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"> <h2>Cutting through circumcision and foreskin myths</h2> Further evidence that intelligent Americans are rejecting and abandoning circumcision is provided in a September issue of the on-line journal Psychology Today, which has published a series of articles tackling common myths about the foreskin and circumcision. In one of these articles Dr Darcia Narverez considers the perennial issues of hygiene, cleanliness and sexually transmitted diseases. <h3>Is circumcision cleaner and healthier?</h3> There's a lot of hype about how circumcision is better for a man's health. But is it really? Here is Part 2 of our series on myths about circumcision. Myth: You have to get the baby circumcised because it is really hard to keep a baby's penis clean. Reality check: In babies, the foreskin is completely fused to the head of the penis. You cannot and should not retract it to clean it, as this would cause the child pain, and is akin to trying to clean the inside of a baby girl's vagina. The infant foreskin is perfectly designed to protect the head of the penis and keep feces out. All you have to do is wipe the outside of the penis like a finger. It is harder to keep circumcised baby's penis clean because you have to carefully clean around the wound, make sure no feces got into the wound, and apply ointment. Myth: Little boys won't clean under their foreskins and will get infections. Reality check: The foreskin separates and retracts on its own sometime between age 3 and puberty. Before it retracts on its own, you wipe the outside off like a finger. After it retracts on its own, it will get clean during the boy's shower or bath. Once a boy discovers this cool, new feature of his penis, he will often retract the foreskin himself during his bath or shower, and you can encourage him to rinse it off. But he should not use soap as this upsets the natural balance and is very irritating. There is nothing special that the parents need to do. Most little boys have absolutely no problem playing with their penises in the shower or anywhere else! It was harder to teach my boys to wash their hair than it was to care for their penises. (Camille 2002) Myth: Uncircumcised penises get smelly smegma. Reality check: Actually, smegma is produced by the genitals of both women and men during the reproductive years. Smegma is made of sebum and skin cells and lubricates the foreskin and glans in men, and the clitoral hood and inner labia in women. It is rinsed off during normal bathing and does not cause cancer or any other health problems. Myth: "My uncle wasn't circumcised and he kept getting infections and had to be circumcised as an adult." Reality check: Medical advice may have promoted infection in uncircumcised males. A shocking number of doctors are uneducated about the normal development of the foreskin, and they (incorrectly) tell parents that they have to retract the baby's foreskin and wash inside it at every diaper change. Doing this tears the foreskin and the tissue (called synechia) that connects it to the head of the penis, leading to scarring and infection. Misinformation was especially prevalent during the 1950s and 60s, when most babies were circumcised and we didn't know as much about the care of the intact penis, which is why the story is always about someone's uncle. Doing this to a baby boy would be like trying to clean the inside of a baby girl's vagina with Q-tips at every diaper change. Rather than preventing problems, such practices would cause problems by introducing harmful bacteria. Remember that humans evolved from animals, so no body part that required special care would survive evolutionary pressures. The human genitals are wonderfully self-cleaning and require no special care. Myth: "My son was diagnosed with phimosis and so had to be circumcised." Reality check: Phimosis means that the foreskin will not retract. Since children's foreskins are naturally not retractable, it is impossible to diagnose phimosis in a child. Any such diagnoses in infants are based on misinformation, and are often made in order to secure insurance coverage of circumcision in states in which routine infant circumcision is no longer covered. Even some adult men have foreskins that do not retract, but as long as it doesn't interfere with sexual intercourse, it is no problem at all, as urination itself cleans the inside of the foreskin (note that urine is sterile when leaving the body.) Phimosis can also be treated conservatively with a steroid cream and gentle stretching done by the man himself, should he so desire it, or, at worst, a slit on the foreskin, rather than total circumcision. (Ashfield 2003) These treatment decisions can and should be made by the adult man. Myth: Uncircumcised boys get more urinary tract infections (UTIs.) Reality check: This claim is based on one study that looked at charts of babies born in one hospital (Wiswell 1985). The study had many problems, including that it didn't accurately count whether or not the babies were circumcised, whether they were premature and thus more susceptible to infection in general, whether they were breastfed (breastfeeding protects against UTIs), and if their foreskins had been forcibly retracted (which can introduce harmful bacteria and cause UTI) (Pisacane 1990). There have been many studies since which show either no decrease in UTIs with circumcision, or else an increase in UTI from circumcision. Thus circumcision is not recommended to prevent UTI (Thompson 1990). Girls have higher rates of UTI than boys, and yet when a girl gets a UTI, she is simply prescribed antibiotics. The same treatment works for boys. Myth: Circumcision prevents HIV/AIDS. Reality check: Three studies in Africa several years ago that claimed that circumcision prevented AIDS and that circumcision was as effective as a 60% effective vaccine (Auvert 2005, 2006). These studies had many flaws, including that they were stopped before all the results came in. There have also been several studies that show that circumcision does not prevent HIV (Connolly 2008). There are many issues at play in the spread of STDs which make it very hard to generalize results from one population to another. In Africa, where all the recent studies have been done, most HIV transmission is through male-female sex, but in the USA, it is mainly transmitted through blood exposure (like needle sharing) and male-male sex. [Circumcision has been shown to have no protective effect in these situations.] Male circumcision does not protect women from acquiring HIV, nor does it protect men who have sex with men (Wawer 2009, Jameson 2009). What's worse, because of the publicity surrounding the African studies, men in Africa are now starting to believe that if they are circumcised, they do not need to wear condoms, which will increase the spread of HIV (Westercamp 2010). Even in the study with the most favorable effects of circumcision, the protective effect was only 60% - men would still have to wear condoms to protect themselves and their partners from HIV. In the USA, during the AIDS epidemic of the 1980s and 90s, about 85% of adult men were circumcised (much higher rates of circumcision than in Africa), and yet HIV still spread. It is important to understand, too, that the men in the African studies were adults and they volunteered for circumcision. Babies undergoing circumcision were not given the choice to decide for themselves. Myth: Circumcision is worth it because it can save lives. Reality check: Consider breast cancer: There is a 12% chance that a woman will get breast cancer in her lifetime. Removal of the breast buds at birth would prevent this, and yet no one would advocate doing this to a baby. It is still considered somewhat shocking when an adult woman chooses to have a prophylactic mastectomy because she has the breast cancer gene, yet this was a personal choice done based upon a higher risk of cancer. The lifetime risk of acquiring HIV is less than 2% for men, and can be lowered to near 0% through condom-wearing (Hall 2008). How, then, can we advocate prophylactic circumcision for baby boys? Bottom line: Science and data do not support the practice of infant circumcision. Circumcision does not preclude the use of the condom. The adult male should have the right to make the decision for himself and not have his body permanently damaged as a baby. REFERENCES Ashfield, J., et al., <a href="http://www.cirp.org/library/treatment/phimosis/ashfield1/">Treatment of phimosis with topical steroids in 194 children</a>, JOURNAL OF UROLOGY, Volume 169, Number 3: Pages 1106-1108, March 2003. Auvert, B. et al., Randomized, controlled intervention trial of male circumcision for reduction of HIV infection risk: the ANRS 1265 Trial, PLoS Med. 2005 Nov;2(11):e298. Epub 2005 Oct 25. Camille CJ, Kuo RL, Wiener JS. <a href="http://www.cirp.org/library/hygiene/camille1/">Caring for the uncircumcised penis: What parents (and you) need to know</a>. Contemp Pediatr 2002;11:61. Connolly, C. et al., <a href="http://www.cirp.org/library/disease/HIV/connolly2008/">Male circumcision and its relationship to HIV infection in South Africa: Results of a national survey in 2002</a>, South African Medical Journal, October 2008, Vol. 98, No. 10. Hall, H. et al., Estimating the lifetime risk of a diagnosis of the HIV infection in 33 states, 2005-2005; J Acquir Immune Defic Syndr. 2008;49(3):294-297. Jameson, D. et al., The Association Between Lack of Circumcision and HIV, HSV-2, and Other Sexually Transmitted Infections Among Men Who Have Sex With Men, Sex Transm Dis. 2009 Nov 6. Pisacane A, et al. <a href="http://www.cirp.org/library/disease/UTI/pisacane/">Breastfeeding and urinary tract infection</a>. The Lancet, July 7, 1990:50. Thompson RS: <a href="http://www.cirp.org/library/disease/UTI/thompson/">Does circumcision prevent urinary tract infection? An opposing view</a>. J Fam Pract 1990; 31: 189-96. Wawer, M. et al., Circumcision in HIV-infected men and its effect on HIV transmission to female partners in Rakai, Uganda: a randomised controlled trial, The Lancet, Volume 374, Issue 9685, Pages 229 - 237, 18 July 2009. Westercamp, W., et al., <a href="https://www.circinfo.org/AIDSnews.html#kenya">Male Circumcision in the General Population of Kisumu, Kenya: Beliefs about Protection, Risk Behaviors, HIV, and STIs</a>, PLoS ONE 5(12): e15552. doi:10.1371/journal.pone.0015552 Wiswell TE, Smith FR, Bass JW. Decreased incidence of urinary tract infections in circumcised male infants. Pediatrics 1985, 75: 901-903. Source: Darcia Narvaez, Ph.D, <a href="http://www.psychologytoday.com/blog/moral-landscapes/201109/more-circumcision-myths-you-may-believe-hygiene-and-stds">Circumcision myths you may believe: Hygiene and sexually transmitted diseases (STDs)</a>, Psychology Today, 13 September 2011. Darcia Narvaez is an Associate Professor of Psychology and Director of the Collaborative for Ethical Education at the University of Notre Dame, USA. </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 Circumcision myths you may believe 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>Circumcision of females: Cultural and medical rationales</h3> <h4>Introduction</h4> Like its male counterpart, circumcision of females has two histories. First it is a ritual or customary practice among tribal societies (mostly in Africa) and some Islamic communities. Secondly it is a medical intervention, justified by Victorian (and, in the USA, some twentieth century) doctors in exactly the same way as they rationalised circumcision of boys: to deter masturbation, to treat obscure nervous disorders such as hysteria, neurasthenia and epilepsy, and thereby to promote health. <h4>MGM and FGM</h4> Given the similarities between the male and female genitals, the nature of the surgery and the justifications offered, it is surprising that male and female circumcision enjoy such strikingly different reputations, at least in Anglophone societies: the first, a mild and harmless adjustment which should be tolerated, if not actively promoted; the second, a cruel abomination which must be stopped by law, no matter how culturally significant to its practitioners. If you call circumcision of boys male genital mutilation, you are accused of emotionalism; if you fail to call circumcision of women or girls female genital mutilation you are accused of trivialising the offence. While the United Nations, Amnesty International and other international agencies spend millions on programs to eradicate FGM, they have never uttered a word against circumcision of boys. It might be thought that the reason for this double standard lies in the greater physical severity of female circumcision, but this is to confuse cause with effect. On the contrary, it is the tolerant or positive attitude towards male circumcision and the rarity of female circumcision in western societies which promote the illusion that the operation is necessarily more sexually disabling, and without benefit to health, when performed on girls or women. It is, of course, also true that the term female circumcision is vague, referring to any one or more of a number of surgical procedures. These have been defined by the World Health Organisation as follows: Female Genital Mutilation comprises all procedures that involve partial or total removal of female external genitalia and/or injury to the female genital organs for cultural or any other non-therapeutic reason. Classification Type 1: Excision of the prepuce with or without excision of part or all of the clitoris Type 2: Excision of the clitoris together with partial or total excision of the labia minora Type 3: Excision of part or all of the external genitalia and stitching/narrowing of the vaginal opening (infibulation) Type 4: Unclassified (but may include): <ul> <li>pricking, piercing or incision of the clitoris and/or labia;</li> <li>stretching of the clitoris and/or labia;</li> <li>cauterization by burning of the clitoris and surrounding tissue;</li> <li>introcision;</li> <li>scraping (angurya cuts) or cutting (gishri cuts) of the vagina or surrounding tissue;</li> <li>introduction of corrosive substances or herbs into the vagina;</li> <li>any other procedure that falls under the definition of female genital mutilation given above.</li> </ul> Source: Female Genital Mutilation: Report of a WHO Technical Working Group, Geneva, July 1995. (World Health Organization: Geneva, 1996) Revised classification This classification has been modified since 1996 but still retains the basic division into four types, as set out in a WHO "Fact Sheet" of May 2008: Female genital mutilation is classified into four major types: <ul> <li>Clitoridectomy: partial or total removal of the clitoris (a small, sensitive and erectile part of the female genitals) and, rarely, the prepuce (the fold of skin surrounding the clitoris) as well.</li> <li>Excision: partial or total removal of the clitoris and the labia minora, with or without excision of the labia majora (the labia are "the lips" that surround the vagina).</li> <li>Infibulation: narrowing of the vaginal opening through the creation of a covering seal. The seal is formed by cutting and repositioning the inner, and sometimes outer, labia, with or without removal of the clitoris.</li> <li>Other: all other harmful procedures to the female genitalia for non-medical purposes, e.g. pricking, piercing, incising, scraping and cauterizing the genital area.</li> </ul> <a href="http://www.who.int/mediacentre/factsheets/fs241/en/print.html" rel="noopener" target="_blank">See WHO Fact Sheet 241, May 2008</a> The severity of female circumcision depends on which of these operations are performed (as well as how roughly), and it is true that the most extreme forms (involving the amputation of the external genitalia, with or without infibulation) are significantly worse than even the most radical foreskin amputation. But it should be remembered that the most extreme forms of FGM are rare, and that male circumcision in general is far more common on a world scale than female: about 13 million boys, compared with two million girls annually. [1] On top of this, it should be appreciated that the effects of male circumcision are also highly unpredictable, depending on how much penile tissue is removed, on the skill of the surgeon, on the precise configuration of penile blood vessels and nerve networks, and on the eventual size attained by the penis at puberty and maturity. The more tissue excised, the greater the damage to the penis, the greater the effect on sexual functioning and capability; the same quantity of tissue lost will be worse in cases where the penis is programmed to grow larger in maturity, or where the location of blood vessels and nerves (always variable) means that important connections are severed. Because the slack tissue is needed to accommodate the enlarged penis when tumescent, a really severe circumcision will make erections painful or even impossible. [2] <a href="https://www.historyofcircumcision.com/templates/pages/fgm_and_circumcision_problems_of_definition.html">Further discussion of this issue here.</a> <a href="http://www.circinfo.org/FGMclassification.html">Inconsistencies in classification of female genital mutilation and male circumcision</a> Given the respective numbers of victims involved and the fact that some circumcisions are worse than some instances of FGM, there is no justification for perpetuating the gender discrimination which has characterised discussion of these issues. Indeed, a female victim of circumcision during a "holy war" by Islamic extremists in Indonesia recently commented afterwards that what was done to the men was worse than what the women suffered: "I know the men suffered more than us women. The circumcision hurt them more that it did to us because their scars could not heal fast. Several of the men I knew got serious infections after suffering from severe bleeding." (<a href="https://www.historyofcircumcision.com/templates/pages/islamic_extremism.html">See Christina's story</a>.) To compare female and male circumcision is not to trivialize the enormity of the first, as some feminists seem to fear, but to recognise that the physical and moral similarities between the two are very real. (<a href="https://www.historyofcircumcision.com/templates/pages/fgm_and_the_united_nations.html">See the insightful analysis by R. Charli Carpenter</a>.) Since many of them come from countries where male circumcision is tolerated or even the norm, such as the USA, campaigners against FGM are inclined to stress how much worse it is than male circumcision, and in the process they tend to excuse or even affirm the latter. Although they do not realise it, in this manoeuvre they are treading directly in the footsteps of the opponents of Isaac Baker Brown, the mid-Victorian exponent of clitoridectomy as a cure for masturbation and nervous complaints. They could not disagree with Brown that masturbation was an evil that had to be stamped out; indeed, the man who brought him down actually wrote: "If the habit [masturbation] could be overcome, if the mind could be restored to its purity by any mutilation of the person, one would feel that no penalty would be too great to pay for such a boon." Nor did they question the emerging consensus that circumcision of boys was desirable for reasons of health and morality. They thus found it necessary to quarantine the case against clitoridectomy from the case for circumcision, playing up the harm of the former while minimising the impact of the latter; the result was a double standard on genital alteration that has endured to this day. (<a href="https://www.historyofcircumcision.com/templates/pages/clitoridectomy_and_medical_ethics.html">See the editorial, Clitoridectomy and medical ethics</a>.) <h4>Anthropological accounts</h4> Unlike male circumcision, which was familiar from Jewish practice, female circumcision was an exotic custom about which Europeans knew very little until the explorations of the eighteenth century. Because the phenomenon was first studied by sceptical anthropologists and naturalists who had little regard for religion, there was no attempt to explain female circumcision in religious terms as a divine command or a ritual requirement; on the contrary, from the very first, explanations for such a bizarre and horrific mutilation were sought in materialist terms, particularly in relation to some possible advantage to human health in peculiar physical environments. The most popular explanation was that the hot climate of Egypt and Africa caused the labia and clitoris to grow to an inordinate length, thus necessitating their reduction or removal in order to permit intercourse. While the French traveller C.S. Sonnini explained male circumcision in Egypt purely as an initiation into the Mahometan religion, he accounted for the female operation in terms of the hypertrophy of the parts allegedly common in hot regions, and the consequent need to avoid both reproductive difficulties and the disgust of the husband. [3] The great French naturalist Georges-Louis de Buffon, in his Natural History, also offered the climatic explanation for male circumcision among the Jews and Arabs: in the heat of the desert the foreskin grew so long that it hindered procreation. [4] Rumours about the "Hottentot apron", the supposedly hypertrophic labia found among "Hottentot" women, fed these speculations, which were further stimulated by the public exhibition of one unfortunate native in London and Paris in 1810. [5] Variants of these stories filtered through the nineteenth century medical world and often turned up as "well known facts" in journal articles. Other explanations for female circumcision stressed protection against disease or parasites, and one reported by John Davenport cited the necessity to prevent the accumulation of secretions and smegma: Cleanliness has rendered it necessary. In some climates the nymphae, from their great length, become inconvenient, for in the vicinity of the clitoris of women is collected an acrid and stimulating humour called smegma (from its resemblance to soap), and this secretion is partly covered by the nymphae. This white saponaceous and almost foetid substance is one of the most powerful stimuli of the sexual organ. Thus, such persons as observe great cleanliness are generally less given to venery than those who are negligent in this respect. In cold or even temperate regions this secretion becomes less abundant, and, as it is consequently less active in its effects, the sexual organs are more quiescent than in southern regions. [6] Similar comments were made by Dr Kellogg in the 1880s. In some countries females are also circumcised by removal of the nymphae [i.e. the labia]. The object is the same as that of circumcision in the male. The same evils result from inattention to personal cleanliness, and the same measure of prevention, daily cleansing, is necessitated by a similar secretion. Local cleanliness is neglected by both sexes. Daily washing should begin with infancy, and continue through life, and will prevent much disease. [7] It is an interesting comment on changed attitude to both cleanliness and sexuality that in the late twentieth century the smell of smegma was regarded not as a stimulant, but as a sexual turn-off, at least by such luminaries as <a href="https://www.historyofcircumcision.com/templates/pages/dr_fishbeins_fantasies_1960s.html">Morris Fishbein</a> and <a href="http://www.circinfo.org/quote.html#37" rel="noopener" target="_blank">David Reuben</a> - who seem, however, to be so obsessed with imaginary male smells that they have completely forgotten that uncircumcised women also produce smegma. Off course, the mere existence of smegma in males has been the basis of most justifications for routine circumcision, from Lallemand and William Acton to <a href="http://www.circumstitions.com/Langerhans.html" rel="noopener" target="_blank">Gerald Weiss</a> and <a href="http://www.circumstitions.com/Morris.html" rel="noopener" target="_blank">Brian Morris</a>. There is now a vast literature and constant controversy over the history and current practice of female genital cutting (which now seems to be the preferred term). What most anthropological sources agree on is that the cultural significance of female circumcision is usually the same as for male: it represents the transition from girlhood to womanhood, and the entry into a new set of adult rights and responsibilities, the most important of which relate to sexual relations, marriage and child-bearing. There is also wide agreement that circumcision was introduced to males first and only later extended to females, often in an attenuated form. [8] As the Encyclopaedia of Religion and Ethics put in 1910, female circumcision "evolved much later than male circumcision", of which it was "but a pale shadow"; Ernest Crawley (in The mystic rose, p. 138, 309) "is doubtless right in tracing it to the same origin as the analogous operation in the male". [9] It is a striking fact that while there are cultures which practise male but not female circumcision (most notably the Jewish), there are no societies which practise female but not male circumcision. <h4>The medical or health case</h4> Although the health advantages of or medical justifications for clitoridectomy were similar to those offered for male circumcision (cleanliness, deterrence of masturbation, control of nervous diseases) the practice remained rare in Britain and never became a routine precaution. Doctors generally held that women's lower sex drive meant they were less given to self abuse than males, and thus that drastic surgery was rarely necessary. There are occasional reports of masturbating girls being subjected to involuntary clitoridectomy, but it was only in the late 1850s that a few doctors started to apply to women the theories of nervous disease which already legitimised circumcision in boys. Britain The most famous of these was the prominent London obstetrician, Isaac Baker Brown, who specialised in the surgical treatment of disorders such as epilepsy, catalepsy and hysteria induced by "irritation of the pudic nerve" (that is, masturbation). Although he attracted considerable interest at first, his procedures fell rapidly into disfavour, and he was expelled from the London Obstetrical Society in 1867. While his critics condemned clitoridectomy as a "questionable, compromising, unpublishable mutilation" which would ruin the women's sex lives, leave them permanently maimed and cast an indelible slur on their honour, Brown defended himself by claiming that masturbation caused hysteria, epilepsy, mania, insanity and death, and argued that clitoridectomy was no more mutilating than male circumcision, as proved by the subsequent pregnancy of several of his patients. As he wrote in reply to his attackers: Clitoridectomy is neither more nor less than circumcision of the female; and as certainly as that no man who has been circumcised has been injured in his natural functions, so it is equally certain that no woman who has undergone the operation ... has lost one particle of the natural function of her organs. [10] His critics did not dissent from the proposition that masturbation could provoke the ills he mentioned, but they insisted that the practice was so rare in women that radical interventions of this kind were not necessary. Brown's disgrace put a stop to clitoridectomy in Britain, and there are no reliable reports of its performance after the 1860s. Looking back on the controversy, his principal antagonist, Charles West, commented that "all right-minded men" were compelled to reject both the operation and its leading proponent, but that "happily we need not now dwell further on the subject, for all practitioners are agreed that the only indication for removal of the clitoris is furnished by the disease of the organ itself". It was a long time before doctors reached the same conclusion about the foreskin. Since the debate had been fought largely on the question as to whether the clitoris was the functional equivalent of the foreskin, and thus whether clitoridectomy was the female version of circumcision (as Brown insisted and his opponents denied), the effect of the negative decision on these points was to clear the way for circumcision of boys at the same time as it protected the genitals of women. The outcome has been the tenacious double standard on genital mutilation which still dominates discussion of this subject. Female circumcision in the USA Clitoridectomy and other circumcision-like operation on girls and women had a longer career in United States, where doctors deplored Baker Brown's disgrace and The Medical Record defended him with the question "What now will be the chance for recovery for the poor epileptic female with a clitoris?" [11] There was also a vigorous attempt to apply the theories of Lewis Sayre - that many nervous diseases were caused by a tight or non-retractable foreskin - to women, and a number of doctors urged that girls also should have their clitoral hoods excised if there was any suspicion of adhesions of the accumulation of "secretions". In 1892 another defender of Brown (he was "almost on the right track"), Dr Robert Morris, went so far as to suggest that, since 80 per cent of American women suffered from preputial adhesions, all schoolgirls should be inspected to ensure that proper separation between prepuce and clitoris had occurred. He was apparently confident that most of the girls would require surgery, and added: "The separation of adhesive prepuces in young unmarried women should be done by female physicians anyway, and such physicians can be abundantly occupied with this sort of work". [12] It was a valiant effort to expand the market for medical services, and he must have been disappointed that his suggestions were not more widely taken up. Even so, articles on the virtues of female circumcision continued to appear sporadically in American medical journals until the 1960s, and there are regular reports of girls or women being subjected to various procedures, particularly the shortening of their labia or clitoris when parents or a husband judged them "too long". As with circumcision of boys, the medical case for female circumcision has always contained a strong element of cultural or aesthetic preference. <h4>NOTES</h4> 1. George C. Denniston, Frederick Hodges and Marylin Milos (eds), Understanding circumcision: A multi-disciplinary approach to a multi-dimensional problem (London and New York: Kluwer Academic and Plenum Press, 2001), Introduction, p. v 2. As nineteenth century circumcisers such as <a href="https://www.historyofcircumcision.com/templates/pages/treating_masturbation_1895.html">Dr Spratling realised</a>. See also <a href="http://www.circinfo.org/account.html" rel="noopener" target="_blank">Shane Peterson's account</a> of his own terrible experiences. 