| |

Received: 24 November 2018    Revised: 8 November 2019    Accepted: 3 December 2019

DOI: 10.1111/bioe.12714

ORIGINAL ARTICLE

What is the best age to circumcise? A medical and ethical

analysis

Alex Myers1  | Brian D. Earp2,3,4

1
Department of Philosophy, University of
Cape Town, Cape Town, South Africa Abstract
2
Yale-Hastings Program in Ethics and Circumcision is often claimed to be simpler, safer and more cost-effective when per-
Health Policy, Yale University, New Haven,
formed in the neonatal period as opposed to later in life, with a greater benefit-to-risk
Connecticut
3
The Hastings Center, Garrison, New York
ratio. In the first part of this paper, we critically examine the evidence base for these
4
Uehiro Centre for Practical Ethics, claims, and find that it is not as robust as is commonly assumed. In the second part,
University of Oxford, Oxford, UK we demonstrate that, even if one simply grants these claims for the sake of argu-
Correspondence ment, it still does not follow that neonatal circumcision is ethically permissible absent
Alex Myers, University of Cape Town, Upper urgent medical necessity. Based on a careful consideration of the relevant evidence,
Campus, Rondebosch, Cape Town, Western
Cape 7700, South Africa. arguments and counterarguments, we conclude that medically unnecessary penile
Email: [email protected] circumcision—like other medically unnecessary genital procedures, such as ‘cosmetic’
labiaplasty—should not be performed on individuals who are too young (or otherwise
unable) to provide meaningful consent to the procedure.

KEYWORDS

American Academy of Pediatrics, circumcision, consent, medical necessity, neonatal

circumcision, non-therapeutic surgery

1 |  I NTRO D U C TI O N into question,2 with additional concerns raised about the decision pathways
by which this evidence was rushed into policy,3 and reports of an
Over recent decades, two major trends have emerged in the academic liter-
2
 Van Howe, R. S., & Boyle, G. (2018). Meta-analysis of HIV acquisition studies incomplete and
ature concerning penile circumcision (partial or total removal of the penile unstable. BJUI International, e-letter. Retrieved from http://www.bjuin​terna​tional.com/lette​
prepuce). On the one hand, findings from three randomized controlled trials rs/meta-analy​sis-circu​mcisi​on-incom​plete-unsta​ble/ [accessed Nov 3, 2019]; Boyle, G. J., &
Hill, G. (2011). Sub-Saharan African randomised clinical trials into male circumcision and HIV
(RCTs) conducted in Africa in the 2000s1 have been taken to show that clin-
transmission: Methodological, ethical and legal concerns. Journal of Law and Medicine, 19(2),
ical circumcision of adult males can reduce their risk of contracting HIV 316–334; Van Howe, R. S., & Storms, M. R. (2011). How the circumcision solution in Africa will
increase HIV infections. Journal of Public Health in Africa, 2(1), 11–15; Garenne, M., Giami, A., &
through penile–vaginal intercourse, at least in settings with a high preva-
Perrey, C. (2013). Male circumcision and HIV control in Africa: Questioning scientific evidence
lence of heterosexual HIV transmission and a low prevalence of such circum- and the decision-making process. In T. Giles-Vernik & J. Webb (Eds.), Global health in Africa:
cision. Although the quality of the evidence from these trials has been called Historical perspectives on disease control (pp. 185–210). Athens, OH: Ohio University Press. For
a contrary view, see, e.g., Wamai, R. G., Morris, B. J., Waskett, J. H., Green, E. C., Banerjee, J.,
Bailey, R. C., ... Hankins, C. A. (2012). Criticisms of African trials fail to withstand scrutiny:
1
 Auvert, B., Taljaard, D., Lagarde, E., Sobngwi-Tambekou, J., Sitta, R., & Puren, A. (2005). Male circumcision does prevent HIV infection. Journal of Law and Medicine, 20(1), 93–123.
3
Randomized, controlled intervention trial of male circumcision for reduction of HIV  Dowsett, G. W., & Couch, M. (2007). Male circumcision and HIV prevention: Is there really
infection risk: The ANRS 1265 Trial. PLoS Med, 2(11), e298; Bailey, R. C., Moses, S., Parker, enough of the right kind of evidence? Reproductive Health Matters, 15(29), 33–44; Bell, K.
C. B., Agot, K., Maclean, I., Krieger, J.N., ... Ndinya-Achola, J.O. (2007). Male circumcision (2015). HIV prevention: Making male circumcision the ‘right’ tool for the job. Global Public
for HIV prevention in young men in Kisumu, Kenya: A randomised controlled trial. Lancet, Health, 10(5–6), 552–572; de Camargo, K. R. Jr., de Oliveira Mondonça, A. L., Perrey, C., &
369(9562), 643–656; Gray, R. H., Kigozi, G., Serwadda, D., Makumbi, F. Watya, S. Giami, A. (2013). Male circumcision and HIV: A controversy study on ‘facts’ and ‘values’.
Nalugoda, F., ... Wawer, M. J. (2007). Male circumcision for HIV prevention in men in Rakai, Global Public Health, 8(7), 769–783; de Camargo, K. R., Jr., de Oliveira Mondonça, A. L.,
Uganda: A randomised trial. Lancet, 369(9562), 657–666. A fourth trial looking at male to Perrey, C., & Giami, A. (2015). Making the circumcision controversy controversial: Going
female transmission of HIV as a consequence of penile circumcision was stopped early meta and taking aim at the messenger(s): Reply to Wamai et al. Global Public Health, 10(5–6),
owing to ‘futility’, with female partners of circumcised men becoming infected with HIV at 667–671. The dominant policy paradigm appears to have been driven by a relatively small
a higher rate than female partners of genitally intact men; see Wawer, M. J., Makumbi, K., network of actors with influence at the WHO, among other organizations; see Giami A.,
Kigozi, G., Serwadda, D., Watya, S. Nalugoda, F., ... Gray, R. H. (2009). Circumcision in Perrey, C., de Oliveria Mendonça, A. L., & de Camargo, K. R. (2015). Hybrid forum or
HIV-infected men and its effect on HIV transmission to female partners in Rakai, Uganda: network? The social and political construction of an international ‘technical consultation’:
A randomised controlled trial. Lancet, 374(9685): 229–237. Male circumcision and HIV prevention. Global Public Health, 10(5–6), 589–606.

