Non-therapeutic male genital cutting and harm: Law, policy and evidence from U.K. hospitals.

Female genital cutting (FGC) is generally understood as a gendered harm, abusive cultural practice and human rights violation. By contrast, male genital cutting (MGC) is held to be minimally invasive, an expression of religious identity and a legitimate parental choice. Yet scholars increasingly problematize this dichotomy, arguing that male and female genital cutting can occasion comparable levels of harm. In 2015 this academic critique received judicial endorsement, with Sir James Munby's acknowledgement that all genital cutting can cause 'significant harm'. This article investigates the harm occasioned by MGC. It is informed by a Freedom of Information (FoI) study which provides some empirical evidence of the nature and frequency of physical harm caused by MGC in U.K. hospitals. While acknowledging the challenges and limitations of FoI research, we outline important lessons that this preliminary study contains for medical ethics, law and policy. It provides some empirical evidence to support claims regarding the risks which accompany the procedure and the obligation of health professionals to disclose them, and reveals the paucity of measures in place to ensure that harms are recorded, disclosed and monitored.

Nontherapeutic Circumcision of Minors as an Ethically Problematic Form of Iatrogenic Injury.

Nontherapeutic circumcision (NTC) of male infants and boys is a common but misunderstood form of iatrogenic injury that causes harm by removing functional tissue that has known erogenous, protective, and immunological properties, regardless of whether the surgery generates complications. I argue that the loss of the foreskin itself should be counted, clinically and morally, as a harm in evaluating NTC; that a comparison of benefits and risks is not ethically sufficient in an analysis of a nontherapeutic procedure performed on patients unable to provide informed consent; and that circumcision violates clinicians' imperatives to respect patients' autonomy, to do good, to do no harm, and to be just. When due consideration is given to these values, the balance of factors suggests that NTC should be deferred until the affected person can perform his own cost-benefit analysis, applying his mature, informed preferences and values.

Foreskin and the molecular politics of risk.

In this paper, I examine disputes over recent claims that male circumcision reduces HIV risk to suggest a complicated relationship between risk individualization and categorization. Whereas randomized controlled trials (RCTs) conducted in sub-Saharan Africa appear to have provided key evidence for the World Health Organization's endorsement of male circumcision as an HIV prevention strategy, RCTs alone did not provide evidence for the underlying causal mechanism. For that, medical authorities have turned to histo-immunological studies of the foreskin's biomolecular vulnerability to HIV, thus molecularizing risk. Some actors used these studies both as a way of shoring up results of RCTs conducted in sub-Saharan Africa and as an important rationale in arguments for making neonatal circumcision more widely available. Others, however, resisted this move to generalize the RCT results to other parts of the world, citing both contextual differences in HIV transmission patterns and conflicting scientific details regarding the biomolecular basis of the foreskin's susceptibility. Nevertheless, by locating an abstract notion of relative risk in the body itself, I argue that histological studies of foreskin have played a key role in stabilizing male circumcision status as a new risk category, largely independent of a given individual's risk profile.

Between Moral Relativism and Moral Hypocrisy: Reframing the Debate on "FGM".

The spectrum of practices termed "Female Genital Mutilation" (or FGM) by the World Health Organization is sometimes held up as a counterexample to moral relativism. Those who advance this line of thought suggest the practices are so harmful in terms of their physical and emotional consequences, as well as so problematic in terms of their sexist or oppressive implications, that they provide sufficient, rational grounds for the assertion of a universal moral claim--namely, that all forms of FGM are wrong, regardless of the cultural context. However, others point to cultural bias and moral double standards on the part of those who espouse this argument, and have begun to question the received interpretation of the relevant empirical data on FGM as well. In this article I assess the merits of these competing perspectives. I argue that each of them involves valid moral concerns that should be taken seriously in order to move the discussion forward. In doing so, I draw on the biomedical "enhancement" literature in order to develop a novel ethical framework for evaluating FGM (and related interventions--such as female genital "cosmetic" surgery and nontherapeutic male circumcision) that takes into account the genuine harms that are at stake in these procedures, but which does not suffer from being based on cultural or moral double standards.

Risks, benefits, complications and harms: neglected factors in the current debate on non-therapeutic circumcision.

