Tuesday, August 2, 2011

Male Circumcision is Not Genital Mutilation

One evening I was dining with my anthropologist friend Natalie and I expressed just how viscerally and zealously I abhor the African practice of female genital mutilation. As a male champion of women’s rights and a lover of the female form I believe that there is no reason to hack off a pubescent girl’s clitoris and/or labia other than to make the act of intercourse painful, to deprive women of their inherent sexual freedom and to oppress them as a permanently subservient class. I think that female genital mutilation is such a patently wrong act, a reification of misogynist and phallocentric violence that should be prohibited and criminalized. Anyone who practices female genital mutilation is a menace to society, and our police forces should lock them up behind bars.

Natalie threw a wrench into my crusade for the sanctity of the clitoris; “But Zac, aren’t you Jewish?”

“Yeah, so? What’s that have to do with anything?”

She looked down in the direction under the table and cleared her throat.

At that moment I realized the hypocrisy of my zeal. I was so humbled and dressed down that I concluded that when speaking of subjects as delicate as a culture’s practices pertaining to the sexual organs – especially those of cultures that are not one’s one – perhaps one should generally abstain from casting matters in sweeping judgments of “right” and “wrong”. I’m not saying that one shouldn’t criticize the genital practices of foreign cultures; sometimes one must. But perhaps we should limit our analysis to those things that we can prove at least somewhat scientifically and avoid subjective critiques of metaphysics and postmodern gender theory.

My friend Natalie isn’t the only one who thinks that my righteous indignation against genital mutilation should apply to both genders. There is in fact a growing faction of feminists, human rights activists and lovers of the natural male form want to broaden the definition of assault to include those who circumcise the foreskin. The self-proclaimed “Intactivists” advocate for the preservation of “genital integrity” and an end to the practice of male circumcision – or “male genital mutilation” as they prefer to call it.

One such group known as the Bay Area Intactivists values the foreskin as a nerve-rich portion of the male genital organ. From their perspective, male circumcision is means of denying to a male and his future partner(s) the potential for maximum sexual satisfaction.

Other groups such as Intact America are organizing the opposition to male circumcision from comparatively more scientific, rationally more compelling grounds. If you read their literature, you get the sense that they represent a faction within the American medical community who oppose the practice under the logic that 1. the act of circumcision can be painful; 2. it can lead to infections and other harmful complications, and 3. removing the foreskin is not medically necessary.

Now the combined Intactivists of San Francisco have garnered enough signatures to put a referendum on the ballot which extend the definition of assault to those who circumcise males under the age of 18. If the proposition passes, the circumcising of a male’s foreskin would be a misdemeanor offense punishable by up to a $1,000 fine or up to one year in jail. The consent of the underage male in question would be irrelevant; a male could only consent to having his foreskin removed if he is a legal adult. There would be no religious exemptions.

The movement to utilize the compelling force of criminal law to prohibit male circumcision is not without foundation. After all, since federal legislation was passed in 1996, Section 116 of the U.S. Code has defined whomever “circumcises, excises, or infibulates the whole or any part of the labia majora or labia minora or clitoris of another person who has not attained the age of 18 years” as a perpetrator of assault. The Intactivists make a reverse-sexist argument that by creating a set of legal protections for women – but not extending those same protections to men – the continued legality of male circumcision is a violation of the Equal Protection Clause.

As much as this blogger disagrees with the claims of the Intactivists, I am equally critical of the campaign by the Anti-Defamation League and the American Civil Liberties Union who are arguing against the San Francisco ballot measure in terms of religious freedom. If a federal judge were to strike down a municipal ordinance banning male circumcision because it is a violation of the Jewish people’s freedom to exercise our religion, then that same judge would have to uphold the right of West African Muslims to practice female genital mutilation on the same grounds. This would be an argument of cultural relativism; e.g. “Yes, it is a barbaric practice, but we live in a barbaric society in which cruelty and torture are woven into the fabric of our culture.” This is not the argument that the defenders of male circumcision ought to take.

If defenders of circumcision are going to make a valid argument based on moral logic and reason, one must contend why the practice itself is not just a tolerable tradition with religious significance but actually a positive good with secular and tangible benefits. And moreoever, it doesn't hurt to deconstruct the logic for the argument against circumcision.

From what I gather after a comprehensive reading of their literature, the moral logic of the Intactivist movement runs as following:

1. Female circumcision is a cruel, inhumane practice which can cause disease and pain over the course of the victim’s lifetime. (Given)
2. The only reason why cultures practice female circumcision is to make the act of sexual intercourse excruciatingly painful and undesirable. (Given)
3. Therefore, female circumcision is a form of assault (1, 2)
4. Gender is only a social construct, there is no substantive difference between men and women, in fact, the binary characterization of human beings as either men or women is a form of gendered chauvinism. (Given)
5. Therefore, male circumcision is also a cruel, inhumane practice (1, 4)
6. Therefore, the only reason why Western culture practices male circumcision is to make the act of sexual intercourse excruciatingly painful and undesirable (2, 4)
7. Therefore, male circumcision is a form of assault (5, 6) Q.E.D.

