Non-therapeutic Circumcision Research Articles

Cultural background, non-therapeutic circumcision and the risk of meatal stenosis and other urethral stricture disease: Two nationwide register-based cohort studies in Denmark 1977–2013

BackgroundMeatal stenosis is markedly more common in circumcised than genitally intact males, affecting 5–20 per cent of circumcised boys. However, no population-based study has estimated the relative risk of meatal stenosis and other urethral stricture diseases (USDs) or the population attributable fraction (AFp) associated with non-therapeutic circumcision. MethodsIn two nationwide cohort studies (comprising 4.0 million males of all ages and 810 719 non-Muslim males aged 0–36 years, respectively), we compared hospital contact rates for USD during 1977–2013 between circumcised and intact Danish males. Hazard ratios (HRs) were obtained using Cox proportional hazards regression, and the AFp estimated the proportion of USD cases in <10 year-old boys that is due to non-therapeutic circumcision. ResultsMuslim males had higher rates of meatal stenosis than ethnic Danish males, particularly in <10 year-old boys (HR 3.44, 95 per cent confidence interval 2.42–4.88). HRs linking circumcision to meatal stenosis (10.3, 4.53–23.4) or other USDs (5.14, 3.48–7.60) were high, and attempts to reduce potential misclassification and confounding further strengthened the association, particularly in <10 year-old boys (meatal stenosis: 26.3, 9.37–73.9; other USDs: 14.0, 6.86–28.6). Conservative calculations revealed that at least 18, 41, 78, and 81 per cent of USD cases in <10 year-old boys from countries with circumcision prevalences as in Denmark, the United Kingdom, the United States and Israel, respectively, may be attributable to non-therapeutic circumcision. ConclusionOur study provides population-based epidemiological evidence that circumcision removes the natural protection against meatal stenosis and, possibly, other USDs as well.

Non-therapeutic infant male circumcision. Evidence, ethics, and international law perspectives.

Objectives:To review the evidence of the benefits and harms of infant male circumcision, and the legal and ethical perspectives of infant male circumcision.Methods:We conducted a systematic search of the literature using PubMed, EMBASE, and the Cochrane library up to June 2015. We searched the medical law literature using the Westlaw and Lexis Library law literature resources up to June 2015.Results:Male circumcision significantly reduced the risk of urinary tract infections by 87%. It also significantly reduced transmission of human immunodeficiency virus among circumcised men by 70%. Childhood and adolescent circumcision is associated with a 66% reduction in the risk of penile cancer. Circumcision was associated with 43% reduction of human papilloma virus infection, and 58% reduction in the risk of cervical cancer among women with circumcised partners compared with women with uncircumcised partners. Male infant circumcision reduced the risk of foreskin inflammation by 68%.Conclusion:Infant male circumcision should continue to be allowed all over the world, as long as it is approved by both parents, and performed in facilities that can provide appropriate sterilization, wound care, and anesthesia. Under these conditions, the benefits of infant male circumcision outweigh the rare and generally minor potential harms of the procedure.

Towards safer male infant circumcision: The health visitor's role

For many parents, male infant circumcision is an important part of their religious, cultural or family beliefs. However, non-therapeutic neonatal circumcision is no longer available via the NHS. Serious complications occur when circumcision is performed by unqualified, untrained or careless practitioners. Recognised and approved community-based circumcision services exist, but are unevenly distributed throughout the UK. Little information is available for parents to help them find good-quality private providers. Health visitors can play a vital role in seeing that interested parents understand the procedure and have all the information needed to access a safe and reliable service. This article gives an overview of the operation and offers guidance on how to access a proficient facility.

Foreskin Morbidity in Uncircumcised Males.

