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Genital Modifications in Prepubescent Minors: When May Clinicians Ethically Proceed? THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2024:1-50. [PMID: 39018160 DOI: 10.1080/15265161.2024.2353823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/19/2024]
Abstract
When is it ethically permissible for clinicians to surgically intervene into the genitals of a legal minor? We distinguish between voluntary and nonvoluntary procedures and focus on nonvoluntary procedures, specifically in prepubescent minors ("children"). We do not address procedures in adolescence or adulthood. With respect to children categorized as female at birth who have no apparent differences of sex development (i.e., non-intersex or "endosex" females) there is a near-universal ethical consensus in the Global North. This consensus holds that clinicians may not perform any nonvoluntary genital cutting or surgery, from "cosmetic" labiaplasty to medicalized ritual "pricking" of the vulva, insofar as the procedure is not strictly necessary to protect the child's physical health. All other motivations, including possible psychosocial, cultural, subjective-aesthetic, or prophylactic benefits as judged by doctors or parents, are seen as categorically inappropriate grounds for a clinician to proceed with a nonvoluntary genital procedure in this population. We argue that the main ethical reasons capable of supporting this consensus turn not on empirically contestable benefit-risk calculations, but on a fundamental concern to respect the child's privacy, bodily integrity, developing sexual boundaries, and (future) genital autonomy. We show that these ethical reasons are sound. However, as we argue, they do not only apply to endosex female children, but rather to all children regardless of sex characteristics, including those with intersex traits and endosex males. We conclude, therefore, that as a matter of justice, inclusivity, and gender equality in medical-ethical policy (we do not take a position as to criminal law), clinicians should not be permitted to perform any nonvoluntary genital cutting or surgery in prepubescent minors, irrespective of the latter's sex traits or gender assignment, unless urgently necessary to protect their physical health. By contrast, we suggest that voluntary surgeries in older individuals might, under certain conditions, permissibly be performed for a wider range of reasons, including reasons of self-identity or psychosocial well-being, in keeping with the circumstances, values, and explicit needs and preferences of the persons so concerned. Note: Because our position is tied to clinicians' widely accepted role-specific duties as medical practitioners within regulated healthcare systems, we do not consider genital procedures performed outside of a healthcare context (e.g., for religious reasons) or by persons other than licensed healthcare providers working in their professional capacity.
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Mehta KS, Marfatia YS, Jain AP, Shah DJ, Baxi DS. Male circumcision and Sexually transmitted Infections - An update. Indian J Sex Transm Dis AIDS 2021; 42:1-6. [PMID: 34765930 PMCID: PMC8579597 DOI: 10.4103/ijstd.ijstd_20_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Revised: 03/13/2021] [Accepted: 03/18/2021] [Indexed: 11/04/2022] Open
Abstract
Role of male circumcision (MC) as a tool to prevent sexually transmitted infections (STIs)/human immunodeficiency virus (HIV) was assessed. An attempt was made to search articles related to association between MC and STIs/HIV. A thorough search was carried out to find out quality articles published in indexed specialty journals. Centers for Disease Control and Prevention and World Health Organization (WHO) sites were also referred. Warm and moist environment of area under foreskin facilitates some pathogens to persist and replicate. Further, the thinness of foreskin predisposes it to minor trauma and abrasions that facilitate the entry of pathogens. MC reduces HIV infection risk by 50%–60% over time and reduces the risk of men acquiring herpes simplex virus-2 and human papillomavirus (HPV) that can cause penile and other anogenital cancers, by 30%. There is no significant reduction in risk of acquiring syphilis, but reduced risk of acquisition of Haemophilus ducreyi is reported. MC is reported to be beneficial in conditions such as traumatic injury, Balanitis Xerotica Obliterans, refractory balanoposthitis, and chronic, recurrent urinary tract infections. MC also reduces the chances of penile carcinoma by facilitating improved penile hygiene, lowering HPV/HIV transmission rates, and reducing chronic inflammatory conditions such as phimosis and balanitis. MC has been recommended by the WHO and UNAIDS in 2007 as an additional HIV prevention intervention in settings of high HIV prevalence. MC is an important adjunct to safe sex education, condom use, and vaccination (HPV) in reducing the global burden of HIV/STIs-related morbidity and mortality.