The crucial fallacy in this logical argument is postulate number 4. Though traditional gender roles and identities might be a mere social construction, it is more than fair to say that there is, in fact, at least one significant difference between the vast majority of individuals born as males or female; generally speaking, males are endowed with penises and females are endowed with vaginas. In light of this fundamental distinction, the removal of the clitoris and/or the labia should be banned while the removal of the foreskin should remain legal because there is in fact a very compelling case to be made that male circumcision and female “circumcision” are two very different operations performed on two very different organs which ought to be distinguished as such under law.

Intactivists’ Sophistry #1: “Surgically removing part of a baby boy’s penis causes pain.”

If one were to practice circumcision with the same crude instruments and techniques as say, the Dogon tribe of Mali, then it is indeed an unnecessary painful procedure. The Dogons gather all of the uncircumcised boys 12 years old and up and to have the village blacksmith remove the boys’ foreskins with a homemade blade which is not very sharp by Western standards – and they perform the operation without any sort of anesthetic. Perhaps this argument over pain might be valid if Jews in America were to practice circumcision in a way similar to the Dogons; if that were the case, maybe circumcision should be prohibited under law.

The modern Diasporic Jews of America, however, have developed a method of circumcising our boys at the age of eight days when the nerves of the appendage are not as sensitive as a pubescent boy and we utilize various means of anesthesia which all but eliminate pain. The most effective of these is nerve-block applied locally with a shot to the penis – a remarkably effective anesthetic which renders the applied area completely numb. Rabbinical student Josh Stanton and Dr. Anne Epstein write: “While the idea of an injection to the penis sets teeth on end, it is as close to pain-free as we can get in this sort of minor surgery… It hardly hurts.”

Just about any operation involving the cutting of flesh – even an operation as minor as a tonsillectomy or the removal of an ingrown toenail – would be painful without anesthesia. But if the prick of a needle was reason to ban a medical procedure on the basis of pain, then banning circumcision would make no more sense than banning tetanus or polio vaccinations. In this day and age of modern anesthetics, the contention that circumcision should be banned because the procedure causes pain holds little ground.

Intactivists’ Sophistry #2: “Male circumcision creates immediate health risks and can lead to serious complications.”

Indeed, a botched circumcision could lead to an infection of the penis or worse. In cultures that perform this operation with crude tools and unsanitary conditions – such as the Dogon blacksmiths with their homemade iron blades – yes, the removal of a boy’s foreskin does sometimes lead to more serious complications including not only local infections but hemorrhage, scarring, difficulty urinating, loss of part or all of the penis, and even death. According to the Center for Disease Control, between 2% and 8% of all circumcisions performed in African cultures lead to an infection or more serious complications.

However, such fears are essentially unwarranted in the developed West because we utilize modern medical practices, the doctors and mohels who perform circumcisions are rigorously trained, and we perform the operation in a sanitary environment. Even if the most basic aspect of male circumcision remains the same, the cleanliness of our foreskin-cutting arenas, our medical instruments and our practices make a world of a difference. Local infection is still nevertheless possible – but then again, even having your bellybutton pierced can lead to an infection if it is not done by the right person in the right place the right way.

Whether an adequately trained, certified mohel conducts a circumcision in a synagogue or if a bona fide doctor circumcises a baby boy in a hospital, the risk of immediate health risks with serious complications is extremely small. According to the CDC, the rate of complications due to male circumcision in the United States is around 0.2% of all cases – in other words, just about negligible.

Indeed, the medical Intactivists are correct when they argue that male circumcision can cause infections – there is that 1 case in 500 in which the circumcision does lead to a complication – but that fact cannot be adequately evaluated in isolation. In a study of circumcised boys in Washington State conducted over the course of a decade, it was found that for every circumcision complication there were 6 urinary tract infections prevented. Circumcision also reduces the chance of contracting human papillomavirus (and thereby penile cancer), genital herpes and HIV.

Intactivists’ Sophistry #3: “Male circumcision is unnecessary” because “Claims that circumcision prevents HIV have repeatedly been proven to be exaggerated or false. Only abstinence or safe sex, including the use of condoms, can prevent the spread of sexually transmitted diseases including HIV/AIDS.”

At this point in the evolution of homo sapiens, the continued possession of a foreskin actually poses a risk to the health of males and those who have sex with them. The main reason why not circumcising a boy creates a health risk is that this vestigial structure creates a cavity which can retain smegma which can sit and fester, inviting bacterial and viral infection. Uncircumcised males are more likely to contract and transmit HIV than those who are circumcised, largely because the smegma which can be retained in the foreskin allows for the transmission of the virus to and from vaginal fluids. In addition, the foreskin has considerable surface area which renders the penis more susceptible to minor trauma and ulcerative disease – thus increasing the chance of transmitting the HIV virus.