UNLABELLED: Much of the contemporary debate about the propriety of non-therapeutic circumcision of male infants and boys revolves around the question of risks vs. BENEFITS: With its headline conclusion that the benefits outweigh the risks, the current circumcision policy of the American Academy of Pediatrics [AAP] (released 2012) is a typical instance of this line of thought. Since the AAP states that it cannot assess the true incidence of complications, however, critics have pointed out that this conclusion is unwarranted. In this paper it is argued that the AAP's conclusion is untenable not only for empirical reasons related to lack of data, but also for logical and conceptual reasons: the concept of risk employed-risk of surgical complications-is too narrow to be useful in the circumcision debate. Complications are not the only harms of circumcision: the AAP and other parties debating the pros and cons of circumcision should conceptualize their analysis more broadly as risk of harm vs. prospect of benefit, thereby factoring in the value of the foreskin to the individual and the physical and ethical harms of removing it from a non-consenting child.

Important considerations for the newborn: access to postdischarge newborn care, pulse oximetry screening for congenital heart disease, and circumcision.

PURPOSE OF REVIEW: This article addresses three areas in which new policies and research demonstrate the opportunity to impact the health of neonates: access to postdischarge newborn care, pulse oximetry screening for congenital heart disease, and circumcision. RECENT FINDINGS: Recent research has identified that child healthcare providers are not typically adhering to the recommended first newborn visit within 48 h of hospital discharge. Despite its benefits, cost-effectiveness, and the recommendation that routine screening for cyanotic congenital heart disease be added to the panel of universal newborn screening, adoption of this practice is variable. Evidence suggests a significant reduction in the transmission of HIV linked to circumcision, leading professional organizations to generate new policy statements on neonatal male circumcision. SUMMARY: Pediatric healthcare providers should pay careful attention to the timing of the first newborn outpatient follow-up visit. Pulse oximetry screening for cyanotic congenital heart disease is specific, sensitive and meets criteria for universal screening, and providers should utilize well designed screening protocols. In addition, healthcare providers for newborns, especially those who perform circumcisions, should provide nonbiased, up-to-date information on the medical, financial, and ethical aspects of the procedure.

Neonatal circumcision: new recommendations & implications for practice.

Neonatal male circumcision is the most common surgical procedure performed on pediatric patients. While the rate of neonatal circumcision in the United States has been dropping, circumcision continues to be frequent, ranging from 42% to 80% among various populations. While the cultural debate over circumcision continues, recent evidence of medical benefits led to a revision of the American Academy of Pediatrics (AAP) circumcision policy statement. In contrast to the 1999 AAP policy statement, the 2012 policy asserts that the preventive benefits of neonatal circumcision outweigh the risk of the procedure, which is well tolerated when performed by trained professionals, under sterile conditions, and with appropriate pain management. This Circumcision Policy Statement has also been endorsed by the American College of Obstetricians and Gynecologists and a similar policy statement is in place from the American Urologic Association. Despite the new recognized health benefits found by the 2012 Task Force of Circumcision (TFOC), circumcision remains controversial even among medical professionals. Other well recognized medical organizations including The American Academy of Family Practice and some international pediatric societies have not adopted such a strong endorsement of circumcision. The policy statements from these organizations continue to more closely resemble the 1999 AAP policy statement that stated, "Existing scientific evidence demonstrates potential medical benefits of newborn male circumcision; however, these data are not sufficient to recommend routine neonatal circumcision." In this review we will summarize historical, cultural and ethical factors in neonatal circumcision and briefly compare common surgical techniques including anesthesia. In addition, we will discuss recent information regarding the benefits and risks of neonatal circumcision. Finally, we will discuss the financial reimbursement of practitioners and the benefits of standardized circumcision curriculum for trainees.

Forced circumcision of men (abridged).

The forced circumcision of men is a widespread human rights abuse that often accompanies other human rights violations. It occurs in clashes between circumcising and non-circumcising cultures, or when individuals in circumcising cultures reject circumcision. This article documents the forced circumcision of men against their will, shows how evidence of forced circumcision has been downplayed and discounted, and outlines and discusses some measures that could help to reduce its prevalence.

Recommendation by a law body to ban infant male circumcision has serious worldwide implications for pediatric practice and human rights.

