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Until recently, the
American Academy of
Pediatrics (AAP) was the generally recognized
medical authority on male circumcision in the USA. That
role is now being shared with other
health and
human rights groups who are working on behalf of male
infants and children to protect them from the sexually
and emotionally damaging practice of genital cutting.
The AAP
advises
in
its 2012
Male Circumcision Policy Statement
and
Male Circumcision Technical Report that the health
benefits of infant male circumcision outweigh the risks.
That policy contrasts sharply with the AAP's
Female Genital Mutilation Policy Statement,
which strongly opposes all forms of female circumcision:
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Male Circumcision Policy Statement |
Female Genital Mutilation Policy
Statement * |
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"Male circumcision is a common procedure,
generally performed during the newborn
period in the United States. In 2007, the
American Academy of Pediatrics (AAP) formed
a multidisciplinary task force of AAP
members and other stakeholders to evaluate
the recent evidence on male circumcision and
update the Academy’s 1999 recommendations in
this area. Evaluation of current evidence
indicates that the health benefits of
newborn male circumcision outweigh the risks
and that the procedure’s benefits justify
access to this procedure for families who
choose it. Specific benefits identified
included prevention of urinary tract
infections, penile cancer, and transmission
of some sexually transmitted infections,
including HIV. The American College of
Obstetricians and Gynecologists has endorsed
this statement."
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"The traditional custom of ritual cutting
and alteration of the genitalia of female
infants, girls, and adolescents, referred
to as female genital mutilation (FGM),
persists primarily in Africa and
among certain communities in the Middle East
and Asia. Immigrants in the
United States from areas where FGM is
endemic may have daughters who
have undergone a ritual genital procedure or
may request that such a procedure
be performed by a physician. The
American Academy of Pediatrics (AAP)
believes that pediatricians and
pediatric surgical specialists should be
aware that this practice has
serious, life-threatening health risks for
children and women. The AAP
opposes all forms of FGM, counsels its
members not to perform such
ritual procedures, and encourages the
development of community
educational programs for immigrant
populations."
* An
April
2010 revision to this statement (which called for
legalization of Type IV FGM) was
retracted by the AAP after a
storm of
public protest.
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Medical
ethicists now generally
agree that the AAP's current policy
on circumcision
discriminates
against males. MGMbill.org urges the AAP
Committee
on Bioethics to eliminate
this gender discrimination by updating the AAP Male
Circumcision Policy Statement to read as follows (PDF),
replacing "MGMbill.org" with "American Academy of
Pediatrics" or "AAP":
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POLICY STATEMENT
MGMbill.org:
Male Genital Mutilation
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ABSTRACT |
The
traditional custom of ritual cutting and alteration of
the genitalia of male infants, boys, and adolescents,
referred to as male genital mutilation
(MGM), persists primarily in the United States, Canada,
Australia, South Korea, the Philippines, Africa and among
certain communities in the Middle East and Asia.
Families from all regions in the United
States may have sons who have undergone a
ritual genital procedure or may
request that such a procedure be performed by a
physician. MGMbill.org believes that pediatricians and
pediatric surgical specialists should be aware that this
practice has serious, life-threatening health
risks for children and men. MGMbill.org opposes
all forms of MGM, counsels all physicians and
practitioners not to
perform such ritual procedures, and encourages the
development of community educational programs
for hospitals and religious groups.
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INTRODUCTION |
Ritual
cutting and alteration of the genitalia of male
infants, boys, and adolescents has been a tradition
since antiquity. It persists today primarily
in the United States, Canada, Australia, South Korea,
the Philippines, Africa and among certain communities in
the Middle East and Asia. The spectrum of these genital
procedures has been termed male
circumcision, or more frequently, male
genital mutilation (MGM) as a collective name describing
several different traditional rituals that
emphasizes the physical disfigurement
associated with the practice. It is estimated that at
least 650 million men have undergone MGM
and that 13 million procedures
are performed annually in male infants and boys,
with the most severe types of MGM carried out in
African populations. 1,2
Pediatricians, therefore, are likely to encounter
patients who have undergone these procedures and
pediatric surgeons and pediatric urologists
may be requested by patients or by the
parents of patients to perform surgery considered a
ritual genital operation.