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Affiliation(s)
- Kajal S Mehta
- Consultant Dermatologist, SBKS Medical Institute and Research Centre, Vadodara, Gujarat, India
| | - Yogesh S Marfatia
- Department of Skin and VD, SBKS Medical Institute and Research Centre, Vadodara, Gujarat, India
| | - Apexa P Jain
- Department of Skin and VD, SBKS Medical Institute and Research Centre, Vadodara, Gujarat, India
| | - Dhiral J Shah
- Department of Skin and VD, Baroda Medical College, Vadodara, Gujarat, India
| | - Disha S Baxi
- Department of Skin and VD, SBKS Medical Institute and Research Centre, Vadodara, Gujarat, India
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Earp BD. Male or female genital cutting: why 'health benefits' are morally irrelevant. JOURNAL OF MEDICAL ETHICS 2021; 47:medethics-2020-106782. [PMID: 33462078 DOI: 10.1136/medethics-2020-106782] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/08/2020] [Revised: 12/03/2020] [Accepted: 12/08/2020] [Indexed: 06/12/2023]
Abstract
The WHO, American Academy of Pediatrics and other Western medical bodies currently maintain that all medically unnecessary female genital cutting of minors is categorically a human rights violation, while either tolerating or actively endorsing medically unnecessary male genital cutting of minors, especially in the form of penile circumcision. Given that some forms of female genital cutting, such as ritual pricking or nicking of the clitoral hood, are less severe than penile circumcision, yet are often performed within the same families for similar (eg, religious) reasons, it may seem that there is an unjust double standard. Against this view, it is sometimes claimed that while female genital cutting has 'no health benefits', male genital cutting has at least some. Is that really the case? And if it is the case, can it justify the disparate treatment of children with different sex characteristics when it comes to protecting their genital integrity? I argue that, even if one accepts the health claims that are sometimes raised in this context, they cannot justify such disparate treatment. Rather, children of all sexes and genders have an equal right to (future) bodily autonomy. This includes the right to decide whether their own 'private' anatomy should be exposed to surgical risk, much less permanently altered, for reasons they themselves endorse when they are sufficiently mature.
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Affiliation(s)
- Brian D Earp
- Yale-Hastings Program in Ethics and Health Policy, Yale University and The Hastings Center, New Haven, CT 06511, USA
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Raveenthiran V. Reply to letter to the Editor: Tracing the origins of circumcision. J Pediatr Surg 2019; 54:360-361. [PMID: 30391150 DOI: 10.1016/j.jpedsurg.2018.10.042] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Accepted: 10/04/2018] [Indexed: 10/28/2022]
Affiliation(s)
- V Raveenthiran
- Department of Pediatric Surgery, SRM Medical College, 200, Fifth Street, Viduthalai Nagar, Kovilambakkam, Chennai 600117, India.
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Earp BD, Allareddy V, Allareddy V, Rotta AT. Factors Associated With Early Deaths Following Neonatal Male Circumcision in the United States, 2001 to 2010. Clin Pediatr (Phila) 2018; 57:1532-1540. [PMID: 30066572 DOI: 10.1177/0009922818790060] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
We sought to quantify early deaths following neonatal circumcision (same hospital admission) and to identify factors associated with such mortality. We performed a retrospective analysis of all infants who underwent circumcision in an inpatient hospital setting during the first 30 days of life from 2001 to 2010 using the National Inpatient Sample. Over 10 years, 200 early deaths were recorded among 9 833 110 subjects (1 death per 49 166 circumcisions). Note: this figure should not be interpreted as causal but correlational as it may include both undercounting and overcounting of deaths attributable to circumcision. Compared with survivors, subjects who died following newborn circumcision were more likely to have associated comorbid conditions, such as cardiac disease (odds ratio [OR] = 697.8 [378.5-1286.6]; P < .001), coagulopathy (OR = 159.6 [95.6-266.2]; P < .001), fluid and electrolyte disorders (OR = 68.2 [49.1-94.6]; P < .001), or pulmonary circulatory disorders (OR = 169.5 [69.7-412.5]; P < .001). Recognizing these factors could inform clinical and parental decisions, potentially reducing associated risks.
