Circumcision

In some cultures, males are generally required to be circumcised shortly after birth, during childhood or around puberty as part of a rite of passage. Circumcision is commonly practiced in the Jewish and Islamic faiths and in Coptic Christianity and the Ethiopian Orthodox Church and the Eritrean Orthodox Tewahedo Church.[7][24][25][26][111][112][113]

Judaism

Circumcision is very important to most branches of Judaism, with over 90% of male adherents having the procedure performed as a religious obligation. The basis for its observance is found in the Torah of the Hebrew Bible, in Genesis chapter 17, in which a covenant of circumcision is made with Abraham and his descendants. Jewish circumcision is part of the brit milah ritual, to be performed by a specialist ritual circumciser, a mohel, on the eighth day of a newborn son's life, with certain exceptions for poor health. Jewish law requires that the circumcision leaves the glans bare when the penis is flaccid. Converts to Conservative and Orthodox Judaism must also be circumcised; those who are already circumcised undergo a symbolic circumcision ritual. Circumcision is not required by Judaism for one to be considered Jewish, but some adherents foresee serious negative spiritual consequences if it is neglected.[24][114]

According to traditional Jewish law, in the absence of an adult free Jewish male expert, a woman, a slave, or a child who has the required skills is also authorized to perform the circumcision, provided that they are Jewish.[115] However, most streams of non-Orthodox Judaism allow female mohels, called mohalot (Hebrew: מוֹהֲלוֹת‎, the plural of מוֹהֶלֶת mohelet, feminine of mohel), without restriction. In 1984 Deborah Cohen became the first certified Reform mohelet; she was certified by the Berit Mila program of Reform Judaism.[116]
Some contemporary Jews in the United States choose not to circumcise their sons.[117] They are assisted by a small number of Reform and Reconstructionist rabbis, and have developed a welcoming ceremony that they call the brit shalom ("Covenant [of] Peace") for such children, also accepted by Humanistic Judaism.[118][119]

This ceremony of brit shalom is not officially approved of by the Reform or Reconstructionist rabbinical organizations, who make the recommendation that male infants should be circumcised, though the issue of converts remains controversial[120][121] and circumcision of converts is not mandatory in either movement.[122]

Islam

Although there is some debate within Islam over whether it is a religious requirement, circumcision (called khitan) is practiced nearly universally by Muslim males. Islam bases its practice of circumcision on the Genesis 17 narrative, the same Biblical chapter referred to by Jews. The procedure is not explicitly mentioned in the Quran, however, it is a tradition established by Islam's prophet Muhammad directly (following Abraham), and so its practice is considered a sunnah (prophet's tradition) and is very important in Islam. For Muslims, circumcision is also a matter of cleanliness, purification and control over one's baser self (nafs). [26][111][123]

There is no agreement across the many Islamic communities about the age at which circumcision should be performed. It may be done from soon after birth up to about age 15; most often it is performed at around six to seven years of age. The timing can correspond with the boy's completion of his recitation of the whole Quran, with a coming-of-age event such as taking on the responsibility of daily prayer or betrothal. Circumcision may be celebrated with an associated family or community event. Circumcision is recommended for, but is not required of, converts to Islam.[26][111][123]

Christianity

The New Testament chapter Acts 15 records that Christianity did not require circumcision. In 1442 the Catholic Church banned the practice of religious circumcision in the 11th Council of Florence[124] and currently maintains a neutral position on the practice of non-religious circumcision.[125] Coptic Christians practice circumcision as a rite of passage.[4][25][113][126] The Ethiopian Orthodox Church calls for circumcision, with near-universal prevalence among Orthodox men in Ethiopia.[4] Some Christian churches in South Africa disapprove of the practice, while others require it of their members.[4]