As a consequence of the discussion on whether the health benefits of newborn male circumcision outweigh the risks and the discrepancies in reported figures of complications, we evaluated the incidence and morbidity of foreskin surgery due to medical indications in boys from the Capital Region of Denmark in 2014. Medical records from all boys operated on the foreskin due to medical reasons in the Capital Region in 2014 were reviewed. Patients with hypospadias, ritual circumcision, and redo-surgery because of complications to nontherapeutic circumcision were excluded. A total of 181 patients were included. The cumulative risk of undergoing foreskin operation before 18 years of age was 1.7%. Forty patients had histologic verified balanitis xerotica obliterans (BXO) corresponding to a total risk of 0.37% of developing BXO. Mean age at surgery was 10.1 years (range 1-17). Phimosis was the most frequently reported indication (95.0%). The remaining 5.0% underwent surgery because of frenulum breve causing problems during erection. Before surgery, 27.1% had foreskin-related voiding problems and 17.1% had at least 1 episode of balanitis. Circumcision was initially performed in 44 cases. The remaining 137 patients had a foreskin-preserving operation performed. Nine boys had secondary circumcision after initially having foreskin-preserving operation. Fifty patients initially had preputial histology performed. BXO was verified in 37 patients. Of the 9 patients with redo-surgery due to recurrent phimosis, a further 3 had histologically verified BXO. Childhood foreskin-related problems in a region with no tradition of newborn male circumcision should not be neglected.

In defence of genital autonomy for children

Arora and Jacobs (2016) assume that liberal societies should tolerate non-therapeutic infant male circumcision, and argue that it follows from this that they should similarly tolerate—or even encourage—what the authors...

Between Moral Relativism and Moral Hypocrisy: Reframing the Debate on "FGM".

The spectrum of practices termed "Female Genital Mutilation" (or FGM) by the World Health Organization is sometimes held up as a counterexample to moral relativism. Those who advance this line of thought suggest the practices are so harmful in terms of their physical and emotional consequences, as well as so problematic in terms of their sexist or oppressive implications, that they provide sufficient, rational grounds for the assertion of a universal moral claim--namely, that all forms of FGM are wrong, regardless of the cultural context. However, others point to cultural bias and moral double standards on the part of those who espouse this argument, and have begun to question the received interpretation of the relevant empirical data on FGM as well. In this article I assess the merits of these competing perspectives. I argue that each of them involves valid moral concerns that should be taken seriously in order to move the discussion forward. In doing so, I draw on the biomedical "enhancement" literature in order to develop a novel ethical framework for evaluating FGM (and related interventions--such as female genital "cosmetic" surgery and nontherapeutic male circumcision) that takes into account the genuine harms that are at stake in these procedures, but which does not suffer from being based on cultural or moral double standards.

Helping parents achieve safer male infant circumcision

Non-therapeutic neonatal circumcision, whether for religious or cultural reasons, is generally not available via the NHS. Tragedies can occur with unqualified practitioners, and some health-care Trusts have cooperated with local communities to provide approved services. Unfortunately, these are unevenly distributed throughout the UK and most involve cost. Midwives are well placed to help interested parents understand the procedure and contact an acceptable provider. This article hopes to give midwives some knowledge of infant circumcision, its controversial nature, the pros and cons, the groups for whom it is important and the methods commonly used in the UK. Points are listed for patient discussion and suggestions made for examining websites. As with Scottish guidelines, were midwives to discuss neonatal circumcision with all parents in the antenatal period, it would give them time to consider the procedure and access a safe and reliable service.

Male circumcision debate has made progress

Gillam's assessment that the debate on non-therapeutic circumcision of boys has ‘gone round in circles’1 is too pessimistic. It is true that the statements of the Australian Paediatric Association in 1971 and the College of Paediatrics in 1983 were unequivocal in their rejection of circumcision and advised doctors actively to discourage the practice, but they were only brief, unsupported statements of opinion. The current (2010) policy of the RACP may contain reservations, but it is a far more detailed document that surveys the medical literature and reaches the evidence-based conclusion that there is no medical basis for routine circumcision in Australia. This conclusion has been endorsed by subsequent reviews of the literature.2 Unlike the old statements, moreover, the current policy pays due attention to bioethical and human rights issues and observes that the value of the foreskin and the likely future wishes of the boy are factors to be taken into account. It is in these areas – bioethics and human rights – that developments have been most dramatic. Forty years ago, scarcely anybody questioned the ethics of NTC, but since the passage of the UN Convention on the Rights of the Child (1989), there has been an upsurge of ethical analysis and the emergence of many contending viewpoints. Critics of circumcision stress the human rights of boys, draw parallels between circumcision and other forms of genital cutting (especially female genital mutilation)3 and question the propriety of doctors circumcising minors for cultural or religious reasons. Highlights since 2010 include a special issue of the Journal of Medical Ethics (July 2013), increased questioning of circumcision from Jewish4 and Muslim5 thinkers, and serious legal challenges to the practice. A report from the Tasmania Law Reform Institute (2012) concluded that the harms of non-therapeutic circumcision are great enough to warrant regulation and partial prohibition, while a senior British judge has stated that circumcision amounts to ‘significant harm’ and is more damaging than mild forms of FGM.6 On the other side of the fence, defenders of religious and culturally motivated circumcision stress tradition, parental rights and religious freedom. In view of these developments, it would seem that future debates about circumcision are likely to be less about the medical benefits than its ethical and legal status. As Gillam remarks, these arguments are sure to be with us for a long time yet.

