not my friends in the locker rooms, and not my own sons. (I ran track and was a swimming champion, so I have been around a lot of naked guys.) When I moved from Massachusetts in 1981, I was fully prepared, as trained, to continue mutilating little baby boys, but I was given articles at my clinic in Santa Fe which immediately made me seriously question what I was doing. Giving up a procedure which I thought I had learned as part of my fine training was an ego issue; the money was not, since I had never been paid for doing circs as a resident. Circumcision is not simply a little snip, but a major and brutal surgery on the most sensitive part of a male's anatomy, with lifetime consequences for all cut boys. Erectile dysfunction, increased infections in boys, such as multi-antibiotic resistant staphylococcus aureus (MRSA), lack of sensitivity, etc. <a href="http://www.cirp.org/library/general/laumann/" rel="noopener" target="_blank">The Lauman lifestyle study </a> (University of Chicago) mentioned in the first Mothering article was fascinating since it showed that circumcised men were more likely than uncircumcised (entire) men to need anal and oral sex, girlie magazines, X-rated movies, prostitutes, sex toys, masturbation, and were more likely to get syphilis and chlamydia, all simply the end results of seeking out avenues for stimulation because of the decreased functionality from lacking a foreskin and from the scarring caused by the mutilation itself. I prescribe many times more Viagra, Cialis, etc. for circumcised guys than normal men. Circumcision prevents no disease, and does not improve anyone, except perhaps certain Hasidic Jews (<a href="http://www.slate.com/id/2125225/" rel="noopener" target="_blank">see today's New York Times</a>) who mistakenly believe that God commanded them (and no other Jews, of course) to perform a certain weird type of circumcision in which the boy's penis needs to be sucked clean of blood by the circumciser. Several babies have recently died from herpes communicated by this unhygienic practice. In the 19th century this practice was banned in New York and many other places because of transmission of syphilis, tuberculosis and other diseases. Anyway, my two sons were left intact, and are quite pleased that they were not cut. The older one (Lycia remembers Christopher) is now 23, and when he was a college student won an international essay contest questioning the ethics of circumcision. The younger one, Benjamin, now in college, surprisingly, wrote a similarly powerful paper on it in prep school. So I have attached my paper and two graphs which are part of it, a listing of the crazy justifications for circumcision given in the US over the last century, and the legal definition of surgery. I suppose you are not in the medical field, so for someone like me to load you up with this might seem weird. I know I felt that way when my assumptions and lack of knowledge were first challenged. Now it seems so normal not to cut, and so perverted and wrong medically, ethically, and legally to allow circumcision, and so right and honest to help parents make the correct and caring decision for their son. Hello to Lycia ... Christopher Fletcher MD </div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource American doctors today (2000s) darby Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Robert Darby Subject The topic of the resource Circumcision history Description An account of the resource Archive of the work published by Robert Darby Creator An entity primarily responsible for making the resource Robert Darby Source A related resource from which the described resource is derived circinfo.org historyofcircumcsion.org Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Text Any textual data included in the document <div class="intro" id="intro"> <h3>Why I wrote a book about circumcision</h3> <h4>Dr Leonard Glick explains how he came to write Marked In Your Flesh</h4> A number of years ago I learned that infants undergoing circumcision cry â€“ in fact, scream â€“ in an entirely distinctive manner. That ought to have rung an alarm bell in my mind; instead it just left me feeling vaguely uneasy. Yet if anyone should have understood what I now call "the circumcision dilemma," it was me. I'm a cultural anthropologist with a medical background, and I taught European Jewish history to college students. In an earlier book, Abraham's Heirs: Jews and Christians in Medieval Europe, I mentioned circumcision incidentally a few times. But its real importance only dawned on me when I came across a historian's statement that European Christians thought of the "typical Jew" as a circumcised male â€“ a genitally depleted half-man, weakened and "feminized" by this most mysterious of all Jewish practices. Had I really studied the history of Jewish-Christians relations all those years and never realized something so fundamental? Soon came another surprise: I learned that in the United States circumcision was by no means a Jewish practice alone â€“ that today a substantial majority of male American newborns are being circumcised. The practice had become popular in the early to mid-twentieth century, just at the time when childbirth was medicalized â€“ moved from home to hospital, managed by physicians, and accompanied by such now discredited practices as episiotomy, isolation of newborns from mothers, artificial feeding, and rigidly defined feeding schedules. There was more. I found that the practice had never been accepted in Continental Europe, Asia, or Latin America; that in other Anglophone nations (England, Canada, Australia) it had been adopted for a time, then largely discontinued. Finally, the clincher: I came to understand that not only is circumcision medically unnecessary, it removes the most sensitive tissue in the male genitals. Mothers don't have to be told that a normal newborn infant, male or female, is a perfectly formed little person, with nothing useless, nothing designed by nature for removal! If there can be no good reason for removal of a body part from any normal, non-consenting person, circumcision raises a serious ethical issue. Why then has the practice continued? Why are nearly 60 per cent of male infants still routinely circumcised in our hospitals, despite statements by leading medical organizations that there is no need to do this? For one thing, despite oceans of articles in the medical literature and efforts by opponents to raise public awareness, many parents take it for granted that circumcision of newborn boys is the American thing to do. It's a "<a href="http://www.cirp.org/library/legal/USA/waldeck1/" rel="noopener" target="_blank">social norm</a>" â€“ a practice that's widely accepted because people know that it's widely accepted. So physicians, whether they approve or not, let parents decide on such a sensitive issue as the medically unnecessary, irreversible removal of a normal body part â€“ surely the only situation in which anyone is permitted to make such a decision for another person. I think that's unjust, and I wrote this book to try to explain why. Marked in Your Flesh: Circumcision from Ancient Judea to Modern America was published by Oxford University Press in June 2005. I hope it will help to show why routine circumcision should have no place in American society. Originally published in <a href="http://www.compleatmother.com/" rel="noopener" target="_blank">Compleat Mother Magazine</a>, No. 79, Fall 2005, p. 25 Dr Leonard Glick, MA, MD, PhD, is Emeritus Professor of Anthropology at Hampshire College, and lives in New Salem, Massachussetts. Marked in your flesh is available from Amazon by clicking on the image to the left. <h2>A thoughtful and troubled review</h2> The following review was pubished in the Jewish American magazine <a href="https://www.forward.com/articles/3883" rel="noopener" target="_blank">Forward</a> in September 2005. <h4>A Little off the Top</h4> <h4>The Controversy About Circumcision</h4> <h4>By Jay Michaelson</h4> <h4>September 2, 2005</h4> Marked in Your Flesh: Circumcision From Ancient Judea to Modern America By Leonard B. Glick Oxford University Press, 384 pages, $30. To put it mildly, circumcision is a delicate subject. It's almost impossible to discuss the matter without cracking a joke, probably because the ritual makes at least 49% of the population wince and cross its legs. And yet, as a quick Google search will easily reveal, in the past two decades there has been a trove of writing about circumcision â€” most of it negative, and a lot of it generated by cranks. Lately, however, the debate has moved into the mainstream. That circumcision reduces sexual pleasure, and that it is fully experienced by the traumatized infant, is now well established. Jewish intellectuals have debated the practice's merits in magazines and at conferences, and even bloodless "brit shalom" ("covenant of peace") rituals have been developed to replace circumcision surgery. Meanwhile, medical professionals have cast doubt on the supposed hygienic and salutary benefits of the practice, causing the rate of circumcision to fall in America from 80% of newborn males in 1980 to fewer than 60% today (circumcision is only practiced rarely among gentiles in Continental Europe and Asia), although recent data suggesting that circumcision reduces the threat of contracting HIV may reverse that trend. Finally, Jewish ritual circumcision has even become the center of a small controversy in New York City, with Mayor Michael Bloomberg publicly urging Orthodox Jews to change the way they carry out the rite after a single mohel allegedly spread herpes to three babies he had circumcised. "Marked in Your Flesh," the new book by Leonard Glick, professor emeritus of anthropology at Hampshire College, does not add considerably to the substantive debate; it is at times insightful, and other times intensely biased. Yet a book published by Oxford University Press, by a noted Jewish anthropologist, has at least one unambiguous effect: It raises the stakes of the conversation. The anti-circumcision crowd is not just on the Internet anymore. To those who take brit milah â€” the covenant of circumcision â€” for granted, the contemporary debate around the practice may come as a surprise. Isn't this one of the foundations of the Jewish religion? And what's all the fuss about "a little off the top," as one of the multitude of circumcision jokes puts it? Well, for starters, there's the nature of the act itself. Glick is not the first to narrate the gruesome details of circumcision â€” but that doesn't stop him from piling on plenty of stretching, cutting and bloodletting detail. The first page alone includes phrases such as "piercing scream," "his foreskin pinched and crushed," "tugging, whimpering, and then crying helplessly." Few of the remaining 359 pages are any different. At least we know what we're in for: The book lets us know that it will be a polemic, and an NC-17 one at that. Still, the details of circumcision really are unsettling. It's no mere "snip, snip," as I was taught back at summer camp; as every new parent knows, it's a brutal, bloody operation that, neonatal science now tells us, is fully experienced by the newborn infant. It's trauma, it's mutilation and it's done without consent. Of course, it also may be commanded by God. What Glick tries to show in "Marked in Your Flesh" is that all the original reasons for circumcision are dubious. Religiously, he argues that Jewish circumcision "was instituted by priests as a religious practice in the 5th century BCE" as "the rite of initiation into their male-centered society." And medically, he convincingly shows how the original 19th-century introduction of circumcision â€” after centuries of contempt for the practice in Christian literature â€” was tied to outmoded concerns about fecundity and sexual expression, and how so many successive medical rationales have been adopted and discarded, in so curious and cavalier a way, one wonders about the real purpose of the practice. From controlling masturbation to healing paralysis, reducing the threat of syphilis to curbing AIDS, doctors have proposed dozens of benefits of circumcision â€” none of them scientifically proven. The trouble with Glick's book is that its author is so blinded by his own particular bias â€” a rationalistic, ethically oriented ideology reminiscent of the early Reform movement â€” that he simply dismisses the primal, nonrational and ultimately emotional reasons that many people today cling to religiously motivated circumcision. At the outset, Glick's reading of the biblical text is really more a midrash than biblical criticism; it is good speculation, but only that. Yet he takes it as fact that "P," the priestly writer of parts of the Torah, inserted the requirements for circumcision as a way of solidifying the priests' hold on ancient Israelite religion. Maybe, but that kind of argument can be applied to all sorts of practices that nonetheless became cornerstones of traditional Jewish religion, from the incest taboo to the dietary laws. Even if Glick's analysis is correct, however, his normative program requires an overly narrow view of what religion is and does. Of course circumcision is a "barbaric" ritual â€” if by "barbaric" we mean rooted in instinct and emotion â€” but since when is religion only about that which is civilized? Glick writes that "deepest significance of circumcision resides not in abstract spiritual realms but in the basic facts of social life: sexuality and masculinity, power and weakness, dominance and submission." This is a false dichotomy. True spiritual realms are never "abstract." They are, historically, exactly about the basic facts, fears and energies of human life. For better or for worse, altering the flesh of male babies' penises goes to the deepest heart of those primal fears. As an anthropologist, Glick offers insightful readings of how circumcision might have functioned in different Jewish cultures. Yet as a psychologist of religion, his analysis is impoverished. Glick offers an excellent analysis of Paul's critique of circumcision â€” it's all about the flesh, not about the spirit â€” but ironically, he repeats the same critique in his book. He seems unable to accept, despite capable readings of Lawrence Hoffman, Sander Gilman and Harold Eilberg-Schwartz, that ancient Jewish religion was about the body, not just the "soul." Notably, Glick finds himself agreeing with Martin Luther's notorious pamphlet, "On the Jews and Their Lies," which, he says, "includes a telling critique of ritual circumcision." Yes, circumcision is about the body, and it is particularistic, and patriarchal. So is much of Judaism. Occasionally, Glick's bias even leads him to historical error or lapses in reasoning â€” not to mention extreme rhetoric that is surprising to find in a book published by Oxford. For example, Glick claims that no Orthodox Jews "care much about secular rationales for circumcision.... Mystical and numerological interpretations fully satisfy their desire for explanation." Really â€” Orthodox Jews are satisfied with numerology? Glick also labels as "Orthodox" the opponents of early Reform, who did not identify in that way and who were not identified that way until decades later â€” and only then, in a derogatory fashion, by the Reformers themselves. The oddest parts of the book are toward the end, where Glick launches a combined survey of, and rant against, present-day