3. C.S. Sonnini, Travels in upper and lower Egypt, trans. Henry Hunter (3 vols, London: John Stockdale, 1799), Vol. 2, pp. 29-33 4. Georges-Louis Leclerc, Comte de Buffon, Barr's Buffon: Buffon's natural history, Containing a theory of the earth, a general history of man, of the brute creation, and of vegetables, minerals etc, trans. from the French (10 vols, London, 1797), Vol. 4, p. 25 5. The "Hottentots" were actually the Khoikhoi people of what are now Cape Province and Namibia, South Africa. They were a nomadic, pastoral people, related to the San, or Bushmen. See Stephen Jay Gould, "The Hottentot Venus", in The flamingo's smile: Reflections in natural history (Penguin 1986) 6. John Davenport, "Circumcision", in Aphrodisiacs and love stimulants, with other chapters on the secrets of Venus, edited by Alan Hull Watson (New York: Lyle Stuart, 1966), p. 189. John Davenport (1789-1877) was an unsuccessful businessman and amateur scholar of erotic subjects. Publication of his books, originally entitled Aphrodisiacs and anti-aphrodisiacs and Curiositates eroticae physiologiae, or Tabooed subjects freely treated, was financed by Henry Spencer Ashbee. See Ian Gibson, The erotomaniac: The secret life of Henry Spencer Ashbee (New York: Da Capo Press, 2001), pp. 24 and 54. 7. J.H. Kellogg, Plain facts for young and old: Embracing the natural history of hygiene and organic life, 2nd edition, Burlington (Iowa), 1888, facsimile reprint (New York: Arno, 1974), pp. 106-7 8. In his study of circumcision rituals among the Kuguru people of central Tanzania, T.O. Beidelman notes the mildness of contemporary female circumcision practices (usually no more than a nick on part of the vulva) compared with the severity of the procedure on boys - amputation of the entire foreskin. His impression was that the female version used to be more radical. See The cool knife: Imagery of gender, sexuality and moral education in Kuguru initiation ritual (Washington: Smithsonian Institution, 1997), p. 167 9. Encyclopaedia of Religion and Ethics, ed. James Hastings (Edinburgh: T. & T. Clark, 1910), Vol. 3, p. 669 10. "Replies to the remarks of the Council", Medical Times and Gazette, 13 April 1867, p. 391 11. "Clitoridectomy" (Editorial), Medical Record, Vol 2, 1867, p. 71; cited in Frederick Hodges, "A short history of the institutionalization of involuntary sexual mutilation in the United States", in George C. Denniston and Marilyn Milos (eds), Sexual mutilations: A human tragedy (New York: Plenum Press, 1997), p. 21 12. Robert T. Morris MD, "Is evolution trying to do away with the clitoris?", Transactions of the American Association of Obstetricians and Gynecologists, Vol. 5, 1892, pp. 288, 293 <h4>FURTHER READING</h4> Anthropology Bettina Shell-Duncan and Ylva Hernlund (eds.), Female "Circumcision" in Africa: Culture, Controversy, and Change (Boulder, Colorado: Lynne Rienner Publishers, 2000) Ellen Gruenbaum, The Female Circumcision Controversy: An Anthropological Perspective (Philadelphia: University of Pennsylvania Press, 2001) <a href="http://www.arclaw.org/Shell-Duncan.htm" rel="noopener" target="_blank">Both reviewed briefly by ARCLaw</a> <a href="http://www.circinfo.org/fgm_reviews.html" rel="noopener" target="_blank">Reviews of recent books on female genital cutting</a> Hanny Lightfoot-Klein Secret wounds Prisoners of ritual: An odyssey into female genital circumcision in Africa A woman's odyssey into Africa <a href="http://www.lightfoot-klein.com/" rel="noopener" target="_blank">All available directly from her website</a> FGM in Islam Sami A. Aldeeb Abu-Sahlieh, "Jehovah, his cousin Allah and sexual mutilations", in George C. Denniston and Marilyn Milos (eds), Sexual mutilations: A human tragedy, New York, Plenum Press, 1997 <a href="http://www.nocirc.org/symposia/fourth/aldeeb.html" rel="noopener" target="_blank">Available online from Nocirc USA</a> Dr Sami Aldeeb, "To mutilate in the name of Allah or Jehovah: The legitimation of male and female circumcision", Medicine and Law, Vol 13, No 7-8, 1994, pp. 575-622 <a href="http://www.cirp.org/library/cultural/aldeeb1/" rel="noopener" target="_blank">Available from CIRP</a> <a href="http://www.fgmnetwork.org/authors/samialdeeb/index.html">Also available at FGM Network</a> <a href="https://www.historyofcircumcision.com/templates/pages/islamic_extremism.html" rel="noopener" target="_blank">Christina's story of fundamentalist Islam in Aceh, Indonesia</a> On Baker Brown J.B. Fleming, "Clitoridectomy: The disastrous downfall of Isaac Baker Brown FRCS (1867)", Journal of Obstetrics and Gynaecology of the British Empire, Vol. 67, 1960, pp. 1017-34 Ornella Moscucci, "Clitoridectomy, circumcision and the politics of sexual pleasure in mid-Victorian Britain", in Andrew H. Miller and James Eli Adams (eds), Sexualities in Victorian Britain (Bloomington: Indiana University Press, 1996) Elizabeth A. Sheehan, "Victorian clitoridectomy: Isaac Baker Brown and his harmless operation", in Roger N. Lancaster and Micaela di Leonardo (eds), The gender/sexuality reader: Culture, history, political economy (London: Routledge, 1997) Robert Darby and J. Steven Svoboda, A rose by any other name: Rethinking the differences/similarities between male and female genital cutting, Medical Anthropology Quarterly, Vol. 21, September 2007 Kirsten Bell, Genital Cutting and Western Discourses on Sexuality. Medical Anthropology Quarterly 19(2) 2005 :125â€“148 Robert Darby and J. Steven Svoboda, "A rose by any other name: Symmetry and asymmetry in male and female genital cutting", in Chantal Zabus (ed.), Fearful Symmetries: Essays and Testimonies around Excision and Circumcision (Amsterdam and New York: Rodopi, 2009) </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 Circumcision of females 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"> <h4>"I for one have circumcised as many girls as boys,</h4> <h4>and always with happy results." (1898)</h4> After reading Dr Pratt's article in the March Journal of Orificial Surgery I thought of a case which might be of some interest, bearing out the thought advanced, and as well showing how little those who are blind can see; or are any so hopelessly blind as those who absolutely refuse to see. On February 15 1897 a young couple, bright, intelligent appearing people, came into my office with their only living child, a little girl of two years. She was large for her age, with an abundance of light golden hair, fair smooth skin, blue eyes, and a child who had never appeared to notice anything, could not sit alone, or help herself in the least, could not speak a word. Aggravated case of strabismus of one year's standing. Every few moments she would grind her teeth, of which she had her full complement, squint her eyes, straighten out and utter a cry, not unlike the familiar one of an epileptic. Parents had taken he to every doctor in town, as well as before the Missouri State Medical Society, where after careful examination they pronounced her about hopeless, but advised to do nothing and that at maturity she would probably improve. The parents were not satisfied, as that was the advice given to them with an older child, and it died at two and one-half, with symptoms identical to this one. Next they took her to an oculist to see if he could relieve the strabismus. He examined the eyes carefully and pronounced them perfect. Told the parents the trouble was of deeper origin, he did not know where, and advised bringing her to me, which they did as before stated. The family history was nil, save mother had history of brain fever one year before marriage. Both parents very nervous. No other history of any severe illness for generations. I had the child stripped and immediately saw that the body was covered with hair, as completely as if she were a fully developed woman instead of a two-year-old child. Knowing such a growth of hair came at puberty, and puberty meant an activity of the sexual system, I examined the clitoris, or where it ought to have been, but it was so neatly sealed in by a hypertrophied hood that I could not find a trace of it. I told the parents I believed we had the key to the situation, and although it might not entirely cure her, still we had a good foundation upon which to build hope of a cure. As it was the first ray of hope they had ever received, they said by all means try. We immediately administered chloroform and began to unearth the most completely bound-down clitoris I have ever seen. The hood where it was amputated was just one-half inch in thickness. From that day the child began to improve; and now fifteen months later, with no medicine whatever save possibly zinc phosphate and passiflora, she can walk, talk some, sleeps and eats well, eyes nearly straight, but little grinding of her teeth. Is still very nervous, but infinitely improved, and according to her mother's statement of May 19th, she is getting better, stronger and in every way improving every day. Some of the blind doctors have opened their eyes and are anxious to know what has brought about such a change. Only the circumcision of a girl, and as many little girls would be benefited by such treatment as boys. And I for one have circumcised as many girls as boys, and always with happy results. T. Scott McFarland, "Circumcision of girls", Journal of Orificial Surgery, Vol. 7, July 1898, pp. 31-33 <h2>Necessity for female circumcision, 1915</h2> <h4>"Female circumcision just as necessary as male"</h4> AJCM Editorial note: We have had several inquiries from readers regarding this operation, especially as to the method of performing it. In the most interesting paper which follows, Doctor Dawson answers all our correspondents' questions. Also, he shows that intervention of this kind is imperatively required in many conditions not understood. <div>* * * * * * * *</div> Baker Brown, [1] nearly half a century ago, recognizing the disastrous reflexes and nervous disturbances, often caused by the clitoris, boldly amputated the offending organ with excellent results in some cases, while in others great disaster followed and the work fell into disrepute. Naturally surgical attention to the clitoris sank into oblivion. Within the last two decades this much abused and neglected organ has received some consideration, and now it is much better understood and the proper surgery applied when required. A large number of physicians fail to realize the importance of the proper condition of the foreskin in the male; that in order to avoid the dangers of convulsions, eczema, paralysis, constipation, tuberculosis, locomotor ataxia, rheumatism, idiocy, insanity, lust and all its consequences, the prepuce must be completely loosened; if too long, amputated; if too tight, slit open. The same category of diseases having their origin in nerve-waste, caused by a pathological foreskin in the male, may be duplicated in the female. A much larger number of physicians are seemingly ignorant of the fact that females have an organ anatomically corresponding to the penis in the male. They are both erectile; each consists of a glans, a body and two crura; the glans in each is partly covered by a prepuce with a frenum attached below; each has corpora cavernosa, separated by an incomplete septum; each is supplied by nerve filaments from the pudic nerve and hypogastric plexus; each produces a cheesy substance (smegma), which hardens under an adherent prepuce. The clitoris is more richly supplied with nerve filaments than any other organ in the body in proportion to its size. The same category of diseases having their origin in nerve-waste, caused by a pathological foreskin in the male, may be duplicated in the female, from practically the same cause, and in addition, other diseases peculiar to females. Chorea, chlorosis, hysteria, and various nervous disturbances, nearly always have their origin in a faulty condition of the hood of the clitoris. The neglect of the clitoris is fraught with such disastrous results that the sin of omission, its neglect, which is almost universal, is painful to contemplate. Importance of the Sympathetic Nerve In the study of the waste and repair of the sympathetic nerve and the law of reflexes, we delve into a mine rich with precious, practical gems of truth; we harvest in a field rich with the golden grain of valuable knowledge. This study would readily show why a neglected clitoris is prolific of so much mischief. Doctors are not easily educated out of well-worn ruts. The sympathetic nerve concerns itself with the life of the viscera; it presides over the visceral economy. The sympathetic system performs the vital functions which are independent of mind and present to us the idea of life. It dominates absorption, secretion, sensation, nutrition, peristalsis and functions of the sexual organs. Pathology in tissues supplied by the sympathetic nerves is manifested by disordered function; in tissues supplied by the cerebrospinal nerves, by pain. Pathological conditions, flashing out the most disastrous reflexes, are usually subconscious. Doctors are not easily educated out of well-worn ruts. Because there is no pain, no gross pathology in the clitoris, it is ignored by many otherwise careful diagnosticians. The Causes and Consequences of Genital Alteration The blood stream is that which does all bodily repair, heals all diseases, removes all pathologic conditions, includes growth and sustains life. It is of such vast importance that its circulation is dominated by the vasomotor system, a combination of both sympathetic and cerebrospinal nerves. An increased supply of blood to any organ invites function. The blood supply to any organ may be increased by either one of two methods, external irritation or internal emotions. A cinder in the eye will summon an increased flow of blood to the lacrimal glands, and tears come into the eyes; a message of sorrow or joy, that sweeps over the deep vibrant chords of the soul, will produce the same result. There is no exception to this rule, even the sexual organs being included. Internal emotions may elicit a desire to functionate in these organs; so may external irritation. Masturbation in a child under the age of puberty is not provoked by internal emotions. It is downright cruelty to punish a little child for masturbating. It would be as reasonable to punish one for crying with a grain of sand in the eye, or for being fidgety with ants under his clothing. Many neuroses and even psychoses have their origin in pathological conditions of the hood of the clitoris. Girls have been sadly neglected; therefore, I make a plea in their behalf. Reflexes travel along the line of least resistance. Irritation in the sexual organs, therefore, may reach the mental or moral faculties, resulting in imbecility, sexual perversion or moral degeneracy. Many neuroses and even psychoses have their origin in pathological conditions of the hood of the clitoris. The girls have been sadly neglected; therefore, I make a plea in their behalf. I feel an impulse to cry out against the shameful neglect of the clitoris and hood. A Hooded Clitoris as a Factor in Marasmus Some two months ago, a child two and a half years old, was brought to me from Ottawa, Kansas. It presented a bad case of marasmus, malnutrition, anemia. There was little development; the lower limbs hanging almost as useless as strings. The child made no effort at vocal articulation. The clitoris was completely snowed under with an adherent hood. The adhesions were broken up and circumcision performed. The mother was instructed to retract the hood each day, in order to prevent adhesions reforming. This was neglected to some extent. The child was bought back, since I began this article. While the hood had adhered to the clitoris again, yet the improvement in the baby's condition is very gratifying. Her muscles have filled out; her thighs enlarged; she can bear her weight on the limbs and use them in taking a few steps; she speaks plainly several words; a slight pinkish tint has flushed the previously chalky white skin, and there is a marvellous improvement in her general appearance. Under a general anesthetic the adhesions were again broken up. This child will recover. Other Cases Relieved by Circumcision A few months ago a little babe, three or four weeks old, had colic each time after taking the bottle. Examination revealed a hooded clitoris. The indicated work promptly and permanently cured her. In a few hours after circumcision the red, angry boils on her face had perceptively paled. Her kidneys began to act normally, and she was transformed from a cross, peevish, discontented child into a state of perpetual sunshine. A girl baby, two years of age, had been troubled all her life with furunculosis, anuria, and malnutrition. She had been treated by different doctors for different diseases, but with no benefit. The clitoris was completely buried beneath an adherent hood. In a few hours after circumcision the red, angry boils on her face had perceptively paled; in thirty-six hours they were dried up. Her kidneys began to act normally, and she was transformed from a cross, peevish, discontented child into a state of perpetual sunshine. A girl sixteen years of age, well developed but neurotic, had been troubled with nocturnal enuresis from babyhood. Circumcision, with some other indicated orificial work, at once stopped this embarrassing condition. Another, Sarah C., seven years old; a bright, beautiful child, well-nourished, a masturbator. She was brought to me to have this evil habit corrected. Examination showed she needed circumcision, to relieve constant external irritation, which was exciting the sexual passion. A widow of forty-six came into my office, heavily veiled and requested a private interview. She handed me a copy of the Journal of Orificial Surgery, with a request that I read page 83. On this page was an article giving the symptoms of nymphomania caused by a hooded clitoris. With deep mortification, she said she had been bound in chains by this demon since she was a little girl, and that I was the first person to whom she had ever mentioned it. She requested permission to remain veiled, while I circumcised her under local anesthesia. She afterward expressed her heartfelt gratitude for her release. A girl of ten, following an injury to the hip, presented all the characteristic symptoms of hip-joint disease, tenderness, heat, swelling, pain in the knee with soreness in the hip-joint in pressing upon the knee, also, from pressing against the trochanter; slight elongation of the limb, with a tendency to throw the knee across the other limb. This case was presented to a doctor, who was an orificialist, [2] as well as a general surgeon. He found the clitoris in a very irritable condition and its hood firmly adherent. Following the needed attention to the clitoris, a few weeks in bed, without even using extension upon the limb, restored the limb to a perfectly normal state. How to Circumcise the Female Since beginning this paper, a surgeon of considerable prominence, with twenty years' experience, at the head of a reputable hospital, casually dropped into my office. I mentioned the subject, with my usual enthusiasm, when he asked what I meant by circumcision; was it amputating the clitoris? Another physician, with an experience of more than a score of years, acknowledged to me that he never saw a clitoris to recognize it. This reminds me that my paper would be incomplete without a description of the technic. Before undertaking this work it is needful that one should have a clear conception of a normal clitoris and hood. Only two days ago a physician brought a lady to me for circumcision. Everything ready, I started to do the work, when a normal clitoris smilingly said, "Keep off the grass, please." In a normal clitoris and hood the point of the glans is exposed and the complete retraction of the hood is easily accomplished. There is no smegma or irritable condition found between them. No tension of the hood is found upon stretching the parts laterally with the thumbs. If the hood is so long as to cover the glans completely, it should be partly amputated; if adhesions exist, they should be thoroughly loosened; where smegma is found, it should be removed. Circumcision is performed by cutting a V-shaped piece from the hood over the center of the clitoris. If very redundant, it will require a large piece; if tight, only a slit will be necessary. Grasp the hood in the center with Pratt's plug forceps or a pointed hemostat; lift it up from the clitoris and, with scissors, cut each side of the forceps, the cuts meeting above the point of the forceps, taking out a V from the hood. With a No. 0 or No. 1 plain catgut suture, take a stitch in the point of the V, uniting the under mucous membrane to the outer skin, just as in circumcision in the male. Usually an additional stitch will be required on either side to join the skin and mucous membrane. When strong adhesions have been broken up, it will be necessary to slide the hood up each day to prevent their reforming. What is preferable is to put a drop of flexible collodion on the clitoris, holding the hood up until it dries. It will then require no further attention. This work can be done with local anesthesia. Cleanse the parts thoroughly and place a piece of cotton, saturated with a 10-percent solution of cocaine, over the hood and clitoris. After a few minutes you can inject a 4-percent solution of the cocaine with a hypodermic syringe in a fold of the hood pinched up between the thumb and finger. Massage for a moment and proceed with the work. Abbott's anesthaine will answer well, and in many ways is preferable to cocaine. Benjamin E. Dawson AM, MD, "Circumcision in the Female: Its Necessity and How to Perform It", American Journal of Clinical Medicine, Vol. 22, No. 6, June 1915, pp. 520-523 <h4>NOTES</h4> 1. Isaac Baker Brown, the English obstetrician who was expelled from the Obstetrical Society in 1867 for his advocacy and practice of clitoridectomy as a cure for nervous maladies in females. 