Bioethics. 2020;00:1–19. wileyonlinelibrary.com/journal/bioe© 2020 John Wiley & Sons Ltd     1 |

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2       MYERS and EARP

apparent lack of real-world effectiveness at the population level now begin- (incapable of consent), and the cutting is ‘medically necessary’ (see
4
ning to emerge, a heavily funded campaign to ‘scale up’ mass circumcision Box 1) and thus ‘cannot reasonably be deferred’.6
5
of African boys and men as a public health measure is currently underway. Building on this perspective, we argue that the best age to circum-
On the other hand, human rights scholars have increasingly ob- cise, considering both empirical/medical and normative/ethical fac-
jected to the medically unnecessary genital cutting of any person— tors, is no earlier than an appropriate age of consent (depending on the
whether female, male, or intersex—who either does not or cannot jurisdiction, the legal age of consent to sexual relations, for instance, is
consent to the cutting. Such objections were recently summarized in usually between 14 and 18).7 At that age, the individual’s own informed
an international consensus statement published in the American consent can at least potentially be obtained, and indeed must be ob-
Journal of Bioethics, in which the authors argued that under most tained for the circumcision to be morally permissible.8
conditions, ‘cutting any person’s genitals without their informed Our proposal is motivated in part by a concern for children’s sexual
consent is a serious violation of their right to bodily integrity. As self-determination. In contemporary Western societies, children of all
such, it is impermissible unless the person is non-autonomous sexes and genders are taught from an early age that adults should not
touch—let alone cut or remove healthy tissue from—their so-called ‘pri-
vate parts’ before they are sexually autonomous. The only widely rec-
ognized exceptions to this rule concern (a) the youngest of children,
insofar as they are not yet able to wash themselves adequately and
need help with this from a designated caregiver; and (b) required med-
ical examinations or procedures. The emphasis here is on ‘required’.
Under ordinary conditions, if  a doctor or other healthcare provider
4
handles a child’s genitals beyond what is ‘strictly necessary for diagno-
 O r even higher rates of infection among some medically circumcised males:
Rosenberg, M. S., Gómez-Olivé, F. X., Rohr, J. K., Kahn, K., & Bärnighausen, T. W. sis or treatment’, this is immediately understood to cross an ethical line.
(2018). Are circumcised men safer sex partners? Findings from the HAALSI cohort in Moreover, if the child-patient happens to be unconscious or otherwise
rural South Africa. PloS ONE, 13(8), e0201445. See also Garenne, M., & Matthews, A.
(2019). Voluntary medical male circumcision and HIV in Zambia: Expectations and does not remember the medically unnecessary genital  interference,
observations. Journal of Biosocial Science, e-pub ahead of print, 1-13. However, see this does not normally make the action morally permissible.9
Davis, S., Toledo, C., Lewis, L., Maughan-Brown, B., Ayalew, K., & Kharsany, A. B.
(2019). Does voluntary medical male circumcision protect against sexually transmitted
infections among men and women in real-world scale-up settings? Findings of a
household survey in KwaZulu-Natal, South Africa. BMJ Global Health, 4(3), e001389.
For preliminary evidence of risk-compensation or behavioral disinhibition as a potential
mechanism for increased STI acquisition in some populations over the long term—based
on biomarkers and a randomized design—see Kim, H. B., Pop-Eleches, C., Jung, J., & 6
 The Brussels Collaboration on Bodily Integrity (BCBI). (2019). Medically unnecessary genital
Kim, B. (2018). Male circumcision, peer effects and risk compensation. Presented to the cutting and the rights of the child: Moving toward consensus. American Journal of Bioethics,
Association of Public Policy Analysis and Management, November 10, 2018. Retrieved 19(10), 17–28. The authors clarify that the scope of their argument for purposes of the
from http://barre​t t.dyson.corne​ll.edu/NEUDC/​p aper_226.pdf [accessed Nov 3, 2019]. statement is the so-called Western medicolegal context, especially countries with a strong
5
 H ankins, C., Forsythe, S., & Njeuhmeli, E. (2011). Voluntary medical male tradition of individual rights. For arguments and evidence in support of the main thesis of the
circumcision: An introduction to the cost, impact, and challenges of accelerated scaling ‘Brussels’ statement that go into greater depth, see Lightfoot-Klein, H., Chase, C., Hammond,
up. PLoS Med, 8(11): e1001127; Torres-Rueda, S., Wambura, M., Weiss, H., Plotkin, M., T., & Goldman, R. (2000). Genital surgeries on children below an age of consent. In L. T.
Kripke, K., Chilongani, J., ... Terris-Prestholt, F. (2018). Cost and cost-effectiveness of a Szuchman & F. Muscarella (Eds.), Psychological perspectives on human sexuality (pp. 440–479).
demand creation intervention to increase uptake of voluntary medical male New York, NY: John Wiley & Sons; Svoboda, J. S. (2013). Promoting genital autonomy by
circumcision in Tanzania: Spending more to spend less. JAIDS: Journal of Acquired exploring commonalities between male, female, intersex, and cosmetic female genital cutting.
Immune Deficiency Syndromes, 78(3), 291–299. Originally termed ‘Voluntary Medical Global Discourse, 3(2), 237–255; Townsend, K. G. (2019). The child’s right to genital integrity.
Male Circumcision’ (VMMC) with the aim of recruiting men to be circumcised Philosophy & Social Criticism, 0191453719854212; Kehrer, I. (2019). Cuts into children’s future:
voluntarily, the scale-up now appears to be targeting younger and younger males, A comparative analysis between FGM, male circumcision and intersex genital surgeries. Peace
including until recently infants by way of their mothers, who are presumably much less Human Rights Governance, 3(3), 333–363. See also Earp, B. D., & Steinfeld, R. (2017). Gender
capable (or incapable) of refusing the procedure. See, for example, Sgaier, S. K., and genital cutting: A new paradigm. In T. G. Barbat (Ed.), Gifted women, fragile men. Euromind
Sharma, S., Eletskaya, M., Prasad, R., Mugurungi, O., Tambatamba, B., ... Kretschmer, S. Monographs 2. Brussels, Belgium: ALDE Group-EU Parliament; Earp, B. D., & Steinfeld, R.
(2017). Attitudes and decision-making about early-infant versus early-adolescent male (2018). Genital autonomy and sexual well-being. Current Sexual Health Reports, 10, 7–17.
circumcision: Demand-side insights for sustainable HIV prevention strategies in 7
 See https​://www.ageof​conse​nt.net/world​[accessed Nov 3, 2019]. Please note that
Zambia and Zimbabwe. PLoS ONE, 12(7), e0181411; Sidler, D., Earp, B. D., van Niekerk, although most jurisdictions have a set age at which capacity to consent to sexual
A. A., Moodley, K., & Kling, S. (2017). Targeting mothers and selling men what they do relations is presumed for legal purposes, the moral capacity to provide valid consent
not want: A response to ‘missed opportunities for circumcision of boys’. South African (whether to sex or other activities) in adolescence develops variably and individually.
Medical Journal, 104(4), 281. There are now disturbing indications that many thousands Some adolescents who have reached the age at which they can legally consent to sex, for
of young boys have been forcibly circumcised without parental knowledge or consent example, might nevertheless not be Gillick-competent for purposes of deciding about
as a part of this scale-up: Luseno, W. K., Field, S. H., Iritani, B. J., Rennie, S., Gilbertson, certain medical procedures (and vice versa). On Gillick competence, see Larcher, V., &
A., Odongo, F.S., ... Hallfors, D.D. (2019). Consent challenges and psychosocial distress Hutchinson, A. (2010). How should paediatricians assess Gillick competence? Archives of
in the scale-up of Voluntary Medical Male Circumcision among adolescents in Western Disease in Childhood, 95(4), 307–311.
Kenya. AIDS and Behavior, 23(12), 3460–3470. Further problems include ‘potentially 8
 For an overview of debates concerning the capacity of legal minors to consent to
misleading or questionable mobilization practices (including possibly undue
certain medical treatments, see for example Alderson, P. (2007). Competent children?
inducements), problematic uses of social pressure, and circumcision of children under
Minors’ consent to health care treatment and research. Social Science & Medicine, 65(11),
age ten’. Gilbertson, A., Ongili, B., Odongo, F.S., Hallfors, D.D., Rennie, S. Kwaro, D., &
2272–2283. Note, however, that medically unnecessary circumcision does not normally
Luseno, W.K. (2019). Voluntary medical male circumcision for HIV prevention among
constitute treatment (on most common understandings of that term).
adolescents in Kenya: Unintended consequences of pursuing service delivery targets.
9
PLoS ONE, 14(11), e0224548. See also the 2019 report of the VMMC Experience  Paraphrasing and quoting from the BCBI, ‘Medically unnecessary genital cutting’, op cit.
Project, an African-led NGO, alleging widespread human rights abuses associated with note 6. For related arguments, see Myers, A. (2015). Neonatal male circumcision, if not
the campaign, as submitted to the United Nations Committee on the Rights of the already commonplace, would be plainly unacceptable by modern ethical standards.
Child: https​://www.vmmcp​r oject.org/un-repor​t / [accessed Nov 3, 2019]. American Journal of Bioethics, 15(2), 54–55.
MYERS and EARP |
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performed on an infant or neonate as opposed to on an adolescent or