Jewish discourse on circumcision. Glick seems outraged that contemporary Jews maintain the practice for such reasons as Jewish community, spiritual practice or Jewish continuity, since those reasons are very different from the priestly interests that Glick theorizes are behind the Torah's injunctions. Yet Judaism is all about new reasons for old practices, as Glick surely knows. Why, then, the harsh derogation of Daniel Gordis, Jon Levenson, David Zaslow and other figures who seek contemporary meaning in this ancient rite? Simply because they do not agree with Glick's reckoning of the practice's costs and benefits? Glick is no more objective when it comes to the medical evidence. Certainly, anyone who believes circumcision is harmless should read this book. Its grisly details will make most readers cringe, and the evidence of the damage done by circumcision is sound. Yet few today really claim there is no harm done; the claim is that the harm is justified by various benefits. Reading through Glick's analysis of these medical claims is intensely frustrating. Certainly, he is right that the original rationales for circumcision lie in the same neurotic literature that taught us that masturbation makes one go blind, and that oral sex leads to perdition. Glick is also quite right to observe that European males, most of whom are uncircumcised, seem to lead quite healthy sexual lives â€” and that circumcision undoubtedly causes a reduction in sensitivity. Yet Glick never quite refutes the statistical evidence that circumcision reduces the threat of certain kinds of cancer and venereal diseases; the best I could tell, from both his book and other sources, is that the jury is still out on the subject. What's more, new data corroborates the claims that circumcision reduces the risk of contracting HIV, the virus that causes AIDS. In a study whose results were released this summer (after "Marked in Your Flesh" went to press), of 3,000 South African men, those who were circumcised were 70% less likely to contract HIV from infected women than uncircumcised men. This is serious, sound evidence, and, to be fair, it was unavailable to Glick. Still, the book acts as though the impure motives of circumcision's original advocates contaminate the practice today. The most controversial part of the book is where Glick claims that Jewish doctors, and some doctors who are Christian, were swayed by their religious opinions to color the evidence in favor of circumcision. As Glick admits, he has not a shred of evidence to support this claim, other than the curious fact that, even as one rationale after another fell into discredit, the same doctors kept finding new ones. Yet the advocates of circumcision are both Jew and gentile, and so are its foes: For every Jewish doctor praising the practice, there is another one opposing it. Once again, Glick's own bias colors his analysis. Convinced that there is no rational basis for this practice, he imputes religious bias onto those who believe that there is. Even with these flaws, though, "Marked in Your Flesh" is a fascinating read. Glick has unearthed little-known Reform movement documents from the 19th century, proposing to alter or abolish circumcision â€” and similarly interesting documents, from the same movement, defending it. Equally absorbing are the 19th-century Christian documents praising Moses as a "brilliant sanitarian," and finding in the Jewish religious law â€” which, like the Jewish dietary laws, had nothing to say about health or hygiene in the Biblical sources â€” a proto-scientific worldview. Perhaps most importantly, "Marked in Your Flesh" brings together the scientific consensus that, despite the claims of some, circumcision does diminish sexual pleasure. The foreskin is itself full of sensitive nerve endings, which never can be replaced. The movement of the foreskin generates naturally lubricated sexual pleasure. And without the foreskin's protection, the glans of the penis is chafed and toughened, reducing sensitivity still more. Maimonides, as well the kabbalists and many other Jewish figures, recognized this effect of circumcision and praised it for curbing sexual desire. So did the initial proponents of medical circumcision in Britain and America. We may debate the benefits for many years to come, but at least one cost is clear: Circumcision diminishes pleasure. As these facts about circumcision become known, the practice may well become a source of controversy within the Jewish community. Every day, Jewish boys are having their sexual organs damaged without their consent â€” and even without the knowing consent of their parents, who, if they knew the costs, might well agree with Glick that the spiritual and possible health benefits do not justify them. For generations, circumcision has been seen as making a male body Jewish â€” and it has been the body, not the mind or the "soul," that is the site of holiness. But one wonders if the current wave of anti-circumcision backlash, formerly the domain of marginal eccentrics but now the purview of Oxford University Press, might cause the practice to diminish in importance. On the other hand, maybe not. Philip Roth, in a letter quoted toward the end of "Marked in Your Flesh," makes a point that Glick himself seems to miss, and that says much about the perverse appeal of a practice that is so violent, painful and irreversible. It's hard to understand, Roth writes, "how serious this circumcision business is to Jews. I am still hypnotized by uncircumcised men when I see them at my swimming pool locker room... I asked several of my equally secular Jewish male friends if they could have an uncircumcised son, and they all said no, sometimes without having to think about it and sometimes after the nice long pause that any rationalist takes before opting for the irrational." Jay Michaelson's next book is God in Your Body (Jewish Lights, 2006). He is the chief editor of Zeek: A Jewish Journal of Thought and Culture. </div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource An American obsession (2005) darby Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Robert Darby Subject The topic of the resource Circumcision history Description An account of the resource Archive of the work published by Robert Darby Creator An entity primarily responsible for making the resource Robert Darby Source A related resource from which the described resource is derived circinfo.org historyofcircumcsion.org Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Text Any textual data included in the document <div class="intro" id="intro"> <h3>Why can't the United States stop circumcising boys?</h3> This is an expanded and more fully referenced version of an essay of mine published in Contexts magazine, Spring 2005. People have always eaten people, What else is there to eat? If the Juju had meant us not to eat people He wouldn't have made us of meat. â€” Flanders and Swan, "<a href="http://www.thurb.com/humour/cannibal.htm" rel="noopener" target="_blank">The Reluctant Cannibal</a>" The unquestioning acceptance of routine circumcision of a newborn ... deserves a hard look and wide-ranging debate. â€” Marianne Legato, "Rethinking circumcision" [1] The pediatrician spent hours resuscitating and assessing the injuries of a boy who had been born unable to breathe, without a pulse, and with a broken humerus and depressed skull fracture resulting from a difficult forceps delivery. He then visited the mother, whose first question was "When can he be circumcised?" [2] Such a sense of priorities spotlights the privileged place of male circumcision in modern America and highlights the difficulties in explaining what Edward Wallerstein has called "the uniquely American medical enigma": why routine circumcision [3] persists in the United States long after it has been abandoned in the other English-speaking countries which originally took it up. Despite statements from the American Academy of Pediatrics and the College of Obstetricians and Gynecologists in 1971, 1975, 1978 and 1983, he noted in 1985 that the practice had abated little. [4] Even today, after further statements in 1989 and 1999, the operation is performed on well over half of all of newborns. [5] <h4>An American paradox</h4> The American situation remains a conundrum: why has a custom initiated by our Victorian forebears continued to prosper in the age of medical miracles, and in the world's most scientifically advanced superpower at that? Some doctors blame parents for demanding circumcision, while parents accuse physicians of suggesting, and even urging the operation, and of not warning them about possible risks and adverse effects. Critically-minded pediatricians admit that the "circumcision decision" is no longer a medical one, but a "cultural ritual", [6] and call for "the organized advocacy of lay groups ... rather than the efforts of the medical profession", [7] while others object to the interference of "outsiders" in what they insist is a strictly clinical question. Wallerstein felt the practice continued because both "medical and popular literature abounds in serious errors of scientific judgement, equivocation and obfuscation", with the result that the medical profession is reluctant to take a firm and consistent stand. Although few think there is any compelling value in circumcision, and many regard it as cruel and harmful, doctors seem mesmerised by the force of parental demand and social expectation; like the sorcerer's apprentice in Fantasia, they watch helplessly as the waters mount, waiting for the master magician to return and restore normality. The US experience stands in sharp contrast with that of the other countries in which routine circumcision became common. In Britain the procedure was widely recommended in the 1890s, reached its peak of popularity in the 1920s (a rate of about 35 per cent), declined in the 1950s and all but disappeared in the 1960s. In Australia the incidence of circumcision peaked at over 80 per cent in the 1950s, but declined rapidly in the 1980s after statements by pediatric authorities, and now stands at about 12 per cent. The Canadian pattern is broadly similar to the Australian, though the decline was slower until the late 1990s, when rates fell sharply. In New Zealand the procedure was nearly universal between the wars, but fell so precipitately in the 1960s that it now affects less than 2 per cent of boys. [8] We thus face a classic puzzle of comparative sociology: Why did routine circumcision arise in the first place? Why only in Anglophone countries? Why did it decline and all but vanish in Britain and its dominions? Why does it survive in the United States? Nobody has firm answers to these questions. The rise of circumcision was associated with the "great fear" of masturbation and anxiety about juvenile sexuality generally; the misidentification of infantile phimosis as a congenital abnormality; the rise of puritan moralities in the nineteenth century; dread of many incurable diseases, especially syphilis; and the rising prestige of the medical profession, particularly surgeons, leading to excessive faith in surgical approaches to disease control and prevention. Most of these features were common to all European countries, however, and the factors which provoked the Anglophone Sonderweg remain obscure. (Perhaps language itself is the key.) The fall of circumcision in Britain was associated with the rise of modern medicine, especially the discovery of antibiotics; the decline of anxiety about masturbation; concern about complications and deaths; and the development of a more positive attitude to sexual pleasure. In 1979 an editorial in the British Medical Journal attributed much of the trend to better understanding of normal anatomical development and the consequent disappearance of fears about childhood phimosis. [9] <h4>Incidence of circumcision</h4> There has been remarkably little research into this problem. Circumcision is a highly controversial subject, and the literature is vast, but most of the debate remains at a fairly childish level (the "pros and cons") and focuses on whether it should be done, not on why the practice continues; defenders of the practice regard circumcision of infants as an unproblematic hygiene precaution, or at least a parent's right to choose, and often become annoyed when critics ask them to justify it. Discussion of the issue has been hampered by uncertainty as to the incidence of routine circumcision, its social distribution and the reasons parents want it or agree to have it done. There has been a significant decline since the 1970s, but it has been neither steady nor uniform across the country. From 85 per cent of newborns in the 1970s, the rate fell to 60 per cent in 1988, rose again to 67 per cent in 1995, then fell slightly to 65 per cent in 1999 â€“ the last year for which authoritative figures are available, though a substantial reduction since then has been claimed. [10] The incidence of circumcision varies significantly by region, and nearly all the reduction observed has occurred in the west, particularly California, where it fell from 63 per cent in 1979 to 36 per cent in 1999. In the north-east the rate has remained constant at about 65 per cent over the same period, while in the mid-west and south it has actually increased â€“ from 74 to 81 per cent and 55 to 64 per cent respectively. [11] Other variations are found on the basis of ethnic origin and education level. When Edward Laumann and colleagues analysed data from the National Health and Social Life Survey (covering men aged 18 to 59) he found that while 81 per cent of whites were circumcised, the figure was only 65 per cent for Blacks and 54 per cent for Hispanics. Where 87 per cent of men whose mothers were college graduates were circumcised, the figure for those whose mothers did not complete high school was only 62 per cent. [12] Laumann also found that circumcision was less common among conservative Protestants, but noted that all these differences shrank as the sample got younger, suggesting that the trend was towards homogeneity. We can thus say that circumcision is rarer among Blacks and Hispanics (though more common than it was), and probably non-Muslim Asians; among the less educated; and in the western states; but we can't know which of these is the decisive variable. It may be that Blacks, Hispanics and Asians tend to be less educated than whites, and also to be concentrated in the south and west. Laumann did not consider the impact of economic factors such as financial incentive, yet there is evidence that this may be the most important influence of all: in 1982 California dropped medically unnecessary circumcision from the schedule of benefits covered by Medicaid, and the practice went into steady decline. <h4>Medical arguments invalid</h4> Preventive posthectomy has always been an experimental and controversial surgery, never one endorsed by the medical profession as a whole. Given the uncertainty of its benefits, the high risk of harm, and the significance of the organ being so dramatically altered, you might expect a few ultra-nervous adults to elect it for themselves, but not that it would be inflicted on millions of babies who had never even inquired. These days it is only a few superannuated diehards who seriously believe that circumcision confers meaningful health benefits, and nobody suggests that the practice continues because the inhabitants of