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Affiliation(s)
- Brian D Earp
- 1 Yale University, New Haven, CT, USA.,2 The Hastings Center, Garrison, NY, USA
| | - Veerajalandhar Allareddy
- 3 Stead Family Children's Hospital, Iowa City, IA, USA.,4 University of Iowa, Iowa City, IA, USA
| | | | - Alexandre T Rotta
- 6 UH Rainbow Babies & Children's Hospital, Cleveland, OH, USA.,7 Case Western Reserve University, Cleveland, OH, USA
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Frisch M, Earp BD. Circumcision of male infants and children as a public health measure in developed countries: A critical assessment of recent evidence. Glob Public Health 2016; 13:626-641. [DOI: 10.1080/17441692.2016.1184292] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Affiliation(s)
- Morten Frisch
- Department of Epidemiology Research, Division of Epidemiology and Disease Surveillance, Statens Serum Institut, Copenhagen, Denmark
- Department of Clinical Medicine, Center for Sexology Research, Aalborg University, Aalborg, Denmark
| | - Brian D. Earp
- The Hastings Center Bioethics Research Institute, Garrison, NY, USA
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Na AF, Tanny SPT, Hutson JM. Circumcision: Is it worth it for 21st-century Australian boys? J Paediatr Child Health 2015; 51:580-3. [PMID: 25683279 DOI: 10.1111/jpc.12825] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/21/2014] [Indexed: 12/15/2022]
Affiliation(s)
- Angelika F Na
- F. Douglas Stephens Surgical Research Laboratory, Murdoch Childrens Research Institute, Melbourne, Victoria, Australia
| | - Sharman P T Tanny
- F. Douglas Stephens Surgical Research Laboratory, Murdoch Childrens Research Institute, Melbourne, Victoria, Australia
| | - John M Hutson
- F. Douglas Stephens Surgical Research Laboratory, Murdoch Childrens Research Institute, Melbourne, Victoria, Australia.,Department of Urology, Royal Children's Hospital, Melbourne, Victoria, Australia
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Earp BD. Do the Benefits of Male Circumcision Outweigh the Risks? A Critique of the Proposed CDC Guidelines. Front Pediatr 2015; 3:18. [PMID: 25853108 PMCID: PMC4364150 DOI: 10.3389/fped.2015.00018] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2015] [Accepted: 02/21/2015] [Indexed: 01/12/2023] Open
Abstract
The Centers for Disease Control and Prevention (CDC) have announced a set of provisional guidelines concerning male circumcision, in which they suggest that the benefits of the surgery outweigh the risks. I offer a critique of the CDC position. Among other concerns, I suggest that the CDC relies more heavily than is warranted on studies from Sub-Saharan Africa that neither translate well to North American populations nor to circumcisions performed before an age of sexual debut; that it employs an inadequate conception of risk in its benefit vs. risk analysis; that it fails to consider the anatomy and functions of the penile prepuce (i.e., the part of the penis that is removed by circumcision); that it underestimates the adverse consequences associated with circumcision by focusing on short-term surgical complications rather than long-term harms; that it portrays both the risks and benefits of circumcision in a misleading manner, thereby undermining the possibility of obtaining informed consent; that it evinces a superficial and selective analysis of the literature on sexual outcomes associated with circumcision; and that it gives less attention than is desirable to ethical issues surrounding autonomy and bodily integrity. I conclude that circumcision before an age of consent is not an appropriate health-promotion strategy.