BOX 1 Medically necessary versus medically adult, and that the accumulated health benefits are also greater.13

beneficial10 Thus, to delay penile circumcision until it could be undertaken volun-

tarily, they claim, is to increase the associated risks and costs (both
According to the Brussels Collaboration on Bodily Integrity medical and monetary), as well as to reduce the associated benefits,
(BCBI), an intervention to alter a bodily state is medically assuming the procedure will be performed either way. Whether this latter
necessary when (a) the bodily state poses a serious, time- assumption is an appropriate one will be discussed later. Nevertheless,
sensitive threat to the person’s well-being, typically due to for at least some advocates of NNMC, such financial and health-re-
a functional impairment in an associated somatic process, lated considerations are so compelling that they may override the de-
and (b) the intervention, as performed without delay, is the fault moral presumption against medically unnecessary interference
least harmful feasible means of changing the bodily state with a child’s genitals—not only by touching in this case, but indeed by
to one that alleviates the threat. ‘Medically necessary’ is cutting into and irreversibly excising healthy and functional tissue.14
therefore different from ‘medically beneficial’, a weaker Against this moral presumption, it is often noted that pre-autono-
standard, which requires only that the expected health- mous children are not yet capable of consenting to any surgical proce-
related benefits outweigh the expected health-related dure, medically necessary or otherwise. Hence, it is claimed, the child’s
harms.11 The BCBI states that although the weaker, ‘medi- parents must decide about such matters. It is true that parents are nor-
cally beneficial’ standard may well be appropriate for cer- mally (and appropriately) entrusted with many decisions surrounding
tain interventions into the body, it is not appropriate for the care and upbringing of their children. But in contemporary Western
cutting or removing healthy tissue from the genitals of a societies, at least, parents are not permitted to authorize simply what-
non-consenting person (given, among other things, the ever encroachments into their child’s bodily integrity they may choose.
special significance of the body part in question). Rather, there are clear moral and legal limitations. For example, in addi-
tion to encroachments involving genital contact of any kind, those that
involve cutting into the skin, acute tissue damage, or permanent modi-
fication of the external physical features of a child must normally clear
An opposing view has been advanced by those who advocate for a very high bar to be considered ethically acceptable. In fact, some
12
non-voluntary neonatal male circumcision (NNMC). According to encroachments, such as child facial scarification, foot binding, and
these advocates (Box 2), penile circumcisions performed  in infancy medically unnecessary female genital cutting—including ‘symbolic’
(roughly, the first year of life)  and especially in the neonatal period forms that are less invasive than penile circumcision—are categorically
(roughly, the first month of life) are relevantly different from circumci-
sions performed later in life. Specifically, they claim that penile circum-
cision is technically simpler, safer and more cost-effective when it is