2. The Orificial Surgical Society was founded in 1890 by E.H. Pratt, a surgeon at the Cook County Hospital in Chicago. The organization was largely concerned with orifices below the waist, and provided training for surgery of the prepuce, clitoris and rectum, the latter organ being given special emphasis. It was obsessed with the idea that most diseases were caused by tightness of the preputial or anal sphincters. For further information, see Edward Wallerstein, Circumcision: An American Health Fallacy (New York, 1980), p. 38 </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 Circumcision of girls (c.1900) 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"> Although the World Health Organisation has hailed circumcision as the "great white hope" against AIDS and poured billions into programs of mass circumcision of African men, many Africans, including doctors, are sceptical of the effectiveness, the ethics and the cost of such a strategy. On this page we summarise papers recently published in African medical journals and provide an update on South African efforts to protect boys from circumcision. Oddly enough, despite the advice of the new white witchdoctors, South Africa is one of the very few countries to have passed legislation making it an offence (in certain circumstances) to circumcise a minor. <h2> <a id="criticise" name="criticise"></a>Circumcision and HIV infection: African doctors wonder</h2> Clutching at straws to control the African HIV/AIDS epidemic has included strident advocacy for circumcision of males (MC) from some (mainly American) quarters, especially following three trials held in South Africa, Kenya and Uganda in 2006-2007. These seemed to show that circumcision did have a limited protective effect, and they were quickly hailed by the circumcision lobby as justifying an immediate “roll-out” of a massive circumcision campaign. Three contributions in the October 2008 edition of the South African Medical Journal, including an editorial, vigorously contest the usefulness, cost and ethics of circumcision in the prevention of HIV and condemn the indecent haste with which the Word Health Organisation, under pressure from American money, has sought to enforce mass circumcision on African men. <h3>1. South Africa: No difference in HIV incidence between cut and uncut men</h3> Objective. To investigate the nature of male circumcision and its relationship to HIV infection. Methods. Analysis of a sub-sample of 3,025 men aged 15 years and older who participated in the first national population based survey on HIV/AIDS in 2002. Chi-square tests and Wilcoxon rank sum tests were used to identify factors associated with circumcision and HIV status, followed by a logistic regression model. Results. One-third of the men (35.3%) were circumcised. The factors strongly associated with circumcision were age >50, black living in rural areas and speaking SePedi (71.2%) or IsiXhosa (64.3%). The median age was significantly older for blacks (18 years) compared with other racial groups (3.5 years), p <0.001. Among blacks, circumcisions were mainly conducted outside hospital settings. In 40.5% of subjects, circumcision took place after sexual debut; two-thirds of the men circumcised after their 17th birthday were already sexually active. HIV and circumcision were not associated (12.3% HIV positive in the circumcised group v. 12% HIV positive in the uncircumcised group). HIV was, however, significantly lower in men circumcised before 12 years of age (6.8%) than in those circumcised after 12 years of age (13.5%, p=0.02). When restricted to sexually active men, the difference that remained did not reach statistical significance (8.9% v. 13.6%, p=0.08.). There was no effect when adjusted for possible confounding. Conclusion. Circumcision had no protective effect in the prevention of HIV transmission. This is a concern, and has implications for the possible adoption of the mass male circumcision strategy both as a public health policy and an HIV prevention strategy. <a href="http://www.samj.org.za/index.php/samj">Full article here</a>. PDF available on request. Catherine Connolly, Leickness C Simbayi, Rebecca Shanmugam, Ayanda Nqeketo, Male circumcision and its relationship to HIV infection in South Africa: Results of a national survey in 2002, South African Medical Journal, Vol. 98, No. 10, October 2008 <h3>2. Neonatal circumcision does not reduce HIV/AIDS infection rates</h3> A second article by Sidler et al argues that there are profound objections on grounds of effectiveness, cost and ethics to the use of circumcision as a a tactic against AIDS. The article opens as follows: Non-therapeutic, non-religious circumcision is the surgical procedure most commonly published about, but for which substantive indications are lacking. Since its introduction to the USA during the Victorian period, when it was thought that it prevented masturbation, medical justifications for the procedure progressed to prevention of various infective conditions (sexually transmitted diseases, penile and cervical cancer) and controlling of the sexual drive. Recent Joint United Nations Programme on HIV/AIDS/World Health Organization (UNAIDS/WHO) policy proposes male circumcision for the prevention of HIV/AIDS. HIV/AIDS in Africa is mainly spread by multiple concurrent heterosexual relationships, compounded by female subjugation and poverty. Condoms, although highly protective, are infrequently used, particularly among circumcised males. The HIV/AIDS crisis demands extraordinary curtailment measures. It is, however, questionable how circumcision, and particularly neonatal circumcision, could achieve such a goal. A rational and critical analysis of the scientific evidence ought to conclude that non-therapeutic infant circumcision is merely the medicalisation of an old ritual that should not, in the 21st century, be advocated as prevention strategy for HIV/AIDS. Repeated publications of matching opinions do not necessarily lead to solid scientific evidence and policies. They rather suggest that the peer review process of journal publication may be unreliable. Information overload can cause limitations, for example influencing expert and public opinion with ideological and pseudoscientific content. This context and such therapeutic misconceptions contribute to circumcision still being practised as a non-therapeutic infant procedure. This mainly applies to English-speaking countries, where circumcision appears to have become a medicalised ritual. In contrast, in Europe non-therapeutic circumcision is not the norm. Many reviews question the necessity of non-therapeutic infant circumcision, showing it to have neither short- nor long-term medical benefits. It has been suggested that parents should be granted responsibility and final decision making authority after having thoroughly considered all the relevant facts. The reported increase in demand for preventive circumcision, long before publication of results of the three randomised controlled trials (RCTs) in South Africa, Kenya and Uganda that have shown that circumcision is partially protective against HIV, suggests that informed proxy consent, within the context of the HIV/AIDS epidemic and the prevalence of poverty and ignorance, has to be seriously questioned. The desperate hope and need for action of people ravaged by HIV/AIDS, rather than solid scientific evidence, may be driving the increased demand for preventive circumcision. A recent Centers for Disease Control (CDC) and WHO report confirms previous reports that circumcision does not prevent sexually transmitted diseases (STDs). <a href="http://articles.mercola.com/sites/articles/archive/2004/03/10/std-rates.aspx">Teens 15 years and older in the USA</a> have the highest rate of STDs in any industrialised country and half will contract a sexually transmitted disease by age, despite two-thirds of young males having been circumcised. Such reports suggest that the social experiment of circumcision to prevent STDs, including HIV, has already failed in the USA, which has the highest rate of non-therapeutic infant circumcision in industrialised countries and the highest rate of HIV in the developed world. <a href="http://www.samj.org.za/index.php/samj">Rest of article here with references</a>. PDF available on request Conclusion Male non-therapeutic infant circumcision is neither medically nor ethically justified as an HIV prevention tool. Circumcision is not equivalent to successful immunisation, is being practised with decreasing frequency in English-speaking countries, and is becoming illegal in South Africa under the new Children’s Act. There are far more effective prevention tools costing considerably less and offering better HIV reduction outcomes than circumcision. Finally, the WHO and UNAIDS appear to be basing these multi-million-dollar prevention programmes on limited and in some instances biased information. In order to prevent confusion and parents making misguided decisions on behalf of their infants, and to offer effective help in alleviating the suffering that is being created by HIV/AIDS, a much broader review process would be called for. Such a process would involve more objective scientific opinion, and the involvement of a representative panel of African experts, such as paediatric surgeons and neonatologists. D Sidler, J Smith, H Rode, Neonatal circumcision does not reduce HIV/AIDS infection rates, South African Medical Journal, Vol. 98, No. 10, October 2008, 764-766 <h3>3. Editorial: Rolling out male circumcision as a mass HIV/AIDS intervention seems neither justified nor practicable</h3> Two articles [1, 2] published in this issue address male circumcision (MC). Connolly et al.1 show in a national survey that MC, whether pre-pubertal or post-pubertal, has no protective effect on acquisition by males of HIV infection as measured by prevalence. Sidler et al. [2] state that neonatal MC continues to be promoted without adequate justification as a medicalised ritual, via an HIV prevention rationale. They caution that for MC to be a therapeutic as opposed to a non-therapeutic procedure, it is necessary to gather more corroborative and consistent evidence of its benefit, consider the potential harms (psychological, sexual, surgical and behavioural/disinhibition), examine the ethical implications, and examine effectiveness and efficiency (costs and benefits) at the population and societal levels. They point out that MC is not just a technical surgical intervention – it takes place in a social context that can radically alter the anticipated outcome. At the 2008 International AIDS Conference [3] in Mexico cultural, political and educational issues raised by the intervention, such as decreased condom use and marginalisation of women, were hotly debated. Some cultural interpretations may view MC as a licence to have unprotected sex. A case in point is Swaziland, where men are flocking to be circumcised with the understanding that this means they no longer need to use other preventive methods (e.g. wear condoms or limit the number of sexual partners). [4] The 2003 Cochrane review5 of observational studies of MC effectiveness concluded that there was insufficient evidence to support it as an anti-HIV intervention. Three randomised controlled trials (RCTs) from South Africa, Kenya and Uganda in 2006-2007 show a protective effect of MC. However, Garenne [6] has subsequently shown from observational data that there is considerable heterogeneity [inconsistency] of the effect of MC across 14 African countries. Despite the South African RCT showing a protective effect, he reports for the nine South African provinces that ‘there is no evidence that HIV transmission over the period 1994-2004 was slower in those provinces with higher levels of circumcision’. Interestingly, in both Kenya and Uganda, where two of the RCTs were done, a protective effect of MC was observed, but a harmful effect was observed in Cameroon, Lesotho and Malawi. The other eight countries showed no significant effect of MC. These somewhat discordant findings are difficult to interpret. While RCTs are theoretically strong designs, it is conceivable that their findings are not generalisable beyond their settings. Furthermore, there have been no trials of neonatal MC. Study flaws such as inability to obtain double blinding, and loss to follow-up in RCTs, may effectively degrade their quality to that of observational studies. Meanwhile other disturbing findings referred to by Sidler et al. are emerging, including the reported higher risk for women partners of circumcised HIV positive men, disinhibition, urological complications, relatively small effect sizes of MC at the population level, and relative cost-inefficiency of MC. Not all objections to MC as an HIV intervention have to do with evidence of effectiveness or cost. Sidler et al. raise ethical objections. Owing to the current climate of desperation with regard to the HIV epidemic, evidence in favour of MC frequently seems overstated. This reduces the scope for informed consent and autonomy for adult men considering the procedure. Further problems arise in the case of neonates whose parents may be considering the procedure. Whereas informed consent is at least possible for adult men, it is clearly not possible for neonates. Parents can only guess what the child’s wishes would be if he were presented with the information they have at their disposal. If it could be shown that circumcision was necessary in the neonatal period, parental consent on behalf of the neonate would be justified. But since no valid surgical indications for circumcision exist in this period, and the future benefit to the child in respect of HIV avoidance is not relevant before sexual debut, the duty of parents may well be to err on the side of caution, and defer the procedure until the child can make an autonomous decision. In the absence of compelling indications, a procedure such as circumcision could also be seen as a violation of the child’s right to bodily integrity. Furthermore, the ethical principle of non-maleficence cannot be upheld as there are clear harms attached to this practice, to which Sidler et al. refer in their article. Lastly, at a societal level MC may be unjust insofar as it could compete for resources with more effective and less costly interventions [7] and disadvantage women. Despite a strong pro-circumcision lobby driven by enthusiasts who have been promoting MC as an (HIV) intervention for many years, and impatience expressed by protagonists about the long delay after the 2006-2007 RCT results and the UNAIDS/WHO policy recommendations8 of March 2007, few mass campaigns have been launched in African countries. Given the epidemiological uncertainties and the economic, cultural, ethical and logistical barriers, it seems neither justified nor practicable to roll out MC as a mass anti-HIV/AIDS intervention. A Myers Humanities student, University of Cape Town J Myers School of Public Health and Family Medicine University of Cape Town Corresponding author: J Myers (<a class="__cf_email__" data-cfemail="4b2126322e39380b222a2d3922282a65282426" href="/cdn-cgi/l/email-protection">[email protected]</a>) References 1. Connolly C, Simbayi LC, Shanmugam R, Nqeketo A. Male circumcision and its relationship to HIV infection in South Africa: Results from a national survey in 2002. S Afr Med J 2008; 98: 789-794. 2. Sidler D, Smith J, Rode H. Neonatal circumcision does not reduce HIV infection rates. S Afr Med J 2008; 98: 764-766. 3. Male Circumcision: To Cut or Not to Cut (dedicated session, 7 August). AIDS 2008 – Mexico City 3-8 August 2008 – XVII International AIDS Conference. http://www.aids2008.org/Pag/ PSession.aspx?s=41 (last accessed 8 August 2008). 4. Swaziland: Circumcision gives men an excuse not to use condoms. http://www.irinnews. org/Report.aspx?ReportId=79557 (last accessed 7 August 2008). 5. Siegfried N, Muller M, Volmink J, et al. Male circumcision for prevention of heterosexual acquisition of HIV in men. Cochrane Database of Systematic Reviews 2003, Issue 3. Art. No.: CD003362. DOI: 10.1002/14651858.CD003362. 6. Garenne M. Long-term population effect of male circumcision in generalised HIV epidemics in sub-Saharan Africa. African Journal of AIDS Research 2008; 7(1): 1-8. 7. New study shows condoms 95 times more cost-effective than circumcision in HIV battle. http://www.prweb.com/releases/2008/08/prweb1151894.htm (last accessed 7 August 2008). 8. WHO/UNAIDS Technical Consultation Male Circumcision and HIV Prevention: Research Implications for Policy and Programming. Montreux, 6 - 8 March 2007. Conclusions and Recommendations. http://data.unaids.org/pub/Report/2007/mc_recommendations_en.pdf (accessed 25 August 2008). October 2008, Vol. 98, No. 10 SAMJ See also A. and J. Myers, <a href="http://www.historyofcircumcision.net/index.php?option=content&task=view&id=77">Male circumcision: The new hope?</a>, South Africa Medical Journal, Vol. 97 (5), May 2007 <h2> <a id="uganda" name="uganda"></a>Ugandan writer attacks WHO circumcision propaganda</h2> The following editorial was published in the Ugandan newspaper Daily Monitor in December 2009. A few days ago I found it necessary to restate my position, calmly and quietly, that my sons – two so far – should under no circumstances be circumcised. Two very simple and I am persuaded, logical reasons. First, while I respect the standpoint of those who argue for circumcision, I personally do not believe in it. Circumcision is such a personal affair; nobody has the right to decide for anybody else whether or not they should undergo it. And since kids are too young to appreciate the merits (probably lack of them) of a matter as personal and important as losing their foreskin, I argue that it is improper for somebody else (parent though they be) to make that decision for them, unless it is a medical emergency that has implications on their immediate survival or potency. If as adults they decide to submit to the knife, that is their responsibility. The other reason is that the advocates of circumcision in Uganda today are advancing very lame, wrong and wholly incompetent reasons for it. Their message is two-fold: that circumcision will help protect men from contracting HIV – the virus that causes AIDS. Secondly we are told that circumcision promotes hygiene among men. As we speak, billions of shillings have been sunk into programmes about circumcision, telling every Ugandan that this is the new miraculous discovery that will keep them safe. This lie needs to be unmasked and exposed, because we are playing with fire. Who in their right mind would believe that a man can have unprotected sexual intercourse with an infected woman and come out intact just because he is circumcised? Any argument about how hardened a circumcised male organ is and how it is able to withstand whatever period of sexual intercourse and emerge without scratches and, therefore, without possibility of infection is purely academic … and deadly. The truth behind circumcision is that it is just a new excuse invented by unscrupulous and incompetent scientists, plus bureaucrats in the United Nations, African governments and civil society to eat free money. They have not told us who did the research, what methodology they employed or which experimentation humans they used. In the end, therefore, the current campaign for circumcision has nothing to do with your health and safety. It is all about people making money. Our young men will now believe that you can sleep with whoever it is and you’ll be safe just because you are circumcised. And they will die. Our girls will be told, “I am circumcised” and they will presume they are safe. And they will die. Strangely enough, the protagonists of circumcision argue that it affords only a 60 per cent chance at best of avoiding the virus and that circumcision should be used “in combination” with other safety measures such as condom use. I think the ABC strategy that Uganda had adopted is good enough to help us fight AIDS. Abstain from sex, or Be faithful to your (one) partner or if push comes to shove, use a condom. For hygiene I will encourage my sons to take a bath regularly. I will also take them through another course on how a man ought to keep himself clean. For now I find it important to put the country on notice: we are being duped and as your kids bleed all the way from hospital, a small clique is laughing all the way to the bank. Unmasking the Lie: Circumcision, Sex and HIV/AIDS By Gawaya Tegulle <a href="http://www.monitor.co.ug/" rel="noopener" target="_blank">Daily Monitor</a> (Uganda) December 12, 2009 <h2> <a id="legislate" name="legislate"></a>South African legislation against circumcision of minors</h2> Despite the AIDS crisis about which we hear so much, South Africa is one of the very few countries in the world that has actually passed a law regulating and to some extent prohibiting circumcision of male minors. This is a fact about which we hear very little. The relevant sections of the Children's Act (2005) are as follows. 7. (1) Whenever a provision of this Act requires the best interests of the child standard to be applied, the following factors must be taken into consideration where relevant, namely - (l) the need to protect the child from any physical or psychological harm that may be caused by ... (i) subjecting the child to maltreatment, abuse, neglect, exploitation or degradation or exposing the child to violence or exploitation or other harmful behaviour 12. (1) Every child has the right not to be subjected to social, cultural and religious practices which are detrimental to his or her well-being (3) Genital mutilation or the circumcision of female children is prohibited. ... (8) Circumcision of male children under the age of 16 is prohibited, except when (a) circumcision is performed for religious purposes in accordance with the practices of the religion concerned and in the manner prescribed; or (b) circumcision is performed for medical reasons on the recommendation of a medical practitioner. As you can see, there are problems with this. For a start there is gross gender discrimination, in that girls are given blanket protection against any kind of harm, but boys have to make do with qualified protection. The exception for "religious purposes" allows practising Jewish and Muslim parents to circumcise without constraint, but the failure to specify the religions accorded the exemption provides a loophole for anybody who wants to invent his own religion. More seriously, the reference to "medical reasons" fails to define what they are. If they mean a situation where circumcision is necessary to treat an injury, deformity or disease that has failed to respond to conservative treatment after reasonable efforts, that is one thing and will provide a significant level of protection If, on the other hand, they mean circumcision performed in the belief that it will reduce the risk of contracting diseases to which the child may be exposed at some later date (i.e. prophylactic or precautionary circumcision), that is quite another, and will provide no protection at all against the circumcision promoters. Most non-religious circumcision is prophylactic circumcision, but it should not be confused with therapeutic (i.e. treatment for an existing problem). It is significant that in its paper on the legal status of circumcision of male minors the Tasmanian Law Reform Institute is careful to explain that prophylactic circumcision is not therapeutic. Still, South Africa is way ahead of Australia and most developed nations in making some attempt to crack this difficult nut. <h3>South African Medical Association rejects circumcision</h3> Interestingly enough, the South African Medical Association does not consider the AIDS crisis a sufficient justification for routine circumcision of male infants or other normal male minors. In response to an inquiry from Nocirc of South Africa, the South African Medical Association stated that there was no justification for routine circumcision of infants or children. In letter to Nocirc SA, dated 4 February 2005, and signed by Professor Ed Coetzee, Chairperson of the SAMA Education, Science and Technology Committee, the Association states: “After lengthy DISCUSSION on the matter, the Committee RESOLVED that it be conveyed to NOCIRC-SA that, from a medical point of view, there was no medical justification for routine circumcision in males and children.” In this conclusion, SAMA joins medical authorities in Britain, Canada, the USA, Australia and New Zealand in agreeing that there is no medical case for routine circumcision. In fact, it goes slightly further than the Royal Australian College of Physicians, which states that there is “no medical indication”; SAMA says there is “no medical justification”, an even stronger rejection. Coming from a country with an extremely high incidence of HIV infection (and also a high incidence of male circumcision), this is a significant declaration. <a href="http://www.nocirc-sa.co.za/">Nocirc-South Africa website</a> <a href="http://www.samedical.org/">South African Medical Association website</a> <a href="http://www.cirp.org/library/statements/">Policy statements by medical associations</a> <h2> <a id="ritual" name="ritual"></a>Ritual circumcision leaves dozens killed and hundreds injured</h2> One of the concerns driving the South African legislation is the sad fact that each year traditional ritual circumcision of Xhosa teenagers leaves a trail of devastation: dozens of boys killed and many more injured. Appalled by the general indifference to this toll, the South African Medical Journal in 2003 called for "action to stop the carnage". <h3>EDITORIAL: Astonishing indifference to deaths due to botched ritual circumcision</h3> “Circumcision leaves 24 dead, 10 in hospital”, read the headline in The Star of Kuala Lumpur, Malaysia, on 16 July 2002. The report continued: “South Africa’s initiation season ended this weekend with a gruesome toll of 24 deaths reported to police and more than 100 teenagers hospitalised with gangrene and septicaemia after botched circumcisions and severe beatings. One boy’s penis dropped off as a result of gangrene, at least one other had to have his penis amputated, and another will have to have both legs amputated, authorities said”. Similar horrifying circumcision outcomes have been <a href="http://www.cirp.org/news/">observed again this year</a>, with reports of the deaths and mutilations being beamed across the world by all the major news services. No one understands why we as a country – or as communities – have seemingly stood by and done little or nothing as these deaths rock the country year after year. Anywhere else in the enlightened world, this kind of mayhem would have evoked community outrage and led to urgent and drastic action to prevent it. Why are we not sufficiently agitated by the slaughter to find ways to stop it? Perhaps in today’s South Africa, where violence constitutes one of the leading causes of death (including 23,000 officially acknowledged murders per annum), we have become hardened against the horror of needless death. In any event, deaths due to ritual circumcision largely occur in the impoverished and faceless rural and peri-urban communities, and those of us north of he railroad are in denial about this, just as we are about much of the other misery in that quarter. The communities themselves have perhaps come to accept these occurrences as part of their fate, along with unsafe minibus taxis and random street shootings. Middle class families from circumcising backgrounds ensure that their sons are circumcised in safe and nurturing environments. Unless this elite is moved and inspire to do something about the circumcision deaths among the