African cultures

Certain African cultural groups, such as the Yoruba and the Igbo of Nigeria, customarily circumcise their infant sons. The procedure is also practiced by some cultural groups or individual family lines in Sudan, Democratic Republic of the Congo, Uganda and in southern Africa. For some of these groups, circumcision appears to be purely cultural, done with no particular religious significance or intention to distinguish members of a group. For others, circumcision might be done for purification, or it may be interpreted as a mark of subjugation. Among these groups, even when circumcision is done for reasons of tradition, it is often done in hospitals.[112]

The Maasai people, who live predominantly in Kenya and Tanzania, use circumcision as a rite of passage. It is also used for distinguished age groups. This is usually done after every fifteen years where a new "age set" are formed. The new members are to undergo initiation at the same time. Whenever new age groups are initiated, they will become novice warriors and replace the previous group. The new initiates will be given a unique name that will be an important marker of the history of the Maasai. No anesthesia is used, and initiates have to endure the pain or be called flinchers.[127]

The Xhosa community practice circumcision as a sacrifice. In doing so, young boys will announce to their family members when they are ready for circumcision by singing. The sacrifice is the blood spilt during the initiation procedure. Young boys will be considered an "outsiders" unless they undergo circumcision.[128] It is not clear how many deaths and injuries result from non-clinical circumcisions.[129]

Australian cultures

Some Australian Aborigines use circumcision as a test of bravery and self-control as a part of a rite of passage into manhood, which results in full societal and ceremonial membership. It may be accompanied by body scarification and the removal of teeth, and may be followed later by penile subincision. Circumcision is one of many trials and ceremonies required before a youth is considered to have become knowledgeable enough to maintain and pass on the cultural traditions. During these trials, the maturing youth bonds in solidarity with the men. Circumcision is also strongly associated with a man's family, and it is part of the process required to prepare a man to take a wife and produce his own family.[112]

Filipino culture

In the Philippines, circumcision known as "tuli" is sometimes viewed as a rite of passage.[130] About 93% of Filipino men are circumcised.[130] Often this occurs, in April and May, when Filipino boys are taken by their parents. The practice dates back to the arrival of Islam in 1450. Pressure to be circumcised is even in the language: one Tagalog word for 'uncircumcised' is supot, meaning 'coward' literally. A circumcised eight or ten year-old is no longer considered a boy and is given more adult roles in the family and society.[131]

Ethical and legal issues

There is a long-running and vigorous debate over ethical concerns regarding circumcision, particularly neonatal circumcision for reasons other than intended direct medical benefit. There are three parties involved in the decision to circumcise a minor: the minor as the patient, the parents (or other guardians) and the physician. The physician is bound under the ethical principles of beneficence (promoting well-being) and non-maleficence ("first, do no harm"), and so is charged with the responsibility to promote the best interests of the patient while minimizing unnecessary harms. Those involved must weigh the factors of what is in the best interest of the minor against the potential harms of the procedure.[9]

With a newborn involved, the decision is made more complex due to the principles of respect for autonomy and consent, as a newborn cannot understand or engage in a logical discussion of his own values and best interests.[8][9] A mentally more mature child can understand the issues involved to some degree, and the physician and parents may elicit input from the child and weigh it appropriately in the decision-making process, although the law may not treat such input as legally informative. Ethicists and legal theorists also state that it is questionable for parents to make a decision for the child that precludes the child from making a different decision for himself later. Such a question can be raised for the decision by the parents either to circumcise or not to circumcise the child.[9]

Generally, circumcision on a minor is not ethically controversial or legally questionable when there is a clear and pressing medical indication for which it is the accepted best practice to resolve. Where circumcision is the chosen intervention, the physician has an ethical responsibility to ensure the procedure is performed competently and safely to minimize potential harms.[8][9] Worldwide, most legal jurisdictions do not have specific laws concerning the circumcision of males,[4] but infant circumcision is not illegal in many countries.[132] A few countries have passed legislation on the procedure: Germany allows non-therapeutic circumcision,[133] while non-religious routine circumcision is illegal in South Africa and Sweden.[4][132]