10
 This Box is adapted from Box 1 of the BCBI, op cit. note 6. Internal references omitted.
The definition of medical necessity is based on Earp, B. D. (2019). The child’s right to
bodily integrity. In D. Edmonds (Ed.), Ethics and the contemporary world (pp. 217–235).
Abingdon, U.K.: Routledge.
11 13
 The BCBI notes that benefit/harm comparisons are often contested as they depend on  See for instance Dickson, K. E., Samuelson, J., Ashengo, T. A., Chrouser, K., Curran, K.,
‘the specific weights assigned to the possible outcomes of the intervention, given among Otolorin, E., … Tomlinson, D. (2010). Manual for early infant male circumcision under
other things (a) the subjective value to the individual of the body parts that may be local anesthesia. World Health Organization and Jhpeigo. Geneva, Switzerland: WHO
affected, (b) the individual’s tolerance for different kinds or degrees of risk to which Press. According to the Los Angeles Times, one of the main authors of this manual, David
those body parts may be exposed, and (c) any preferences the individual may have for Tomlinson, was then serving as ‘the World Health Organization’s chief circumcision
alternative (e.g. less risky or invasive) means of pursuing the intended health-related expert’. Hennessy-Fiske, M. (2011, Sep 2). Injuries linked to circumcision clamps. Los
benefits’. BCBI, op cit. note 6, 18. For in-depth discussions of the contested nature of Angeles Times. Retrieved from https​://www.latim​es.com/healt​h/la-xpm-2011-sep-26-la-
benefit/harm ratios concerning male circumcision in particular, emphasizing that he-circu​mcisi​on-20110​926-story.html [accessed Nov 3, 2019]. Prior to consulting for the
evaluations of the primary literature may be shaped by cultural bias or other potentially WHO, it appears that Tomlinson had filed for a patent for a newborn circumcision clamp,
distorting factors, see Darby, R. (2015). Risks, benefits, complications and harms: claimed to be preferable to those most widely in use: https​://paten​t s.justia.com/paten​
Neglected factors in the current debate on non-therapeutic circumcision. Kennedy t/20080​0 04631 [accessed Nov 3, 2019]. Notably, Tomlinson’s clamp is touted in the
Institute of Ethics Journal, 25(1), 1–34; Earp, B. D., & Shaw, D. M. (2017). Cultural bias in WHO manual for potential mass adoption in Africa ‘for the purposes of HIV prevention’,
American medicine: The case of infant male circumcision. Journal of Pediatric Ethics, 1(1), despite no empirical evidence that newborn circumcision specifically has a protective
8–26; Frisch, M., Aigrain, Y., Barauskas, V., Bjarnason, R., Boddy, S., Czauderna, P., ... effect against HIV. Instead, the manual repeatedly conflates adult and newborn
Wijnen, R. (2013). Cultural bias in the AAP’s 2012 technical report and policy statement circumcision, citing evidence drawn from studies of the former to justify claims about the
on male circumcision. Pediatrics, 131(4), 796–800. See also Van Howe, R. S. (2018). latter. A similar conflation problem can be found in Morris, B. J., Waskett, J.H., Banerjee,
Response to Vogelstein: How the 2012 AAP Task Force on circumcision went wrong. J., Wamai, R.G., Tobian, A.A., Gray, R.H., ... Mindel, A. (2012). A ‘snip’ in time: What is the
Bioethics, 32(1), 77–80; and Svoboda, J. S., & Van Howe, R. S. (2013). Out of step: Fatal best age to circumcise? BMC Pediatrics, 12(20), 1–15. It should be noted that these
flaws in the latest AAP policy report on neonatal circumcision. Journal of Medical Ethics, authors appear to assume that the circumcision will be performed at some point or
39(7), 434–441 (replies and counter-replies are available at the journal website). another. However, if an adult decides to stay genitally intact, as most do when given the
12
 In keeping with a familiar distinction in bioethics, we use the term ‘non-voluntary’, opportunity, the hypothetical circumcision will be even ‘simpler, safer and more
which concerns a moral patient unable to express their will in relation to a given cost-effective’ because it will not occur.
14
procedure, rather than ‘involuntary’, which implies a moral agent able to express their  That is, the penile prepuce. Cold, C. J., & Taylor, J. R. (1999). The prepuce. BJU
will who refuses the procedure. International, 83(S1), 34–44.
 |
4       MYERS and EARP

forbidden in such societies.15 Even slapping or spanking a child for their

own supposed good (i.e. as a means of discipline) is banned in more BOX 2 Who advocates for non-voluntary neonatal
than 50 countries.16 male circumcision (NNMC)?
When a child faces a medical emergency such that a bodily en-
croachment cannot be delayed without significantly increasing the risk Throughout this article, we refer to the arguments of NNMC

of death or disability, this creates a special situation. In such an emer- advocates, who have been described as falling into two main

gency situation, the permission of the child’s parents or other appropri- camps: (a) strong advocates, who argue that the health bene-

ate caregiver must be relied upon as the closest available proxy for the fits of NNMC are so great and the risks so trivial that boys

child’s consent, assuming that the child is not yet in a position to consent should be ‘circumcised as a matter of routine, or even that the

on their own behalf. 17

By contrast, when there is no disease or defor- operation should be compulsory’, and (b) weak advocates,

mity present for which immediate medical intervention is required, it is who believe that ‘while the benefits outweigh the risks they

normally understood that the permission for a surgery must come from are not so great that doctors should recommend the opera-

the individual whose body will be altered and/or exposed to the associ- tion, but great enough to authorize parental discretion’.19 The

ated risk. As Hutson argues: ‘strong’ position is associated primarily with a grouping around
Brian J. Morris, a former professor of molecular medical sci-