During the
past 2 decades several international and national
humanitarian and medical organizations have drawn
worldwide attention to the physical harms
associated with MGM. The National Organization of
Circumcision Information Resource Centers and the International
Coalition for Genital Integrity oppose
MGM as a medically
unnecessary practice with serious,
potentially life-threatening complications. 3,4
Doctors Opposing Circumcision and Nurses for the Rights
of the Child also oppose MGM and
advise their members not to perform these
procedures.5,6
In 1989 the First International Symposium on
Circumcision recommended that
all physicians in the United States strongly
denounce all medically unnecessary procedures to alter
male genitalia, as well as promote culturally
sensitive education about the physical
consequences of MGM.7
In 1996 the Congress of the United States enacted
legislation to criminalize the performance of FGM
by practitioners on female infants and
children or adolescents younger than 18 years
and to develop educational programs at the community
level and for physicians about the harmful
consequences of the practice. 8 Because the Fourteenth Amendment to the U.S.
Constitution guarantees equal protection of the law to
all citizens regardless of gender, Attorneys for the
Rights of the Child and MGMbill.org argue that MGM is
illegal and subject to criminal prosecution.9,
10
MGMbill.org encourages
all physicians to:
1) become informed about the major types of MGM and
their complications; 2) be able to recognize
the physical signs of MGM; 3) be aware of the
cultural, religious, and ethical issues associated with
MGM; 4) develop a compassionate educational approach for
patients who have undergone or who request
such a procedure; and 5) decline performing
all medically unnecessary procedures to alter male
genitalia.
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TYPES OF MALE GENITAL
MUTILATION |
MGM is most
often performed between the ages of infancy and 14 years,
although in some communities it may be postponed until
20 years of age. 11
In developing countries, typically a local village practitioner
or lay
person is engaged for a fee to
perform the procedure, which is done without anesthesia
using a variety of instruments, such as knives,
razor blades, broken glass, or scissors. In
developed countries physicians or mohels may be sought
to perform MGM under clean or sterile conditions with or
without the use
of anesthesia. Figure
1
shows the normal genital anatomy of a
prepubertal male. The various ritual genital practices
are classified into four types based on the
severity of structural disfigurement.12
Type I MGM,
often termed circumcision, involves excision or injury
of part or all of the skin and specialized mucosal
tissues of the penis including the prepuce and ridged
band (Fig 2).
When this procedure is performed in infants
and young boys, a portion of or all of the
frenulum may be removed. If only the tip of
the foreskin is removed, or if the foreskin
has only been prematurely and forcibly retracted, the physical
manifestation of Type I MGM may be subtle,
necessitating a careful examination of the glans,
foreskin, and
adjacent structures for recognition.
Type II MGM,
referred to as glandectomy or penectomy, is excision or
injury to the glans and/or penis shaft, along with Type
I MGM. (Fig 3).
Crude stitches may be
used to control bleeding from the penile
artery and raw tissue surfaces, and patients
with Type II MGM have a shortened urethra
resulting from the absence of the glans and/or penile
shaft that may cause problems urinating and/or
ejaculating.
Type III MGM,
known as castration, is the most severe form in which
the testicles are excised with or without some or all of the foreskin and/or
penile shaft (Fig 4).
The raw surfaces are stitched together and the patient
may no longer be able to maintain an erection or father
children.
Type IV
includes different practices of variable severity
including pricking, piercing or incision of the prepuce,
glans, scrotum or other genital tissue; cutting and
suturing of the prepuce over the glans (infibulation);
slitting open the urethra along the ventral surface of
the penis (subincision); slitting open the foreskin
along its dorsal surface (superincision); severing the
frenulum; stripping the skin from the shaft of the
penis; introducing corrosive or scalding substances onto
the genital area; and any other procedure which falls under
the definition of MGM given above.
The physical
complications associated with MGM may be acute or
chronic. Early, life-threatening risks include
hemorrhage, infection, excessive skin loss, skin
bridges, glans deformation, bowing, meatal stenosis,
loss of penis, and death.13,14
Circumcision (Type I) is often associated
with long-term sexual function difficulties. Common problems
involve chafing and dryness during intercourse, reduced
sexual feeling, and a buildup of desensitizing keratin
on the exposed glans and remaining inner foreskin.