less privileged, nothing will change. A further reason for playing down the deaths may be a deep-sated fear among the affected communities (largely in the eastern Cape and the Limpopo provinces) that this hallowed ancient tradition is under threat of extinction, and that any move to modernise it may push it over the edge. Certainly, some voices coming through on radio talk shows seem much more concerned with the survival of the ritual itself (often rather broadly if inaccurately labelled “our African culture”) than about the reported deaths and mutilations. Daniel J. Ncayiyana, Editor South Africa Medical Journal, Vol. 93, No. 8, August 2003 <h3>But the carnage continues</h3> In 2006 the British Medical Journal reported: Fourteen boys have died as a result of botched circumcisions in the past month in the Eastern Cape province of South Africa. Hundreds more boys have been maimed and mutilated in the same process which takes place annually at “circumcision schools,” usually conducted in the bush, away from towns and villages. In South Africa, in many groups, boys are circumcised between puberty and adulthood, and it marks the ritualised passing from boyhood to manhood. In the past few years, however, this “circumcision season” has been marred by untrained and bogus traditional surgeons trying to make money but whose technique lacks expertise and hygiene. The provincial department of health says that 243 deaths and 216 genital amputations from circumcisions were recorded between 1995 and 2004. Last year there were more than 20 deaths. Laws and regulations in the Eastern Cape were passed in the hope of controlling the practice and ensuring hygienic conditions. Traditional surgeons have to be officially recognised and register with the department. Surgeons caught running initiation schools without authority can be sent to prison. Pat Sidley, Johannesburg <a href="http://bmj.bmjjournals.com/cgi/content/short/333/7558/62-d?etoc">British Medical Journal, Vol. 333, 8 July 2006, p. 62</a> Further information <a href="http://www.historyofcircumcision.net/index.php?option=content&task=view&id=66">South African Medical Association calls for action to “stop the carnage”</a> <a href="http://www.nocirc-sa.co.za/">Circumcision in South Africa</a> And the story is much the same this year: see news reports at <a href="http://www.cirp.org/news/">CIRP</a> and <a href="http://www.circumstitions.com/">Circumstitions</a>. According to the latter, there have been 53 deaths so far this year in Eastern Cape Province. Not much evidence there that circumcision is improving child health. <h2> <a id="sama" name="sama"></a>“Unethical and illegal”: South African Medical association</h2> <h2>rejects circumcision of infants</h2> In a letter dated 23 June 2011, the South African Medical Association has stated that it does not support the practice of circumcision of infants as a means of preventing HIv transmission and that it considers circumcision of infants to be both unethical and illegal. The letter was signed by Ms Ulundi Behrtel, Chairperson of the Human Rights, Law and Ethics Committee. The full text of the letter follows: 23 June 2011 Mr Dean Ferris, Co-Director National Organisation of Circumcision Information Resource Centres South Africa Dear Mr Ferris CIRCUMCISION OF BABIES FOR PROPOSED HIV PREVENTION We refer to the above matter and your email correspondence of 16 February 2011. The matter was discussed by the members of the Human Rights, Law & Ethics Committee at their previous meeting and they agreed with the content of the letter by NOCIRC SA. The Committee stated that it was unethical and illegal to perform circumcision on infant boys in this instance. In particular, the Committee expressed serious concern that not enough scientifically-based evidence was available to confirm that circumcisions prevented HIV contraction and that the public at large was influenced by incorrect and misrepresented information. The Committee reiterated its view that it did not support circumcision to prevent HIV transmission. We trust that you will find this in order. Yours faithfully Ms Ulundi Behrtel Head: Human Rights, Law & Ethics unit Obo Chairperson: Human Rights, Law & Ethics Committee SA Medical Association A pdf of the letter is available on request through <a href="https://www.circinfo.org/contact.html">the contact form</a>. <h2> <a id="boyle" name="boyle"></a>Circumcision and HIV prevention: New study slams flaws in African clinical trials</h2> In 2007 the World Health Organisation recommended circumcision of adult males as an additional measure to control the spread of HIV-AIDS in African countries with high levels of HIV prevalence in the general population. The recommendation was based on limited evidence: no more than three clinical trials (in South Africa, Kenya and Uganda), the results of which appeared to show that circumcision could reduce a male’s risk of acquiring HIV through sexual intercourse with an infected female partner by a significant degree - commonly reported as 60 per cent, but subsequently estimated by the Cochrane Review as somewhere between 38 and 66 per cent. These trials have already been the target of <a href="http://www.circumstitions.com/HIV-SA-garenne.html">several critical reviews</a>, all of which have found them flawed in many crucial areas - most importantly that they exaggerate the protective effect of circumcision, while ignoring complications, ethical and human rights issues, and harm to sexual function and body image. A new critique by George Hill and Professor Greg Boyle, in the Journal of Law and Medicine, goes further: after a careful analysis of the data reported in the published reports of the trials, finds that the protective effect of circumcision was nothing like 60 per cent. The impression of significance was achieved by reporting the risk reduction in terms of relative risk, suppressing the fact the the absolute risk reduction was pretty insignificant - probably as low as 1.3 per cent. But even as an estimate of relative risk the 60 per cent figure was an exaggeration; after correcting for lead-time bias it should be lowered to 49 per cent. This is not the only problem. Boyle and Hill find numerous flaw in the methodology of the three trials, any one of which would be enough to cast doubt on the results: <ul> <li>researcher expectation bias;</li> <li>participant expectation bias;</li> <li>inadequate double blinding;</li> <li>lead-time bias;</li> <li>selection and sampling bias;</li> <li>experimental mortality; and</li> <li>early termination.</li> </ul> To measure researcher expectation bias, they analysed the references the researchers used and found significantly more pro-circumcision and fewer anti-circumcision or neutral references than are available in the HIV literature. In an appendix, the authors identify no fewer than 13 studies that found no association between circumcision and HIV status, and three studies that found a greater risk of HIV infection in circumcised men. These compare with only three studies (the famous African trials that supposedly gave us the “gold standard” of proof) finding a higher risk of HIV among the uncircumcised. No prizes for guessing which studies the media have highlighted, and which they have ignored. The authors point out that the early termination of all three trials would have amplified the protective effect of "lead-time bias" (delay by circumcised men in resuming sex). In at least four cases in the Kenyan trial, men apparently contracted HIV through circumcision. Just as seriously, in a separate trial of the effect of circumcision on male to female transmission of HIV, there appears to have been a 61 per cent relative increase in the incidence of HIV infection among the female partners of HIV-positive circumcised men. The authors also raise serious concerns about the ethical and human rights aspects of all the trials, and especially the male-to-female trial, in that the women were not informed that their partners were HIV-positive so that they could protect themselves. “Since some men acquired HIV without reporting unprotected sexual exposures, the RCT authors had a duty of care to investigate such non-sexual transmission," they say. "Researchers controlled the information available to men so that provision of fully informed consent may have been compromised.” Given all these problems, the authors conclude that “Male circumcision is a dangerous distraction and waste of scarce resources that should be used for known preventive measures.” It is obvious that if the circumcision solution is not the right approach for Africa's vast HIV problem, there is no shadow of an argument for the deployment of circumcision as an AIDS control measure in developed countries. Boyle GJ, Hill G. Sub-Saharan African randomised clinical trials into male circumcision and HIV transmission: Methodological, ethical and legal concerns. Journal of Law Med and Medicine, Vol. 19, December 2011: 316-34. The full article may be purchased from the <a href="http://sites.thomsonreuters.com.au/journals/2011/11/28/journal-of-law-and-medicine-update-december-2011/">Journal of Law and Medicine homepage</a>. For other options, contact Circumcision Information Australia through the <a href="https://www.circinfo.org/contact.html">contact page</a>. <h3> Relative vs absolute risk reduction</h3> According to most of the media reports, the African circumcision trials are supposed to have achieved a “60 per cent reduction” in the risk of acquiring HIV. This statement has been repeated so often that it has become a received “truth”, and has been been inflated into the totally false claim that “circumcision prevents AIDS.” Even if the data in the trials were valid, the most that could be claimed is that circumcision reduced the risk. But there are many misrepresentations in the report that the degree of risk reduction is “60 per cent”. The most serious are: 1. It is not stated that this reduction, even if true, occurs only in a highly specific context: unprotected vaginal intercourse with an infected female partner, in a population with a high level of HIV prevalence, widespread sexual promiscuity, a low level of condom use, and numerous infected females. 2. Analysis by the Cochrane review (a research unit that assesses clinical trials and similar studies)* concluded that the risk reduction was not 60 per cent at all, but somewhere between 38 and 66 per cent. On average, this would mean a risk reduction of about 50 per cent. All this means is that in a population such as that described in point 1, circumcised men who have sex with a variety of sexual partners and do not use condoms will take twice as long to get infected. 3. The magical 60 per cent figure is relative risk reduction, not actual risk reduction. What dos this mean? As Boyle and Hill explain, Across all the female to male trials, of the 5,411 men circumcised, 64 (1.18 per cent) became HIV-positive. Of the 5,497 controls (men who were not circumcised), 137 (2.49 per cent) became HIV-positive. As you can see, the actual numbers are very small (a measly 1.3%), but expressed as a percentage, the difference turns into an impressive “60%”. There were many reasons why the circumcised sample might have presented fewer infections, including less time to get infected (since they could not have sex while the circumcision would was healing), better knowledge of safe sex from the counselling they received, and greater condom use, since they were given condoms in the counselling sessions. There is actually no proof that the observed risk reduction was the effect of circumcision, rather than factors such as these. This is the entire extent of the evidence for circumcision having a protective effect against HIV, and the basis for billions of dollars being spent on bribing and coercing African men to get themselves and their male children circumcised, largely at the expense of Western taxpayers. For further analysis and graphic representation of the evidence, <a href="http://www.circumstitions.com/HIV-SA.html">see the deconstruction by Hugh Young at Circumstitions.com</a>. * Siegfried N, Muller M, Deeks JJ, Volmink J. Male circumcision for prevention of heterosexual acquisition of HIV in men (Cochrane Review). In: <a href="http://www.cochrane.org/cochrane-reviews">The Cochrane Database of Systematic Reviews</a>; Issue 2; 2009 Apr 15. Chichester ( UK ): John Wiley; 2009. <h3>Zimbabwe newspaper critical of circumcision solution</h3> Impact of male circumcision on HIV doubted by Gilbert Nyambabvu New Zimbabwe News, 22 February 2012 Dangerous distraction ... Circumcision impact questioned MALE circumcision is a dangerous distraction in the fight against HIV/AIDS, researchers have warned insisting that contrary to widespread claims the procedure only reduces transmission rates by no more than 1.3 percent. Zimbabwe is among several countries in sub-Saharan Africa that have launched mass male circumcision campaigns after the World Health Organisation (WHO) and UNAIDS recommended the procedure in 2007 as an effective HIVAIDS preventive measure. The WHO/UNAIDS recommendation was based on clinical trials carried out in Kenya, South Africa and Uganda which suggested that circumcision could reduce female-to-male HIV transmission by up to 60 percent. Thousands of men have undergone the surgical nip and tuck since Zimbabwe launched the campaign in 2009 with promoters enthusiastically claiming that if at least 80 percent of the adult male population was circumcised about 750 000 cases of HIV infections could be prevented. But new research has cast doubt on the supposed efficacy of the procedure with an article in the December Australian Journal of Law and Medicine citing numerous flaws in the Kenya, South Africa and Uganda studies. Researchers Gregory J. Boyle and Gregory Hill claimed the 60 percent reduction in transmission was only relative with the absolute reduction rate actually no more than 1.3 percent. Boyle and Hill said: “What does the frequently claimed ‘60 percent relative reduction’ in HIV infections actually mean? “Across all the three female-to-male trials, of the 5,411 men subjected to male circumcision, 64 (1.18 percent) became HIV positive while among the 5,497 controls 137 (2.49 percent) became HIV positive. “So the absolute decrease in HIV infection was only 1.31 percent, which is statistically not significant.” The authors of the article insisted that the WHO/UNAIDS recommendation “uncritically accepted” the findings of the Kenya, South Africa and Uganda trials, in the process ignoring a vast body of contradictory evidence. “Examination of epidemiological data shows that male circumcision does not provide protection against HIV transmission in several sub-Saharan African countries including Cameroon, Ghana, Lesotho, Malawi, Rwanda and Tanzania all of which have higher prevalence of HIV infection among circumcised men,” they said. “In Malawi, the HIV prevalence rate is 13.2 percent among circumcised men and 9.5 percent among those who are intact. (Again) in Cameroon prevalence among those circumcised is 5.1 percent compare to 1.5 percent for those who are intact. “If male circumcision reduces HIV transmission as the trials claim then why is HIV prevalence much higher in the United States (where most men are circumcised) than in developed countries where most men are intact (such as Europe, the United Kingdom and Scandinavia)?” The article warns that relying on male circumcision in the fight against HIV/AIDS is especially dangerous for sub-Saharan Africa women because circumcised men could still acquire and transmit the virus to their sexual partners. “Evidence suggests that mass circumcision programs may exacerbate the HIV epidemic among women (and) under these circumstances it would be irresponsible and unethical to advocate mass circumcision programmes in southern Africa,” the article concludes. “Male circumcision is a dangerous distraction and a waste of scarce resources that should be used for known preventive measures (such as condoms which are 80 percent effective.” <a href="http://www.newzimbabwe.com/news-7273-Circumcision%20HIV%20impact%20doubted/news.aspx" rel="noopener" target="_blank">New Zimbabwe News, 22 February 2012</a> <h2> <a id="samj" name="samj"></a>A case of medical colonialism?: South African Medical Journal</h2> <h2>condemns HIV-circumcision push</h2> In a hard hitting editorial that raises the spectre of neocolonialism, the South African Medical Journal has condemned the push for mass circumcision of African men as the solution to the nation’s HIV-AIDS problem. The editorial, by the journal editor Professor Daniel Ncayiyana, reviews the evidence for the claim that circumcision reduces the risk of female-to-male infection, and finds it less conclusive than assumed (and far less significant than regularly proclaimed in sensationalist newspaper headlines). The weakness of the case arises partly because the three clinical trials on which it is based were terminated prematurely, and partly because surveys show no consistency in the pattern of HIV infection among circumcised and uncircumcised men. (In some places there is little difference, and in some the incidence of HIV is higher in circumcised men.) There is certainly nothing in the results of the trials to justify the wild claim that circumcision provides “lifelong protection” against HIV; the most that could be said is that in areas of high HIV prevalence circumcision reduces the risk of female-to-male transmission in unprotected intercourse. Despite the much-touted “60 per cent” figure, nobody really knows the extent of the risk reduction in real world situations. Circumcision provides no protection to homosexual men or injecting drug users, and may increase the risk of male-to-female transmission. The editorial warns that an excessive and disproportionate focus on expensive surgical interventions such as circumcision will discourage condom use (known to be 90 per cent effective against HIV transmission) and deplete the resources needed in other critical health areas (such as malaria and tuberculosis). Already there is evidence that many men believe that the chief advantage of circumcision is that they will no longer have to wear condoms. At the same time, promoters of the circumcision solution still insist on condom use even after circumcision. Clearly, as Van Howe and Storms point out, this demand implies lack of faith in their own prescription: “Circumcision is either inadequate (otherwise there would be no need for continued condom use) or redundant (as condoms provide nearly complete protection).” * The editorial urges South Africa to follow the recommendation of the Australian Federation of AIDS Organisations, which has rejected circumcision and reiterated that “correct and consistent condom use … is the most effective means of reducing female-to-male transmission, and vice-versa.” ** Raising the spectre of human rights abuses and colonialism, the editorial is particularly concerned at the push for universal circumcision of infants and children, despite the fact that the South African Children’s Act specifically prohibits circumcision of boys under the age of 16 years. The editorial notes that much of the push for circumcision in Africa comes not from native Africans, but from international aid agencies dominated by United States funders and policy-makers, and that many programs are funded by the vastly wealthy Bill and Melinda Gates Foundation. It comments that it is “curious and even worrisome that the campaign to circumcise African men seems to be driven by donor funding and research from the North.” Mutilation of African native bodies by white and Arab slave traders and other exploiters was a sad feature of African experience in the dark days of colonialism, before the various nations achieved independence. In more modern times, western pharmaceutical companies have treated African and other “Third World” peoples as convenient guinea pigs on which to test their drugs – often with tragic results. It is strange to see such similar practices being revived and enforced by benevolent white medical missionaries, but their determination to carve their mark on the bodies of African men certainly looks like a new and particularly insidious form of cultural imperialism. Source: “Editorial: The illusive promise of circumcision to prevent female-to-male HIV infection: Not the way to go for South Africa”. <a href="http://www.samj.org.za/index.php/samj/issue/view/119/showToc">South African Medical Journal, Vol. 101, November 2011, 775-776</a>. References * Van Howe RS, Storms MR. <a href="http://www.publichealthinafrica.org/index.php/jphia/article/view/jphia.2011.e4/html_9">How the circumcision solution in Africa will increase HIV infections</a>. Journal of Public Health in Africa 2011;2:e4. doi:10.4081/jphia.2011.e4 A study of Nigerian prostitutes in 1988 found that, after counselling sessions, condom use increased markedly and that even occasional condom use had a significant protective effect: of 28 women who never used a condom, only eight escaped infection with HIV; but of 50 women who used them in approximately one third of sexual encounters, 27 (54 per cent) avoided infection. It is instructive to compare this with the results of the recent clinical trials of circumcision, which reported a risk reduction of between 50 and 60 per cent: about the same as the risk reduction achieved by condom use 30 per cent of the time. See E.N. Ngugi et al, “Prevention of transmission of human immunodeficiency virus in Africa: Effectiveness of condom promotion and health education among prostitutes”. Lancet, Vol. 332, No. 8616, 15 October 1988, 887-890. ** Australian Federation of AIDS Organizations. Male circumcision has no role in the Australian HIV epidemic. Briefing Paper, 23 July 2007. Available at http://www.afao.org.au/__data/assets/pdf_file/0019/4528/BP0709_Circumcision.pdf <h2> <a id="zimb" name="zimb"></a>Circumcision campaigns failing to reduce HIV incidence</h2> Health officials in Zimbabwe are worried that the massive drive to have 1, 2 million men circumcised by 2015 might backfire following indications that HIV prevalence is higher among men that have undergone the procedure. According to [very limited] research, circumcision reduces the transmission of the HIV virus by 60 percent [actually, by an unknown factor, believed to be somewhere between 38 and 66 per cent] among heterosexual men. But the latest Zimbabwe Health Demographic Survey (ZHDS 2010/2011), indicates that the HIV prevalence rate among circumcised men is 14 percent but only 12 percent among the uncircumcised. The findings are for circumcised males between the ages of 15 and 49. This is blamed on the misconception that circumcision completely shields people from HIV infection. National Aids Council (NAC) public health officer Blessing Mutede said authorities were concerned about the high rate of infection among the circumcised. Health officials say most men, after circumcision, harbour the false impression that they have been equipped with an invisible condom. “It is a worrying development that at a time when we are promoting male circumcision as a preventive measure to combat HIV, we are recording a high prevalence rate amongst the group that has been circumcised largely due to uninformed risky compensatory behaviours,” Mutede said. Source: <a href="http://www.theafricareport.com/index.php/20120711501815186/southern-africa/zimbabwe-concern-over-high-hiv-rates-among-circumcised-males-501815186.html">The Africa Report, 22 July 2012</a> Meanwhile, Mugabe's health advisor, Timothy Stamps, has rubbished claims that male circumcision reduces HIV and Aids prevalence rate at a time the country had embarked on a foreskin cutting crusade, ostensibly to lessen chances of contracting the deadly disease. The former minister of health said circumcision did not make any difference to the adult prevalence rate, noting researches had shown that countries with a higher number of circumcised men, like the US, also had a high HIV prevalence rate. He said instead of channelling funds towards circumcision, the money must be used to save pregnant mothers who die in huge numbers in this country. “When we are losing 960 mothers for every 100 000 pregnancies, should circumcision be a priority?” said Stamps. He said circumcision had led to men being more reckless in sleeping around. “Young men are happier to take risks and chances without the use of condoms or any other preventive measures because they are told circumcision will protect them,” he said. Source: <a href="http://allafrica.com/stories/201207231533.html">All Africa News, 22 July 2012</a> <a href="http://www.circumstitions.com/Images/zim-2005-12-750.png" rel="noopener" target="_blank">This diagram shows</a> that the incidence of HIV infection is consistently higher among circumcised men in Zimbabwe, and that while there has been s slight reduction in the over all incidence of HIV infection since 2005, the reduction has been just as great among the uncircumcised as among the circumcised. <h2> <a id="Zimb" name="Zimb"></a>Africa: Mass circumcision campaigns failing to reduce HIV incidence</h2> Recent reports from African countries that have pursued ambitious American-funded circumcision campaigns in the belief that they would solve their HIV-AIDS problem show that circumcision is not reducing the incidence of infection, but (as in parts of Kenya) actually increasing it. At the same time, opposition to the programs is growing, especially in Zimbabwe, where critics have accused the (highly authoritarian) government of misleading propaganda and unethical efforts to circumcise boys and infants rather than consenting adults. (This is contrary to the original recommendations of the World Health Organisation, which stressed that circumcision should be performed only as a free, informed choice, and that programs should be conducted in accordance with human rights principles.) <h3>Zimbabwe: Growing opposition to circumcision campaign</h3> In Zimbabwe critics of the American-funded circumcision campaign have accused the (authoritarian) government of misleading propaganda and unethical efforts to circumcise boys and infants rather than consenting adults. As in several African countries, the testing and circumcision procedures are being carried out by Population Services International, a US-based global health agency. One of their methods of persuading boys and adolescent to get circumcised is to send actors and entertainers into schools. Dr. Karin Hatzold, deputy head of PSI Zimbabwe said: “We have campaigns that are specifically targeting adolescents, people in schools — so during school holidays we are doing massive mobilisations on mass media. So get smart, get circumcised. Male circumcision is not only HIV prevention intervention, but it is improving hygiene, you are cleaner, you are smarter.” But some Zimbabweans