During most of human history, religious explanations and rituals imparted meaning to people’s lives and justified controlling their conduct. Today, medical explanations and rituals often perform those functions. For example, masturbation and homosexuality were first forbidden on religious grounds, then on medical grounds. Being a male infant is, of course, not behavior. Accordingly, routine neonatal circumcision (RNC) is justified—if and where it is justified—not by the subject’s behavior but by the significance his parents and society attach to his foreskin. Remarkably, the United States is the only modern Western country in which most parents and society in general view RNC as a good thing, and hence where the majority of newborn males is circumcised.
Webster’s defines circumcision as “The cutting off of the prepuce of males being practiced as a religious rite by Jews and Muslims and as a sanitary measure in modern surgery” (emphasis added). For Jews, the ritual removal of the infant’s foreskin symbolizes his entrance into the Jewish community. For educated Americans, its prophylactic removal symbolizes his entrance into the community of medically enlightened persons.
The biblical origin of circumcision is the covenant between God and Abraham (Genesis, 17:9): “And God said to Abraham, . . . ‘This is my covenant, which you shall keep, between me and you and your descendants after you: Every male among you shall be circumcised. . . . Any uncircumcised male who is not circumcised in the flesh of his foreskin shall be cut off from his people; he has broken my covenant.” That the practice of circumcision has its origin in religious ritual is so incontrovertible that not even the most zealous advocates of the procedure try to deny it. They do, however, try to rationalize it (much as people have tried to rationalize the Jewish dietary laws) as an expression of primitive insight into its hygienic character. However, there is no basis, in either religious history or medicine, for this contention.
How and when did ritual circumcision become prophylactic circumcision, and why did it become especially popular in the United States? For millennia, neither circumcision nor the delivery of the pregnant woman was considered to be a medical procedure. The penile foreskin was regarded as a normal body part, and pregnancy was regarded as a normal event. Women gave birth unassisted or were delivered by female relatives or by informally trained midwives. So long as that remained the practice, circumcision could not become a medical procedure. Much has been written about the conquest of pregnancy and delivery for medicine, male professionals displacing female amateurs as the sole, legally authorized providers of so-called obstetrical services. Along with this change, the place of delivery was transferred from the home to the hospital, and normal birth itself became seen as a surgical intervention, supposedly facilitated by routine episiotomy. The stage was set for the routine, surgical circumcision of the normal, male infant by the obstetrician, rationalized as prophylaxis. Against what? The answer is masturbation, a plague that could be prevented as well as cured by circumcision.
Virtually all medical texts at the end of the 19th century and the beginning of the 20th prescribed circumcision for a variety of ills, ranging from epilepsy and hydrocephalus to malnutrition and tuberculosis, and confidently asserted that it was a cure for the “disease” of masturbation. The following statement from a standard medical text published in 1887 is typical: “Whether masturbation is a cause of epilepsy is doubted. But there can be no doubt of its injurious effect. . . . Circumcision should always be practiced. It may be necessary to make the genital so sore by blistering fluids that pain results from attempts to rub the part.”
It requires education to see the world through disease-colored glasses. Thus, members of the upper classes are the most ardent consumers of medical fables, while members of the lower classes tend to be skeptical of health information, both valid and invalid. The role of medical misinformation is humorously mocked in Knock, a 1920’s masterpiece by Jules Romains that is all but forgotten today. Dr. Knock explains his views as follows:
“Get sick” is an old idea. It can’t stand up to modern science. “Health” is a word which we could just as well erase from our vocabularies. For me there are only people more or less sick of more or less numerous diseases progressing at a more or less rapid rate. . . . A profoundly modern theory, M. Mosquet. If you think it over, you’ll be struck by its relation to the admirable concept of the nation in arms, a concept from which our modern states derive their strength.
This parody has become our social reality. We conceptualize every problem in living—from the misbehavior of youth to the melancholia of the elderly—as a disease. Given this mindset, it is not surprising that circumcision became medicalized and that RNC proved to be especially popular in the United States. About the same time (in the 1950’s) that the British National Health Service stopped paying for RNC, American third-party payers, including welfare programs, began to reimburse the procedure and circumcision became the American standard. By 1993, the rate of circumcision dropped to between five and six percent in Britain, and stood at 80 to 90 percent in the United States. Despite this, the incidence of the cancer of the penis is higher in the United States than in Denmark and Japan, “where circumcision is done only for clear medical indications.”
Why is RNC legal? Because it is defined as preventive medicine. Why is it defined as preventive medicine? To avoid having to ban it as male genital mutilation. This reciprocal relationship between language and law is intrinsic to our concept of legality. Whether a particular act is legal or illegal depends on what we call it. Killing in the name of “self-defense” is legal; “murder” is a crime. We call the removal of the foreskin of the male newborn “routine neonatal circumcision,” and the removal of parts of the female genitalia “female genital mutilation” (FGM). Language thus prejudges the legitimacy (or illegitimacy) of the practice.
Although female circumcision is not the subject of this essay, and although it is an anatomically far more serious mutilation than RNC, I wish to add two brief remarks. First, because FGM is banned in many Western countries and is not an accepted medical procedure in the United States, RNC at home is a more important civil rights issue than FGM is abroad. Second, although most Americans refuse to compare the two procedures, the similarities are obvious (and apparent to Europeans): both interventions alter the normal anatomy of the genital organs, and the people who practice them attribute health benefits to both (Americans to male circumcision. Africans to female circumcision).
Neither the risk of cancer of the penis nor the risk of other problems associated with the male urogenital organ justifies routine circumcision. Cancer of the penis is a rare condition that occurs only in middle age or later, affording young males who fear developing the disease time to submit to prophylactic circumcision. Other pathological conditions associated with the uncircumcised penis, such as phimosis severe enough to interfere with urination and urinary tract infections, are indications for treating the affected children, not for RNC.
It requires more credulity than befits us to believe the absurd premise on which the practice of RNC ultimately rests, namely, that the only mammal in creation born in a condition that requires immediate surgical correction is the human male. Accordingly, it is not enough for physicians to conclude, as does the author of a comment in the prestigious New England Journal of Medicine, that “The benefits [of circumcision] appear to be uncertain. It, therefore, seems prudent to consider neonatal circumcision a procedure to be performed at the discretion of parents, not as a part of routine medical care. Omitting circumcision in the neonatal period should not be considered medical neglect. Parents should be informed of the current state of medical knowledge regarding the risks and benefits of the procedure. Their ultimate decision may hinge on nonmedical considerations.” (Emphasis added.)
If the parents’ ultimate decision to circumcise their male infant hinges on nonmedical considerations, then RNC is a medically unjustifiable practice. It is relevant to note that observant Jewish parents still employ mohels to circumcise their male infants, a practice the American Medical Association explicitly endorses.
If RNC is medically unjustifiable, does it constitute a form of child abuse? Persons unbound by Jewish and Islamic religious rules might reach that conclusion. Should it be illegal? Therein lies our ethical dilemma. We must balance the (relatively small) harm RNC does to the individual against the (potentially vast) harm that strengthening the state at the expense of the family does to everyone. Because the family remains our most secure shield against the encroachments of the therapeutic state, the dilemma calls for compromise. Preventing RNG does not warrant enlisting the coercive apparatus of the state against the religious values of parents. It does warrant, however, enlisting the persuasive powers of physicians—and the media— in the task of informing parents of newborn males about the medically dubious and morally problematic nature of this ostensibly hygienic procedure.