The most fundamental principle of surgery is that no op- ences at the University of Sydney and a driving force behind

eration should be done if there is no disease, as it cannot the Circumcision Academy of Australia (CAA), a network of

be justified if the risk of the procedure is not balanced by circumcision proponents and financially interested provid-

the risk of a disease. Even when patients have significant ers.20 The ‘weak’ position is associated primarily with certain

disease, potentially dangerous operations can hardly be actors within the U.S. medical establishment, including, most

justified if their risks are much greater than the disease notably, the eight-member Task Force behind the now-ex-

itself. The problem for routine circumcision is that since pired  2012 circumcision policy statement of the American

there is no disease, no complication whatsoever can be Academy of Pediatrics (AAP).21 Rejecting both positions—that

tolerated, since the risks of the procedure are not being is, failing to conclude that the benefits of NNMC outweigh the

balanced against the risks of any present disease.18 risks, or reaching the opposite conclusion, that the risks out-
weigh the benefits—are most child health authorities outside

Against this view, NNMC advocates (Box 2) argue that future diseases the United States, including all comparable national-level

must also be considered; that is, potential future diseases to which the medical bodies to have issued formal statements on NNMC

individual might be exposed, depending largely on their own choices, and (see later discussion).

for which there are both less risky and more effective modes of preven-
tion that do not involve genital cutting. We address this argument in the
19
 These quotes are from Darby, op cit. note 11, pp. 1–2, summarizing the position of NNMC
present paper. In doing so, we carefully examine some of the main em-
advocates. Some of the material in this Box is lightly adapted from Darby’s discussion.
pirical and conceptual claims put forward by advocates of NNMC. We 20
 See https​://www.circu​mcisi​onaus​tralia.org [accessed Nov 3, 2019]. The CAA lobbies for
argue, first, drawing on recent evidence, that the strictly medical case for government health insurance coverage for medically unnecessary newborn circumcisions;
billing for such circumcisions appears to be a primary source of income for several CAA
NNMC is not as compelling as its advocates maintain. But going beyond
board members, including some whose private practices are centered around offering the
procedure. For details, see Frisch, M., & Earp, B. D. (2018). Circumcision of male infants and
15
children as a public health measure in developed countries: A critical assessment of recent
 One such ‘symbolic’ form is so-called ritual nicking of the clitoral hood/foreskin, which does
evidence. Global Public Health, 13(5), 626–641, especially note 4.
not remove tissue and often leaves no visible mark on the vulva. According to a recent ruling
21
from Australia’s highest court, for legal purposes, (a) the clitoral foreskin is part of the clitoris,  A AP Task Force on Circumcision. (2012). Circumcision policy statement. Pediatrics, 130(3),
and (b) any medically unnecessary cutting of this tissue, no matter how slight, constitutes 585–586. Although the AAP policy formally expired in 2017, an anonymous working group
illegal mutilation, irrespective of whether there is any lasting damage or functional impairment. at the US Centers for Disease Control and Prevention (CDC) subsequently released a similar
Australian Associated Press. (2019, Oct 16). High Court upholds NSW genital mutilation policy, in 2018, which remains online: https​://www.cdc.gov/hiv/risk/male-circu​mcisi​on.html
convictions. Sydney Morning Herald. Retrieved from https​://www.smh.com.au/natio​nal/nsw/ [accessed Nov 3, 2019]. This release came in the face of extensive criticism from
high-court-uphol​ds-nsw-genit​al-mutil​ation-convi​ctions-20191​016-p53197.html [accessed international medical authorities and at least one invited peer reviewer, many of whose
Nov 3, 2019]. For further discussion of ritual nicking and different Western legal standards for substantive objections to an earlier draft of the CDC policy were effectively ignored during
male versus female genital cutting, see Davis, D. S. (2001). Male and female genital alteration: the process of revision. See Kupferschmid, C., Barauskas, B., Bjarnason, R., Boddy, S.,
A collision course with the law. Health Matrix, 11(1), 487–570; Davis, D. S. (2003). Cultural bias Czauderna, P., & Fasching, G. (2015). Commentary on the CDC ‘Recommendations for
in responses to male and female genital surgeries. American Journal of Bioethics, 3(2), providers counseling male patients and parents regarding male circumcision and the
W15–W16; Earp, B. D., Hendry, J., & Thomson, M. (2017). Reason and paradox in medical and prevention of HIV infection, STIs, and other health outcomes’. CDC Public Submission.
family law: Shaping children's bodies. Medical Law Review, 25(4), 604–627; and Earp, B. D. Retrieved from https​://www.regul​ations.gov/docum​ent?D=CDC-2014-0012-2455
(2020). Protecting children from medically unnecessary genital cutting without stigmatizing [accessed Nov 3, 2019]; and Van Howe, R. S. (2015). A CDC-requested, evidence-based
women's bodies: Implications for sexual pleasure and pain. Archives of Sexual Behavior, available critique of the Centers for Disease Control and Prevention 2014 draft on male circumcision:
online ahead of print at https​://doi.org/10.1007/s10508-020-01633-x. How ideology and selective science lead to superficial, culturally-biased recommendations
16 by the CDC. CDC Peer Review Report. https​://doi.org/10.13140/​2.1.1148.4964. For
 Cole, D. (2019, Sep 3). Whatever happened to the campaign to ban … spanking? NPR.
additional articulations of ‘weak’ NNMC advocacy as described above, see Benatar, M., &
Retrieved from https​://www.npr.org/secti​ons/goats​andso​da/2019/09/03/75513​6 377/
Benatar, D. (2003). Between prophylaxis and child abuse: The ethics of neonatal male
whate​ver-happe​ned-to-the-campa​ign-to-ban-spanking [accessed Nov 3, 2019].
circumcision. American Journal of Bioethics, 3(2), 35–48; Mazor, J. (2013). The child’s
17
 See Alderson, op cit. note 8. interests and the case for the permissibility of male infant circumcision. Journal of Medical
18
 Hutson, J. M. (2004). Circumcision: A surgeon’s perspective. Journal of Medical Ethics, Ethics, 39(7), 421–428; and Jacobs, A. J., & Arora, K. S. (2015). Ritual male infant
30(3), 238–240. circumcision and human rights. American Journal of Bioethics, 15(2), 30–39.
MYERS and EARP       5|
this, we suggest that the narrow parameters of a medical cost–benefit comparing the disparate conclusions of otherwise similar medical
analysis are insufficient to draw meaningful moral conclusions about the bodies that have assessed the vast and often contradictory body of
acceptability of NNMC.22 Instead, what is required is more thorough- evidence on penile circumcision.
going engagement with the particular ethical issues posed by medically Consider first the position of the American Academy of
unnecessary genital cutting of minor children. Pediatrics (AAP). In 2012, an eight-member AAP Task Force28 as-
In the end, we argue that children’s interest in future bodily auton- serted that the health benefits of NNMC outweigh the risk of sur-
omy, especially over those parts of the body that have special psychosex- gical complications—albeit not to such an extent that the procedure