Indiana are healthier than those of California, or Americans in general are healthier than the populations of countries where the practice is rare. Indeed, readily available statistics suggest the opposite scenario. Although health spending per head in the USA is vastly greater than anywhere (over 14 per cent of GDP), health outcomes on key indicators such as infant mortality, life expectancy and the incidence of STDs are significantly worse than in comparably developed countries where most men retain their foreskins. (See Tables 1 and 2.) Far from circumcision being a protection against STDs as often claimed, Laumann found that circumcised men had more STDs, both bacterial and viral, than the uncut; and it is well known that the USA has the highest incidence of HIV infection of any country in the developed world except Portugal. Although advocates of mass circumcision as a strategy against AIDS are constantly calling for randomised trials, the circumcision experiment has already been performed in the United States. How successful has it been? With the highest rate of circumcision, the USA also has higher rates of infant mortality ans shorrter male life-expectancy than similar developed nations; the highest rates of sexually transmitted diseases of any developed nation; the highest rates (by far) of heterosexually transmitted HIV infection of any developed nation; and rates of cervical and penile cancer that are similar to those of other developed nations. (See Table 3.) Yet these are the very diseases that circumcision has been touted as a sure preventive for: any impartial observer must conclude that the century-long experiment has failed. A similar informal experiment in Australia has actually found that children's health has improved as circumcision has declined. A report issued by the <a href="http://www.aihw.gov.au/" rel="noopener" target="_blank">Australian Institute of Health and Welfare</a> in 2005 (A picture of Australia's children) found that since 1983 children's health had improved markedly, and that infant mortality had halved, from 9.6 per 1000 live births in 1983 to 4.8 live births in 2003. These dates are very significant, since 1983 was the year in which the Australian College of Paediatrics issued <a href="http://www.circinfo.org/previous_statements.html" rel="noopener" target="_blank">a policy to discourage circumcision</a>, and it was the start of the huge slide in circumcision incidence, from about 40 per cent to less than 12 per cent of baby boys. The report is striking proof that "lack of circumcision" does not increase child health problems. Even more significantly, it is a decisive refutation of "scientific" predictions by circumcision crusaders such as Terry Russell and Brian Morris that the fall in the circumcision rate would lead to an explosion of genito-urinary problems in boys. No such problems are identified in this report. In fact, if one were to be as unscrupulous in conflating correlation with causation as many pro-circumcision zealots tend to be, one might conclude that Australian children have become healthier not just at the same time as the incidence of circumcision has fallen, but because the incidence has fallen. But at the very least it is incontrovertible that there is zero connection between circumcision and improved health outcomes. <a href="http://www.aihw.gov.au/publications/index.cfm/title/10127" rel="noopener" target="_blank">The report can be downloaded in several pdfs here</a>. The very scale and status of the American health industry may be part of the problem, for as Shannon Brownlee has observed, there is good evidence that too much medical care may be worse than not enough. [13] A recent investigation into hospital safety found that "adverse events" occurred so frequently in hospital admissions, and so many of these led to death, that errors in medical treatment could be the eighth highest cause of death â€“ at 44,000 per year, exceeding deaths from motor vehicle accidents (43,458), breast cancer (42,297) and AIDS (16,516). [14] Since the risk of dying from medical misadventure is so much greater than the risk of dying from penile cancer or AIDS, it would seem that the most prudent course would be for parents to minimise their children's exposure to the dangers of medical treatment by avoiding unnecessary surgery. If American health outcomes are no better than those of non-circumcising countries, why does this "health precaution" survive on a mass scale? Robert Van Howe has suggested seven lines of inquiry. (1) The foreskin is the focus of myths, misconceptions and irrationality affecting medical profession and public alike. (2) Lack of respect for the rights and individuality of children. (3) A contrasting exaggerated delicacy with respect to the presumed sensibilities of religious minorities which practise circumcision for cultural reasons. (4) The reluctance of physicians to take a firm stand against circumcision and to refuse parental requests. (5) Bias in American medical journals, which tend to favour articles with a pro-circumcision tendency and are reluctant to publish critiques, much less developed arguments against. (6) Failure to subject circumcision to the normal protocols for surgery, such as the need for informed consent, evidence of pathology and proof of prophylactic benefit. (7) Strong financial incentives to perform the operation, usually guaranteed by medical insurance coverage. [15] <h4>Financial incentives</h4> The last of these points has been stressed by a number of critics. In their analysis of Medicaid funding, Amber Craig and colleagues found that low and declining rates of circumcision correspond to regions where the procedure is not funded, most noticeably in California. Even more striking is their finding that the higher the rebate, the higher the incidence of circumcision: in states where it is $50 or less the incidence is 20 per cent; in those which pay $50 to $60 it is 27 per cent; and in those which pay more than $60 it is 38 per cent â€“ vivid proof of the power of market signals. [16] Such observations might seem to justify the bitter observation of one critic that, in the eyes of many MDs, little boys are born with a redeemable tag of skin on the end of their penis; all they have to do to make a quick dollar is to cut it off and cash it in, like a huntsman turning in dingo scalps. Nor do the advantages of circumcision end there. Despite optimistic claims that the rate of injury and death is low, there has never been an adequate assessment of long term complications, and they are certainly more frequent than most people think. (Does David Reimer's recent suicide [17] count as a circumcision-related death?) The dirty little secret in pediatric surgery is that badly performed circumcisions, causing discomfort or poor cosmetic outcomes, often necessitating repeat operations and repair jobs, are common; one attorney who specialises in medical malpractice reports that some urologists see at least one such case each week. In this way the division of professional labour ensures that the benefits of circumcision are spread far beyond the original operator: his botches provide work for many colleagues, and the disasters add lawyers to the equation. Yet the physicians may not be the major beneficiaries. In the age of biotechnology and tissue engineering, human body parts have a high market value, and baby foreskins are especially prized as the raw material for many biomedical products, from skin grafts to anti-wrinkle cream. The strongest pressure for the continuation of circumcision may not be from doctors at all, but from the hospitals which harvest the foreskins and sell them to commercial partners. [18] This would explain why so many mothers are still pressured to sign consent forms when they arrive for their delivery. [19] <h4>Historical factors</h4> As well as Van Howe's suggestions as to why circumcision continues, we should consider the distinctive features of the American past which brought the practice into prominence. Among these the medicalisation of childbirth and the role of the armed forces are the most significant. Although experts in venereal disease such as Abraham Wolbarst had called for universal circumcision as early as 1914, [20] it was the obstetricians and gynecologists who were responsible for realising his dream. It may seem strange that the most influential advocates of routine male circumcision within the medical profession have been experts in women's health, but from the 1930s onwards it has been the obstetricians and gynecologists who most vigorously touted the advantages of the procedure and performed most of the operations. Symptomatic of their power was the introduction of the Gomco clamp by the obstetrician Hiram Yellen, [21] who wanted a device that was so simple to use that his colleagues would be able to claim the circumcision procedure from fussy and expensive surgeons who still insisted on anaesthetics and strict control of bleeding. As maternity hospitals and clinics replaced home births, and as the ob-gyns displaced midwives, circumcision came to be seen as part of the birth process, often performed within a day or even a few hours of the boy's arrival in the world â€“ a procedure no more surgical or problematic than tying his umbilical cord. [22] The armed forces also played a significant role. During the two world wars the US military made a concerted effort to circumcise servicemen, ostensibly because it was believed that this would make them less susceptible to venereal disease, though partly because true believers in circumcision held powerful positions within the Medical Corps. Military discipline forced men to submit to a procedure they would not otherwise have agreed to, and thousands of men were circumcised in their late teens and early 20s. When they returned home and became fathers, doctors began asking whether they wanted their sons circumcised. Remembering the ordeal that they or their buddies had endured from the operation as adults, many said yes, thinking it would avoid the need to do it later, when the pain was thought to be worse than in infancy. With two generations circumcised, the foreskinned penis became a rare sight, and few men now had the personal experience to refute the derogatory stories told about it. <h4>Confusion in the American medical establishment</h4> Lack of unanimity and conviction among the medical profession has been stressed by Lawrence Dritsas, [23] who attempts to deconstruct the AAP's unwillingness to make a firm recommendation and corresponding tactic of throwing the burden of decision onto parents. Dritsas quotes from one article which explained that <div>we are reluctant to assume the role of active advocacy (one way or the other) because ... the decision is not usually a medical one. Rather it is based on the parents perceptions of hygiene, their lack of understanding of the surgical risks, or their desire to conform to the pattern established by the infant's father and their own societal structure. [24]</div> He translates this to mean that circumcision is irrational but that, contrary to the usual protocol, "parental wishes become sufficient, while medical necessity, normally a guiding rule for the surgeon's knife, takes a back seat". Dritsas contrasts this hands-off approach with the AAP's ethically-based rejection of female genital mutilation (where the possibility of health benefit is not even entertained) [25], and even more tellingly with its position statement on informed consent: <div>Providers have legal and ethical duties to their child patients to render competent medical care based on what the patient needs, not what someone else expresses. ... the pediatrician's responsibility to his or her patient exists independently of parental desires or proxy consent. [26]</div> Except when it comes to circumcision. Dritsas is genuinely puzzled by the glaring contradictions in AAP policy and explains them in terms of medical culture and the apprenticeship model of professional training, which do not encourage students to question authority. "For a physician to cease performing circumcisions represents a condemnation of past practice and an admission of error", he writes, and nobody holding the power of life and death wants to be seen as doing that. The doctors are thus in much the same position as the parents themselves, whose unconsidered assumption that the baby will be circumcised is an expression of the authority of past generations of physicians who convinced their grandparents that it was the done thing. But if a previous cohort of doctors was responsible for establishing circumcision, is it not the responsibility of their successors to put a stop to it? Dritsas condemns the stance of the AAP as reminiscent of the response of Pontius Pilate when confronted with the problem of what to do with Jesus. In his view, what they are really saying is that "As scientific doctors we find ourselves unable to recommend or deny this procedure; therefore, you will decide, and we shall be your scalpels." As he concludes, the AAP "decided not to make a decision and absolved itself of all guilt while continuing to perform a questionable operation". [27] This sort of acquiescent hand-washing contrasts with the proactive stances of pediatric bodies in Britain, Australia, New Zealand and, most forcefully, Canada, which have seen it as their duty not only to discourage parents from seeking circumcision, but to educate them as to the value and correct care of the prepuce and, in the end, to refuse to perform the operation. <h4>Demonization of the foreskin</h4> There must be an explanation for these national differences. The medical profession is not an independent force; its members are subject to the same social pressures which mould the beliefs and condition the actions of everybody else. Several recent commentators have thus argued that circumcision should not be seen as medical issue at all, but as an expression of social norms. At a superficial level this has long been known. In the 1950s Dr Spock urged circumcision because it would help a boy to feel "regular", and pediatricians since then have noted that "entrenched tradition of custom is probably the greatest obstacle faced by those who would decrease the number of circumcisions done in this country". [28] But it is only recently that the sociological aspect of the question has received serious attention. In a comprehensive survey of the history of modern circumcision and the debate over its "advantages", Geoffrey Miller shows in brilliant detail how late Victorian physicians succeeded in demonizing the foreskin as a source of moral and physical decay. Acting as "norm entrepreneurs" they "reconfigured the phallus", transforming the foreskin from a feature that was regarded as healthy, natural and good into one which was feared as polluted, chaotic and bad. The incessant quest for novel associations between the foreskin (often expressed as "lack of circumcision") and nasty diseases is a tribute to the lasting success of their enterprise. As a legal scholar, Miller is surprised at the law's indifferent and often supportive attitude to what one might expect it to regard as an assault, or at least a mutilation, but he points out that the law is itself an expression of the surrounding culture and cannot be expected to be too far ahead of prevailing norms. Even so, he considers routine circumcision in the mainstream community to be on the