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Affiliation(s)
- Brian D Earp
- Uehiro Centre for Practical Ethics, University of Oxford , Oxford , UK
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Abstract
Circumcision is one of the oldest and the most controversial surgical procedures performed worldwide and is almost universal among Muslim and Jewish men. Most medical institutions in various countries agree that although there may be health benefits, there is no medical justification for routine circumcision in neonates or children. It should be performed only for established medical reasons and should not be universally recommended. There are modern techniques that provide safer, simpler, quicker, and cheaper alternatives to the traditional means of circumcision with good functional and cosmetic results. Female genital mutilation (FGM) includes procedure that alters or injures female genital organs for nonmedical reasons. Various degrees of FGM are prevalent, the most mutilating one being infibulation. There are numerous gynecologic and obstetrical complications with infibulation. FGM also plays a significant role in facilitating the transmission of HIV infection through numerous mechanisms. Health care providers have an important role to play in the eradication of this practice. Increased professional and public awareness about such a practice is required.
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Affiliation(s)
- Poonam Puri
- Department of Dermatology, Venereology and Leprosy, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi - 110 029, India
| | - Joginder Kumar
- Department of Dermatology, Venereology and Leprosy, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi - 110 029, India
| | - V. Ramesh
- Department of Dermatology, Venereology and Leprosy, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi - 110 029, India
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Bleeding complications after ritual circumcision: about six children. Eur J Pediatr 2010; 169:359-62. [PMID: 19585146 DOI: 10.1007/s00431-009-1021-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2009] [Accepted: 06/16/2009] [Indexed: 10/20/2022]
Abstract
Circumcision is the most common surgical procedure in boys. Even if the procedure is frequent, circumcision can have tragic complications. We report the cases of six children, seen over 1 year at the emergency department for bleeding complication or mutilation after ritual home circumcision. To avoid such complications, it is recommended that circumcision should be performed by doctors trained in this procedure. Parents have to be cautioned about the risks of possible complications after this procedure.
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Puri P, Kumar J, Ramesh V. Circumcision. Indian J Sex Transm Dis AIDS 2010. [PMID: 21716785 PMCID: PMC3122584 DOI: 10.4103/2589-0557.74967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Circumcision is one of the oldest and the most controversial surgical procedures performed worldwide and is almost universal among Muslim and Jewish men. Most medical institutions in various countries agree that although there may be health benefits, there is no medical justification for routine circumcision in neonates or children. It should be performed only for established medical reasons and should not be universally recommended. There are modern techniques that provide safer, simpler, quicker, and cheaper alternatives to the traditional means of circumcision with good functional and cosmetic results. Female genital mutilation (FGM) includes procedure that alters or injures female genital organs for nonmedical reasons. Various degrees of FGM are prevalent, the most mutilating one being infibulation. There are numerous gynecologic and obstetrical complications with infibulation. FGM also plays a significant role in facilitating the transmission of HIV infection through numerous mechanisms. Health care providers have an important role to play in the eradication of this practice. Increased professional and public awareness about such a practice is required.