Risks, benefits, complications and harms: neglected factors in the current debate on non-therapeutic circumcision.

Much of the contemporary debate about the propriety of non-therapeutic circumcision of male infants and boys revolves around the question of risks vs. With its headline conclusion that the benefits outweigh the risks, the current circumcision policy of the American Academy of Pediatrics [AAP] (released 2012) is a typical instance of this line of thought. Since the AAP states that it cannot assess the true incidence of complications, however, critics have pointed out that this conclusion is unwarranted. In this paper it is argued that the AAP's conclusion is untenable not only for empirical reasons related to lack of data, but also for logical and conceptual reasons: the concept of risk employed-risk of surgical complications-is too narrow to be useful in the circumcision debate. Complications are not the only harms of circumcision: the AAP and other parties debating the pros and cons of circumcision should conceptualize their analysis more broadly as risk of harm vs. prospect of benefit, thereby factoring in the value of the foreskin to the individual and the physical and ethical harms of removing it from a non-consenting child.

Infant male circumcision and the autonomy of the child: two ethical questions

Routine neonatal circumcision—the non-therapeutic circumcision of infant males—has generated considerable ethical controversy. In this article, I suggest that much of the disagreement results from conflicting ideas about the autonomy of...

Circumcision: Is it worth it for 21st-century Australian boys?

Circumcision: Is it worth it for 21st-century Australian boys?

Ritual circumcision and risk of autism spectrum disorder in 0- to 9-year-old boys: national cohort study in Denmark.

Based on converging observations in animal, clinical and ecological studies, we hypothesised a possible impact of ritual circumcision on the subsequent risk of autism spectrum disorder (ASD) in young boys. National, register-based cohort study. Denmark. A total of 342,877 boys born between 1994 and 2003 and followed in the age span 0-9 years between 1994 and 2013. Information about cohort members' ritual circumcisions, confounders and ASD outcomes, as well as two supplementary outcomes, hyperkinetic disorder and asthma, was obtained from national registers. Hazard ratios (HRs) with 95% confidence intervals (CIs) associated with foreskin status were obtained using Cox proportional hazards regression analyses. With a total of 4986 ASD cases, our study showed that regardless of cultural background circumcised boys were more likely than intact boys to develop ASD before age 10 years (HR = 1.46; 95% CI: 1.11-1.93). Risk was particularly high for infantile autism before age five years (HR = 2.06; 95% CI: 1.36-3.13). Circumcised boys in non-Muslim families were also more likely to develop hyperkinetic disorder (HR = 1.81; 95% CI: 1.11-2.96). Associations with asthma were consistently inconspicuous (HR = 0.96; 95% CI: 0.84-1.10). We confirmed our hypothesis that boys who undergo ritual circumcision may run a greater risk of developing ASD. This finding, and the unexpected observation of an increased risk of hyperactivity disorder among circumcised boys in non-Muslim families, need attention, particularly because data limitations most likely rendered our HR estimates conservative. Considering the widespread practice of non-therapeutic circumcision in infancy and childhood around the world, confirmatory studies should be given priority.