ual significance—such as the penis, vulva, or breasts—is sufficiently could be recommended on medical grounds alone. 29 However, no
weighty to render NNMC morally impermissible in most cases.23 Even recognized procedure for assigning weights, whether to benefits
taking health considerations into account, that is, we find that the best or to risks, was used by the Task Force, so the basis for its conclu-
age to circumcise is the age at which the individual is developmentally sion was unclear. In a subsequent publication, Task Force members
capable of providing informed consent to the permanent alteration of clarified that the benefits of NNMC were only ‘felt to outweigh
their own genitals. the risks’, and urged readers to ‘draw their own conclusions’. 30
As a final note, we will be using gender-neutral language (as in the (Testifying at a government hearing on behalf of Germany’s pedi-
previous sentence) as far as possible in this paper while staying true to atric associations in late 2012, Dr. Wolfram Hartmann reported
particular empirical findings. This is because we recognize that some that the ‘AAP statement has been graded by almost all other pedi-
people with penises may not identify as boys or men, such as trans atric societies and associations worldwide as being scientifically
24
women or some genderqueer individuals. In fact, the potential harm of untenable’. 31)
neonatal or early-childhood circumcision for trans women who elect a In 2015, the Canadian Paediatric Society weighed in, concluding
penile inversion surgery—as a part of gender-affirming care, for exam- that the medical benefits and risks of NNMC were ‘closely balanced’,32
ple—has yet to receive much attention.25 However, the preemptive re- while the Royal Dutch Medical Association maintained that there ‘is no
moval of a large proportion of sensitive, elastic genital tissue from the convincing evidence that [NNMC] is useful or necessary in terms of
penis that could otherwise have been used in the construction of a ne-
ovagina—i.e. the penile foreskin—is undoubtedly of relevance to the wel- 28
 It is concerning that there appears to have been financial, religious and political
fare interests of such women.26 conflicts of interest among the AAP Task Force members, although none were disclosed
in the original statement. Task Force member Waldemar Carlo is a director of Mednax,
the publicly traded medical services company; although he failed to declare this financial
conflict of interest in the original AAP policy statement, it was added to an AAP response
2 | E M PI R I C A L I S S U E S to international critics: AAP Task Force on Circumcision (2013). Cultural bias and
circumcision: The AAP Task Force on Circumcision responds. Pediatrics, 131(4), 801–804.
Task Force member Andrew Freedman stated in an interview, ‘I circumcised [my son]
2.1 | Benefits myself on my parents’ kitchen table on the eighth day of his life. But I did it for religious,
not medical reasons. I did it because I had 3,000 years of ancestors looking over my
shoulder.’ Merwin, T. (2012, Sep 19). Fleshing out change on circumcision. Jewish Week.
Let us begin by looking at the issue of health benefits, a number of Retrieved from https​://jewis​hweek.times​ofisr​ael.com/flesh​ing-out-change-on-circu​mcisi​
on/ [accessed Nov 3, 2019]. In a subsequent editorial, Freedman stated that ‘protecting’
which have been claimed to follow from penile circumcision, al-
this parental option to circumcise ‘was not an idle concern’ for the AAP Task Force
though their likelihood, magnitude and causal relationship to NNMC members ‘at a time when there are serious efforts in both the United States and Europe
in particular remain in dispute. 27 This dispute can be illustrated by to ban the procedure outright’. Freedman, A. (2016). The circumcision debate: Beyond
benefits and risks. Pediatrics, 137(5), e20160594. For extensive discussion of these
matters, including analysis of the AAP response to its mostly European critics, see Earp &
22
 See also Darby, op cit. note 11. Shaw, op cit. note 11.
29
23  A AP Task Force on Circumcision. (2012). Male circumcision. Pediatrics, 130(3),
 See the discussion by Munzer, who refers to the physical and symbolic ‘salience’ of the
e756–785. For extensive critiques of the AAP analysis and further context, see note 11.
genitals as a relevant moral consideration. Munzer, S. R. (2018). Examining
See also Earp, B. D. (2015). Do the benefits of male circumcision outweigh the risks? A
nontherapeutic circumcision. Health Matrix, 28(1), 1–78.
critique of the proposed CDC guidelines. Frontiers in Pediatrics, 3(18), 1–6.
24
 See for example Dembroff, R. (2019). Beyond binary: Genderqueer as critical gender 30
 A AP Task Force on Circumcision. (2013). The AAP Task Force on Neonatal
kind. Philosopher's Imprint, online ahead of print at http://phils​ci-archi​ve.pitt.edu/16317/​;
Circumcision: A call for respectful dialogue. Journal of Medical Ethics, 39(7), 442–443,
Vogler, S. (2019). Determining transgender: Adjudicating gender identity in US asylum
p. 442.
law. Gender & Society, 33(3), 439–462.
31
 Hartmann, W. (2012). Expert Statement: Dr med. Wolfram Hartmann, President of
25
 A s the authors of a recent review state: ‘The inner layer of the foreskin, the neurovascular
Berufsverband der Kinder- und Jugendärzte, ‘for the hearing on the 26th of November
bundle, and the glans are used as a pedicled island flap. This flap is used to construct the
2012 concerning the drafting of a federal government bill.’ Cologne, Germany:
inner part of the labia minora, the neoclitoris, and its prepuce’. They note that in cases
Berufsverband der Kinder- und Jugendärzte (BVKJ. e.V.). Retrieved from http://www.
where ‘more tissue might be required (e.g. because of circumcision or a small penis), further
rz-etels​en.net/Hartm​ann%20-%20Ger​man%20Sta​tement.pdf [accessed Nov 3, 2019].
full-thickness skin grafts (e.g. from the proximal medial thigh)’ will likely have to be
32
 C anadian Paediatric Society. (2015). Newborn male circumcision. Paediatrics & Child
transplanted. Papadopulos, N. A., Lellé, J. D., Zavlin, D., Herschbach, P., Henrich, G.,
Health, 20(6), 311–320. For further discussion, see Earp, B. D. (2015). Letter to the editor:
Kovacs, L., … Schaff, J. (2017). Quality of life and patient satisfaction following
Strengths and weaknesses in the 2015 Canadian Paediatric Society statement regarding
male-to-female sex reassignment surgery. Journal of Sexual Medicine, 14(5), 721–730.
newborn male circumcision. Paediatrics & Child Health, 20(8), 433; Morris, B. J., Klausner,
26
 For an intriguing discussion of certain tensions in this area, see Levy, I. (2017, Jun 23). J. D., Krieger, J. N., Willcox, B. J., Crouse, P. D., & Pollock, N. (2016). Canadian Pediatrics
Transgender and Jewish. Tablet Magazine. Retrieved from https​://www.table​tmag.com/ Society position statement on newborn circumcision: A risk–benefit analysis revisited.
jewish-life-and-relig​ion/23708​0/trans​gender-and-jewish [accessed Nov 3, 2019]. Canadian Journal of Urology, 23(5), 8495–8502; Robinson, J. L., Jefferies, A., & Lacaze, T.
27
 For a discussion of some of the controversy, see Jansen, M. (2016). Routine (2017). Letter to the editor – Re: Canadian Pediatrics Society position statement on
circumcision of infant boys: It's time to make progress through the common ground. newborn circumcision: A risk–benefit analysis revisited. Canadian Journal of Urology,
Journal of Paediatrics & Child Health, 52(5), 477–479. 24(1), 8684–8687.
 |
6       MYERS and EARP