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Affiliation(s)
- Poonam Puri
- Department of Dermatology, Venereology and Leprosy, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi - 110 029, India,Address for correspondence: Dr. Poonam Puri, Department of Dermatology, Venereology and Leprosy, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi - 110 029, India. E-mail:
| | - Joginder Kumar
- Department of Dermatology, Venereology and Leprosy, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi - 110 029, India
| | - V. Ramesh
- Department of Dermatology, Venereology and Leprosy, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi - 110 029, India
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Ahaghotu C, Okafor H, Igiehon E, Gray E. Psychosocial factors influence parental decision for circumcision in pediatric males of African American descent. J Natl Med Assoc 2009; 101:325-30. [PMID: 19397222 DOI: 10.1016/s0027-9684(15)30879-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND The most recent policy statement by the American Academy of Pediatrics suggests there are insufficient data to recommend routine newborn circumcision. Nevertheless, circumcision rates have not declined in the United States. Some studies suggest that African Americans are less likely to be circumcised. In blacks that choose to circumcise their males, we sought to examine the factors that drive parents to favor circumcision. METHODS The Parental Attitudes on Circumcision questionnaire was utilized to obtain demographic information and attitudinal responses to circumcision during urology clinic sessions at Howard University Hospital, a major teaching hospital located in an urban setting. Parents and caregivers of male children aged 3 months to 7 years participated. Valid responses from 146 participants were collected. RESULTS Ninety-six percent of our respondents believe that circumcision is healthy. Forty-one percent indicated health reasons as the most important influencing factor for choosing to circumcise their child, while 25% selected maternal preference. Eighty-one percent of all respondents indicated that 1 or more health care providers asked about their decision to circumcise their child. The mother was 12 times more likely than the father to make the final decision for circumcision, especially when her personal preference played a role. Eighty-eight percent of respondents felt that circumcision is painful, but 87% considered the procedure safe, and another 72% believe that it is a necessary procedure. CONCLUSION African American parents strongly believe that circumcision is essential for a healthy state and are willing to opt for the procedure despite the belief that it may be painful for the child. The mother primarily made the final decision to circumcise her child, largely based on the perceived health and hygiene benefits. In blacks, the mother yields considerable influence in the decision to circumcise the child, with maternal preference as the main reason for seeking circumcision in as much as a quarter of cases.
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Affiliation(s)
- Chiledum Ahaghotu
- Division of Urology, Howard University Hospital Washington, DC 20001, USA.
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Fox M, Thomson M. A covenant with the status quo? Male circumcision and the new BMA guidance to doctors. JOURNAL OF MEDICAL ETHICS 2005; 31:463-9. [PMID: 16076971 PMCID: PMC1734197 DOI: 10.1136/jme.2004.009340] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Abstract
This article offers a critique of the recently revised BMA guidance on routine neonatal male circumcision and seeks to challenge the assumptions underpinning the guidance which construe this procedure as a matter of parental choice. Our aim is to problematise continued professional willingness to tolerate the non-therapeutic, non-consensual excision of healthy tissue, arguing that in this context both professional guidance and law are uncharacteristically tolerant of risks inflicted on young children, given the absence of clear medical benefits. By interrogating historical medical explanations for this practice, which continue to surface in contemporary justifications of non-consensual male circumcision, we demonstrate how circumcision has long existed as a procedure in need of a justification. We conclude that it is ethically inappropriate to subject children-male or female-to the acknowledged risks of circumcision and contend that there is no compelling legal authority for the common view that male circumcision is lawful.
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Affiliation(s)
- M Fox
- School of Law, Keele University, Staffordshire ST5 5BG, UK
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Affiliation(s)
- A M Viens
- Departmrent of Philosophy, St. Anne's College, Oxford University, Oxford, UK.
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Affiliation(s)
- R V Short
- Department of Obstetrics and Gynaecology, Royal Women's Hospital, 132 Grattan Street, Carlton, Victoria 3053, Australia.
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Hellsten SK. Rationalising circumcision: from tradition to fashion, from public health to individual freedom--critical notes on cultural persistence of the practice of genital mutilation. JOURNAL OF MEDICAL ETHICS 2004; 30:248-53. [PMID: 15173357 PMCID: PMC1733870 DOI: 10.1136/jme.2004.008888] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
Abstract
Despite global and local attempts to end genital mutilation, in their various forms, whether of males or females, the practice has persisted throughout human history in most parts of the world. Various medical, scientific, hygienic, aesthetic, religious, and cultural reasons have been used to justify it. In this symposium on circumcision, against the background of the other articles by Hutson, Short, and Viens, the practice is set by the author within a wider, global context by discussing a range of rationalisations used to support different types of genital mutilation throughout time and across the globe. It is argued that in most cases the rationalisations invented to provide support for continuing the practice of genital mutilation--whether male or female--within various cultural and religious settings have very little to do with finding a critical and reflective moral justification for these practices. In order to question the ethical acceptability of the practice in its non-therapeutic forms, we need to focus on child rights protection.
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Affiliation(s)
- S K Hellsten
- Centre for the Study of Global Ethics, University of Birmingham, Birmingham, UK.
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