way out. Although still normative, it is in decline, and edging towards the critical half-way mark, or "tipping point", where the incidence can be expected to fall precipitously as parents come to believe that their children will now suffer stigma if they are circumcised. Like foot-binding in China or wife beating in nineteenth century Britain, a widely accepted social convention is "likely to collapse as the culture reaches a 'tipping point' and turns against the practice". [29] The increasingly desperate search for new "health" reasons to circumcise â€“ urinary tract infections (1985), HIV-AIDS (1989) and cervical cancer in potential future partners (revived in 2002) â€“ may delay the process, but cannot permanently halt it. [30] <h4>Cultural norms</h4> Extending Miller's argument, Sarah Waldeck [31] offers a subtle analysis of how norms contribute to a person's behavioural cost-benefit calculations, how the desire to have a child circumcised fits into this assessment, and thus why parents continue to seek it. She is particularly interested in the "stigma" supposedly attached to the uncircumcised penis in a society where most of the males are cut, and considers the role of the popular media in perpetuating a stereotype of the foreskin as somehow disagreeable. (Indeed, if the malevolent jokes fired casually at normal male anatomy in popular American soaps and movies were directed at targets seen as entitled to protection from vilification there would be howls of outrage.) [32] She also notes that few parents have any clear reasons for wanting their sons circumcised and produce them only when challenged; the most common justifications then turn out to be the supposed need to look like the father or peers, and not to be teased in the proverbial locker room. If "health benefits" are mentioned at all, they enter as an afterthought or when other arguments fail. Waldeck still subjects the medical case to scientific, legal and ethical scrutiny, and finds it inadequate to justify the removal of healthy tissue from non-consenting minors. She also cites a study from 1991, which found that, even if the claims for its health benefits were true, circumcision was not a cost effective means of achieving these outcomes. [33] Waldeck concludes with a thoughtful discussion of how the American norm might be changed and suggests three specific strategies: requiring parents to pay for the procedure; requiring doctors who perform the operation always to use effective pain control; and tightening the informed consent process. The first of these is partly achieved by dropping circumcision from the schedule of procedures covered by Medicaid, though Waldeck warns that private and company health insurance schemes must also be considered. The value of such a move arises not only because it is good public policy to encourage people to place a value on services by requiring them to pay, nor just in the cost disincentive, but in the fact that not being covered by a government program implies that circumcision is not an approved procedure. If not publicly funded, it is less likely to be seen as either beneficial or normative. <h4>Doctors as cultural brokers</h4> The USA thus presents the paradoxical picture of a cultural ritual justified in medical terms and a surgical procedure justified as a cultural necessity. Defenders of ritual circumcision point to the health benefits claimed by those who perform it for medical reasons; while those who perform it for medical reasons try to justify it as an ancient operation, performed by "many different cultures", without which ethnic or religious identity would be lost. The whole thing ends up rather circular. When doubt is thrown on the medical benefits of circumcision, supporters of the operation stress its cultural importance; when its cultural necessity is questioned, they stress the alleged health benefits. Many medical personnel who regard circumcision as unnecessary or harmful still urge respect for cultural traditions, and show little hesitation in cutting boys from traditionally circumcising cultures (mostly Islamic, these days) at the request of their parents. The claims of culture are taken very seriously in this age of globalization, but the problem with this particular claim is that it is applied inconsistently. First, there is discrimination based on gender. No matter how important circumcision of girls may be to the cultural/ethnic/religious groups that practise it, American opinion has determined that girls' bodies are more important than tradition, and that any cutting of the female genitals is Female Genital Mutilation, now banned by law. Secondly, the cultural argument seems to be a one-way street. When faced by parents from circumcising cultures, doctors say they must respect their traditions and accede to their wishes, at least in relation to boys. But when it comes to non-circumcising cultures (the great majority) the argument is suddenly reversed: instead of enjoying automatic respect for their traditions, parents from non-circumcising cultures are pressured to conform to the American norm and to consent to have their sons circumcised, so that they will be "like other boys". Here it is not the traditional culture or the condition of the father's penis that matters, but American custom and medical ideology, to which the immigrants are expected to conform, and often coerced into doing so. When discussing this issue, defenders of children's rights have argued that doctors should not be cultural brokers, but this formulation does not quite grasp the complexity of the situation. What they are really suggesting is that it is not the role of doctors, nurses etc to enforce the rules of a given sub-culture against its members, particularly when the issue is one of conformity or outdated rituals. Concerns with identity are important in the traditional, monocultural societies where practices such as male and female circumcision originated; in such tribal situations, circumcision functions as an age card and passport. But such rituals are unnecessary, and certainly do not need to be nurtured, in the modern, multicultural societies to which these people have relocated, where identity and entitlements are registered in other ways. Immigrants from backward regions don't expect to retain all their village customs (infanticide, widow burial, walking round naked, tribal medicine?) when seeking to improve their condition in the industrialised world; the main reason circumcision tends to be retained is that those with power (the parents and other adults) would not personally benefit from dropping the operation, while those who would enjoy the benefit are only helpless children, who lack the power to voice, much less enforce, their opinion. There is no harm in nurturing cheerful customs like dance, dress and food, but why privilege cruel or harmful ones? In practice it is inevitable that doctors and other providers of professional services will act as cultural brokers when dealing with families from foreign cultures, and this is not necessarily a bad thing at all. It is actually quite appropriate that they should help people from backward collectivist cultures (in which the rights of children as individuals and citizens are not recognized) to negotiate the transition to a culture based on the autonomy of the individual and respect for personal rights. The problem is not that doctors act as cultural brokers, but that they do so in an inconsistent and discriminatory manner, respecting the traditions of the circumcisers but not the traditions of non-circumcising cultures â€“ American Indian, Hispanic, Catholic and other Christian, European, South American and most Asian, to name a few. Circumcising cultures are a small minority: Islamic, some Africans and Jewish. You would think that the one of the first acts of cultural retrieval performed by American Indian peoples, none of which ever practised circumcision, might be to revive such historic traditions. If the "respect for culture" policy was applied consistently, the vast majority of American immigrants and ethnic subcultures would not be circumcised, and half-drugged mothers would not be obliged to fight off the advances of scalpel-happy ob-gyns in maternity wards. <h4>The lessons of history</h4> In 1979 the British Medical Journal applauded the decline of routine circumcision in Britain from about 35 per cent in the 1930s to under 6 per cent in the 1970s, [34] and contrasted the British case with the situation in the United States, where the majority of boys were still circumcised, and doctors still defended the procedure with vehemence. It offered no suggestions as to why the experience of the two leading anglophone powers should have diverged so sharply after the 1940s, but a clue may be found in the relatively low incidence of circumcision in Britain and its brief lifespan: even at the height of its popularity it was still a minority practice, and it lasted scarcely more than two generations. Where the practice affects the majority and endures for more than two generations, however, there will soon be few doctors and parents who have any familiarity with the normal penis, and thus know how to manage it; and most circumcised fathers will want their sons to be treated likewise. In Britain there were always doctors and relatives who had not lost touch with the way things used to be. In my research on the British and Australian experience, I found that routine circumcision began slowly as a doctor-driven innovation; became established in the medical repertoire and spread rapidly; and then declined slowly as doctors ceased to recommend it but parents, having absorbed the advice of the generation before and many fathers being circumcised, continued to ask for it. The fundamental reason for circumcision of children is a population of circumcised adults. A significant factor in the decline of circumcision in Australia during the 1960s â€“ before the paediatricians took a stand â€“ was the arrival of large numbers of immigrants from non-circumcising European countries (particularly Greece and Italy), most of whom settled in the cities. In contrast with the situation reported by Laumann, a recent study in Western Australia found a far higher incidence of circumcision in country areas, with their greater proportion of older, less well educated Anglo-Celtic stock, than in major urban centres, with their more multicultural and better educated populations. [35] As a celebrated German-Jewish philosopher once observed, "the tradition of all the dead generations weighs like a nightmare on the brains of the living". When preventive circumcision was introduced in the late nineteenth century, concepts of medical ethics, informed consent, therapeutic evidence and the cost-benefit trade-off were rudimentary. Neither the morality nor the efficacy of the procedure was seriously debated, nor was there any study of its long-term consequences, and it became established in the medical culture of Anglophone countries by virtue of the authority of its early promoters. No matter how many statistics-laden articles get published in medical journals, circumcision cannot shake off the traces of its Victorian origins. It remains the last surviving example of a once respectable proposition that disease could be prevented by the pre-emptive removal of normal body parts which, though healthy, were thought to be a weak link in the body's defences. In its heyday this medical breakthrough, described by Ann Dally as "fantasy surgery", enjoyed wide esteem and included excisions of other supposed foci or portals of infection, such as the adenoids, tonsils, teeth, appendix and large intestine. [36] Few doubted that if the doctor thought you, or your children, were better off without any of these it was your duty to follow his orders. <h4>The burden of proof</h4> Because there was no real debate about the propriety or efficacy of pre-emptive amputation as a disease control strategy when it was introduced, those who wanted to remove healthy body parts from children were able to throw the burden of proof onto their opponents. Instead of the advocates having to demonstrate that the gain outweighed the loss, it was up to the doubters to prove that the loss outweighed the gain â€“ or as Abraham Wolbarst put in it his call for universal infant circumcision in 1914: "If there is any objection to circumcision it should be based on valid, scientific grounds." [37] The consequence is that what should have been a debate about the introduction of preventive circumcision in the 1890s has turned into a debate about its abolition a century later. Miller and Waldeck may be right to argue that circumcision will not die out until the uncut penis becomes an acceptable â€“ and perhaps the preferred â€“ option. But the transformation of attitude will not seem so improbable, nor the task of effecting it so daunting, if it is remembered that there is no need to invent a new norm, merely to restore the sensibility that governed the Western world before the late nineteenth century. [38] In her popular midwifery manual of the 1670s, Jane Sharp wrote that a few people believed that the "Venerious action" might be performed better without the foreskin, but pointed out that circumcision had been forbidden by St Paul and hoped that <div>no man will be so void of reason and Religion, as to be Circumcised to make trial which of these two opinions is the best; but the world was never without some mad men, who will do anything to be singular: were the foreskin any hindrance to procreation or pleasure, Nature had never made it, who made all things for these very ends and purposes. [39]</div> When, in the 1870s, Richard Burton remarked that Christendom "practically holds circumcision in horror", [40] the observation was ceasing to be true, but it was certainly the case before Victorian doctors reconfigured the phallus, and bequeathed a thorny problem to their successors. <h4>Table 1: Male infant mortality and male life expectancy at birth, 2004</h4> <table border="0" cellpadding="8" cellspacing="4"> <tbody> <tr> <td width="168"> Country </td> <td width="194"> Male infant mortality (deaths per 100,000) </td> <td width="195"> Male life expectancy at birth (years) </td> </tr> <tr> <td> Australia </td> <td> 5.16 </td> <td> 77.4 </td> </tr> <tr> <td> Canada </td> <td> 5.28 </td> <td> 76.59 </td> </tr> <tr> <td> Denmark </td> <td> 4.65 </td> <td> 75.17 </td> </tr> <tr> <td> Finland </td> <td> 3.91 </td> <td> 74.73 </td> </tr> <tr> <td> Germany </td> <td> 4.64 </td> <td> 75.56 </td> </tr> <tr> <td> Indonesia* </td> <td> 42.09 </td> <td> 66.84 </td> </tr> <tr> <td> Malaysia* </td> <td> 21.23 </td> <td> 69.29 </td> </tr> <tr> <td> Netherlands </td> <td> 5.68 </td> <td> 76.15 </td> </tr> <tr> <td> Portugal </td> <td> 5.6 </td> <td> 74.06 </td> </tr> <tr> <td> Sweden </td> <td> 2.93 </td> <td> 78.12 </td> </tr> <tr> <td> Turkey* </td> <td> 46.3 </td> <td> 69.68 </td> </tr> <tr> <td> United Kingdom </td> <td> 5.83 </td> <td> 75.84 </td> </tr> <tr> <td> United States* </td> <td> 7.31 </td> <td> 74.63 </td> </tr> </tbody> </table> * Countries where male circumcision is prevalent Source: US Census Bureau, 2004 <h4>Table 2: HIV prevalence, 2000</h4> <table border="0" cellpadding="8" cellspacing="4" width="371"> <tbody> <tr> <td width="183"> Country </td> <td width="178"> HIV prevalence: Male and female, cases per 100,000 </td> </tr> <tr> <td> Australia </td> <td> 15 </td> </tr> <tr> <td> Canada </td> <td> 30 </td> </tr> <tr> <td> Denmark </td> <td> 17 </td> </tr> <tr> <td> Finland </td> <td> 5 </td> </tr> <tr> <td> Germany </td> <td> 10 </td> </tr> <tr> <td> Japan </td> <td> 2 </td> </tr> <tr> <td> Malaysia </td> <td> 42 </td> </tr> <tr> <td> Netherlands </td> <td> 19 </td> </tr> <tr> <td> New Zealand </td> <td> 6 </td> </tr> <tr> <td> Sweden </td> <td> 8 </td> </tr> <tr> <td> United Kingdom </td> <td> 11 </td> </tr> <tr> <td> United States </td> <td> 61 </td> </tr> </tbody> </table> <h4>Table 3: Circumcision compared with male life expectancy, HIV prevalence and incidence of cervical cancer, 2001</h4> <table border="0" cellpadding="8" cellspacing="4"> <tbody> <tr> <td class="Normal" width="156"> Country </td> <td class="Normal" width="182"> Proportion of adult males circumcised (%) </td> <td class="Normal" width="214"> Male life expectancy </td> <td class="Normal" width="233"> Prevalence of HIV in adults (cases per 100,000) </td> <td class="Normal" width="220"> Cervical cancer incidence (cases per 100,000) </td> </tr> <tr> <td class="Normal"> USA </td> <td class="Normal"> 70 </td> <td class="Normal"> 73.9 </td> <td class="Normal"> 61 </td> <td class="Normal"> 8 </td> </tr> <tr> <td class="Normal"> Australia </td> <td class="Normal"> 50 </td> <td class="Normal"> 76 </td> <td class="Normal"> 15 </td> <td class="Normal"> 7 </td> </tr> <tr> <td class="Normal"> Canada </td> <td class="Normal"> 50 </td> <td class="Normal"> 75.9 </td> <td class="Normal"> 19 </td> <td class="Normal"> 8 </td> </tr> <tr> <td class="Normal"> Britain </td> <td class="Normal"> <20 </td> <td class="Normal"> 75 </td> <td class="Normal"> 11 </td> <td class="Normal"> 9 </td> </tr> <tr> <td class="Normal"> Sweden </td> <td class="Normal"> <5 </td> <td class="Normal"> 77 </td> <td class="Normal"> 8 </td> <td class="Normal"> 9 </td> </tr> <tr> <td class="Normal"> Norway </td> <td class="Normal"> <5 </td> <td class="Normal"> 75.4 </td> <td class="Normal"> 7 </td> <td class="Normal"> 13 </td> </tr> <tr> <td class="Normal"> Finland </td> <td class="Normal"> <5 </td> <td class="Normal"> 73.7 </td> <td class="Normal"> 5 </td> <td class="Normal"> 4 </td> </tr> <tr> <td class="Normal"> Japan </td> <td class="Normal"> <5 </td> <td class="Normal"> 77.3 </td> <td class="Normal"> 2 </td> <td class="Normal"> 11 </td> </tr> </tbody> </table> Sources: HIV Prevalence: UNAIDS, Epidemic update report, 2002, Table E Cervical Cancer: <a href="http://www-dep.iarc.fr/" rel="noopener" target="_blank">CANCERMondial</a> Circumcision Prevalence: Own estimates Australia, Canada and Britain were selected because of their cultural similarities with the USA and because they have an intermediate level of circumcision prevalence. The Scandinavian countries and Japan were selected because they have very low rate of circumcision. There is nothing in the table to suggest that circumcision confers any health advantage at all, let alone a significant one, to males in the USA compared with males in the other countries. There is a strong correlation between circumcision prevalence and HIV prevalence, and a negative correlation between circumcision and life expectancy. The association between male circumcision and cervical cancer is also very weak. <h3>References</h3> 1. Marianne Legato, <a href="http://www.cirp.org/library/general/legato1/" rel="noopener" target="_blank">Rethinking circumcision: medical intervention, religious ceremony or genital mutilation?</a>, Journal of Gender Specific Medicine, Vol. 5, July-Aug. 2002, pp. 8-10 2. Robert Van Howe, <a href="http://www.nocirc.org/symposia/fourth/vanhowe.html" rel="noopener" target="_blank">Why does neonatal circumcision persist in the United States?</a>, in Marylin Milos and George Denniston (eds), Sexual mutilations: A human tragedy (London and New York: Plenum Publishers, 1997), p. 112. 3. By routine circumcision I mean circumcision of healthy male minors, showing no signs of abnormality or disease, on the decision of adults and without the consent of the child. Since the operation excises a normal mammalian anatomical feature in the belief that its loss will provide protection against fairly rare diseases, the risk of which lies mostly in the distant future, a more accurate term would be preventive or pre-emptive posthectomy (posthe being the Greek for foreskin). 4. Edward Wallerstein, <a href="http://www.cirp.org/library/general/wallerstein/" rel="noopener" target="_blank">Circumcision: The uniquely American medical enigma</a>, Urologic Clinics of North America, Vol 12, Feb. 1985, 123-32. Statements from medical organizations are conveniently collected at <a href="http://www.cirp.org/library/statements/" rel="noopener" target="_blank">http://www.cirp.org/library/statements/</a> 5. The frequency of circumcision did fall more sharply after the 1989 statement, then rose again in the mid-1990s, before levelling off; data released in early 2005 suggests that the more critical policy issued in 1999 has made a noticeable impact. See footnote 11. 6. M.S. and C.A. Brown, "Circumcision decision: Prominence of social concerns", Pediatrics, Vol. 80, 1987, pp. 215-19 7. Wallerstein, p. 129, citing M.J. Maisels et al, "Circumcision: The effect of information on parental decision-making", Pediatrics, Vol. 71, 1983, p. 453 8. See Robert Darby, A surgical temptation: The demonization of the foreskin and the rise of circumcision in Britain (Chicago and London: University of Chicago Press, 2005), conclusion 9. Editorial, <a href="http://www.cirp.org/library/general/BMJ/" rel="noopener" target="_blank">The case against neonatal circumcision</a>, British Medical Journal, 5 May 1979, 1163-4 10. Dan Bollinger, <a href="http://www.cirp.org/library/statistics/bollinger2003/" rel="noopener" target="_blank">Normal versus circumcised: US neonatal male genital ratio</a> (2003): 11. <a href="https://www.cdc.gov/nchs/products/pubs/pubd/hestats/circumcisions/circumcisions.htm" rel="noopener" target="_blank">National Center for Health Statistics</a> More recent statistics based on data from the National Hospital Discharge Survey show that the incidence of neonatal circumcision declined from 61.5 per cent in 1999 to 55.9 per cent in 2003, the largest falls being recorded in the south and west, and hardly any in the north-east. If this trend continues, circumcised boys will indeed soon be in the minority. See <a href="http://www.cirp.org/library/statistics/USA/" rel="noopener" target="_blank">http://www.cirp.org/library/statistics/USA/</a> 12. Edward Laumann et al, <a href="http://www.cirp.org/library/general/laumann/" rel="noopener" target="_blank">Circumcision in the United States: Prevalence, prophylactic effects and sexual practice</a>, Journal of the American Medical Association, Vol. 277, 1997, 1052-7, Table 1 13. Shannon Brownlee, "The overtreated American", Atlantic Monthly, Jan-Feb 2003; see also Ted Halstead, "The American paradox" in the same issue 14. Linda Kohn et al (eds), To err is human: Building a safer health system (Washington: National Academies Press, 2000), p. 1. <a href="http://nap.edu/info/browse.htm" rel="noopener" target="_blank">Available online here</a>. 15. Robert Van Howe, "Why does neonatal circumcision persist in the United States?" 16. Amber Craig et al, Tax dollar funding of medically unnecessary circumcision through Medicaid (2001): pdf available at <a href="http://www.icgi.org/" rel="noopener" target="_blank">http://www.icgi.org</a> 17. After they burned off his entire penis during a routine circumcision procedure, doctors decided that it would be better if David was turned into a girl. The experiment did not work. See <a href="http://www.circumstitions.com/News13.html" rel="noopener" target="_blank">http://www.circumstitions.com/News13.html</a> 18. Lori Andrews and Dorothy Nelkin, Body bazaar: The market for human tissue in the biotechnology age (New York: Crown, 2001); Norm UK, <a href="http://www.norm-uk.org/where_do_foreskins_go.html" rel="noopener" target="_blank">Where do all the foreskins go?</a> 19. In 2004 Allena Tapia was asked four times to allow doctors at a hospital in Michigan to circumcise her newborn son, and on two of these occasions she was so drowsy from drugs that it is doubtful if she was capable of giving informed consent. Informant (<a href="http://www.nocircofmi.org/" rel="noopener" target="_blank">Newsletter of Nocirc Michigan</a>), December 2004. In 2003 there was a case in which Spanish mothers who could barely understand English were bamboozled into signing consent forms â€“ <a href="http://www.arclaw.org/news/0000001a.htm" rel="noopener" target="_blank">now the subject of litigation</a>. 20. Abraham Wolbarst, "Universal circumcision as a sanitary measure", Journal of the American Medical Association, Vol. 62, 1914, p. 92-7 21. Hiram S. Yellen, "Bloodless circumcision of the newborn", American Journal of Obstetrics and Gynecology, Vol. 30, July 1935, pp. 146-7; Julian Wan, "Gomco circumcision clamp: An enduring and unexpected success", Urology, Vol. 59, 2002, pp. 790-94. <a href="https://www.historyofcircumcision.com/templates/pages/templates/pages/the_gomco_clamp_1935.html">Further details on the Gomco clamp</a> 22. Richard Miller and Donald Snyder, "Immediate circumcision of the newborn male", American Journal of Obstetrics and Gynecology, Vol. 65, 1953, p. 1-11 23. Lawrence Dritsas, <a href="http://www.cirp.org/library/general/dritsas1/" rel="noopener" target="_blank">Below the belt: Doctors, debate and the ongoing American discussion of routine neonatal male circumcision</a>, Bulletin of Science and Technology, Vol. 21, 2001, 297-311 24. Dritsas, p. 363, citing Maisels et al, 1983 25. <a href="http://aappolicy.aappublications.org/cgi/content/full/pediatrics;102/1/153" rel="noopener" target="_blank">Available from the American Academy of Pediatrics</a> 26. American Academy of Pediatrics, Committee on Bioethics, <a href="http://www.cirp.org/library/ethics/AAP/" rel="noopener" target="_blank">Informed consent, parental permission, and assent in pediatric practice</a>, Pediatrics, Vol. 95, 1995, pp. 314-17. 27. Dritsas, p. 310 28. Thomas Metcalf et al, "Circumcision: A study of current practices", Clinical Pediatrics, Vol. 22, 1983, p. 578 29. Geoffrey Miller, <a href="http://www.cirp.org/library/legal/miller1/" rel="noopener" target="_blank">Circumcision: Cultural-legal analysis</a>, Virginia Journal of Social Policy and the Law, Vol. 9, 2002, pp. 497-585 30. The reasons are desperate because the remoteness of the theoretical benefits do not justify the real damage, the absence of consent or the urgency. In the case of cervical cancer it has been repeatedly shown that a male partner's circumcision status is not a significant factor in whether a woman develops cervical cancer, and, even if it was, Sarah Waldeck (see Ref. 31) has pointed out that Western medical ethics do not permit a person to be mutilated without consent in order to benefit a third party, and all the moreso if the identity, or even the existence, of the supposed beneficiary is unknown. On top of this, an effective vaccine will soon be available. See <a href="http://www.cirp.org/library/disease/cancer/" rel="noopener" target="_blank">http://www.cirp.org/library/disease/cancer/</a>; Waldeck, pp. 486-491; <a href="http://www.circinfo.org/cervical.html" rel="noopener" target="_blank">http://www.circinfo.org/cervical.html</a>. Urinary tract infections seem to be problem only in countries with a history of widespread circumcision, and where incorrect foreskin care (such as premature retraction) is thus common. In any case, UTIs are usually minor infections which clear up quickly with antibiotics; persistent infections may indicate a malformation of the urinary tract or bladder, which will indeed require surgery, but not on the foreskin. For further information, see <a href="http://www.cirp.org/library/disease/UTI/" rel="noopener" target="_blank">http://www.cirp.org/library/disease/UTI/</a> and <a href="http://www.circumstitions.com/Utis.html" rel="noopener" target="_blank">http://www.circumstitions.com/Utis.html</a>. As to HIV, the debate about how to control AIDS in the Third World, where the disease is an epidemic mainly affecting heterosexuals, both male and female, has no relevance to conditions in developed countries, where it is a less serious problem mainly affecting small subcultures, such as promiscuous male homosexuals and intravenous drug users. It has no relevance at all to infants and children, who are not at risk of sexually-transmitted HIV because they do not have sex with carriers of the virus. See <a href="http://www.cirp.org/library/disease/HIV/" rel="noopener" target="_blank">http://www.cirp.org/library/disease/HIV/</a> and <a href="http://www.circinfo.org/hiv.html" rel="noopener" target="_blank">http://www.circinfo.org/hiv.html</a>. 31. Sarah Waldeck, <a href="http://www.cirp.org/library/legal/USA/waldeck1/" rel="noopener" target="_blank">Using circumcision to understand social norms as multipliers</a>, University of Cincinnati Law Review, Vol. 72, 2003, 455-526 32. See the astounding <a href="http://www.circumstitions.com/Movies.html" rel="noopener" target="_blank">analysis of movies</a> and of <a href="http://www.circumstitions.com/TVSitcoms.html" rel="noopener" target="_blank">TV shows</a> at circumstitions.com 33. Waldeck, p. 500, citing Theodore Ganiats et al, "Routine neonatal circumcision: A cost-utility analysis", Medical Decision Making, Vol. 11, 1991, pp. 282-93. (<a href="http://www.cirp.org/library/procedure/ganiats/" rel="noopener" target="_blank">Abstract available here</a>) This conclusion has recently been confirmed in an exhaustive study by Robert Van Howe, <a href="http://www.cirp.org/library/procedure/vanhowe2004/" rel="noopener" target="_blank">A cost-utility analysis of neonatal circumcision</a>, Medical Decision Making, Vol. 24, 2004, pp. 584-601 34. The case against neonatal circumcision 35. Katrina Spilsbury et al, <a href="http://www.cirp.org/library/procedure/spilsbury1/" rel="noopener" target="_blank">Routine circumcision practice in Western Australia 1981-1999</a>, ANZ Journal of Surgery, Vol. 73, 2003, pp. 610-14 36. Ann Dally, Fantasy surgery, 1880-1930: With special reference to Sir William Arbuthnot Lane (Amsterdam: Rodopi, 1996) 37. Abraham Wolbarst, "Universal circumcision" 38. Frederick Hodges, <a href="http://www.cirp.org/library/history/hodges2/" rel="noopener" target="_blank">The ideal prepuce in Ancient Greece and Rome</a>, Bulletin of the History of Medicine, Vol. 75, 2001, 375-405 39. Jane Sharp, The midwives book: Or the whole art of midwifery discovered (London 1671; facsimile reprint, New York: Garland, 1985), pp. 31-2 40. Richard Burton, Love, war and fancy: The customs and manners of the East from writings on the Arabian Nights, ed. Kenneth Walker (London: William Kimber, 1964), p. 106 </div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource The sorcerer's apprentice (2005) darby Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Robert Darby Subject The topic of the resource Circumcision history Description An account of the resource Archive of the work published by Robert Darby Creator An entity primarily responsible for making the resource Robert Darby Source A related resource from which the described resource is derived circinfo.org historyofcircumcsion.org Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Text Any textual data included in the document <div