prevention or hygiene’.33 Meanwhile, the Royal Australasian College of In short, when a potential health benefit can be achieved either via
Physicians, upon revisiting its 2010 policy in light of the AAP state- (a) a non-voluntary surgical procedure performed on an individual to
ment, affirmed that ‘the frequency of diseases modifiable by circumci- whom the benefit does not currently apply, and likely will not apply for
sion, the level of protection offered by circumcision and the many years (if at all); or (b) a similar surgical procedure undertaken vol-
complication rates of circumcision do not warrant routine infant cir- untarily by the same individual when that individual is in a position to
34
cumcision in Australia and New Zealand’. Finally, the Danish Medical decide whether the benefit is actually applicable (and if it is, whether it
Association declared in 2016 that NNMC is ‘ethically unacceptable’ on is worth the medical and non-medical risks given their known values/
account of the known surgical risks, the lack of sufficient evidence of a preferences and the available non-surgical alternatives); it is not nor-
‘clear health benefit’, and the permanency of the anatomical change.35 mally justified, even on medical grounds, to proceed with option (a).37
What these various positions suggest is that insofar as NNMC As we noted in the Introduction, one potential health benefit that
does confer some kind or degree of health-related benefit, it is far has received much attention in the recent literature is a partial reduc-
from clear that this benefit offsets even the strictly health-related tion in the risk of female-to-male, heterosexually transmitted HIV as a
risks, let alone in a decisive manner. Thus, even the AAP, whose pol- result of voluntary medical male circumcision (VMMC). The main sup-
icy among comparable organizations is the most favourable towards port for this claimed benefit stems from studies conducted in sub-Sa-
circumcision, does not actually recommend NNMC on grounds of haran Africa and published in the latter half of the 2000s.38 At present,
health. But even if there were universal agreement among qualified it is scientifically irresponsible to extrapolate from the findings of these
medical authorities that the net health benefits of circumcision were studies on adult circumcisions performed in one epidemiological envi-
36
as impressive as its strongest advocates claim (see Box 2), this ronment to neonatal circumcisions performed in a dissimilar epidemio-
would not entail that NNMC—specifically—was medically, much less logical environment.39 Nevertheless, both ‘strong’ and ‘weak’
all-things-considered morally, justified. advocates of NNMC (Box 2) have appealed to the African RCTs in re-
This is because the strongest evidence of health benefit is de- cent years to promote (in the case of strong advocates) or defend (in
rived from studies of adult, not newborn, circumcision; and this the case of weak advocates) non-voluntary circumcision of newborn
evidence primarily concerns risks pertaining to sexually active males: not only in sub-Saharan Africa, where heterosexually transmit-
persons, which does not include most children. Yet by the time a ted HIV remains at epidemic levels, but also in the United States and
person does become sexually active, they will most likely be ca- other developed countries, where heterosexually transmitted HIV is
pable of consenting to circumcision if that is what they choose. relatively rare.40 In the African context, a plausible motivation for the
They will also be capable of withholding their consent if they de- shift to infancy is the failure of VMMC programs to attract the number
termine that circumcision is not in their medical (or other) best of men set by target quotas, despite the enormous effort and expense
interests, and they can make this judgment on the basis of their directed at supply-side ‘demand creation’.41 This shift is concerning
actual—rather than hypothetical/future—health-related context from an ethical perspective, as infants, in contrast to unwilling adoles-
and behaviour. cents or adults, are unable to refuse the procedure.
Most other claimed health benefits similarly accrue after sexual
debut. As a group of mostly European paediatricians and other medical
33
 The Royal Dutch Medical Association. (2010). Nontherapeutic circumcision of male
authorities argued in response to the 2012 AAP policy statement on
minors. KNMG, 1–17. Retrieved from https​://www.knmg.nl/circu​mcisi​on/ [accessed
November 3, 2019). NNMC, there is only one potentially substantial health benefit that has
34
 Royal Australasian College of Physicians, Paediatrics & Child Health Division. (2010). ‘theoretical relevance in relation to infant male circumcision; namely,
Circumcision of infant males. RACP. Available at https​://www.racp.edu.au/docs/defau​
the possible protection against urinary tract infections in infant boys’.42
lt-sourc​e/advoc​acy-libra​r y/circu​mcisi​on-of-infant-males.pdf [accessed November 3,
2019); see also Pringle, K. (2014, April 4). Circumcision health risks and benefits - experts This potential benefit has never been studied via RCTs, but observa-
respond. Science Media Center. Available at http://www.scien​cemed​iacen​tre.
tional and cohort studies cited by the AAP suggest that urinary tract
co.nz/2014/04/04/circu​mcisi​on-health-risks-and-benef​its-exper​t s-respo​nd/ [accessed
Nov 3, 2019].
35
 Danish Medical Association. (2016). Lægeforeningens politik vedrørende omskæring af 37
 A counterargument to this view is that the surgical procedure in (1) is less medically
drengebørn uden medicinsk indication. Retrieved from https​://www.laeger.dk/laege​
risky than the similar surgical procedure in (2). We discuss this claim in a later section.
foren​ingens-polit​ik-vedro​erende-omska​ering-af-dreng​eboern-uden-medic​insk-indik​ation​
38
[accessed Nov 3, 2019].  Auvert et al., op cit. note 1; Bailey et al., op cit. note 1; Gray et al., op cit. note 1.
36 39
 See for instance Morris, B. J. (2007). Why circumcision is a biomedical imperative for  For a discussion of why, see Bossio, J. A., Pukall, C. F., & Steele, S. S. (2014). A review of
the 21st century. Bioessays, 29(11), 1147–1158. Morris’s typical claim, which has not been the current state of the male circumcision literature. Journal of Sexual Medicine, 11(12),
substantiated by anyone outside his research group, is that the benefits of circumcision 2847–2864.
outweigh the risks by a ratio of 100:1. But as Svoboda, Adler, and Van Howe recently 40
 Morris, B. J., & Krieger, J. N. (2015). The literature supports policies promoting
noted, ‘no recognized procedure for objectively assigning weights to individual benefits neonatal male circumcision in North America. Journal of Sexual Medicine, 12(5), 1305. But
or risks is used by Morris in his calculations [so] the ratio should not be taken seriously. see Bossio, J. A., Caroline F. Pukall, C. F., & Steele, S. S. (2015). Response to: The
For example, with no sound justification for how the higher number was obtained, in literature supports policies promoting neonatal male circumcision in N. America. Journal
2017 Morris et al. increased the ratio to 200 to 1, suggesting that the ratio is not of Sexual Medicine, 12(5), 1306–1307
scientifically meaningful.’ Svoboda, J. S., Adler, P. W., & Van Howe, R. S. (2019). Is 41
 See Van Howe, R. S. (2018). Expertise or ideology? A response to Morris et al. 2016,
circumcision unethical and unlawful? A response to Morris et al. Journal of Medical Law
‘Circumcision is a primary preventive against HIV infection: Critique of a contrary
and Ethics, 7(1), 72–92, p. 84. The 200 to 1 assertion is made in Morris, B. J., Kennedy, S.
meta-regression analysis by Van Howe’. Global Public Health, 13(12),1900–1918; Sidler et
E., Wodak, A. D., Mindel, A., Golovsky, D., Schrieber, L., ... Ziegler, J.B. (2017). Early infant
al., op cit. note 5.
male circumcision: Systematic review, risk–benefit analysis, and progress in policy. World
42
Journal of Clinical Pediatrics, 6(1), 89–102.  Frisch et al., op cit. note 11, p. 796.
MYERS and EARP |
      7