have complained that such tactics were unethical in that the propaganda gave a false sense of security, failed to mention the risks and harms of circumcision and put pressure on schoolboys that amounted to coercion. Raymond Majongwe, a National Aids Council board member, said the media campaigns on male circumcision were mischievous in that they give a false sense of security to those who would have gone under the knife. “They then think they are macho and can go on bedding girls. It is like a licence to be promiscuous. I also do not believe in those said “celebrities” that are being used to promote the idea. Stunner for example, is another male circumcision ambassador who after being circumcised went on to shoot a sex video that went viral, exposing his circumcised manhood,” Majongwe said. He added that he has always been skeptical of the on-going male circumcision campaigns. Supporting Majongwe’s views is the Matobo senator Sithembile Mlotshwa who has called on the ministry of Health and Child Care to stop circumcising children under the 2009 medical male circumcision programme. “In our constitution, everyone is born with a right to life and I think it is wrong for a father and mother to sit down and decide to circumcise this young child who is a month old whereas the father was circumcised at the age of 40. This circumcised man's parents gave him all these years to mature and know the uses of all the organs of his body so as to decide how best to remake what is God-given. So then why does this person want to agree with his wife to circumcise an infant who is a third person who has a right to be fully developed as he is so that he makes his own decisions about his body organs?” Mlotshwa believes children should be allowed to make their own choices when they grow up instead of being circumcised under this programme funded by international donors. “I want to take our minister of Health to task because I believe that you don't have to circumcise infants.” A other member of parliament, Jessie Fungayi Majome said it is a sad or happy (depending on the circumstances) fact of life that children are bundled with the fate and decisions of their parents. “To cut or not to cut must be decided according to which of the two is in the best interests of the child as required in our new Constitution.” Since the authorities insisted that men should still wear a condom even after getting circumcised, it was obvious that the protection given could not be all that great. “I think more research must be done to give objective knowledge of the pros and cons of male circumcision.” Political activist Tabani Moyo said that “those agitating circumcision should engage in ethical advertising by outlining the dangers that come with the process so that when people decide to do it, they do so with all the critical information at hand. At the moment, there is too much high voltage advertising which borders on deceit that might end up leading to unintended consequences as the adverts seem to give an impression that your chances of getting HIV/Aids for example are reduced, this is irresponsible advertising.” <a href="http://www.bulawayo24.com/index-id-news-sc-national-byo-47989.html">Child circumcision ignites debate</a>. Bulawayo 24 Hours, 25 May 2014. <h3>Kenya: HIV increasing in regions of high circumcision incidence</h3> Meanwhile in Kenya, following the arrival of large sums of American cash, the authorities set a target of increasing the number of circumcised men from 85 to 94 per cent. Unfortunately, the governments on studies show that circumcision is not reducing the incidence of HIV, but that infections actually increasing in the regions where the circumcision program has been most successful. As a Kenyan newspaper reports: “Most studies on male circumcision, including the Kenya Aids Indicator Survey 2013 (KAIS), have so far concentrated on the quantity of procedures but none has shown it is achieving its primary objective of reducing HIV infections. Started almost seven years ago, on the promise that it could reduce the risk of infection by 60 per cent, the KAIS report showed a spike in prevalence in places like Nyanza where the circumcision programme is most intense.” If Kenya already had a severe HIV epidemic with 85 per cent of the male population circumcised, it is hard to see how circumcising a further 9 per cent is going to make any difference. Gatonye Gathura. <a href="http://www.standardmedia.co.ke/?articleID=2000122086&story_title=Kenya-study-male-cut-staff-overwhelmed-by-work">Male cut staff overwhelmed with work</a>. Standard Digital (Kenya), 22 May 2014. See also Joseph 4GI, <a href="http://joseph4gi.blogspot.com.au/2014/05/mass-circumcision-campaigns.html">Mass circumcision campaigns: The emasculation and harassment of Africa</a>. <h2> <a id="KenyaViolence" name="KenyaViolence"></a>Kenya: Circumcision as sexual violence and political oppression</h2> In Kenya, circumcision and other forms of sexual violence and genital mutilation are being used to terrorise minority groups and political opponents of the dominant tribal elites. This is the alarming conclusion of a study published in the journal Ethnicity and Health, which also reports that the US-led push for mass circumcision in Africa as a tactic against HIV-AIDS is producing major violations of human rights and doing little for health. In Kenya the majority of the population belong to tribal groups that traditionally practice circumcision as an initiation ritual in late childhood. There are, however, several minority ethnic groups that do not practise circumcision, and these have been subject to various forms of oppression and mistreatment by the majority, including forced circumcision, sometimes by mobs who kidnap men in the street, as Michael Glass reported in the Journal of Medical Ethics last year. These outrages are clearly a form of <a href="https://www.circinfo.org/Sexual_violence_against_males.html">sexual violence against males</a> and a blatant violation of both civil law and human rights principles, and further evidence that the US-funded campaign for mass circumcision in Africa is leading to shameful abuses and placing vulnerable minorities at the mercy of their traditional enemies: the law of unintended consequences at work. It is disgraceful that international human rights agencies have been silent on these developments. The Abstract of the paper follows. Background. As a contribution to ongoing research addressing sexual violence in war and conflict situations in the Democratic Republic of Congo, Kenya and Rwanda, this paper argues that the way sexual violence intersects with other markers of identity, including ethnicity and class, is not clearly articulated. Male circumcision has been popularized, as a public health strategy for prevention of HIV transmission, although evidence of its efficacy is disputable and insufficient attention has been given to the social and cultural implications of male circumcision Methods. This paper draws from media reporting and the material supporting the prosecutor at the International Criminal Court case against four Kenyans accused of crimes against humanity, to explore the postelection violence, especially forcible male circumcision. Results. During the postelection violence in Kenya, women were, as in other conflict situations, raped. In addition, men largely from the Luo ethnic group were forcibly circumcised. Male circumcision among the Gikuyu people is a rite of passage, but when forced upon the Luo men, it was also associated with cases of castration and other forms of genital mutilation. The aim appears to have been to humiliate and terrorize not just the individual men, but their entire communities. The paper examines male circumcision and questions why a ritual that has marked a life-course transition for inculcating ethical analysis of the self and others, became a tool of violence against men from an ethnic group where male circumcision is not a cultural practice. Conclusion. The paper then reviews the persistence and change in the ritual and more specifically, how male circumcision has become, not just a sexual health risk, but, contrary to the emerging health discourse and more significantly, a politicized ethnic tool and a status symbol among the Gikuyu elite. In the view of the way male circumcision was perpetrated in Kenya, we argue it should be considered as sexual violence, with far-reaching consequences for men’s physical and mental health. Source: Beth Maina Ahlberg and Kezia Muthoni Njoroge. ‘Not men enough to rule!’: Politicization of ethnicities and forcible circumcision of Luo men during the post-election violence in Kenya. Ethnicity and Health, Vol 18 (5), 2013. DOI http://dx.doi.org/10.1080/13557858.2013.772326 <h3>Syphilis 1855, HIV-AIDS 2007: Parallel responses</h3> In a related paper, Robert Darby considers the parallels between responses to syphilis in Victorian Britain and HIV-AIDS in contemporary Africa, and finds that circumcision was recommended in both cases for reasons that had little to do with an objective assessment of the value of the surgery, but had everything to do with cultural prejudice. He points out that many African countries hit hard by AIDS already had high rates of circumcision and that the majorities in these places welcomed the US-sponsored circumcision campaign as an excuse to force their non-circumcision minorities into line. Abstract In this paper, I discuss the parallels between responses to syphilis in nineteenth century Britain and HIV/AIDS in contemporary Africa. In each case, an incurable disease connected with sexual behaviour aroused fear, stigmatisation and moralistic responses, as well as a desperate scramble to find an effective means of control. In both cases, circumcision of adult males, and then of children or infants, was proposed as the key tactic. In the ensuing debates over the effectiveness and propriety of this approach, three questions occupied health authorities in both Victorian Britain and the contemporary world: (1) Were circumcised men at significantly lower risk of these diseases? (2) If there was evidence pointing to an affirmative answer, was it altered anatomy or different behaviour that explained the difference? (3) Given that circumcision was a surgical procedure with attendant risks of infection, was it possible that circumcision spread syphilis or HIV? I show that in both situations the answers to these questions were inconclusive, argue that circumcision played little or no role in the eventual control of syphilis and suggest that attention to nineteenth century debates may assist contemporary policy-makers to avoid the treatment dead-ends and ethical transgressions that marked the war on syphilis. Source: Robert Darby. Syphilis 1855 and HIV-AIDS 2007: Historical reflections on the tendency to blame human anatomy for the action of micro-organisms. Global Public Health, Advance access, 30 September 2014. http://dx.doi.org/10.1080/17441692.2014.957231 <h2> <a id="malawi" name="malawi"></a>Malawi sceptics blast United States circumcision obsession</h2> Malawians have questioned the motives of the United States and other Western NGOs that are promoting circumcision despite evidence showing that the questionable initiative does not reduce HIV as claimed. Vetting their anger and frustrations on social media, the people took to task the US for “prioritizing sex” and not real development. The US announced a $6.8 million (K3.8 billion) aid to support male circumcision which the US Ambassador to Malawi, Virginia Palmer, said has “has potential” to curb the spread of HIV. But all the comments that Malawi24 monitored on a story published by one of the local online publications expressed dismay at the focus of the aid, with many hinting that circumcision is not an effective means to fighting the spread of HIV. Athoko Chisale Mbewe wrote “American government is a joke. Chinese are giving money for development and all this ambassador cares about is sex? Ha ha ha …. if you want my foreskin I will trade it for K500,000.00. FYI My uncle has HIV /aids but he is circumsized”. While approving Athoko’s comment, Emmanuel Samikwa said that evidence from the Eastern region of the country back studies which question the credibility of circumcision to reduce HIV. Circumcision is common in the region, particularly among the Yao people, with people being circumcised during childhood. Most commentators made comparison between the support that the US and China are providing Malawi. The people called on the US to support initiatives that would savage Malawi’s ailing economy. “$6.8M for what?? Of all problems Malawi is facing, they think Male circumcision is top priority??. Why cant they learn from their Chinese counterparts?? This is laughable” posed Joseph Mutupha. Jonathan Pierre Ng’oma also urged the US to reflect on the priorities of its aid: “Come on, do we need money for such useless exercise? Our economy is in total shamble, will that going to help our economy?” Like others before him, Abram Nkasala commented by questioning the logic of the US to support circumcision which he observed is encouraging more people to engage in sex after circumcision, putting them at higher risk of infection. “Malawi needs food not jando this is encouraging AIDS because people are not caring after circumsion.People in Nsanje, Zomba are dying now”. Malawi24 previously revealed that there is not conclusive evidence to support claims that male circumcision reduce HIV infection. The Malawi Demographic and Health Survey, a study conducted in 2010 by country’s National Statics Office, also found that circumcised males were more likely to get HIV in Malawi. Another recent report also revealed that the HIV prevalence rate had doubled in Thyolo, one of the areas where medical circumcision was first rolled out in the country. Kondwani Mkhalipi-Manyungwa, <a href="http://malawi24.com/2015/10/25/malawians-blasts-the-us-we-dont-need-aid-for-circumcision/" rel="noopener" target="_blank">Malawians blasts the US: “We don’t need aid for circumcision”</a>. Malawi24, 25 October 2015 </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 Circumcision push by WHO/US/Gates questioned by African doctors 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"> Contrary to recent, ignorant, media reports, the incidence of infant circumcision in Australia is not increasing, but, on the contrary, is static nationally and actually declining in most states and territories. This is the conclusion of an analysis of circumcision figures for the period 2000-2010, published in the August issue of the Australian and New Zealand Journal of Public Health. The article compared the Medicare rebate for circumcision of boys under 6 months with male birth statistics, concluding that the incidence of circumcision had stayed pretty steady at 12 per cent across the nation, but with big falls in some states, offset by small rises in others. The most striking feature of the figures is wide variation among the states – from a low of 1.5 per cent in Tasmania to a high of 17.3 per cent in New South Wales for 2010. In between are the Australian Capital Territory and Western Australia on 6 per cent and 6.8 per cent respectively, and South Australia and Queensland on 15.1 and 14 per cent. Another feature of the figures are the sharp falls in Tasmania, from 9.3 per cent in 2000 to 1.5 per cent in 2010; in the Northern Territory from 7.6 to 2.7 per cent; and in Queensland from 20.3 per cent to 14 per cent. There have been small rises over the same period in Victoria (5.3% to 8%) and New South Wales (14.3% to 17%), though these may well be a product of changes in hospital policy rather than evidence of increased demand for the operation. The article suggests that the rises in NSW and Victoria may be related to the decision by state governments (NSW in 2006, Vic and SA in 2007) to cease providing non-therapeutic (medically unnecessary) circumcision as a service in their public hospitals. This may have resulted in a shift in the provider of the service from hospitals (where no Medicare rebate is payable or recorded) to GPs and specialist clinics, where the procedure shows up in the Medicare statistics. The rise may thus be more apparent than real. The article wonders why Medicare is providing a rebate for circumcision, considering that the latest statement by the <a href="https://www.circinfo.org/doctors.html">Royal Australasian College of Physicians</a> does not recommend it or regard it as necessary, and the Medicare guidelines state that rebates are not available for “medical services which are not clinically necessary”. The article concludes that there is no evidence for recent assertions that “circumcision is back in favour”, and points out that, on the contrary, it is continuing its slow decline from the high-point of the mid-1950s, and is close to its lowest level for nearly a century. Source: Robert Darby, Infant circumcision in Australia: A preliminary estimate, 2000-10, Australian and New Zealand Journal of Public Health 35 (4), August 2011. </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 Circumcision rate continues its slow decline 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"> There is little enough warrant in Western law or custom to coerce a person for the sake of his own health; there is none at all for the proposition that a person should be forcibly deprived of a functioning body part for the benefit of an unknown third party. In this extract from her article "Using male circumcision to understand social norms as multipliers" the American legal scholar Sarah Waldeck explains why the idea of circumcising male babies to reduce the risk of cervical cancer in adult women is not permissible: in summary, it is impossible because the person bearing the risk and suffering the deprivation is not the person reaping the benefit. <h3>Why it is wrong to circumcise baby boys, even if it did benefit adult women</h3> The argument that circumcision affects cervical cancer has floated in and out of the medical literature for years, but most studies attempting to document the connection have been disregarded because of profound methodological flaws, such as women inaccurately reporting the circumcision status of their husbands. Indeed, the AAP’s 1999 policy statement does not even mention cervical cancer prevention as a potential medical benefit. However, in April 2002, the New England Journal of Medicine published a report suggesting that the female partners of circumcised males are less likely to get cervical cancer than the partners of uncircumcised males. Specifically, researchers pooled data from Spain, Colombia, Brazil, Thailand, and the Philippines, and concluded that women whose male partners had six or more sexual partners and were circumcised had a lower risk of cervical cancer than women whose male partners had six or more sexual partners and were uncircumcised. In addition, circumcised males in the study had a lower incidence of the sexually-transmitted disease HPV. Because exposure to certain strains of HPV is a significant risk factor for cervical cancer, researchers hypothesized that circumcision protects against the cancer by reducing the incidence of HPV infection. As an editorial that accompanied the study explains, it does have some shortcomings. First, many risk factors for HPV are more common among uncircumcised men than circumcised men, such as poor genital hygiene and a history of multiple sexual partners. Because these variables are difficult to control for, they may help explain the higher incidence of HPV in uncircumcised males. In other words, because behavioral factors are so important, it is still not certain whether circumcision makes a quantitative difference in the rate of cervical cancer. In addition, progression from infection with a cancer-causing strain of HPV to invasive cervical cancer may take several decades. Therefore, at least some of the females in the study may have become infected by a different male partner, whose circumcision status is unknown. This sort of misclassification would either attenuate or exaggerate the association between non-circumcision and risk of cervical cancer. Finally, the study conflicts with some conducted in the United States which found that uncircumcised males have either the same or lesser incidence of HPV than circumcised males. Nonetheless, if the results of this most recent study are replicated elsewhere and become well-accepted, the medical utility of circumcision might be greatly enhanced. However, the issue of distributional fairness has gone largely undiscussed in the reporting of the recent findings about cervical cancer: who would receive the benefits of circumcision and who would bear the risks. The notion of shared risk is embedded in most public health initiatives, particularly those that involve children. Think, for example, of inoculations, to which circumcision is often compared. Under a universal vaccination policy, each child bears the risk of a complication, just as each child gains immunity to disease. If cervical cancer becomes the “medical argument for circumcision,” however, the non-negligible risks and considerable pain are borne by males, while the medical benefit is reaped by females. Circumcision would be a unique prophylactic intervention, one in which the health of one population was put at risk for the benefit of another population. From a legal prospective, the broad parental discretion to consent on behalf of the child is sharply curtailed when a medical procedure does not benefit the child but may aid third parties. The issue arises most frequently in the context of organ transplants. Whether the court uses a substituted judgment or best interest standard, the overarching focus is on what course of action will give the child the greatest net benefit. In answering this question, courts examine the relationship between the donor and donee, the effect of the procedure on the donor, the urgency of the donee’s need, and the probability that the procedure will be successful. Evaluated by these criteria, circumcision could not be performed or recommended as a prophylactic measure to prevent cervical cancer. First, the beneficiary’s need is far from urgent; many years will elapse before the boy is sexually active. No analogy can be drawn to the cancer patient who needs a bone marrow transplant, or the kidney patient who is kept alive by dialysis. Second, the case law emphasizes the necessity of a close, existing relationship between the child and person who will benefit from the surgery. Here there is not yet a relationship between the boy and the woman who would benefit from circumcision. Moreover, even the most recent study suggests that circumcision offers a protective benefit only to the female partners of men who have six or more sexual partners or engage in other behavior that puts them at high risk for HPV; the boy may end up not fitting this profile. For that matter, the boy may be homosexual and never have female partners. Without knowledge about what sort of man the boy will become, preventive circumcision is highly speculative. These considerations lead to the conclusion that if circumcision is done to prevent cervical cancer, it should be postponed until the boy is old enough to voice his own opinion on the matter. But while some cultures may believe that routine circumcision is more humane if done during adolescence, this is certainly not the American view: many parents say they circumcise during infancy to avoid the possibility that it will need to be done later. Thus, we can easily imagine a court assuming that any relationship between a male and his sexual partner will be close, and that if the procedure is going to be done at all, it has to be done during infancy. But even given these assumptions, circumcision would not pass muster under the usual standards for evaluating medical procedures that are performed for the benefit of third parties. When altruistic surgeries are performed on minors, the beneficiary is usually desperate and helpless. No alternative treatments are available, and without the aid of the minor, death is a near certainty. In contrast, women are capable of protecting themselves from cervical cancer that is connected to HPV. Not only can they practice safe sex, even more critically (and perhaps more realistically), they can receive simple annual Pap tests. Cervical cancer is easily cured if detected early, and for this reason, “[d]octors often say it is a disease that no woman should die of.” If prevention of cervical cancer becomes the medical rationale for circumcision, voiceless infants are subjected to a procedure for the benefit of adult women, who are fully equipped to take control of their own bodies and sexual well-being. Some readers may think that it is inappropriate to compare circumcision to surgeries that are performed for the benefit of third parties; all we are talking about are foreskins, not kidneys or bone marrow. But our exasperated “it’s only circumcision” merely reflects the social norm, which in turn shapes how we perceive the loss of the foreskin. To truly assess the fairness of removing healthy tissue from infants for the benefit of adult women, we need a thought experiment. Temporarily dispense with scientific disbelief and pretend that a new study concludes that amputating a male infant’s little toe would decrease cervical cancer rates in particular populations. Many physicians and the popular press start touting toe amputation as effective preventive medicine. Would you choose to cut off your newborn son’s little toe? Or, if it is difficult to imagine yourself with an infant son, would you think this recommendation represented appropriate public health policy? My guess is that the answer to both questions is no, even though the little toe is not more useful than the foreskin, and even if you think that the absence of a little toe might make the boy a more desirable sexual partner. You may be unwilling to subject infants to the pain of amputation; you may think that “normal” means having a little toe; you may believe it bizarre to amputate something that is likely to cause the boy little trouble beyond the occasional stub; you may be convinced that there are better ways to combat cervical cancer; you may just generally feel possessive about your son’s body parts. That we do not have similar reactions when it comes to cutting off the foreskin for the benefit of adult women is a testament to how deeply embedded the norm of circumcision really is. Of course, the analogy between the foreskin and the little toe is not strictly accurate, because toe amputation (like kidney transplants or bone marrow extractions) holds no possibility of potential health benefits for the child. Circumcision, in contrast, has potential health benefits. But it would be inappropriate to allow these potential benefits