class="intro" id="intro"> <h3>John Taylor on the importance of the ridged band</h3> Taylor criticises studies of "penis sensitivity" that concentrate on the glans or shaft and forget the foreskin and its ridged band â€“ the very structure that both carries the nerves and provides the mobility that stimulates the other regions of the organ. The following letter was published in BJU International. <h4>Fine-touch pressure thresholds in the adult penis</h4> Van Howe et al. [1] found that the prepuce, particularly its ridged band [2,3] is the part of the penis (including the glans) most sensitive to fine touch. This finding is important because it has always been assumed, for good reason, that the glans is by far the most sensitive and important part of the penis. Early and inadequate laboratory studies [1] propelled the idea that 'sex is sex is sex', regardless of circumcision status. Suddenly, the prepuce could be sacrificed with a clear conscience and with no sexual consequences. The anatomy and physiology of the prepuce show otherwise. The range of functions of the ridged band remains uncertain but it is deeply corrugated, rich in distortion-sensitive Meissner corpuscles and subject to the movement of muscularised shaft skin during sexual intercourse. It now seems that the concertina-like ridged band might be reflexogenic as much as fine-touch sensitive. Initial study (J.R.T. unpublished) indicates that the real importance of the ridged band to sexual intercourse lies in an ability to trigger a reflex contraction of muscles responsible for ejaculation. Routine infant circumcision is under attack in Canada and the USA, but we need to know much more about the function of the prepuce in sexual intercourse. Van Howe and his team have contributed to this ideal, and at the same time opened the hide-bound debate on circumcision to fresh thinking. John R. Taylor Department of Pathology, University of Manitoba, Winnipeg, Manitoba, Canada References 1. Sorrells ML, Snyder JL. Reiss MD et al. <a href="http://www.cirp.org/library/anatomy/sorrells_2007/" rel="noopener" target="_blank">Fine-touch pressure thresholds in the adult penis</a>. BJU Int 2007; 99 : 864â€“9 2. Taylor JR, Lockwood AP, Taylor AJ. <a href="http://www.cirp.org/library/anatomy/taylor/" rel="noopener" target="_blank">The prepuce: specialized mucosa of the penis and its loss to circumcision</a>. Br J Urol 1996; 77 : 291â€“5 3. Cold CJ, Taylor JR. <a href="http://www.cirp.org/library/anatomy/cold-taylor/" rel="noopener" target="_blank">The prepuce</a>. Temp. BJU Int 1999; 83 (Suppl. 1):34â€“44 Source: BJU Int 2007;100(1):218. <h4>The forgotten foreskin and its ridged band</h4> And similarly in this letter to the Journal of Sexual Medicine. Circumcision does not diminish the sensitivity of the glans and penile shaft skin [1]. However, the prepuce is always front and center in the great circumcision debate and direct comparison of the glans with prepuce, not shaft skin, is essential. The glans is naturally insensitive to fine touch whether the penis is circumcised or not [2], and study of the effect of circumcision on sexual function should therefore focus on the missing prepuce. Biologically, however, both glans and prepuce contribute to the single mucocutaneous junctional zone of the penis, and it is possible that these apparently dissimilar structures in fact share similar functions related more to sexual reflexes than to touch perception. The ridged band of prepuce [3,4] is tucked just inside the tip of the unretracted prepuce; it is a richly vascular mucosal tissue heavily innervated by movement-sensitive Meissner corpuscles. In addition to touch sensitivity [2], the ridged band is uniquely ridged or corrugated, and not surprisingly, work in progress indicates that retraction and stretching of this accordion-like structure triggers reflex contraction of bulbocavernosus and bulbospongiosus. These "bulb muscles" compress the root or bulb of the penis and among other things, including deep erogenous sensation, are responsible for ejaculation and clearing of residual urine from the posterior urethra following micturition. Almost certainly, removal of the prepuce and its ridged band distorts penile reflexogenic functions but exactly how and to what extent still remains to be seen. John R. Taylor Winnipeg, Manitoba, Canada References 1. Payne K, Thaler L, Kukkonen T, Carrier S, Binik Y. Sensation and sexual arousal in circumcised and uncircumcised men. J Sex Med 2007;4:667â€“74. 2. Sorrells ML, Snyder JL, Reiss CE, Milos MF, Wilcox N, Van Howe RS. Fine-touch pressure thresholds in the adult penis. BJU Int 2007;99:864â€“9. 3. Taylor JR, Lockwood AP, Taylor AJ. The prepuce: Specialized mucosa of the penis and its loss to circumcision. Br J Urol 1996;77:291â€“5. 4. Cold CJ, Taylor JR. The prepuce. BJU Int 1999;83 (1 suppl):34â€“44. Source: J Sex Med 2007;4:1516 <a href="http://research.cirp.org/" rel="noopener" target="_blank">Further information on John Taylor's website: The ridged band.</a> </div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource John Taylor on the importance of the ridged band darby Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Robert Darby Subject The topic of the resource Circumcision history Description An account of the resource Archive of the work published by Robert Darby Creator An entity primarily responsible for making the resource Robert Darby Source A related resource from which the described resource is derived circinfo.org historyofcircumcsion.org Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Text Any textual data included in the document <div class="intro" id="intro"> <h3>The case of Boldt v. Boldt</h3> A long-running legal saga in the United States was finally resolved in late 2009, when courts in the state of Oregon ruled that a parent could not compel a child over which he had custody to get circumcised against the boy’s will. The case is of considerable interest in its potential to limit the power of parents to impose circumcision and similar physical alterations on children and in its implicit recognition that children have their own rights – to physical integrity and freedom of conscience and religion – independently of their parents’ belief. <h2>Background: A messy custody case</h2> The Boldt case was a custody battle, and like all custody battles, it was a complex story, but the basic facts are that the Boldts were adherents of the Russian Orthodox Church and had one child, Mikhail James, whom the mother called Misha and the father Jimmy. After a bitter divorce, custody of the boy was eventually given to the father. Some time after this the father decided to convert to Judaism and tried to take Misha (then aged 9) with him, a transition that necessarily entailed arranging for him to be circumcised. The boy’s mother obtained a temporary court injunction prohibiting the circumcision, and filed an application for custody. The father testified that Misha himself wished to convert and undergo the operation, but that even if he did not his wishes were irrelevant because the custodial parent had complete authority to make what he called “medical decisions” for a child. The mother testified that Misha did not want to be circumcised and was afraid to contradict his father. After a lengthy series of hearings and appeals, by which time the boy was 12, the Oregon Supreme Court decided that “although circumcision is an invasive medical procedure that results in permanent alteration of a body part and has attendant medical risks, the decision to have a male child circumcised for medical or religious reasons is one that is commonly and historically made by parents,” and it concluded that the custodial parent’s rights in this respect were not fettered by the views of the non-custodial parent. But because this was a custody, rather than a right to circumcise, case, the court ruled that forcing the boy to get circumcised would damage his relationship with his father, and sent the case back to the trial court to determine the boy’s own views. When Misha, by now aged 14, finally got the opportunity to express his own opinion (at a hearing in judges’ chambers in April 2009) he made it clear that he did not wish to convert to Judaism, and he most definitely did not want to get circumcised or to remain with his father. Accordingly, the court issued an order that he was not to be circumcised and returned him temporarily to his father while child custody officials worked out the details of how to return him to his mother. <h2>Involvement of Doctors Opposing Circumcision</h2> Although the original trial court ruled that a decision to circumcise was a legitimate power of the custodial parent and refused to hold a hearing on the matter, it issued a stay pending the outcome of an appeal by the mother. The Court of Appeal agreed with the trial court and refused to order a hearing, at which point the mother appealed to the Oregon Supreme Court and requested the American human rights group, Doctors Opposing Circumcision, to intervene in the case as amicus curiae (friend of the court – a role performed by those with no personal interest or standing in a case, but who can assist the court through its expertise in the technical questions raised). DOC filed two briefs in the case, one in support of the petition for review, and then, following the Oregon Supreme Court grant of certiorari (the right to appeal), a second brief on the merits. Parental and child rights were considered under the constitutions of Oregon, Washington (the child’s state of residence), the United States, and even a Supreme Court of Canada decision on parental duties under the Canadian Charter of Rights and Freedoms. DOC’s briefs were limited to arguments against circumcision on medical, legal, and human rights grounds, and did not take a position on the issue of custody. These were matched by three influential American Jewish organisations that submitted their own amicus curiae briefs in support of the father’s claim of an unfettered right to circumcise his son. At no point in their submission did they show the slightest sympathy for the plight of the child or show any interest in his preferences in the matter. They and the father claimed an absolute right to circumcise the boy under the “Free Exercise” clause of the First Amendment to the United States Constitution, which bars Congress from establishing any religion or prohibiting the free exercise thereof. Although the Oregon Supreme Court, in obiter dicta (a passing observation, not related to the legal issues that decided the case), paid deference to a custodial parent’s right to make a decision about circumcision, it remanded the case back to the trial court with an order that it should determine the view of the child. The child was then twelve years of age. <h2>Court recognises that child’s preferences must be considered</h2> The father then petitioned the United States Supreme Court for certiorari (right to appeal), which was denied, and the case returned to the Circuit Court of Jackson County, Oregon, where a hearing was held on 22 April 2009, before Judge Lisa Greif. At that time, Misha, now 14 years of age, testified in her chambers, on the record, that he did NOT want to be circumcised, he did NOT want to convert to Judaism, was afraid of his father and wanted to live with his mother. The court then issued an oral order from the bench that the child NOT be circumcised. The court then followed that with a written order on 2 June 2009, in which the court found that a substantial change of circumstances had occurred and ordered an investigation by an independent child custody evaluator for a future evidentiary hearing. In the meantime, the boy remains in the custody of his father, but under protective orders against circumcision. <h2>Significance of the Boldt case</h2> Despite the Oregon Supreme Court’s remark about the decision to circumcise a child being “commonly and historically made by parents”, the case remained a custody battle throughout, and no determination was ever made as to whether parents did in fact have the right to make such a decision, and if so with what qualifications. Since the question does not seem be as settled in law as the court’s confident words suggest, the observation may be regarded as no more than an obiter dictum. In a similar case, a divorced mother having custody of a nine-year-old son remarried, this time to a Jewish man, and sought to have the boy circumcised at the behest of her new husband. The father objected, and when the matter came to court the judge dismissed the mother’s claim of medical necessity and ordered that the boy be protected from circumcision until his 18th birthday, at which point he would be free to make his own decision. (Schmidt vs. Niznick, Cook County Illinois, 00D18272, cited in Doctors’ Opposing Circumcision, Amicus Curiae Brief on Boldt, 26) In denying that the non-custodial parent had no prerogatives with respect to medical decisions about a child, the Oregon Supreme Court certainly did not mean that the child had no say in the matter; indeed, in directing that the trial court discover Misha’s own views it implied quite the contrary. The significance of the case is in establishing a precedent that a parent’s authority to circumcise a child is not unlimited and may not even exist. Although the court took account of the boy’s age (twelve), recognising that it might be difficult to get a boy of that age to lie down submissively in a doctor’s surgery, it is hard to see why the principle of physical integrity would not apply to a child of any age. There is no obvious reasons why a child has the right to physical integrity at 12, but not at 8 years, 4 years, 6 months or 2 weeks. By the age of 12 Misha certainly knew that he wanted to keep his foreskin and was confident enough to make his views heard, and (this being the case) we may reasonably infer that if an infant or young child too young to be capable of expressing an opinion on the matter were able to do so, he would say NO, or at least ask that the operation be delayed until he was old enough to inform himself as to the pros, cons and harms of circumcision and make his own decision. A <a href="https://www.circinfo.org/news.html#chong">recent study in the USA</a> found that even if circumcision were proved to be effective insignificantly lowering the risk of HIV infection, only 0.7 per cent of adult men would be willing to get themselves circumcised. The clear implication is that if an infant or child were asked if he wanted to get circumcised, and he was capable of giving a rational answer, the answer would be “No way.” This alone is a sufficient reason why circumcision should not be imposed on minors. <h2>Age not the issue:</h2> <h3>All humans have autonomy and the right to physical integrity</h3> Some commentators on the Boldt case have suggested that while a 12 or 14-year old might be mature and competent enough to reject circumcision, younger boys and especially babies must just accept whatever their parents think best for them. This position makes no sense at all, for reasons set out clearly in the Canada Medical Association Journal a long time ago: The performance of unnecessary surgery on minors who have no say in the matter does not sit well with many people who consider circumcision a denial of basic human rights specifically an infant’s right to the respect and autonomy fundamental to Canadian law. … Removal of a