BACKGROUND: Recent attempts in the USA and Europe to ban the circumcision of male children have been unsuccessful. Of current concern is a report by the Tasmanian Law Reform Institute (TLRI) recommending that non-therapeutic circumcision be prohibited, with parents and doctors risking criminal sanctions except where the parents have strong religious and ethnic ties to circumcision. The acceptance of this recommendation would create a precedent for legislation elsewhere in the world, thereby posing a threat to pediatric practice, parental responsibilities and freedoms, and public health. DISCUSSION: The TLRI report ignores the scientific consensus within medical literature about circumcision. It contains legal and ethical arguments that are seriously flawed. Dispassionate ethical arguments and the United Nations Convention on the Rights of the Child are consistent with parents being permitted to authorize circumcision for their male child. Uncritical acceptance of the TLRI report's recommendations would strengthen and legitimize efforts to ban childhood male circumcision not just in Australia, but in other countries as well. The medical profession should be concerned about any attempt to criminalize a well-accepted and evidence-based medical procedure. The recommendations are illogical, pose potential dangers and seem unworkable in practice. There is no explanation of how the State could impose criminal charges against doctors and parents, nor of how such a punitive apparatus could be structured, nor how strength of ethnic or religious ties could be determined. The proposal could easily be used inappropriately, and discriminates against parents not tied to the religions specified. With time, religious exemptions could subsequently be overturned. The law, governments and the medical profession should reject the TLRI recommendations, especially since the recent affirmative infant male circumcision policy statement by the American Academy of Pediatrics attests to the significant individual and public health benefits and low risk of infant male circumcision. SUMMARY: Doctors should be allowed to perform medical procedures based on sound evidence of effectiveness and safety with guaranteed protection. Parents should be free to act in the best interests of the health of their infant son by having him circumcised should they choose.

Forced genital cutting in North America: feminist theory and nursing considerations.

This article will examine forced nontherapeutic genital cutting (FNGC) through the lens of feminist theory and in relation to the concept of social justice in nursing. I will address the underlying assumptions of feminism and how they apply to the two currently legal forms of FNGC in North America: male infant circumcision and intersex infant/child genital cutting. Through a literature review and critical analysis of these practices, I will illustrate the challenges they present when considering the role of nurses in promoting social justice. If feminism asserts that bodily integrity, autonomy, and fundamental human rights are essential components of gender equality, it follows that these must be afforded to all genders without discrimination. Historically, there have been few feminists who have made this connection, yet a growing and diverse movement of people is challenging the frameworks in which we consider genital cutting in our society. Nurses are positioned well to be at the forefront of this cause and have a clear ethical duty to advocate for the elimination of all forms of FNGC.

Science and ethics of human immunodeficiency virus/acquired immunodeficiency syndrome controversies in Africa.

The human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) epidemic in Africa has raised important ethical issues for both researchers and clinicians. The most notorious controversy has been related to the zidovudine (AZT) trials in Africa in the late 1990s, in which the control groups were given a placebo rather than an effective drug to prevent vertical transmission. This raised concerns in the sponsoring country about exploitation of subjects, injustice and an ethical double standard between donor countries and resource-poor settings. However, the real double standard is between clinical practice standards in Western versus African countries, which must be addressed as part of the increasing global inequity of wealth both between countries and also within countries. There are important limitations to ethical declarations, principles and guidelines on their own without contextual ethical reasoning. The focus on research ethics with the HIV epidemic has led to a relative neglect of ethical issues in clinical practice. Although the scientific advances in HIV/AIDS have changed the ethical issues since the 1990s, there has also been progress in the bioethics of HIV/AIDS in terms of ethical review capability by local committees as well as in exposure to ethical issues by clinicians and researchers in Africa. However, serious concerns remain about the overregulation of research by bureaucratic agencies which could discourage African research on specifically African health issues. There is also a need for African academic institutions and researchers to progressively improve their research capacity with the assistance of research funders and donor agencies.

Routine (non-religious) neonatal circumcision and bodily integrity: a transatlantic dialogue.

In the current debate about the pros and cons of routine (non-religious) neonatal circumcision (RNC), the emphasis is on medical justifications for the practice. Questions of human rights also are widely discussed. However, even if the alleged medical benefits of RNC were to outweigh the harms and risks, this is not a sufficient justification for RNC. The practice of RNC is questionable from a variety of viewpoints including not only the ideal of evidence-based medicine and human rights considerations, but also the notion of respect for bodily integrity.

A rose by any other name? Rethinking the similarities and differences between male and female genital cutting.

In this article, we offer a critical examination of the tendency to segregate discussion of surgical alterations to the male and female genitals into separate compartments--the first known as circumcision, the second as genital mutilation. We argue that this fundamental problem of definition underlies the considerable controversy surrounding these procedures when carried out on minors, and that it hinders objective discussion of the alleged benefits, harms, and risks. We explore the variable effects of male and female genital surgeries, and we propose a scale of damage for male circumcision to complement the World Health Organization's categorization of female genital mutilation. The origins of the double standard identified are placed in historical perspective, and in a brief conclusion we make a plea for greater gender neutrality in the approach to this contentious issue.