to cloud the issue of distributional fairness, because the medical establishment has already told us that the potential benefits are not enough to merit routine neonatal circumcision. Some would argue that the analogy between the foreskin and little toe is inapt for another reason: that, in fact, the foreskin has a sexual function that makes it far more useful than the little toe. In adult males, the foreskin comprises one third to one half of the penile skin and acts as platform for nerve and nerve endings, making it as sensitive or more sensitive than other parts of the penis. Except when the penis is erect, the foreskin protects the glans by hanging over it. Without the protection of the foreskin, the glans of a circumcised male becomes keratinized and develops layers of protective cells that act like a callous. But while the physical characteristics of the foreskin are well-understood, whether the loss of the foreskin affects sexual performance or sexual satisfaction is fiercely debated. Unfortunately, but perhaps predictably, the evidence is mixed and mostly anecdotal. The two studies that surveyed men who were circumcised later in life report conflicting results. In one study of 15 men, circumcision resulted in no statistically significant changes in male sexual function. In another study of forty-three men, participants reported a statistically significant reduction in erectile function as well as decreased penile sensitivity. In this same study, however, men were more satisfied with their penis after circumcision, based in large part on its new appearance. This suggests a point made in a large study of American sexual practices: the perception of sexual experience depends not only on the physical characteristics of the individuals involved, but also on the larger cultural and social context. Still, perhaps our thought experiment should be modified to include the possibility that amputation of the little toe negatively affects sexual function. (Remember that you are suspending scientific disbelief.) With this modification the reader is now probably even more reluctant to cut off a newborn’s toe because the sacrifice required of the infant simply seems too great, especially when adult women have a means of safeguarding their own interests. In sum, more research needs to be done before prevention of cervical cancer can be added to the list of circumcision’s potential health benefits. But because of the issue of distributional fairness, as well as the dubiousness of the parent’s ability to consent to circumcision when its purpose is to benefit adult women, we should view with caution any argument that promotes the prevention of cervical cancer as a justification for routine circumcision. Sarah E. Waldeck, Using male circumcision to understand social norms as multipliers, University of Cincinnati Law Review, Volume 72 (3), Winter 2003 455-526; pages 485-491 reproduced here, references omitted <a href="http://www.cirp.org/library/legal/USA/waldeck1/">Full article with references can be read here</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 Circumcision to reduce cervical cancer risk illegal 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 rights and wrongs of circumcision come under scrutiny in the July issue of the <a href="http://jme.bmj.com/">Journal of Medical Ethics</a>. With a series of specially written essays by experts from around the world, this special issue of the journal represents the most detailed and comprehensive analysis of the ethical aspects of male circumcision that has yet appeared in print. The range and quality of the contributions show that the debate about routine circumcision has entered a new and more intense phase, confirming the <a href="http://www.openforum.com.au/content/should-circumcision-be-illegal">prediction of several commentators</a> that the argument is no longer over whether circumcision has “medical benefits”, but whether it is ethically permissible to perform the operation on non-consenting children. The answer given in the world’s leading bioethics journal would appear to be a resounding negative. <h3>Argument is now over conflicting rights, not "health benefits"</h3> The most striking feature of the contributions is that only one contributor sought to defend non-therapeutic circumcision of boys on medical or health grounds, and even then only half-heatedly. Even those who argued that parents should be allowed to have their boys circumcised if the operation was required by or customary in their religion or cultural traditions agreed that there was no valid medical or health argument for the practice. In fact, the near-unanimous sentiment was that the debate about the permissibility of circumcision was relevant only to parents from cultures and religions that traditionally circumcise boys; while they might be entitled to have their boys circumcised, the question did not even arise for parents from non-circumcising cultures. Nobody attempted to argue that all parents were entitled to have their boys circumcised simply by virtue of their parental authority, and one paper (by Robert Van Howe) subjected the very notion of “parental rights” to a searching and sceptical critique. This near-consensus represents a forceful rejection of the position of the American Academy of Pediatrics, in its 2012 circumcision policy statement, that because the “benefits” of circumcision outweighed the “risks of complications”, parental choice on the question was appropriate. On the contrary, while parental preference might be justifiable in relation to circumcision for religious or cultural reasons, it could not possibly play a part in any decision based on medical arguments: parents lack the expertise to make an informed judgement on controversial medical questions, and it is not, in any case, their body that is being subjected to the surgery. In the absence of any consensus on the benefits of circumcision and wide agreement that they are either trivial or non-existent in childhood, the logical and ethically preferable position is to leave the decision up to the owner of the penis. The sole contributor who did consider health benefits to be relevant, David Benatar, claimed that “new” evidence about the possible effect of circumcision in reducing the risk of infection with heterosexually transmitted HIV was a factor that parents ought to add to the “circumcision decision”. The principal objection to this suggestion is its lack of logic, for it is only sexually active heterosexual adults who engage in high-risk sex practices who are at risk of contracting HIV. Since children are not sexually active, the decision can be safely left – and is more appropriately left – until the boy is old enough to make the decision for himself. Such a manifestation of respect for the bodies and rights of others would satisfy the principle of the child’s right to an open future, as argued in this issue by Robert Darby, as well as recognising their human rights, as insisted upon by Steven Svoboda. In other words, this special issue of the Journal of Medical Ethics amounts to a comprehensive rejection of the “American” point of view on circumcision, and an endorsement of the European-British position – that non-therapeutic circumcision of male minors is harmful to the child and is thus ethically impermissible and legally problematic. A summary of each of the articles appears below. <h3>1. Editorial: Bennett Foddy, Medical, religious and social reasons for and against an ancient rite</h3> This month’s issue of the Journal of Medical Ethics is a special issue devoted entirely to the ethics of infant male circumcision—an elective surgical practice that is currently performed on around a third of the world’s male population. The last time the Journal ran a symposium on this issue was in 2004, and there has been relatively scant discussion of the practice in the ethical literature since then. Three events that took place in the past year have brought the ethics of infant male circumcision back into the global spotlight. First, in April of 2012, controversy erupted after it was reported that a baby had died in New York City after contracting Herpes Simplex virus during the Orthodox Jewish variant of circumcision known as metzitzah b’peh, which involves the oral suction of blood from the infant’s penis following the circumcision procedure. Later that year, the American Academy of Pediatrics (AAP) released a policy statement which suggested that the health benefits of ordinary forms of male circumcision outweigh the risks and costs of the practice. A number of articles have since been published in support and in criticism of the AAP’s report, and the debate continues in these pages, as Steven Svoboda and Robert Van Howe write a critique of the evidentiary basis of the AAP’s report, and the AAP Task Force responds. Finally, the issue was also in the news in Europe, after a controversial German court decision ruled that the circumcision of male infants amounts to grievous bodily harm, and that the practice violates a child’s right to bodily integrity and to self-determination. As legal scholars Merkel and Putzke discuss in this issue, the ruling was later accompanied by a new law enshrining the right to perform circumcisions for religious reasons. Much of the debate so far has focused on the medical benefits and risks of circumcision. Yet at least outside of the USA, the great majority of circumcisions are performed as religious rites in Muslim or Jewish families. For this reason, and in light of the German legal decisions, our call for papers asked authors to also consider the non-medical goods and harms associated with the practice, and its religious and cultural justifications. Joseph Mazor’s feature article takes up that challenge in these pages. While he argues that the risks and benefits of male circumcision are finely balanced in non-religious families, he argues that the practice is justified in religious families by its role in integrating the infant into the religious community. His arguments are challenged not chiefly on principled grounds but primarily on empirical grounds in two commissioned commentaries. David Benatar, one author of perhaps the best-known moral defence of circumcision argues that Mazor overstates the medical downsides of circumcision, while David Lang argues that Mazor understates these risks. Mazor, in his response, concludes that parental choices should prevail as long as reasonable disagreements persist over the balance of scientific evidence on benefits and risks. Matthew Johnson also argues in favour of the idea that religious justifications of circumcision should be given some weight. However, he cautions that the use of such justifications can make religious bodies responsible for any ill-consequences that may result from the operation, and he argues that men who believe that they have been harmed by their circumcision should be able to seek damages against their religious community. On the other side of the aisle, several authors in this month’s issue argue more directly for the impermissibility of male infant circumcision. Medical historian Robert Darby argues that circumcision violates a child’s ‘right to an open future’, while paediatrician Robert Van Howe argues that we ought to abandon the idea that parents have a right to make decisions regarding their children’s welfare in cases where these decisions conflict with the rights and/or best interests of the child. Hanoch Ben-Yami takes a different approach to the evidence and to religious justifications in his brief article. Although he concludes that circumcision is on balance a ‘primitive’ and harmful practice, he argues in favour of a policy of harm minimisation rather than an outright ban. In Ben-Yami’s view, outlawing circumcision might engender racial and religious disharmony, and might also make the practice less safe, resulting in an overall greater level of harm to children and to society at large. Bioethicist Dena Davis also argues that harm reduction measures should be employed. But she points out, controversially, that similar measures might also make certain forms of female genital cutting ethically acceptable and justifiable on religious grounds, and she proposes that we re-open the discussion on female genital cutting. It is our hope that by publishing a diverse range of views on controversial subjects such as these, the ethical debate can be driven forward — not only on the medical justifications of circumcision, but on the cultural, political and religious justifications of one of the most common, yet most contentious medical procedures. <h3>2. Editorial: Julian Savulescu, Male circumcision and the enhancement debate: Harm reduction, not prohibition [Extract]</h3> Around a third of men worldwide are circumcised. It is probably the most commonly performed surgical procedure. Circumcision is also one of the oldest forms of attempted human enhancement. It is and has been done for religious, social, aesthetic and health reasons. Circumcision has a variety of benefits and risks, many of which are discussed in this issue. There is some dispute about the magnitude and likelihood of these benefits and risks. Some argue that the risks outweigh the benefits and circumcision should not be performed on children who are not competent to make their own decisions. If the risks of circumcision clearly outweighed the benefits, great harm has been done and is being done globally through this procedure. Around a third of all men would have been harmed. This is an extraordinary public health injury. Presumably, many would be entitled to compensation. The fact that relatively few people think that the situation is as bad as this indicates that most people implicitly believe that circumcision is not generally a significant harm, if a harm at all. (This is an example of the kind of argument called modus tollens. If p, then q. Not-q, therefore not-p.) One might thus conclude either that: (1) It is not clear from existing evidence whether the risks of properly performed circumcision outweigh the benefits, or vice versa. Or (2) If circumcision is against the interests of an infant or young child, it is only mildly so. In general, people should make their own decisions about body modification and human enhancement when this is possible. Such an approach speaks in favour of waiting until a child becomes an adult to make his or her own decision about circumcision. And procedures which are not clearly in a child’s interests should not be performed on that child. <h3>3. Editorial: Brian Earp, The ethics of infant male circumcision [Extract]</h3> With perspectives in this issue ranging from Joseph Mazor’s articulate defence of infant male circumcision as both morally and legally permissible to J Steven Svoboda’s contention that circumcision is an unambiguous affront to human rights, it is clear that the debate on this issue is far from over. Nevertheless, the overall balance of opinion may be shifting toward one of general scepticism concerning circumcision — even within religious communities. Increasingly, individual Muslim and Jewish thinkers are managing to persuade their fellow faith practitioners that the involuntary ablation of children’s foreskins is unnecessary for contemporary religious observance. This type of intra-religious influence can be traced at least to the famous 19th century debates within the German Jewish community concerning whether or not circumcision was to be performed in the modern era. It continues today with the founding of such groups as Jews Against Circumcision as well as with the establishment of symbolic alternatives to preputial amputation. One such alternative is the non-violent, non-sexist welcoming ceremony known as brit shalom officiated by a growing number of Jewish rabbis. As Dena Davis puts it in the title to her essay, we are dealing with a fundamental incompatibility between what she calls ‘ancient rites’ and ‘new laws.’ How this incompatibility will be addressed, and whether it can be dealt with in a way that ensures not only the coherence and proper functioning of religious communities, but also the well-being and basic rights of the children being raised within their care — only time will tell. <h3>4. Joseph Mazor, The child’s interests and the case for the permissibility of male infant circumcision</h3> ABSTRACT Circumcision of a male child was recently ruled illegal by a court in Germany on the grounds that it violates the child’s rights to bodily integrity and self-determination. This paper begins by challenging the applicability of these rights to the circumcision debate. It argues that, rather than a sweeping appeal to rights, a moral analysis of the practice of circumcision will require a careful examination of the interests of the child. I consider three of these interests in some detail. The first is the interest in avoiding a moderate decrease in expected future sexual pleasure. I argue that even if such a decrease were to occur, it is not wholly unreasonable to think that this might actually be a good thing for the child. Second, I consider the interest in self-determination. I argue that this interest is not as strong as it might appear because the adult’s circumcision decision is subject to a variety of biases and a significant lack of information. Finally, I consider the child’s interest in avoiding the future costs of adult circumcision. I argue that this interest becomes much stronger in the religious case because the child is quite likely to choose to become circumcised as an adult. The likelihood of the child choosing circumcision in the religious case also reduces the extent to which infant circumcision violates his interest in self-determination. I conclude that male infant circumcision falls within the prerogative of parental decision-making in the secular case and even more clearly so in the religious case. Finally, I distinguish male circumcision from female genital cutting in several important respects and argue that we can coherently hold that male circumcision is permissible without also endorsing all forms of female genital cutting. <h3>5. Commentary on Mazor (1): David Lang, Circumcision, sexual dysfunction and the child’s best interests: Why the anatomical details matter</h3> The author raises six objections to Mazor’s argument, the most important of which is that he glosses over the anatomy and physiology of the foreskin and thus ignores the damaging effect of circumcision of sexual function and erotic sensation. Two extracts follow: The author insufficiently explores the profound implications of a serious equivocation in the term ‘circumcision’ that is common throughout the literature. He does superficially reference the article on ‘Circumcision’ in The Jewish Encyclopedia, which describes in detail the actual steps involved in brit milah versus brit periah. Despite this general allusion, though, he hardly discusses the matter further, as though the distinction were practically irrelevant. It does have fundamental import, however. Milah is merely a token clip of the very tip (the overhang flap or akroposthion) of the prepuce, which leaves most of the organ system (including all its essential functions) intact. This was evidently the version practiced in biblical times under the old Abrahamic–Mosaic covenant, before the Talmudic guardians of Judaic ethnic and religious identity proposed (around 150 AD) a means to prevent Hellinising Jewish men from attempting foreskin restoration by stretching their remaining preputial tissue forward. The rabbis mandated the replacement of milah with the more drastic procedure of periah, a radical surgery that cuts and tears from the penis its entire covering, leaving the glans irreversibly denuded. Unlike traditional milah, the innovation of periah necessarily has significant adverse consequences. … Despite the distinctions throughout his paper between ‘rights’ and mere ‘interests’ that can be trumped by parental authority, Mazor cannot circumvent the hard reality of the integral role of the prepuce in normal sexual functioning. Speculative gestures at hazily-considered ‘levels’ of ‘expected pleasure’ (averaged across whole populations of men) fall flat in the face of what is actually known about the foreskin, including its protective, erogenous and functional-mechanical properties. Any parental decision to remove this structure in its healthy state risks numerous adverse consequences for the child—if not by organic harm as an infant, then as a man suffering from iatrogenic sexual dysfunction. <h3>6. Commentary on Mazor (2): David Benatar, Evaluations of circumcision should be circumscribed by the evidence</h3> Benatar objects to Mazor’s analysis and conclusions on the grounds that he exaggerates the harm of circumcision with respect to sexuality and sexual functioning, and underestimates the potential benefits, particularly the evidence from Africa that it may reduce the risk of contracting HIV during unprotected intercourse with an infected female partner. He concludes: “The new evidence does not warrant a stronger conclusion—that parents ought to circumcise their sons or that routine neonatal circumcision should be recommended—but it certainly provides parents with further evidence for counting protection against HIV as a benefit of circumcision. Dr Mazor is correct that we need to attend to such benefits and not dismiss them by appealing to the rights of a child. If circumcision is a net benefit to a child, parents do not violate his rights to bodily integrity or self-determination by circumcising him. Careful attention to (the evidence for) the costs and benefits of circumcision to the child himself is thus essential.” <h3>7. J. Steven Svoboda and Robert Van Howe, Out of step: Fatal flaws in the latest AAP policy report on neonatal circumcision</h3> ABSTRACT The American Academy of Pediatrics recently released a policy statement and technical report on circumcision, in both of which the organisation suggests that the health benefits conferred by the surgical removal of the foreskin in infancy definitively outweigh the risks and complications associated with the procedure. While these new documents do not positively recommend neonatal circumcision, they do paradoxically conclude that its purported benefits ‘justify access to this procedure for families who choose it,’ claiming that whenever and for whatever reason it is performed, it should be covered by government health insurance. The policy statement and technical report suffer from several troubling deficiencies, ultimately undermining their credibility. These deficiencies include the exclusion of important topics and discussions, an incomplete and apparently partisan excursion through the medical literature, improper analysis of the available information, poorly documented and often inaccurate presentation of relevant findings, and conclusions that are not supported by the evidence given. <h3>8. Douglas Diekema, The AAP Task Force on Neonatal Circumcision: a call for respectful dialogue [Reply to Svoboda and Van Howe]</h3> The AAP Task Force was invited to reply to this critique, but ignored the substantive criticisms raised here (as well in the <a href="http://pediatrics.aappublications.org/content/early/2013/03/12/peds.2012-2896">letter from European, British and Canadian paediatricians</a>), and confined itself to complaints about being misunderstood and demands for greater respect. To be fair, it must be said that the AAP’s 2010 policy statement does not recommend circumcision, and might well have been announced with the headline: “Circumcision not recommended: AAP policy statement”. A short extract from the full reply follows. The American Academy of Pediatrics (AAP) Task Force on Circumcision published its policy statement and technical report on newborn circumcision in September 2012. Since that time, some individuals and groups have voiced objections to the work of the Task Force, while others have conveyed their support. The AAP task force is pleased that the policy statement and technical reports on circumcision have stimulated debate on this topic and welcomes respectful discussion and dialogue about the scientific and ethical issues that surround neonatal circumcision. We believe this is a complex issue that does not lend itself to simplistic solutions. The Task Force encourages those of all viewpoints to contribute to a vibrant, thoughtful and respectful evidence-based dialogue. We appreciate that the free exchange of competing ideas is a necessary component of scientific discovery. We also recognise that all clinical decisions carry ethical dimensions and that a respectful and thoughtful dialogue about these issues is important. However, the Task Force also feels strongly that this debate and the academic literature are demeaned when those with an ideological agenda disseminate inaccurate information, misapply scientific principles, make accusations that are unsupported, communicate in a vitriolic tone, and attempt to discredit and mischaracterise alternative views and those who hold them. <h3>9. Reinhard Merkel and Holm Putzke, After Cologne: male circumcision and the law. Parental right, religious liberty or criminal assault?</h3> ABSTRACT Non-therapeutic circumcision violates boys’ right to bodily integrity as well as to self-determination. There is neither any verifiable medical advantage connected with the intervention nor is it painless nor without significant risks. Possible negative consequences for the psychosexual development of circumcised boys (due to substantial loss of highly erogenous tissue) have not yet been sufficiently explored, but appear to ensue in a significant number of cases. According to standard legal criteria, these considerations would normally entail that the operation be deemed an ‘impermissible risk’ — neither justifiable on grounds of parental rights nor of religious liberty: as with any other freedom right, these end where another person’s body begins. Nevertheless, after a resounding decision by a Cologne district court that non-therapeutic circumcision constitutes bodily assault, the German legislature responded by enacting a new statute expressly designed to permit male circumcision even outside of medical settings. We first criticise the normative foundations upon which such a legal concession seems to rest, and then analyse two major flaws in the new German law which we consider emblematic of the difficulty that any legal attempt to protect medically irrelevant genital cutting is bound to face. <h3>10. Matthew Johnson, Religious circumcision, invasive rites, neutrality and equality: Bearing the burdens and consequences of belief</h3> ABSTRACT The decision of the German regional court in Cologne on 26 June 2012 to prohibit the circumcision of minors is important insofar as it recognises the qualitative similarities between the practice and other prohibited invasive rites, such as female genital cutting. However, recognition of similarity poses serious questions with regard to liberal public policy, specifically with regard to the exceptionalist treatment demanded by certain circumcising groups. In this paper, I seek to advance egalitarian means of dealing with invasive rites which take seriously cultural diversity, minimise harm and place responsibility for the burdens and consequences of beliefs upon those who promote practices. <h3>11. Dena Davis, Ancient rites and new laws: how should we regulate religious circumcision of minors?