normally function healthy body part without medical indication has also been viewed as a violation of the Hippocratic oath, falling under the United Nations’ definition of genital mutilation. As such, circumcision is seen as being against the Universal Declaration of Human Rights and the UN Convention on the Rights of the Child. … In BC [British Columbia], the Infants Act stipulates that a child should be accorded the same protection under law as adults: if an adult male cannot be forced to undergo circumcision in adulthood, it follows that he shouldn’t be forced to have it in infancy simply because he is too small to resist. (Eleanor LeBourdais, Circumcision No Longer a “Routine” Surgical Procedure, 152 CANADIAN MED. ASS’N. J. 1873-4 (1995) The fundamental problem with the idea that circumcision of an adult requires informed consent but circumcision of a minor can be accomplished at the wish of a parent is that childhood is a temporary condition but circumcision a permanent one. A person soon ceases to be a child, but no matter how old he gets he will not get back what has been taken away; as an adult the person has the same mark or absence that his parents were entitled to effect by the mere fact of his being a minor. There is thus no significant difference between forcible circumcision of an adult (which is illegal) and circumcision of a minor, since the result in adulthood, when the parts affected are most needed, is the same in each case. To make an adult’s right to physical integrity meaningful it must be respected in infancy and childhood, implying that irreversible bodily alterations should not be performed. By defining respect for autonomy as “requiring that persons with the mental capacity to make certain medical decisions have these decisions respected”, the parental authority school drastically reduces the scope of autonomy and effectively denies it to children and incompetent adults. This is a radical departure from accepted principles of bioethics [1] and a succession of legal judgements in the USA, Britain and Australia [2] that restrict the power of adults to make medical decisions on behalf of incompetent family members. Lack of mental capacity, neither in infancy nor in adulthood, does not negate a person’s right to physical integrity; if parents are determined to violate this right, the state is entitled to intervene in defence of those who lack the capacity to defend their own interests. <h2>Parental authority and the child’s right to an open future</h2> The following principles would also appear to have been endorsed by the outcome of this case. (1) Parental rights are an extension of, and derivative from, parental responsibilities to the child. Parental rights exist as against outsiders or strangers to the family; they are not rights of the parent against or over the child, who is held in trust during his minority. Behind every assertion of a parental ‘right’ must be a discernible concern for the independent co-relative rights and well-being of the child as a separate person and individual in his own right. (2) The child has an independent right to his own religious beliefs or non-beliefs. These rights are stated clearly in the foundation documents of the modern human rights framework: The Universal Declaration of Human Rights; the International Covenant on Civil and Political Rights; and the Convention on the Rights of the Child. These treaties give all people the right to freedom of religion and conscience and to physical integrity, irrespective of age or gender. To mark a child permanently and physically as a member of any religion deprives him of his own right to religious freedom and personal choice. To take an unfamiliar example, many Shiite Muslims believe they have the right to slit their children’s foreheads each year on the festival of Ashura, commemorating the death, by beheading, of their sainted Imam Hussein. [3] Even if performed by a doctor under sterile conditions, it is hard to believe that Western law or custom would accept this practice as an appropriate exercise of the religious freedom of the parent. (3) In his paper “The Children We Abandon: Religious Exemption to Child Welfare and Education Laws as Denials of Equal Protection to Children,” [4] James Dwyer has argued that far too often Anglophone law has abridged the child’s more fundamental rights to health and even life itself, to accommodate mere beliefs, even whims, of the parent. It is to be hoped that the Boldt case marks the beginning of a more child-centred tradition. (4) As argued by the late legal philosopher Joel Feinberg, children have a “right to an open future”, that is, one in which all options for the future development of the child as an adult-to-be are protected and retained. [5] This applies not only to affection, food, shelter, and education, but also to freedom from irrevocable parental choices of which circumcision is a permanent, palpable and entirely unnecessary example. For these reasons and many others, we should make sure that we maintain a sharp focus on the rights of the child as an independent entity distinct from his parents, one whom they hold in trust and cannot treat as property, and who is entitled to human rights of his own, of which the right to a set of intact genitals is surely one of the most fundamental. <h3>Documents relating to the case available here</h3> <a href="http://www.doctorsopposingcircumcision.org/pdf/2007-04BoldtReview.pdf">Doctors Opposing Circumcision, Brief of amicus curiae in support of the petition for review</a> (PDF, 184 kb) <a href="http://www.doctorsopposingcircumcision.org/pdf/2007-07BoldtMerits.pdf">Doctors Opposing Circumcision, Brief on the merits of amicus curiae</a> (PDF, 102 kb) <a href="http://www.doctorsopposingcircumcision.org/info/appeal.html" rel="noopener" target="_blank">Summary of early phases of case at DOC website</a> <a href="https://www.circinfo.org/DOC_Boldt_case.html">Letter from Doctors Opposing Circumcision to Journal of Clinical Ethics</a> <h2>References</h2> 1. Tom L. Beauchamp and James F. Childress, Principles of Biomedical Ethics (Oxford University Press, 1977) As set out in this basic text, the fundamental principles of bioethics are: Beneficence — Does the proposed procedure provide a net therapeutic benefit to the patient, considering the risk, pain, and loss of normal function? Non-maleficence — Does the procedure avoid permanently diminishing the patient in any way that could be avoided? Proportionality — Will the final result provide a significant net benefit to the patient in proportion to the risk undertaken and the losses sustained? Justice — Will the patient be treated as fairly as we would all wish to be treated? Autonomy — Lacking life-threatening urgency, will the procedure honor the patient’s right to his or her own likely choice? Could it wait for the patient’s assent? Medically unnecessary circumcision of male minors violates every one of these principles. 2. J.S. Svoboda et al, <a href="http://www.cirp.org/library/legal/conundrum/">Informed consent for neonatal circumcision</a>, esp. 80-81, 87, 89-90; Gregory Boyle et al, <a href="http://www.cirp.org/library/legal/boyle1/">Circumcision of Healthy Boys: Criminal Assault?</a>, 7 J Law Med 301 (2000); Frank Bates, <a href="http://www.cirp.org/library/legal/bates1/">Males, Medical Mutilation and the Law: Some recent Developments</a>, 9 J Law Med 68 (2001) 3. The theory is that young men slash only their own foreheads, but there are plenty of pictures available on the web that show adults doing it to young children: see “Ashura observed with blood streams to mark Karbala tragedy” at <a href="http://www.jafariyanews.com/2k5_news/feb/20ashur.htm">Jafariya News</a> and <a href="http://atlasshrugs2000.typepad.com/atlas_shrugs/2009/01/islam-celebrate.html">Atlas Shrugs</a>. 4. James Dwyer, The Children we Abandon: Religious Exemptions to Child Welfare and Education Laws as Denials of Equal Protection to Children of Religious Objectors, 74 N.C.L. Rev. 1321 5. Joel Feinberg, The Child’s Right to an Open Future, in Freedom and Fulfilment: Philosophical Essays (Princeton University Press, 1992). See also Dena Davis, Genetic Dilemmas: Reproductive Technology, Parental Choices and Children’s Futures (London and New York: Routledge, 2001), and idem, Genetic Dilemmas and the Child's Right to an Open Future, 28 Rutgers Law Journal 549 (1997) </div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource American legal precedent confirms child’s right to reject circumcision darby Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Robert Darby Subject The topic of the resource Circumcision history Description An account of the resource Archive of the work published by Robert Darby Creator An entity primarily responsible for making the resource Robert Darby Source A related resource from which the described resource is derived circinfo.org historyofcircumcsion.org Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Text Any textual data included in the document <div class="intro" id="intro"> <h1>Where is the voice of the man the child will become?</h1> <h2>Defending the child's right to an open future</h2> Letter from Doctors Opposing Circumcision on case of Boldt v. Boldt In the Fall 2009 issue of the Journal of Clinical Ethics, the authors of papers from a panel discussion at the 2008 Annual Meeting of the American Society for Bioethics and the Humanities reported on a common quandary in clinical ethics, made more challenging by the age of the child-patient. This was the case of “Misha” (Jimmy) Boldt, an Oregon child who faced, for five years, uninvited conversion, including circumcision, occasioned by a religious epiphany his custodial father claimed to have undergone. Each of the authors on the panel had a different perspective: Dena S. Davis, JD, PhD, [1] was the originator and moderator of the panel Janet L. Dolgin, PhD, JD, commented on the legal/sociological aspects; [2] Douglas S. Diekema, MD, MPH, commented on the medical/clinical aspects; [3] and Noam Zohar, PhD, commented on the religious/philosophical issues. [4] Our international physicians’ organization, Doctors Opposing Circumcision (D.O.C.), filed two amicus curiae (friend of the court) briefs in the case, [5] and attended a hearing on 22 April 2009 during which the child, by then 14, testified under oath and on the record in an Oregon court that he did not wish to convert to Judaism (his father’s newly adopted religion), he did not wish to be circumcised, and he did not wish to live with his father any longer. [6] The child’s testimony showed courage and took a risk that he would be ignored, as children too often are. Because it would have been far easier for Misha to accede to his custodial father’s wishes than to defy him in public, perhaps it can be assumed his testimony was truthful. Indeed, the child returned home with his father that day. In September 2009, facing a custody hearing he was likely to lose, the father voluntarily agreed to give up physical custody of Misha to his mother, with court approval. The child’s proposed circumcision, at one point only hours away, remains judicially prohibited. None of the amicus groups that supported the father’s legal position all the way to the U.S. Supreme Court — and back to Oregon — appeared at the hearing on 22 April 2009 to hear the child’s actual “voice” (nor did they express any written sympathy for the plight of the child throughout the proceedings). [7] Our international physicians’ group was pleased to read that Diekema and Zohar stated that the child’s preference must be sought. [8] In this instance that would have been problematic, because there was no way to determine whether the father, who had full custody of the boy for many years, had not systematically steeped the child in his own beliefs. This is a common and challenging scenario in pediatric bioethics. There was, our physicians’ group believed, another voice that needed to be heard — that of the man Misha would soon become. Thus we were stung by the suggestion of Dolgin in ICE that we had ignored the voice of Misha, [9] and so did him a disservice for our own ideological reasons. We did urge the court to protect the child from an irrevocable decision he might later regret — but only if Misha supported his father reflexively. In that sense Dolgin was half correct — and only in the short-term It is overly simplistic to frame this ethical puzzle as fully solvable by merely listening attentively to the voice of the child. Our entire rationale in this case was not only to defend, cautiously, the voice of the child — which might potentially have been manipulated by adults — but also to give a voice to the man this boy is soon to become. That voice, or any voice from within the child, was entirely missing until the end of the five-year litigation. But it may be found throughout our two voluminous briefs on Misha’s behalf. [10] In all, four attorneys eventually contributed more than $80,000 in pro bono legal time to hear the voice of Misha, the future man, and, by inference, others in his situation. Contributions poured in from a half-dozen countries. Even so, ultimately Misha did the heavy lifting, finding within himself the beginnings of his forthright adult voice. We live the bulk of our lives — 60 or so years — intellectually independent from our birth families, even if we are emotionally tied to them, as autonomous individuals with the right to determine our own beliefs and the responsibility to extend the same freedom to our children. The late philosopher Joel Feinberg said that children are entitled to an “open future,” one whose options are not foreclosed by whimsical (or even pious, heartfelt) decisions of their parents, and who ought to be protected from decisions of their own that they may come to regret. [11] The cosmetic surgery or tattoo that a discontented young adolescent might crave, as Diekema warns, comes to mind. [12] Misha/Jimmy Boldt now has an open future; he can schedule his own circumcision at age 18 for religious reasons — or for no reason at all. He can study to become an observant Jew if he wishes, which would be much more credible for being his personal choice. Following the path of millions of secular Jews worldwide, he could also become an agnostic or an atheist, or anything in between. Indeed, we have no way of knowing what personal beliefs a child will develop. We would argue further that parents have no right to force a child to adopt their beliefs merely to reaffirm their own choices. Beyond issues of belief, do we, as parents, acquire a derivative right to mark our child’s body with an indelible symbol of our own belief? For example, in some quarters of fundamentalist Shiite belief, parents slash their child’s forehead three times during Ashura, so that blood flows down the child’s face to memorialize the death of the martyred saint Imam Hussein, beheaded by Sunnis in the year 780. The child is said to be protected from pain or harm by his or her faith. The ritual is repeated each year, even with toddlers. [13] Should Shiite parents be credited with honest piety and their toddlers with independent belief? Or should we attempt to forbid this practice (in North America, anyway), as it presents risks to children whose beliefs cannot yet be determined and whose scars, physical and psychological, may be permanent? One reason this particular religious practice may seem repellent is that, like female genital