Throughout society, circumcision is often considered for reasons other than medical need. Public health advocates of circumcision consider it to have a net benefit, and therefore feel that increasing the circumcision rate is an ethical imperative. They recommend performing the procedure during the neonatal period when it is less expensive and has a lower risk of complications.[8] While studies show there is a modest epidemiological benefit to circumcision, critics argue that the number of circumcisions that would have to be performed would yield an overall negative public health outcome due to the resulting number of complications or other negative effects (such as pain). Pinto (2012) writes "sober proponents and detractors of circumcision agree that there is no overwhelming medical evidence to support either side."[8] This type of cost-benefit analysis is highly dependent on the kinds and frequencies of health problems in the population under discussion and how circumcision affects those health problems.[9]

Parents are assumed to have the child's best interests in mind. Ethically, it is imperative that the medical practitioner inform the parents about the benefits and risks of the procedure and obtain informed consent before performing it. Practically, however, many parents come to a decision about circumcising the child before he is born, and a discussion of the benefits and risks of the procedure with a physician has not been shown to have a significant effect on the decision. Some parents request to have their newborn or older child circumcised for non-therapeutic reasons, such as the parents' desires to adhere to family tradition, cultural norms or religious beliefs. In considering such a request, the physician may consider (in addition to any potential medical benefits and harms) such non-medical factors in determining the child's best interests and may ethically perform the procedure. Equally, without a clear medical benefit relative to the potential harms, a physician may take the ethical position that non-medical factors do not contribute enough as benefits to outweigh the potential harms and refuse to perform the procedure. Medical organizations such as the British Medical Association state that their member physicians are not obliged to perform the procedure in such situations.[8][9]

In 2012 the International NGO Council on Violence against Children identified non-therapeutic circumcision of infants and boys as being among harmful practices that constitute violence against children and violate their rights.[134] The German Academy for Pediatric and Adolescent Medicine (Deutsche Akademie für Kinder- und Jugendmedizin e.V., DAKJ) recommend against routine non-medical infant circumcision.[135] The Royal Dutch Medical Association questions why the ethics regarding male genital alterations should be viewed any differently from female genital alterations.[27]

Economic considerations

The cost-effectiveness of circumcision has been studied to determine whether a policy of circumcising all newborns or a policy of promoting and providing inexpensive or free access to circumcision for all adult men who choose it would result in lower overall societal healthcare costs. As HIV/AIDS is an incurable disease that is expensive to manage, significant effort has been spent studying the cost-effectiveness of circumcision to reduce its spread in parts of Africa that have a relatively high infection rate and low circumcision prevalence.[136] Several analyses have concluded that circumcision programs for adult men in Africa are cost-effective and in some cases are cost-saving.[39][137] In Rwanda, circumcision has been found to be cost-effective across a wide range of age groups from newborn to adult,[47][138] with the greatest savings achieved when the procedure is performed in the newborn period due to the lower cost per procedure and greater timeframe for HIV infection protection.[12][138] Circumcision for the prevention of HIV transmission in adults has also been found to be cost-effective in South Africa, Kenya, and Uganda, with cost savings estimated in the billions of US dollars over 20 years.[136] Hankins et al. (2011) estimated that a $1.5 billion investment in circumcision for adults in 13 high-priority African countries would yield $16.5 billion in savings.[139]

The overall cost-effectiveness of neonatal circumcision has also been studied in the United States, which has a different cost setting from Africa in areas such as public health infrastructure, availability of medications, and medical technology and the willingness to use it.[140] A study by the CDC suggests that newborn circumcision would be societally cost-effective in the United States based on circumcision's efficacy against the transmission of HIV alone during coitus, without considering any other cost benefits.[3] The American Academy of Pediatrics (2012) recommends that neonatal circumcision in the United States be covered by third-party payers such as Medicaid and insurance.[3] A 2014 review that considered reported benefits of circumcision such as reduced risks from HIV, HPV, and HSV-2 stated that circumcision is cost-effective in both the United States and Africa and may result in health care savings.[141] However, a 2014 literature review found that there are significant gaps in the current literature on male and female sexual health that need to be addressed for the literature to be applicable to North American populations.[81]