</h3> ABSTRACT The ancient practice of metzitzah b’peh, direct oral suction, is still practiced by ultra-Orthodox Jews as part of the religious rite of male newborn circumcision. Between 2000 and 2011, 11 children have died in New York and New Jersey, following infection by herpes simplex virus, presumably from infected practitioners. The City responded by requiring signed parental consent before oral suction, with parents being warned of the dangers of the practice. This essay argues that informed consent is not an appropriate response to this problem. An outright ban would a better response to a practice that is dangerous to children, but might prove unconstitutional under New York State law. <h3>12. Hanoch Ben Yami, Circumcision: What should be done?</h3> ABSTRACT I explain why I think that considerations regarding the opposing rights involved in the practice of circumcision—rights of the individual to bodily integrity and rights of the community to practice its religion—would not help us decide on the desirable policy towards this controversial practice. I then suggest a few measures that are not in conflict with either religious or community rights but that can both reduce the harm that circumcision as currently practiced involves and bring about a change in attitude towards the practice, thus further reducing its frequency. These measures are the compulsory administration of anaesthetics; the banning of the metzitzah b’peh; and having an upper age limit of a few months on non-therapeutic circumcision of minors. I conclude with general considerations on why the steps taken towards the reform of circumcision should be moderate. <h3>13. Robert Darby, The child’s right to an open future: Is the principle applicable to non-therapeutic circumcision?</h3> ABSTRACT The principle of the child’s right to an open future was first proposed by the legal philosopher Joel Feinberg and developed further by bioethicist Dena Davis. The principle holds that children possess a unique class of rights called rights in trust—rights that they cannot yet exercise, but which they will be able to exercise when they reach maturity. Parents should not, therefore, take actions that permanently foreclose on or pre-empt the future options of their children, but leave them the greatest possible scope for exercising personal life choices in adulthood. Davis particularly applies the principle to genetic counselling, arguing that parents should not take deliberate steps to create physically abnormal children, and to religion, arguing that while parents are entitled to bring their children up in accordance with their own values, they are not entitled to inflict physical or mental harm, neither by omission nor commission. In this paper, I aim to elucidate the open future principle, and consider whether it is applicable to non-therapeutic circumcision of boys, whether performed for cultural/religious or for prophylactic/health reasons. I argue that the principle is highly applicable to non-therapeutic circumcision, and conclude that non-therapeutic circumcision would be a violation of the child’s right to an open future, and thus objectionable from both an ethical and a human rights perspective. <h3>14. J. Steven Svoboda, Circumcision of male infants as a human rights violation</h3> ABSTRACT Every infant has a right to bodily integrity. Removing healthy tissue from an infant is only permissible if there is an immediate medical indication. In the case of infant male circumcision there is no evidence of an immediate need to perform the procedure. As a German court recently held, any benefit to circumcision can be obtained by delaying the procedure until the male is old enough to give his own fully informed consent. With the option of delaying circumcision providing all of the purported benefits, circumcising an infant is an unnecessary violation of his bodily integrity as well as an ethically invalid form of medical violence. Parental proxy ‘consent’ for newborn circumcision is invalid. Male circumcision also violates four core human rights documents—the Universal Declaration of Human Rights, the Convention on the Rights of the Child, the International Covenant on Civil and Political Rights, and the Convention Against Torture. Social norm theory predicts that once the circumcision rate falls below a critical value, the social norms that currently distort our perception of the practice will dissolve and rates will quickly fall. <h3>15. Robert S. Van Howe, Infant circumcision: The last stand for the dead dogma of parental (sovereignal) rights</h3> ABSTRACT John Stuart Mill used the term ‘dead dogma’ to describe a belief that has gone unquestioned for so long and to such a degree that people have little idea why they accept it or why they continue to believe it. When wives and children were considered chattel, it made sense for the head of a household to have a ‘sovereignal right’ to do as he wished with his property. Now that women and children are considered to have the full complement of human rights and slavery has been abolished, it is no longer acceptable for someone to have a ‘right’ to completely control the life of another human being. Revealingly, parental rights tend to be invoked only when parents want to do something that is arguably not in their child’s best interest. Infant male circumcision is a case in point. Instead of parental rights, I claim that parents have an obligation to protect their children’s rights as well as to preserve the future options of those children so far as possible. In this essay, it is argued that the notion that parents have a right to make decisions concerning their children’s bodies and minds—irrespective of the child’s best interests—is a dead dogma. The ramifications of this argument for the circumcision debate are then spelled out and discussed. Source: <a href="http://jme.bmj.com/">Journal of Medical Ethics, Vol 39 (7), July 2013</a> Abstracts available for free; full articles may be purchased or accessed through a subscribing library See also: <a href="https://www.circinfo.org/Circumcision_and_human_rights.html">Circumcision: A medical or a human rights question?</a> <h2>Is circumcision of male infants ethnically permissible? Further response to Mazor</h2> Following the special issue of the Journal of Medical Ethics special issue on circumcision, the Jewish film maker Eliyahu Ungar-Sargon has published a detailed, courteous but hard-hitting critique of the arguments advanced by Joseph Mazor. His conclusion is as follows: “While Dr Mazor’s argument at first glance appears to be somewhat compelling, upon closer examination it really falls apart. As I’ve sought to demonstrate above, he doesn’t actually prove that bodily integrity and self-determination are mere interests in the case of infant circumcision. Moreover, there are serious problems with the manner in which he weighs the various conflicting interests to arrive at his conclusions. Parenting is an ethical minefield and I’m willing to concede that under certain circumstances the child’s rights to bodily integrity and self-determination can be overridden. But nothing in Mazor’s argument convinces me that being born male is a sufficiently compelling circumstance to justify infant circumcision." ABSTRACT This is a response to Dr Joseph Mazor’s paper “The child’s interests and the case for the permissibility of male infant circumcision.” I argue that Dr Mazor fails to prove that bodily integrity and self-determination are mere interests as opposed to genuine rights in the case of infant male circumcision. Moreover, I cast doubt on the interest calculus that Dr Mazor employs to arrive at his conclusions about circumcision. Source: Eliyahu Ungar-Sargon. <a href="https://dx.doi.org/10.1136/medethics-2013-101598">On the impermissibility of infant male circumcision: A response to Mazor</a>. Journal of Medical Ethics, on-line first, 6 September 2013 </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 Circumcision under the spotlight in medical ethics journal 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>Circumcision violates child’s right to an open future</h3> A paper in the Journal of Medical Ethics (on-line first, January 2013) argues that non-therapeutic circumcision (is ethically objectionable and legally borderline because it violates a child’s right to an open future. This principle is widely accepted in ethical and legal circles and has often been applied to limit the power of parents to indoctrinate children into particular political beliefs or cultural identities. It has less often been applied to bodies rather than minds, and never previously to permanent bodily alterations such as circumcision. In this paper, the author (Dr Robert Darby) elucidates the open future principle and consider whether it is applicable to non-therapeutic circumcision of boys, whether performed for cultural/religious or for prophylactic/health reasons. He argues that the principle is highly applicable to non-therapeutic circumcision (NTC), and concludes that NTC would be a violation of the child’s right to an open future, and thus objectionable from both an ethical and a human rights perspective. Dr Darby suggests that NTC is similar to designer deafness (i.e. causing a child to suffer hearing loss) because it also results is sensory deprivation, and also that circumcision is comparable to smoking, in that it is really a bad habit that causes long term harm to the body. Preventing a child from smoking and protecting his foreskin have the same rationale: to preserve the body for future use and ensure that the future adult is able to make autonomous decisions about such intimate personal matters. ABSTRACT The principle of the child’s right to an open future was first proposed by the legal philosopher Joel Feinberg and developed further by bioethicist Dena Davis. The principle holds that children possess a unique class of rights called rights in trust – rights that they cannot yet exercise, but which they will be able to exercise when they reach maturity. Parents should not, therefore, take actions that permanently foreclose on or pre-empt the future options of their children, but leave them the greatest possible scope for exercising personal life choices in adulthood. Davis particularly applies the principle to genetic counselling, arguing that parents should not take deliberate steps to create physically abnormal children, and to religion, arguing that while parents are entitled to bring their children up in accordance with their own values, they are not entitled to inflict physical or mental harm, neither by omission nor commission. In this paper I aim to elucidate the open future principle and consider whether it is applicable to non-therapeutic circumcision of boys, whether performed for cultural/religious or for prophylactic/health reasons. I argue that the principle is highly applicable to non-therapeutic circumcision, and conclude that NTC would be a violation of the child’s right to an open future, and thus objectionable from both an ethical and a human rights perspective. The paper concludes: The child’s right to an open future complements the four principles of bioethics developed by <a href="https://en.wikipedia.org/wiki/Medical_ethics">Beauchamp and Childress</a> by meeting the objection that children cannot possess rights because they lack moral autonomy and the capacity to make rational choices. Children may lack such autonomy now, but as adults-to-be they will develop such autonomy in the normal course of their growth. It also supports and extends the <a href="http://www.cirp.org/library/ethics/hodges3/">argument of Hodges et al</a> that additional scrutiny is demanded when we make decisions about non-essential surgery on children, especially when it entails removal of functional body parts. One of the compelling features of the principle is its alignment with John Locke’s proposition that parental authority derives from their duty of care towards their children and is limited by the interests of the latter. Circumcision is analogous to smoking, eating junk food and not cleaning one’s teeth because it causes long term harm to the body and reduces its future functionality. Forcing children to brush their teeth or endure painful vaccinations, preventing them from smoking and protecting their foreskin all have the same rationale: to preserve the body for future use and ensure that the future adult is able to make autonomous decisions about such matters. The open future principle both constrains parents and gives them authority – constrains them from cutting off their children’s future options, but gives them the authority to prevent their children from recklessly doing the same. Source: Robert Darby. <a href="http://jme.bmj.com/content/early/2013/01/29/medethics-2012-101182.short?g=w_jme_ahead_tab">The child’s right to an open future: Is the principle applicable to non-therapeutic circumcision?</a> Journal of Medical Ethics, on-line first, 30 January 2013 <a href="https://www.circinfo.org/Journal_of_medical_ethics_July13.html">Journal of Medical Ethics, July 2013: Special issue on the ethics of male circumcision</a> <a href="https://www.circinfo.org/Circumcision_and_human_rights.html">Circumcision: A medical or a human rights question?</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 Circumcision violates the child's right to an open future 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>Male and female genital mutilation</h1> <h3>Is gender-neutral classification possible?</h3> Considering the similarities between the male and female genitals, the nature of the surgery, the justifications offered, and the support (in Western societies) for the principle that the genders should be treated equally, it may at first seem surprising that male and female circumcision enjoy such strikingly different reputations, at least in Anglophone countries. The first is regarded as a mild and harmless adjustment that should be tolerated, if not actively promoted, the second as a cruel abomination that must be stopped by law, no matter how culturally significant to its practitioners. Although the term “genital cutting” has been introduced in the hope of calming the debate, and while some culture-focused feminist critics have sought to “challenge western polemics,” [1] it is still generally true that not to call circumcision of women or girls female genital mutilation results in accusations of trivializing the offence, but to call circumcision of boys male genital mutilation is likely to elicit accusations of emotionalism, even by those who agree that routine circumcision of males is unnecessary and should generally not be performed. [2] <h2>WHO double standards</h2> While the World Health Organization (WHO), the United Nations and other international agencies devote substantial resources on programs to eradicate female genital cutting (FGC), they have been conspicuously silent about the circumcision of boys. Indeed, WHO shows acute schizophrenia on the issue, since it funds expensive programs to eradicate FGC while simultaneously funding even more expensive programs to promote and enforce male circumcision. For all the rhetoric about the science behind such programs, it is really no more than an expression of the nineteenth century assumption that circumcision of boys is health-giving while circumcision of girls or women in a mutilation. It was only in the current decade that male circumcision has been raised as a human rights issue at the United Nations, and to date no serious discussion of the topic has occurred, let alone any action. [3] Double standards reign. It might be thought that the reason for this double standard lies in the greater physical severity of FGC, but this is to confuse cause with effect. On the contrary, it is the tolerant or positive attitude toward male circumcision and the rarity of female circumcision in Western societies that promote the illusion that the operation is necessarily more sexually disabling, and without benefit to health, when performed on girls or women. A second reason for the double standard is that, while circumcision of males is mistakenly thought to designate a single surgical procedure, the term “female circumcision” is expansive, referring to any one or more of several different procedures. <h2>WHO classification of female genital mutilation</h2> These procedures have been defined by the WHO (1996) as follows: Type 1: Excision of the prepuce with or without excision of part or all of the clitoris; Type 2: Excision of the clitoris together with partial or total excision of the labia minora; Type 3: Excision of part or all of the external genitalia and stitching/narrowing of the vaginal opening (infibulation); Type 4: Unclassified (includes a wide variety of mutilations not falling into Types 1 through 3). This classification has been modified since 1996 but still retains the basic division into four types, as set out in a WHO “Fact Sheet” of May 2008: Female genital mutilation is classified into four major types: <ol> <li>Clitoridectomy: partial or total removal of the clitoris (a small, sensitive and erectile part of the female genitals) and, rarely, the prepuce (the fold of skin surrounding the clitoris) as well.</li> <li>Excision: partial or total removal of the clitoris and the labia minora, with or without excision of the labia majora (the labia are “the lips” that surround the vagina).</li> <li>Infibulation: narrowing of the vaginal opening through the creation of a covering seal. The seal is formed by cutting and repositioning the inner, and sometimes outer, labia, with or without removal of the clitoris.</li> <li>Other: all other harmful procedures to the female genitalia for non-medical purposes, e.g. pricking, piercing, incising, scraping and cauterizing the genital area.</li> </ol> <a href="http://www.who.int/mediacentre/factsheets/fs241/en/print.html" rel="noopener" target="_blank">See WHO Fact Sheet 241, May 2008</a> The severity of female circumcision depends on which of, as well as how crudely, these operations are performed, and it is true that the most extreme forms (involving the amputation of the external genitalia, with or without infibulation) are significantly worse than even the most radical foreskin amputation. But it should be remembered that the most extreme forms of female circumcision are comparatively rare, and that male circumcision in general is far more common on a world scale than female: about 13 million boys, compared with two million girls annually. [4] Quantity is not the whole story, but the vigorous efforts to protect the two million girls contrast sharply with the absence of interest in protecting the larger number of boys. <h2>Unpredictable effects of male circumcision</h2> But the effects of male genital cutting (MGC) are also highly unpredictable, depending on how much penile tissue is removed, on the skill of the surgeon, on the precise configuration of penile blood vessels and nerve networks, on the genetically determined length of the foreskin, and on the eventual size attained by the penis at puberty and maturity. The more tissue excised, the greater the damage to the penis and the greater the effect on sexual functioning and capability. Although equivalent quantities of tissue may be lost, outcomes will be worse in cases where the penis grows larger in maturity, where the infant or boy has only a short foreskin, or where the unpredictable locations of blood vessels and nerves mean that important connections are severed. Because the slack (“redundant”) surface tissue is needed to accommodate the enlarged penis when tumescent, a severe circumcision will render erections painful or even impossible. [5] A further common outcome among boys circumcised in infancy, especially when the operation excises a large quantity of penile shaft skin (as is the American norm, particularly when the Gomco clamp is used), is that scrotal skin gets pulled up onto the penis shaft as the wound heals, and even more when the penis enlarges at puberty. Such men often present both sebaceous glands and pubic hair on their penis, sometimes growing as far up as the line of the former frenulum. [6] <h2>Attempts to classify the types of male genital cutting</h2> Selecting appropriate terminology to discuss genital alteration may at first appear a straightforward task, but, while much effort has gone into categorizing the types of female genital alteration, surgeries on the penis are classified by a single term. Because MGC, even when non-therapeutic, is construed as harmless, there have been few efforts to provide male circumcision with a classification system similar to that constructed for female circumcision; yet in principle such a project should be no more difficult than devising a scale to measure damage to female genitals. Some attempts have already been made: <a href="http://www.boystoo.com/fgm&mgm.htm">Hanny Lightfoot-Klein</a> (1989) has set out the similarities, and Swiss/Palestinian authority Dr Sami Aldeeb has offered the following: Type 1: This type consists of cutting away in part or in totality the skin of the penis that extends beyond the glans. This skin is called foreskin or prepuce. Type 2: This type is practiced mainly by Jews. The circumciser takes a firm grip of the foreskin with his left hand. Having determined the amount to be removed, he clamps a shield on it to protect the glans from injury. The knife is then taken in the right hand and the foreskin is amputated with one sweep along the shield. This part of the operation is called the milah. It reveals the mucous membrane (inner lining of the foreskin), the edge of which is then grasped firmly between the thumbnail and index finger of each hand, and is torn down the center as far as the corona. This second part of the operation is called periah. It is traditionally performed by the circumciser with his sharpened fingernails. Type 3: This type involves completely peeling the skin of the penis and sometimes the skin of the scrotum and pubis. It existed (and probably continues to exist) among some tribes of South Arabia. Jacques Lantier describes a similar practice in black Africa, in the Namshi tribe. Type 4: This type consists in a slitting open of the urinary tube from the scrotum to the glans, creating in this way an opening that looks like the female vagina. Called subincision, this type of circumcision is still performed by some Australian aborigines. [7] Dr. Aldeeb deserves credit for venturing into terra incognita, but such a mixture of broad and specific categories fails to include the full range and variety of circumcision procedures, yet also identifies operations that are vanishingly rare. The vast majority of circumcision procedures today, especially those performed in hospitals and clinics, fall under none of these headings, while Types 3 and 4 are confined to a very few traditional (tribal) societies and are little more than anthropological curiosities. If the intention was to include all types of penile mutilation, mention should have been made of infibulation, piercing and the various “enhancements” found in southeast Asia. [8] <h3>Weaknesses of this typology</h3> The classification also leaves out the relatively mild forms of penile mutilation, such as slitting of the foreskin without excision of tissue, that are (or were) found in the Philippines [9] and certain Pacific islands, such as Samoa and Fiji. We write “were found” because as these procedures are medicalized (no longer performed as a traditional rite, but as minor surgery in a clinic by trained medical personnel), it is apparent that they are becoming more severe: no longer a mere dorsal slit, but a full-scale foreskin amputation on the United States model – that is, tearing or otherwise separating the foreskin from the glans, stretching it to a lesser or greater degree, and cutting roughly at the line of the corona. Although the setting may be more hygienic and complications such as bleeding and infection reduced, the effect of medicalization is a more damaging surgical outcome. In the developed world, the great diversity in surgical outcomes is the result of the differing techniques applied, the instruments used and the preferences of the surgeon or other operator. More seriously, Aldeeb’s classification neglects the vital fact that there is no precise definition of the foreskin and thus no precise definition of what is removed by MGC. The foreskin is not a discrete organ like a finger or pancreas, but a double-layered extension of the surface tissue of the penis; where the foreskin starts and the rest of the penis ends is a matter for judgment. The foreskin is generally described as a cap that fits over the glans, but the foreskin often extends beyond the glans (always in juveniles), and the point at which the doubling of the tissue begins can be anywhere along the penis shaft and shifts according to the degree of tumescence. On average, the doubling of tissue begins well beyond the corona of the glans, as the position of the circumcision scar on cut men (usually seen at about half an inch to an inch below the glans) testifies. Moreover, the length of the foreskin varies enormously from one individual to another, meaning that the same “standard” cut will be more severe on a boy with a short foreskin than on one who had more tissue to begin with. Since the severity and harm of the surgery depends primarily on how much of the loose penile tissue is removed, and whether it is mainly the outer (skin) layer or the inner (mucous membrane) layer, MGC Types 1 and 2 listed above can easily be broken down into an indefinite number of divisions (10, 20, 30 per cent, etc., of the foreskin), with both the visible damage and the impact on sexual sensation and sexual function increasing at each step. The severity of the operation is also affected by whether it removes the frenulum, the sensitive “bridle” on the underside of the penis, adjoining the cleft in the glans. This is now known as the frenular delta and is understood to support one of the body’s densest concentrations of fine-touch nerve receptors, whose specific function is to detect and transmit pleasurable touch. [10]Because the ridged band is also uniquely ridged or corrugated, retraction and stretching of this accordion-like