cutting, it is unfamiliar. Richard Dawkins, DPhil, Oxford University, has suggested that raising a child in a specific religion, to the exclusion of exposure to other beliefs including skepticism, constitutes child abuse.” [14] Perhaps that is too drastic, but it is a provocative thought in a world that includes too many young suicide bombers. Thus there is a lesson in Misha’s case to guide pediatric care-providers: the voice of the child, as Diekema touches upon but does not elaborate, may be the product of many sources: whims of the child, whims of the family, remnant memes of culture the child has been taught to parrot. Thus care-providers will do well to ignore the clamor and remain focused on what is best for the child qua future adult, preserving, when possible, all of the child’s options to be exercised, autonomously, later. That logically eliminates all occasions in which the child’s options are foreclosed, without therapeutic justification, for reasons the child-now-an-adult may regret. In the medical setting, that means avoiding procedures that humor the family at the expense of the child, who is the only patient and an adult-in-process, whom we are charged to protect. Examples include therapeutically premature, cosmetic “normalization” surgeries like otoplasty or blepharoloplasty (changing an Asian double eyelid), or precipitous gender assignment of the intersexed, when these could wait for the adult child’s expressed preference. Respect for a child’s right to an open future fully obviates the merely cultural, non-therapeutic, surgical modification of minors, including cosmetic labioplasty (alas, on the rise), [15] cosmetic piercing or reduction of the labia or foreskin, tattooing, scarification, circumcision of either gender, and the like. All reduce a child’s options and brand the child as the possession of the parents, with no regard to his or her autonomy as a future adult. Without proven therapeutic justification and pressing necessity, none enhance the child or credit his or her right to an open future or the right to choices — including physical appearance and sexual functioning — of his or her own. Finally, we were disturbed and dismayed by a footnote in Dolgin’s article that could be seen to suggest that the president of Doctors Opposing Circumcision, George C. Denniston, MD, may be anti-Semitic, which is entirely unfounded. [16] In closing, children who are welcomed, gently, into their birth communities have been given the gift of Joel Feinberg’s “open future.” They may embrace their community or they may eventually drift away; there is no way to tell, in advance, what they will choose. But, importantly, their options are left open, and none of their body parts will have been surgically modified or removed — without their consent — prior to the moment when we will be able to hear the voices of the adults they will become. John V. Geisheker, JD, LLM Executive Director, General Counsel Doctors Opposing Circumcision 2040 Westlake Avenue North, Suite 420 Seattle, Washington 98109 <h3>References</h3> 1. D.S. Davis, “Boldt v. Boldt,” The journal of Clinical Ethics 20, no. 3 (Fall 2009): 241-3. 2. J.L. Dolgin, “Where Is the Child? Circumcision and Custody in Boldt v. Boldt,” The Journal of Clinical Ethics 20, no. 3 (Fall 2009): 244-50. 3. D.S. Diekema, “Boldt v. Boldt: A Pediatric Ethics Perspective,” The Journal of Clinical Ethics 20, no. 3 (Fall 2009): 251-7. 4. N. Zohar, “Circumcision, Conversion, and Deciding for a Minor: Some Jewish Perspectives,” The Journal of Clinical Ethics 20, no. 3 (Fall 2009): 258-61. 5. “Boldt v. Boldt: Brief of Amicus Curiae, Doctors Opposing Circumcision, in Support of the Petition for Review,” http://www.doctorsopposingcircumcision.org/ pdf/2007-04BoldtReview.pdf, p. 3, accessed 13 November 2009, and as a record of the State of Oregon Court system; “Brief on the Merits of Amicus Curiae, Doctors Opposing Circumcision,” http://www.doctorsopposingcircumcision. org/pdf/2007-04BoldtReview.pdf, p. 2, accessed 13 November 2009, also as a record of the State of Oregon Court system. 6. In the Circuit Court of the State of Oregon, County of Jackson, In the matter of the marriage of James H. Boldt and Lia Boldt, Case 98-2318-D3(8), Judge’s Order signed June 2, 2009, filed and received June 3, 2009. 7. Through their lawyers, the American Jewish Congress, the American Jewish Committee, the Anti-Defamation League, and the Union of Orthodox Jewish Congregations of America. 8. Zohar writes, “Since the validity of the conversion will depend on the eventual assent of the young man, it seems nothing much would be lost by waiting with the ritual until he reaches the age of competence, at which point he shall be able to decide for himself, both with regard to the circumcision and to the conversion as a whole.” Zohar, see note 4 above, p. 261. 9. Dolgin writes, “The assumptions behind that convergence of opinion reflect a model of childhood … on which the parents and the amici curiae all relied — a model here referred to as “traditional” … between the traditional model of childhood and the individualist model, society and the law have etched a third model of childhood. Referred to here as the “transforming” model of childhood, it bears incidents of each of the other two models and differs from both. This model recognizes the autonomy and individuality of some children, in some settings, to some degree, and it defines some children, in other settings, as dependent and unequal.” Dolgin, see note 2 above, p. 247. 10. At no time did any staff member of Doctors Op¬posed to Circumcision, legal or medical, have even the slightest contact with the mother or the child, lest we be accused in open court of influencing the child’s “voice” ourselves, risking our neutral amicus status. We urged the Oregon Supreme Court to bifurcate and analyze separately the issues of custody and the claimed legality of the impending circumcision, whether unwanted or not (issues the court eventually commingled, unfortunately). At no time did we take any position with respect to which parent might be the better custodian for the child. See: “Boldt v. Boldt: Brief of Amicus Curiae,” note 5 above. 11. J. Feinberg, “The Child’s Right to an Open Future,” in Whose Child? Children’s Rights, Parental Authority, and State Power, ed. W. Aiken and H. LaFollette (Totawa, N.J.: Littlefield, Adams, 1980); also in Freedom and Fulfilment: Philosophical Essays (Princeton University Press, 1992), 12. Diekema, see note 3 above, p. 255. 13. Some recent photos of toddlers commemorating Ashura are posted at http://atlasshrugs2000. typepad.com/ atlas_shrugs/2009/01/islam-celebrate.html, accessed 13 November 2009. 14. R. Dawkins, “Childhood, Abuse, and the Escape from Religion,” in The God Delusion (New York: Houghton Mifflin, 2006), 309 et seq. 15. See, for instance Liao LM, Michala L, Creighton SM, Labial surgery for well women: A review of the literature, British Journal of Gynecology 117 (1) January 2010, 20-25: “Medically non-essential surgery to the labia minora is being promoted as an effective treatment for women's complaints, but no data on clinical effectiveness exist”. Abstract at http://www.ncbi.nlm.nih.gov/pubmed/19906048, accessed 13 November 2009. 16. Dolgin, see note 2 above, note 41, p. 249 Journal of Clinical Ethics (New York), 21 (1), Spring 2010, 86-88 </div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Boldt case: Letter to Journal of Clinical Ethics darby Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Robert Darby Subject The topic of the resource Circumcision history Description An account of the resource Archive of the work published by Robert Darby Creator An entity primarily responsible for making the resource Robert Darby Source A related resource from which the described resource is derived circinfo.org historyofcircumcsion.org Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Text Any textual data included in the document <div class="intro" id="intro"> <h2>If a small tattoo is mayhem, what is circumcision?</h2> In Fresno, California, a father is facing the serious charge of mayhem for imposing a small tattoo on his 7-year-old son. Mayhem is an old offence, referring to any sort of serious maiming or mutilation of the body, and usually attracts a stiff sentence - as much as life imprisonment in California. But if a small mark on the skin, without cutting or loss of tissue, is mutilation, how would you describe the removal of the foreskin from the penis, and what sort of penalty should that attract when performed without need or consent on a minor? A judge in Fresno, California (United States) recently raised the stakes in a case that has drawn widespread attention -- reinstating aggravated mayhem charges against two Bulldog gang members accused of inking a gang tattoo on a 7-year-old boy. Judge Gary Orozco's ruling means that the two men -- the boy's father and his friend -- could face life in prison rather than a maximum term of 16 years. The case also opens the door to a broader definition for child-abuse cases, according to the defense attorneys. Even Orozco acknowledged that the case raises the question of whether a parent ever has a right to subject children to potentially painful procedures such as getting pierced ears or being circumcised. In court Friday, prosecutor William Lacy said Gonzalez held his son down against his will while Gorman inked a gang insignia on the boy's hip. "He's crying and saying he didn't want it," said Lacy, who called the tattoo "a branding." Orozco agreed with Lacy's interpretation of the facts, saying the tattoo -- a quarter-size dog paw, which is a symbol of the Bulldog gang -- was painful to the child and left a permanent disfigurement on the boy's hip. The ruling outraged Foster. He told Orozco that a mayhem charge should be reserved only for more serious cases. "It must be a cruel, savage and gory crime," he said. "A tattoo on a child, though a horrible decision, simply does not rise to mayhem." Foster's research showed that the mayhem charge evolved from the case of Lawrence Singleton, who raped a young runaway, chopped off her forearms with an ax and dumped her into a drainage culvert outside of Modesto to die. In other mayhem cases, a defendant was accused of putting out a cigarette on a victim's breasts or biting off the victim's ear. "It's absurd to compare a tattoo to these cases," Foster said. Attorney Manuel Nieto, who represents Gorman, said he also researched the issue and found that mayhem typically involves cases in which the defendant wants to punish or torture the victim. Nieto said neither Gonzalez nor Gorman wanted to hurt the child or disfigure him. He said Gonzalez just wanted his son to have a tattoo like his father. Both Gorman and Gonzalez have several tattoos. Nieto likened Gonzalez's actions to a parent who has a daughter's ears pierced or a son circumcised. The child might not like the pain, but the parent has a right to do it, Nieto said. Orozco said he doesn't know whether parents have a right to inflict pain on children against their will. Such acts, he said, could indeed be child abuse. Now it will be up to a jury to decide whether a tattoo constitutes mayhem. Pablo Lopex, Charges reinstated in tattooing of boy, Fresno Bee (California), 29 January 2010 <a href="http://www.circumstitions.com/news/news35.html#tattoo3" rel="noopener" target="_blank">Earlier report, with photo of tiny tattoo</a> </div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Mayhem in tattoo charge case darby Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Robert Darby Subject The topic of the resource Circumcision history Description An account of the resource Archive of the work published by Robert Darby Creator An entity primarily responsible for making the resource Robert Darby Source A related resource from which the described resource is derived circinfo.org historyofcircumcsion.org Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Text Any textual data included in the document <div class="intro" id="intro"> Colorado has become the 18th American state to drop medically unnecessary circumcision from the schedule of medical benefits under the Medicaid program. The decision comes as a result of a campaign by human rights and child protection advocates to protect baby boys from genital cutting, and in response to the budgetary crisis affecting so many American public authorities. When there is little enough funds available for necessary medical procedures, it makes little sense to waste valuable health dollars on unnecessary and harmful operations that the recipients do not want. Gillian Longley, a registered nurse in Louisville, looks at the change in Medicaid policy as a critical moment for public education surrounding the issue. She said that until recently, new parents were remarkably ill-informed of the pros and cons of circumcision. “Doctors were not giving them the information they needed to make a decision,” she said. “The usual ethical requirements for informed consent were overlooked. Circumcision was a cultural habit that was accepted as normal.” Colorado lawmakers had to cut hundreds of millions from state spending to balance the budget this year. Halting Medicaid coverage for circumcision is increasingly common across the country and is a relatively easy choice because there is no medical justification for the procedure. “The medical reasons are not convincing either way,” said Dr. Susan Pharo, director of Medicaid and External Pediatric. Research has found a “tiny” benefit in terms of circumcision reducing the frequency of urinary tract infections in the first year of life, Pharo said, “but the numbers are so low it’s not significant.” Some research has found a slight decrease in the transmission of HIV and sexually transmitted diseases among circumcised men in sub-Saharan Africa, “but that’s not really applicable here,” Pharo said, “and the evidence is not strong either way.” The risks of the procedure include relatively rare incidence of complications such as bleeding and infection and, more commonly, “poor cosmetic effect,” said Dr. Sarah Pilarowski, pediatrician at Cherry Creek Pediatrics. “We do have a lot of baby boys going in later for revisions,” she said. The No. 1 risk is pain. “We try to minimize it,” Pilarowski said, but penile nerve blocks don’t always work and numbing creams “are not 100 percent.” In fact, the greatest risk of circumcision, experienced by all victims, is the loss of the foreskin, a normal body part that plays a significant role in sexual experience. As Gillian Longley comments, “This is a normal body part,” said Longley. “We are doing our sons a favor to support them to stay whole.” Pilarowski speculates that the changes in Medicaid policies will spark changes in private insurance coverage. “Everyone is looking to cut costs,” she said. “It’s very possible other insurance companies will follow suit.” Source: Diane Cameron, <a href="http://www.healthpolicysolutions.org/2011/06/21/unkindest-cut-medicaid-wont-cover-circumcision-in-colorado/">Unkindest cut: Medicaid won’t cover circumcision in Colorado</a>, Health Policy Solutions, 21 June 2011 <a href="http://www.circumstitions.com/%24%24%24.html" rel="noopener" target="_blank">Further information about Medicaid coverage of circumcision in the United States</a> </div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Another U.S. state drops circumcision from its medical benefits schedule darby