A 2000 study of the relationship between male circumcision and heterosexual transmission of HIV in Africa noted “a substantial protective effect of male circumcision on risk for HIV infection”; finding that the risk of HIV infection in circumcised men was 44% lower than those who were uncircumcised. The strongest association between circumcision or lack thereof and HIV infection rates was found in high risk populations (e.g. patients at STD clinics) for whom the adjusted relative risk was 71% lower for those who had been circumcised. Another study conducted in 2003 found that the risk of HIV infection in circumcised men was 42% lower than their uncircumcised counterparts.

More macro-level epidemiological studies indicate that the practice of circumcision is not limited to the individual men but also the population as a whole; after all, if a man has contracted HIV due to his smegma-retaining foreskin, he is then liable to transmit the virus to his sexual partner(s), who are then liable to transmit the virus to their sexual partners, etc. African and Asian countries in which less than 20% of the male population has been circumcised have HIV infection rates several times greater than comparable African and Asian countries in which more than 80% of the male population has been circumcised. Of course, there are many other variable including religious mores and sexual norms which also vary among these countries, but the link between relatively high rates of circumcision and relatively low rates of HIV infection is so strong that the value of the practice as a significant factor in reducing disease transmission cannot be ignored.

I have heard a number of objections to this kind of analysis; namely that such studies have only been performed in underdeveloped Third World nations and not the developed West. These skeptics contend that since Americans and Europeans have better hygiene than the typical African, since we generally practice monogamy, wear condoms and bathe regularly we do not need to bother with circumcision.

Such First World-centrics are faulty in their reasoning, particularly because the studies linking the lack of circumcision to higher rates of HIV infection found the greatest correlation in the most at risk populations – precisely those persons in the United States who are the most likely to have sex with multiple or even concurrent partners, those who do not wear condoms, and those who have the worst hygiene. The mere fact that one might reside in the Global North does not separate that person from the basic facts of virology which tend to be associated with the Global South. Likewise, if circumcision has been found to be an effective method of minimizing the HIV epidemic amongst homo sapiens in sub-Saharan Africa, absent any fundamental anatomical or physiological distinction between Americans and Africans, there is only reason to conclude that that practice remains effective amongst homo sapiens in the United States.

I have also heard the argument made that circumcision is unnecessary for homosexual men, because the studies cited above have only demonstrated a link between circumcision and reduced prevalence of HIV amongst heterosexual men. This Intactivist argument maintains that for a parent to decide that they will circumcise their boy to protect him from HIV and AIDS is to make a heteronormative assumption that their child is in fact straight, and that if their boy turns out to be gay then they will be deprived of sexual satisfaction due to a societal bias towards heterosexuality.

This Intactivist sophistry is not only spurious in its logic but quite dangerous in its potential for giving homosexuals a false sense of security. Though the possession of a foreskin is most likely to transmit disease via the mixing of smegma and vaginal fluids – which is exclusive to heterosexual intercourse, that is not the only reason why possession of the foreskin increases the chance of disease transmission. Disease can also be transmitted because the foreskin is more easily susceptible to tearing. One must also take bisexuality into consideration; an uncircumcised man could very easily receive the HIV virus by trading fluids with an HIV+ woman and later on transmit the virus to a male sexual partner (or the other way around) explicitly due to his possession of his original foreskin.

Read Intact America’s sophistry again: “Only abstinence or safe sex, including the use of condoms, can prevent the spread of sexually transmitted diseases including HIV/AIDS.” This is more or less the logic of abstinence-only sex education; “if you don’t have sex, then you can’t get a sexually-transmitted disease; therefore don't wear a condom”; “if you always wear a condom, then you can’t get a sexually-transmitted disease; therefore you don’t need to be circumcised.” The problem with this logic is that uncircumcised men do have sex, sometimes they use condoms, sometimes they don’t, sometimes they have sex with a condom but the condom breaks, etc. Even the highest-quality prophylactics can fail - that is why instead of relying on the effectiveness of one or two disease prevention methods, it is best to employ as many as possible.

Intact America is telling the truth when its literature states that circumcision is not the only way to prevent the transmission of HIV, that abstaining from sex or practicing safe sex are alternative ways of preventing disease transmission. But they're not telling the whole truth. “Male circumcision is unnecessary”; indeed, for a practitioner of celibacy there might not be much of a benefit, but for everyone else it remains a very sound, particularly effective means of reducing the transmission of disease. There is no silver bullet which can by itself inoculate an individual from HIV/AIDS, no one is claiming that circumcision can by itself rid the world of this deadly epidemic. Rather, medical proponents of circumcision are contending that it is but one of many practices which ought to be maintained – along with fidelity to one’s partner, safe sex, regular testing – in order to defend oneself from STD transmission.

Likewise, the Intactivist movement is making a grave mistake in trying to ban male circumcision under the guise of public health; their pseudo-scientific case to ban the practice is so full of misleading language, cherry-picked half-truths and outright falsehoods that it cannot be taken seriously. Perhaps there are other reasons why a parent might reasonably decide to opt to not circumcise their male child – religious, sexual, aesthetic or otherwise – but the health of the child is not one of them. Male circumcision is not genital mutilation; it is a sound medical procedure which is safe, which does not cause undue pain, and it is still a very effective component of our society's efforts to maintain men's health and curb the spread of disease in America and throughout the world.