structure may play an important role in penile reflexes, including urination, erection, and ejaculation. [11] Where the foreskin is still adherent, as it is in nearly all infants and commonly in boys up to the age of about eight, forcibly tearing it from the glans adds a further dimension of both pain and injury (including skin bridges and adhesions). The damage often extends to the parts of the penis that remain, and the pain is severe. [12] Nor is it just a matter of losing nerve endings: the destruction of the sliding mechanism of the foreskin back and forth over the glans, and thus of the stimulation and lubrication it affords, is another serious effect of MGC. Yet it is a harm that cannot be picked up by the sort of “sensitivity studies” that have appeared in the wake of Masters and Johnson’s much cited but deeply flawed study (1966). [13] <h2>A new classification of male genital cutting</h2> In order to assist the development of an objective measuring stick for MGC damage we suggest the following provisional five-point scale: Type 1: A nick to or slitting of the foreskin; or premature or forcible separation of the prepuce from the glans, without amputation of tissue. Type 2: Amputation of the portion of the foreskin extending beyond the glans. Type 3: Amputation of the foreskin at a point partway along the glans; some foreskin and all of the frenulum left; some sliding functionality retained. Type 4: Amputation of the foreskin at or below the corona of the glans. Type 5: Other forms of penis mutilation, including meatotomy, subincision, infibulation, piercing and implants. Type 2 corresponds to the original Judaic operation of bris (before the institution of periah — tearing the foreskin from the glans — in the Hellenic period) [14] ; most of the foreskin and all of the frenulum left; a fair degree of sliding functionality retained. When this procedure is performed after infancy, after separation of prepuce from glans, more of the preputial tissue and some of the frenular tissue tends to be cut. Because there is no agreed understanding of circumcision and the results are highly variable, depending on the quantity of tissue removed, the degree to which the foreskin is stretched during the operation, and the instruments used, it is useful to break Type 4 into three subtypes. Type 4A: Amputation of the foreskin at the corona of the glans, leaving glans fully exposed, but retaining frenulum; little or no sliding functionality; frenular nerves retained. Type 4B: Amputation of the foreskin at the corona of the glans, also excising frenulum; little or no sliding functionality; no frenular nerves left. Type 4C: Amputation of the foreskin beyond the corona of the glans, at any point along the penis shaft; all foreskin and variable quantities of shaft skin excised; all frenular nerves lost; zero sliding functionality; high risk of insufficient slack tissue for accommodating tumescence. It would be interesting to know the proportion of MGC operations falling into each of these categories. The vast majority would probably be the most severe, Type 4, and possibly Types 4B and 4C, particularly in the United States, where the ‘high and tight’ look is favored by the obstetricians and urologists who perform most of the procedures, and whose preference is facilitated by the infamous Gomco clamp, a device that ensures maximum loss of tissue, as well as a slow and painful operation. [15] <h2>Conclusion</h2> With respect to FGC, it is also possible to break the WHO’s definition down more precisely into at least seven procedures: a nick to the clitoris; separation of the clitoral hood or prepuce, without amputation of tissue; removal of the clitoral hood; excision of part or all of the labia minora; excision of part or all of the labia majora; excision of part or all of the clitoris; stitching up the vaginal orifice. The main difference between female and male genital cutting can now be seen to consist in the fact that the severity of FGC increases as the number of procedures rises, thus bringing more parts of the genitals under the knife; while the severity of MGC primarily depends on how much of a single element of the genitals is amputated. It is the variety of the procedures constituting FGC, in contrast with the unitary nature of MGC, which promotes the illusion that the first is a cruel and injurious form of torture called mutilation, while the second is a mild surgical adjustment called circumcision. <h2>References</h2> 1. Stanlie M. James and Claire C. Robertson, eds., Genital Cutting and Transnational Sisterhood: Disputing U.S. Polemics (Chicago: University of Illinois Press, 2002). 2. Robert Nye, “Review of Robert Darby, A Surgical Temptation,” Journal of the American Medical Association 294 (7 Dec. 2005):2771–2772 3. See J. Steven Svoboda, “Male Circumcision,” Paper submitted to the Sub-Commission for the Promotion and Protection of Human Rights, August 9, 2001, United Nations Document No. E/CN.4/Sub.2/2002/1 (March 23, 2002); and “Educating the United Nations about Male Circumcision,” in Flesh and Blood: Perspectives on the Problem of Circumcision in Contemporary Society, ed. G. C. Denniston, M. F. Milos, and F. M. Hodges (New York: Kluwer Academic/Plenum Publishers, 2004). 4. George C. Denniston, Frederick Hodges, and Marilyn Milos, eds., Understanding Circumcision: A Multi-disciplinary Approach to a Multi-dimensional Problem (London: Kluwer Academic/Plenum Press, 2001), p. v. Since accurate statistics on circumcision are not kept, these figures are the roughest of estimates, though it can be said that the vast majority of these boys are from Muslim families, most of whom probably undergo the operation between the ages of four and eight. 5. J. G. Boyle, R. Goldman, and J. Steven Svoboda, “<a href="http://www.cirp.org/library/psych/boyle6/">Male Circumcision: Pain, Trauma and Psychosexual Sequelae</a>,” Journal of Health Psychology 7: 3 (2002):329–343; Tim Hammond, “<a href="http://www.noharmm.org/bju.htm">A Preliminary Poll of Men Circumcised in Infancy or Childhood</a>,” BJU International 83 (Suppl. 1, January 1999):85–92; Shane Peterson. “<a href="http://www.historyofcircumcision.net/index.php?option=com_content&task=view&id=93&Itemid=50">Assaulted and Mutilated: A Personal Account of Circumcision Trauma</a>,” in Denniston, Hodges, and Milos (eds), op. cit., pp. 271–290; John Warren, et al, “<a href="https://www.circinfo.org/account.html#british">Circumcision of Children</a>,” British Medical Journal 312 (1996):37; N. Williams and L. Kapila, “<a href="http://www.cirp.org/library/complications/williams-kapila/">Complications of Circumcision</a>,” British Journal of Surgery 80 (1993):1231–1236. 6. Such men experience further discomfort with erections and find particular difficulty using condoms. The hair can also inflict abrasion and discomfort on sexual partners. For graphic illustrations of just how much damage routinely circumcised penises commonly sustain, and how different they look from uncircumcised penises, see the images of <a href="http://www.circumstitions.com/Botched1.html">damage</a> and <a href="http://www.circumstitions.com/comparison.html">difference</a> at Circumstitions. If a man presented at his GP with these sorts of injuries – scarring, granulated tissue, skin bridges where raw tissue surfaces have fused, distortion – on any part of his body other than his penis, he would be referred, urgently, to a plastic surgeon. But so normal are these results that many of the images have been taken from pornographic magazines and personal ads on sexual contact websites. See C.J. Cold and J. R. Taylor, “<a href="http://www.cirp.org/library/anatomy/cold-taylor/">The Prepuce</a>,” BJU International 83 (Suppl. 1, January 1999):34–44; John Money and Jackie Davison, “<a href="http://www.cirp.org/library/complications/money/">Adult Penile Circumcision: Erotosexual and Cosmetic Sequelae</a>,” Journal of Sex Research 19 (1983):289–292; J. R. Taylor, A. P. Lockwood, and A. J. Taylor, “<a href="http://www.cirp.org/library/anatomy/taylor/">The Prepuce: Specialized Mucosa of the Penis and Its Loss to Circumcision</a>,” British Journal of Urology 7 (1996):291–295; G. Zwang, “Functional and Erotic Consequences of Sexual Mutilations,” in Sexual Mutilations: A Human Tragedy, eds. G. C. Denniston and M.F. Milos (New York: PlenumPress,1997). 7. Sami A. Aldeeb Abu-Sahlieh, Male and Female Circumcision among Jews, Christians and Muslims: Religious, Medical, Social and Legal Debate (Warren, PA: Shangri-La Publications, 2001), p. 9;<a href="http://www.fgmnetwork.org/authors/samialdeeb/"> full text available from FGM Network</a>; Sami A. Aldeeb Abu-Sahlieh, “Male and Female Circumcision: The Myth of the Difference,” in Rogaia Mustafa Abusharaf (ed.) Female Circumcision: Multicultural Perspectives. (Philadelphia: University of Pennsylvania Press, 2006), pp. 60-61. 8. See Terence Hull and Meiwita Budiharsana, “Male Circumcision and Penis Enhancement in Southeast Asia: Matters of Pain and Pleasure,” Reproductive Health Matters 9 (2001):60-67. It is an interesting sidelight on Anglophone attitudes that while anthropologists have devoted much time and ink to the origins and meaning of genital cutting rites, they have neglected the equally (and possibly more) numerous societies that practiced various forms of foreskin elongation or otherwise sought to conceal rather than uncover the glans – anything from the penis sheaths and gourds of New Guinea and Melanesia to the infibulation of slaves in classical Rome and the modesty-preserving kynodesme in ancient Greece. See Eric Dingwall, Male Infibulation (London: John Bale, 1925); and Frederick Hodges, “The Ideal Prepuce in Ancient Greece and Rome: Male Genital Aesthetics and their Relation to Lipodermos, Circumcision, Foreskin Restoration and the Kinodesme,” <a href="http://www.cirp.org/library/history/hodges2/">Bulletin of the History of Medicine</a> 75 (2001): 375-405. 9. Romeo B. Lee “Filipino Experience of Ritual Male Circumcision: Knowledge and Insights for Anti-circumcision Advocacy.” Culture, Health & Sexuality 8:3 (2006): 225–234. 10. See C. J. Cold and J. R. Taylor, “<a href="http://www.cirp.org/library/anatomy/cold-taylor/">The Prepuce</a>,” BJU International 83 (Suppl. 1, January 1999); Ken McGrath, “The Frenular Delta: A New Preputial Structure,” in Denniston, Hodges, and Milos, eds. Understanding Circumcision, op. cit., 199-206; and J. R. Taylor, A. P. Lockwood, and A. J. Taylor, “<a href="http://www.cirp.org/library/anatomy/taylor/">The Prepuce: Specialized Mucosa of the Penis and Its Loss to Circumcision</a>.” British Journal of Urology 7 (1996):291–295. 11. See J. R.Taylor, “The Forgotten Foreskin and its Ridged Band.” Journal of Sexual Medicine 4 (2007):1516. 12. See A. Taddio, J. Katz, A. L. Ilersich, and G. Koren. “<a href="http://www.cirp.org/library/pain/taddio2/">Effect of Neonatal Circumcision on Pain Response during Subsequent Routine Vaccination</a>.” Lancet 1997 349:9052: 599–603. 13. For critiques of Masters and Johnson, see John M.Foley, The Practice of Circumcision: A Revaluation (New York: Materia Medica, 1966); Frederick Hodges and Paul Fleiss, “Letter,” Pediatrics 105:3, Part 1 (2000):683–684; <a href="https://www.circinfo.org/quote.html">available on Quotes page</a>; M. L. Sorrells, J. L. Snyder, M. D. Reiss, et al., “<a href="http://www.cirp.org/library/anatomy/sorrells_2007/">Fine-Touch Pressure Thresholds in the Adult Penis</a>,” BJU International 99 (2007):864–869, and the incisive deconstruction by Hugh Young, <a href="http://www.circumstitions.com/Sexuality.html">The Foreskin, Circumcision and Sexuality</a>. 14. See Leonard Glick, Marked in Your Flesh: Circumcision from Ancient Judea to Modern America (New York: Oxford University Press, 2005), p. 31 & pp. 43–45. 15. See Leonard Glick, Marked in Your Flesh, op. cit., 196–197; R. L. Miller and D.C. Snyder, “Immediate Circumcision of the Newborn Male,” American Journal of Obstetrics and Gynaecology 65 (1953):1–11; and Julian Wan, “Gomco Circumcision Clamp: An Enduring and Unexpected Success.” Urology 59 (2002):790–794. <a href="http://www.historyofcircumcision.net/index.php?option=com_content&task=view&id=43&Itemid=52">Further information on Gomco clamp</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 Classification of male and female genital mutilation 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>Editorial, Medical Times and Gazette, 13 April 1867</h2> <h2>Background</h2> Although this is one of the most hypocritical documents in British medical history, its is also one of the most useful for illuminating the origins and nature of the double standard on male and female genital mutilation which persists to this day in English speaking countries. While it seeks to quarantine "mere circumcision" from real mutilation, it nonetheless makes a cogent and powerful case against any form of genital alteration which is performed without informed consent. The editorial was a response to the disgrace of Isaac Baker Brown, a prominent gynaecologist and dextrous surgeon who had made a name for himself as an authority on the female genitals, and the advocate of a procedure intended (guaranteed!) to cure many obscure nervous diseases â€“ clitoridectomy. Brown claimed that conditions such as hysteria, epilepsy and catalepsy, as well as the masturbation which gave rise to them, could be prevented by the excision of the clitoris, and he insisted that he was merely following the lead of surgeons such as Jonathan Hutchinson, who had similarly asserted that masturbation in boys could be stopped by amputation of the foreskin. We should particularly note Brown's insistence that clitoridectomy is neither more nor less than circumcision of the female; and as certainly as that no man who has been circumcised has been injured in his natural functions, so it is equally certain that no woman who has undergone the operation of excision of the clitoris has lost one particle of the natural functions of her organs. In his genius for self-promotion, as well as in his conviction that he had found the magic bullet for the most intractable diseases of his age, he might be regarded as the Roger Short of the mid-nineteenth century. During the early 1860s Brown enjoyed considerable celebrity, but his methods came under attack in 1866, and the following year he was disgraced and expelled from the Obstetrical Society. In this editorial the Medical Times and Gazette explains why clitoridectomy is both scientifically unsound as medical therapy and a violation of medical ethics in terms which are still relevant today. Although it tries to quarantine male circumcision from female genital mutilation in a manner all too familiar to us, its reasoning here is feeble and the discrimination fails. The foreskin is also "an organ of exquisite sensitiveness, well supplied with blood vessels and nerves"; like clitoridectomy, circumcision is also an operation "occasionally attended with serious bleeding".* On the principle stated here â€“ that sensitive organs, well supplied with blood vessels and nerves should not be excised without the informed consent of their owner â€“ the editorial may be read as an attack on both clitoridectomy and circumcision, and a clear statement of why each procedure is an offence against both medical science and medical ethics. * Indeed, while there are numerous reports in nineteenth century medical journals of deaths and complications from circumcision, similar reports on clitoridectomy are very hard to find, suggesting that the latter was in fact the safer operation. <h4>Further reading:</h4> J.B. Fleming, "Clitoridectomy: The disastrous downfall of Isaac Baker Brown FRCS (1867)", Journal of Obstetrics and Gynaecology of the British Empire, Vol. 67, 1960, pp. 1017-34 Ornella Moscucci, "Clitoridectomy, circumcision and the politics of sexual pleasure in mid-Victorian Britain", in Andrew H. Miller and James Eli Adams (eds), Sexualities in Victorian Britain, Bloomington, Indiana University Press, 1996 Robert T. Morris, "Is evolution trying to do away with the clitoris?", Transactions of the American Association of Obstetricians and Gynaecologists, Vol. 5, 1892, pp. 288-30 <a href="http://www.cirp.org/library/ethics/" rel="noopener" target="_blank">CIRP ethics and human rights pages</a> Margaret Somerville, "<a href="http://www.intact.ca/canary.htm" rel="noopener" target="_blank">Altering baby boys' bodies: The ethics of infant male circumcision</a>" <h3>Clitoridectomy and Medical Ethics</h3> Medical Times and Gazette Saturday, April 13, 1867 THE operation of clitoridectomy, as performed under the conditions described in Mr. Baker Brown's writings and denounced in Dr. West's lectures, is an offence against Medical science and Medical ethics. 1. It is an offence against Medical science in the first place, that it should be described as a mere circumcision. (Note a) Instead of taking away a loose fold of skin, it removes a rudimentary organ of exquisite sensitiveness, well supplied with blood vessels and nerves, and the operation is described by the author as occasionally attended with serious bleeding ; in these respects it differs widely from circumcision. It is a second error to assume that if a woman desired to continue filthy habits this operation would stop her. The organ removed is but one amongst many susceptible of intense excitement. (Note b) In the third place, it is against all Medical science to remove such a part because "subject" (or subjected?â€”see note) "to unbearable irritation." Intense itching is a common malady, but this itching does not depend on local causes, and it may generally be relieved by proper measures. To cut off part of the body because it itches is monstrous. If indeed the clitoris be diseased, that is another thing ; but as clitoridectomy is practised, the part is cut off without any signs of disease in it. It is nothing to the purpose to affirm that clitoridectomy may have been successful in postponing epileptic fits or lengthening their interval. Any positive line of treatment will do that for a time. Many young men believe for three months that they have found a specific for epilepsy. An intimate friend lately thought he had found one in colchinum. Give enough of any potent drug to make the patient ill, break a leg, or cut off the clitoris, and the fits will probably be interrupted for a time. Neither is it to the purpose to accuse Mr. Brown of having performed an operation rashly, groundlessly, and unsuccessfully Many such operations have been performed in the best faith. Marshall Hall used to propose tracheotomy for epilepsy ; a living Surgeon once performed castration for the same malady ; each operation thoroughly unsuccessful, and not to be defended, save on the ground of the good faith of the proposers, and of an enthusiasm which had carried them beyond the bounds of sound discretion. Although, then, clitoridectomy must be condemned as an offence against Medical science, if that were all, it might let pass into oblivion without further notice. It is the offence against Medical ethics which it involves, which has secured for it the reprobation of the Profession. 2. It is an ethical offence, in the first place, if the Practitioner who is consulted for any common complaint, say hysteria, or fissure of the rectum, set himself to consider whether or not the patient is guilty of immoral practices, which have nothing to do with the case before him. Thus, as we said in our last number, and as we implied in the Med. Times and Gaz. June 4, 1864, if the clitoridectoral theory and practice were established, no parent who sent a daughter to any Medical man for any complaint whatever, could be sure that she might not return tainted with filthy inquiries, or branded by filthy suspicionsâ€”a thing incompatible with the honour of the Profession, and the possibility of that unrestrained frank intercourse between Practitioner and patient that happily exists now. As an illustration of this kind of breach of Professional honour and its consequences, we will mention a case which was shortly touched on in our first article in the number for June 4, 1864. A young lady was brought by her friends,* ten or twelve years ago, to a Surgeon practising specially on the rectum, for a fistula. He did not content himself with exploring the fistula, but ascertained that she had lost her virginity, and told her father so. The consequences were frightful, including a painful trial, and loss of honour, character, and position to the parties concerned. All this, because the Surgeon had gone out of the path of his duty, and, instead, of confining himself to the malady for which he was consulted, had gratuitously imported into it certain moral considerations with which he had nothing to do. If this were a habit with Medical men, there would be an end to the present free an honourable intercourse with their patients. We should be accused, and justly, of making prurient, or indecent, or degrading inquiries, and of bringing a knowledge of evil to minds from which it had been absent. Affirming then, in the first place, that the very entry of thoughts of pollution into the Practitioner's mind respecting his patients is an offence of the deepest dye, this offence is aggravated by the kind of evidence which the clitoridectomist is taught to accept as proof of his patient's guilt. That evidence consists, partly, in certain physical signs detailed in Mr. Baker Brown's bookâ€”a "peculiar straight and coarse hirsute growth," a peculiar follicular secretion, and other phenomena detected by inspection, which are as frivolous as they are disgusting. It is said by credible witnesses, that at a clitoridectomical operation nose as well as eyes were called into requisition, and that a respectable Practitioner was invited to apply his nose to the parts implicated, in order to satisfy his mind, by this test, that these parts had been subjected to abnormal irritation. The thing is almost too beastly to tell of, but we want to deal with this subject once for all, and to let our readers know why clitoridectomy does not stand in the same category as any other unsuccessful operation. But says Mr. Brown, "before commencing treatment, I have always made a point of having my diagnosis confirmed by the patient or her friends." And this brings us to what we may call the moral evidence on which the patient's guilt is assumed, the process of obtaining which is one of the most heinous offences against good sense and Professional ethics that can be conceived. We have heard of questions put (not by Mr. Brown) to female out-patients after the following fashion:â€”"Do you feel any irritation in certain organs?" "Is it very bad?" "Does it induce you to rub them?" "Does the rubbing ever make you feel faint?" And if the patient answers these questions affirmatively it is said that the evidence of unnaturally excitation is regarded as complete. Nervous young women, as it s well known, may be profoundly ignorant of the nature and drift of such questions. They delight to magnify their own sensations, they enjoy the Physician's sympathy and are sure to answer " yes " to any leading question whatever. But we say that if young women are subjected to such inquiries as these in out-patient rooms at Hospitals and Dispensaries, or by private Practitioners, the sooner the Profession speaks out the better. A Medical consultation may involve the worst contamination to the patient. We think we are justified in saying that the kind of evidence on which the guilt of the woman is assumed is itself an ethical offence. That the performance of clitoridectomy on a woman without her knowledge and consent, as detailed by Dr. West, is an offence against Medical ethics, needs not to be said. We suspect it is amenable to the criminal law of the land. It is an offence against Medical ethics, also, to obtain the woman's consent, nominally, while she is left in ignorance of the real scope and nature of the mutilation, and of the moral imputations which it involves. Consent to a thing whose nature is not known, is like the consent of an infant or lunaticâ€”null and void. Equally do we repudiate, as an offence against Medical ethics, the performance of such an operation, even with the consent, nominal or real, of the patient, but without the full knowledge and consent of the persons on whom she is dependent, as wife or daughter. As the woman's character affects theirs, they have a right to decide whether a female relative should undergo this operation, with the disgrace it involves, or whether relief shall be sought from other means. We may be pardoned for adding that not one of the supposititious cases alleged by Dr. Routh at the late meeting of the Obstetrical Society has the least bearing on or analogy with the performance of clitoridectomy without the knowledge of the patient or her friends. Dr. Routh argued that all the details of every operation cannot be described to patients. But it is not the detailsâ€”it is the moral questions involved in clitoridectomy, which ought not to be kept secret. Dr. Routh argued, also, that there are cases in which a Practitioner is bound to keep a patient's secrets from her husband ; but in cases before us, it is not secrets imparted by the patient, but dishonourable surmises and filthy imputations generated in the mind of the Practititionerâ€”the nature of the mutilation and its disgraceâ€”that are kept secret. Thus, then, we have shown, as shortly as possible, the real position of clitoridectomy as an offence against science and morality, and the reasons why the Medical Profession, as an honourable, moral Profession, whose members have free and familial access to families, must repudiate and utterly reject it. Note a: "Let it be known, once for all, that clitoridectomy is neither more nor less than circumcision of the female; and as certainly as that no man who has been circumcised has been injured in his natural functions, so it is equally certain that no woman who has undergone the operation of excision of the clitoris has lost one particle of the natural functions of her organs. I would here protest against the cruel insinuation made against me by my accusers, that my reasons for performing the operation are because women are subjected to immoral habits ; when, as I have distinctly again and again asserted, I operation because there is undue and unbearable irritation of the clitoris, and in such cases alone is the operation likely to be successful."â€” (Mr. Baker Brown's "Replies to the Remarks of the Council," Nos. 12 and 13.) Note B: For evidence, see Baker Brown on Curability, etc., pp. 12, 18, etc.** <h3>Notes</h3> * "Friends" means close relatives. ** Isaac Baker Brown, On the curability of certain forms of insanity, epilepsy, catalepsy and hysteria in females (London 1866) </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 Clitoridectomy and medical ethics darby