Less
well-understood are the psychological, sexual, and
social consequences of MGM, because little research has
been conducted in countries where the
practice is endemic. 15
However, personal accounts by men who have
had a medicalized genital procedure recount
anxiety before the event, terror at being seized and
forcibly held during the event, and lack of
sexual pleasure during intercourse.16
Some men have no recollection of the event,
particularly if it was performed in infancy,
while others deny that the procedure has had any
negative effect on their health or sexual
life.
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CULTURAL AND ETHICAL ISSUES |
MGM has been
documented in individuals from many religions, including
Christians, Muslims, and Jews. Some proponents of the
practice claim that it is required by the Islamic
and Jewish
faiths. However, scholars and theologians of
Islam and Judaism state that male circumcision is not
prescribed by their religious doctrine, emphasizing that
the procedure is not universal among Muslims and
Jews. 17,
18
Goldman19,
Winkel20,
and Young21
have summarized four additional reasons proposed to
explain the custom of MGM: 1) to look like others in the
community; 2) to help maintain cleanliness
and health; 3) to control the sexuality of male
children; and 4) financial incentives. Preventive
medicine rationalizations have been noted by
Winkel20
to be of particular importance to physicians
who continue to advocate circumcision.
When parents
request a ritual genital procedure for their son,
they believe that it will promote their son's
integration into their culture, protect his
health and hygiene, and make him more attractive. Parents are often
unaware of the harmful physical consequences
of the custom, because the complications of
MGM are attributed to other causes and rarely
discussed outside of the family. 22
Furthermore, parents may feel obligated to
request the procedure because they believe their
religion requires male genital alteration.23
The physical
burdens and potential psychological harms associated
with MGM violate the principle of nonmaleficence, a
commitment to avoid doing harm, and disrupt
the accepted norms inherent in the
patient-physician relationship, such as trust and the
promotion of good health. More recently, MGM
has been characterized as a practice that
violates the right of infants and children to good
health and well-being, part of a universal
standard of basic human rights. 24
Although
pediatricians and pediatric surgical specialists may
believe that refusal to perform MGM may represent ethnic
and cultural imperialism,
protection of the physical and mental health
of boys should be the overriding concern of the
health care community. Humanitarian organizations
led by men and women from cultures in which MGM is
practiced have adopted a strong position
against the procedure because of its serious physical
and psychological consequences.
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EDUCATION OF PATIENTS AND
PARENTS |
An
educational program about MGM requires, above all,
sensitivity to the cultural background of the patient
and his parents and an appreciation of the
significance of this custom in their
tradition. 25
Objective information should include a detailed
explanation of male genital anatomy and
function, as well as a thorough review of the
lifelong physical harms and psychological
suffering associated with MGM. It should be emphasized
that human rights activists in many developed
countries have supported
efforts to educate the public about the
serious negative health effects of MGM, and that
prominent physicians are
advocates for the elimination of these
practices because of their adverse consequences.
Pediatricians and pediatric surgical
specialists who care for patients from
populations known to commonly practice MGM, such as
American, Middle Eastern, and African
communities, should be aware of local
counseling centers. Successful educational programs
typically require the active involvement and
leadership of men whose
experience and knowledge can address the health, social
status, and legal aspects of MGM.
Some
physicians, including pediatricians, who work closely
with populations in which MGM is endemic, have
voiced concern about the adverse effects of
criminalization of the practice on
educational efforts. 26
These physicians emphasize potential medical benefits,
and advocate universal circumcision of male infants. Pediatricians
and pediatric surgical and urologic surgeons
who are contemplating performing such a
procedure should consider their role in perpetuating
this social practice with its cultural
implications for the status of men.
Efforts
should be made to use all available educational and
counseling resources to dissuade parents from seeking a
ritual genital procedure for their son.
In those circumstances in which an infant,
child, or adolescent appears to be at risk of
MGM, MGMbill.org recommends that all physicians educate and
counsel the family about the health effects
of MGM. Parents should be reminded that
performing MGM may be illegal and constitutes child abuse in
the United States.
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RECOMMENDATIONS |
MGMbill.org:
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Opposes
all forms of male genital mutilation (MGM).