Circumcision of Infants and Children: Short-Term Trauma and Long-Term Psychosexual Harm

Non-therapeutic infant male circumcision is a permanent surgical alteration to the penis that may cause significant physical, sexual and psychological harm. Physical harms include unintended adverse effects of the surgery itself (e.g., complications such as bleeding, infection, excessive removal of foreskin leaving insufficient shaft skin to accommodate erections, etc.), as well as the inherent loss of healthy, functional tissue. Sexual harms that necessarily follow from circumcision include the loss of all sensation in the foreskin itself, and the loss of all sexual functions that involve the physical manipulation of the foreskin. Additional sexual harms that may follow circumcision include reduced sexual sensation in the remaining penile structures, difficulty with masturbation, increased chafing in both the circumcised man and his sexual partner, as well as reduced overall psychosexual/psychological tension relief and subjective satisfaction. Psychological harms include short-term trauma as well as the potential for long-term emotional disturbances, including sadness, frustration, distress, and anger—akin to post-traumatic stress disorder (PTSD). In this paper, the extent and severity of these various harms are considered and it is argued that they are more serious and more widespread than is commonly believed.

Can Culture Justify Infant Circumcision?

The paper addresses arguments in the recent philosophical and bioethical literature claiming that social and cultural benefits can justify non-therapeutic male infant circumcision. It rejects these claims by referring to the open future argument, according to which infant circumcision is morally unjustifiable because it violates the child’s right to an open future. The paper also addresses an important objection to the open future argument and examines the strength of the objection to refute the application of the argument to the circumcision case.

Evaluation of Non-Therapeutic Circumcision by Academic Medical Professionals

Evaluation of Non-Therapeutic Circumcision by Academic Medical Professionals Turgay Karatas, MD; Muharrem Ak, MD; Mehmet Karatas, MD; Mustafa Cakirca, MD Abstract In this study, our aim was to compare the current consensus circumcision approach with a survey given to academic medical professionals on circumcision to of male children in a country like Turkey with increased Muslim population. In Cologne district, Germany, a regional appellate court prohibited non-therapeutic circumcision on June 26, 2012. The court defined non-therapeutic circumcision as a violation of a child’s bodily integrity and a detriment to the child’s well-being. Moreover, the district court reported that circumcision done without stringent consent and is deemed a similar act to female genital mutilation. Non-therapeutic circumcision that is perfomed as a religiously, morally, or culturally motivated rite is not considered a bodily assault or psychologically traumatic act against a child. In addition, it is accepted as medically beneficial and is recommended by a high proportion of medical professionals in a survey that we conducted in Inonu University Medical Faculty in Turkey. According to this questionnaire, the percentage of medical professionals who believed that male circumcision is medically detrimental and medically safe was 2.1% (n:1) and 87.2% (n:41) respectively. Allowing non-therapeutic circumcision would have its benefits, including parental consent for families with the intent to decide on circumcision for religious, public, and moral motives. Legal prohibition of circumcision may prompt operations under inappropriate conditions, which might be destructive for children. Full Text: PDF DOI: 10.15640/ijhs.v2n4a2

The Universal Condition: Medical Constructions of ‘Congenital Phimosis in Twentieth Century New Zealand and their Implications for Child Rearing

‘Congenital phimosis was one of a number of pseudo-pathologies that entered mainstream medicine in the nineteenth century. In the twentieth century Truby King, Henry Jellett, and Eric Corkill advocated premature foreskin retraction as the first intervention to manage ‘congenital phimosis. If that failed they recommended circumcision, although eventually it became more expedient to use circumcision exclusively. The nineteenth-century justification for such interventions was to prevent masturbation, but by the middle of the twentieth century this was replaced by prevention of infections. Gairdner's landmark paper of 1949 turned New Zealand doctors away from ‘congenital phimosis and non-therapeutic circumcision, although some doctors and persisting family traditions maintained both interventions until the end of the century.

The universal condition: medical constructions of 'congenital phimosis' in twentieth century New Zealand and their implications for child rearing.

'Congenital phimosis' was one of a number of pseudo-pathologies that entered mainstream medicine in the nineteenth century. In the twentieth century Truby King, Henry Jellett, and Eric Corkill advocated premature foreskin retraction as the first intervention to manage 'congenital phimosis'. If that failed they recommended circumcision, although eventually it became more expedient to use circumcision exclusively. The nineteenth-century justification for such interventions was to prevent masturbation, but by the middle of the twentieth century this was replaced by prevention of infections. Gairdner's landmark paper of 1949 turned New Zealand doctors away from 'congenital phimosis' and non-therapeutic circumcision, although some doctors and persisting family traditions maintained both interventions until the end of the century.

Do Motives Matter in Male Circumcision? ‘Conscientious Objection’ Against the Circumcision of a Muslim Child with a Blood Disorder

Whilst there have been serious attempts to locate the practice of male circumcision for religious motives in the context of the (respective) religion's narrative and community, the debate, when referring to a clinical context, is often more nuanced. This article will contribute further to the debate by contextualising the Islamic practice of male circumcision within the clinical setting typical of a contemporary hospital. It specifically develops an additional complication; namely, the child has a pre-existing blood disorder. As an approach to contributing to the circumcision debate further, the ethics of a conscientious objection for secular motives towards a religiously-motivated clinical intervention will be explored. Overall, the discussion will provide relevance for such debates within the value-systems of a multi-cultural society. This article replicates several approaches to deconstructing a request for conscientious refusal of non-therapeutic circumcision by a Clinical Ethics Committee (CEC), bringing to light certain contradictions that occur in normatively categorizing motives for performing the circumcision.

Non-therapeutic male circumcision performed on immigrant children from Africa in Spain

To study the frequency, characteristics, and complications of non-therapeutic male circumcision on immigrant children from Africa in Spain. This descriptive study focused on primary care consultations conducted at 21 Aragon health centres during 2010 and 2011. The data were gathered through interviewer-administered questionnaires to the parents of African children. Sociodemographic variables were studied, along with others related to the practice of circumcision. 283 questionnaires were obtained. 98.93 % of the children had undergone or were planning to undergo circumcision. 68.2 % were circumcised. Circumcisions were most frequently performed during a vacation to the country of origin (67.04 %), especially so for the Maghreb population. The remaining circumcisions had been performed in Spain. Half of the circumcisions practiced in Spain were performed at home, and 84 % of these were performed on Gambian children. The current study demonstrates that, in Aragon, Spain, almost all immigrant children from Africa have been or will be circumcised and that a considerable proportion has been circumcised at home by unqualified individuals. Gambians are particularly at risk of performing unsafe circumcision.

Recommendation by a law body to ban infant male circumcision has serious worldwide implications for pediatric practice and human rights.

BackgroundRecent attempts in the USA and Europe to ban the circumcision of male children have been unsuccessful. Of current concern is a report by the Tasmanian Law Reform Institute (TLRI) recommending that non-therapeutic circumcision be prohibited, with parents and doctors risking criminal sanctions except where the parents have strong religious and ethnic ties to circumcision. The acceptance of this recommendation would create a precedent for legislation elsewhere in the world, thereby posing a threat to pediatric practice, parental responsibilities and freedoms, and public health.DiscussionThe TLRI report ignores the scientific consensus within medical literature about circumcision. It contains legal and ethical arguments that are seriously flawed. Dispassionate ethical arguments and the United Nations Convention on the Rights of the Child are consistent with parents being permitted to authorize circumcision for their male child. Uncritical acceptance of the TLRI report’s recommendations would strengthen and legitimize efforts to ban childhood male circumcision not just in Australia, but in other countries as well. The medical profession should be concerned about any attempt to criminalize a well-accepted and evidence-based medical procedure. The recommendations are illogical, pose potential dangers and seem unworkable in practice. There is no explanation of how the State could impose criminal charges against doctors and parents, nor of how such a punitive apparatus could be structured, nor how strength of ethnic or religious ties could be determined. The proposal could easily be used inappropriately, and discriminates against parents not tied to the religions specified. With time, religious exemptions could subsequently be overturned. The law, governments and the medical profession should reject the TLRI recommendations, especially since the recent affirmative infant male circumcision policy statement by the American Academy of Pediatrics attests to the significant individual and public health benefits and low risk of infant male circumcision.SummaryDoctors should be allowed to perform medical procedures based on sound evidence of effectiveness and safety with guaranteed protection. Parents should be free to act in the best interests of the health of their infant son by having him circumcised should they choose.