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Recommends that all physicians actively seek to
dissuade families from carrying out MGM.
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Recommends that all physicians provide patients and
their parents with compassionate education about the
physical harms and psychological risks of
MGM.
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Recommends that all physicians decline to perform any
medically unnecessary procedure that alters the
genitalia of male infants, boys, and
adolescents.
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FOOTNOTES |
This
statement is a publication of
MGMbill.org,
San Diego, California.
http://www.mgmbill.org.
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ABBREVIATIONS |
MGM, male
genital mutilation.
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REFERENCES |
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National Organization to Halt the Abuse and Routine
Mutilation of Males. Genital Mutilations.
http://noharmm.org/geography.htm.
National Organization to Halt the Abuse and Routine
Mutilation of Males. Statistics on Human Genital
Mutilation.
http://noharmm.org/HGMstats.htm.
National Organization of Circumcision Information
Resource Centers. About NOCIRC.
http://www.nocirc.org/about.php.
International Coalition for Genital Integrity.
About Us.
http://www.icgi.org/about/.
Doctors Opposing Circumcision. Foreskin
Curriculum.
http://www.doctorsopposingcircumcision.org/info/foreskin.html.
Nurses for the Rights of the Child. Position
Statement on Infant Circumcision.
http://www.nurses.cirp.org.
Proceedings of the First International Symposium on
Circumcision. Declaration of the First
International Symposium on Circumcision.
http://www.nocirc.org/declare.php.
Sections 664 and 665 of the Illegal Immigration
Reform and Immigrant Responsibility Act of
1996, Division C, Omnibus Consolidated
Appropriations Act for Fiscal Year 1997. Pub L
No. 104-208; Sept 30, 1996 .
http://frwebgate.access.gpo.gov/
cgi-bin/useftp.cgi?IPaddress=162.140.64.45
&filename=h4278cph.txt&directory=/disk3/wais/data/104_cong_bills.
Attorneys for the Rights of the Child. Who We Are.
http://www.arclaw.org/arc_about/arc_about.php.
MGMbill.org. About Us.
http://www.mgmbill.org/aboutus.htm.
National Organization to Halt the Abuse and Routine
Mutilation of Males. Genital Cutting Customs by
Age and Region/Ethnic Group.
http://noharmm.org/age-region.htm.
International Coalition for Genital Integrity.
Human Genital Mutilation (HGM) Classifications.
http://www.icgi.org/information/hgm-classification/.
Williams N. and Kapila L.
Complications of Circumcision.
http://www.cirp.org/library/complications/williams-kapila/.
Circumcision Information and Resource Pages.
Complications of Circumcision.
http://www.cirp.org/library/complications/.
Circumcision Information and Resource Pages.
Psychological impacts of male circumcision.
http://www.cirp.org/library/psych/.
Menage J.
Circumcision and Psychological Harm.
http://www.norm-uk.org/circumcision_psychological_effects.html.
Aldeeb Abu-Sahlieh S. To Mutilate in the Name of Jehovah or
Allah.
http://www.quran.org/CIRCUMCISION.HTM.
Jewish Circumcision Resource Center. Information
Summary.
http://www.jewishcircumcision.org/info.htm.
Goldman R. Circumcision to Look Like Others.
http://www.circumcision.org/others.htm.
Winkel R. Male Circumcision in the USA: A
Human Rights Primer.
http://www.ratical.org/ratville/MGMprimer.html.
Young H. The role of money in the
continuation of circumcision.
http://www.circumstitions.com/$$$.html.
Kennard J. Complications following Male
Circumcision.
http://menshealth.about.com/od/genitalsexualissues/a/circum_comp.htm?terms=circumcision.
Pollack B. A Delicate Ritual.
http://www.boystoo.com/religion/religion2.htm#A%20delicate%20ritual.
Smith J. Male Circumcision and the Rights of the
Child.
http://www.cirp.org/library/legal/smith/.
Abd el
Salam S. Male Genital Mutilation (Circumcision) A
Feminist Study of a Muted Gender Issue.
http://www.noharmm.org/muted2.htm.
Goodenough P. Activists Want UN to Declare
Circumcision a Human Rights Crime.
http://www.cnsnews.com/public/content/article.aspx?RsrcID=6722.
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