infections (UTIs) are anywhere between three and 10 times more likely typically non-serious and easily treatable source of temporary discom-
to occur in genitally intact male infants under 2 years of age than in fort should even be entertained. Phimosis, the inability to fully retract
circumcised ones.43 A problem with interpreting such figures is that the prepuce over the glans of the penis, necessarily occurs less fre-
the rate of false positives may be higher for diagnoses among the for- quently in circumcised males who lack a prepuce.50 However, in young
mer group than among the latter.44 But even if one takes such figures boys, a non-retractile foreskin is normal as the foreskin is fused to the
at face value, the difference between absolute and relative risk needs glans at birth, after which the two structures gradually separate during
to be highlighted. According to the AAP’s own estimates, UTIs affect early childhood. In approximately 50% of cases, this process will be
roughly 1% of boys in the first two years of life regardless of circumci- complete by 10 years of age, but it can continue until after the onset of
sion status, suggesting that ‘the number needed to circumcise to pre- puberty.51 For this reason, phimosis, as such, is difficult to diagnose ac-
45
vent [one] UTI is approximately 100’. However, rather than curately before adolescence. Moreover, if a lack of ability to retract the
permanently excising a sensitive genital structure from 100—or even foreskin does create problems for a child, this can usually be treated in
far fewer—healthy boys to prevent one of them from acquiring a UTI, a less invasive way than by excising the foreskin altogether: topical
the same hypothetical UTI could be safely, successfully and non-inva- creams and gentle stretching will resolve the majority of problematic
46
sively treated with antibiotics in most cases. This is the standard of cases with no cutting of tissue required, and most of the remainder can
care for girls, who are about 4 to 8 times more likely than boys to ac- be addressed with foreskin-preserving preputioplasty (for instance, a
quire a UTI by age 5 years, according to the AAP.47 limited dorsal slit with transverse closure).52
Balanitis (or inflammation of the glans penis) is also thought to Recurrent pathological phimosis is thought to be a risk factor for
occur less often in circumcised males, although it may actually be more penile cancer, which may explain why (especially early) circumcision
common in such males while they are still in diapers.48 According to the has been associated with a lower relative risk of contracting this rare
U.K. National Health Service, balanitis is ‘not usually serious’ and ‘most cancer.53 According to recent estimates, ‘penile cancer is one of the
cases [are] easily treated with good hygiene and creams [or] oint- rarest malignancies for which site-specific data are available in can-
49
ments’. Again, it is not clear why indiscriminately removing genital cer registries. In 2003–2007, penile cancers accounted for 0.15% of
tissue from healthy infants to  reduce—potentially—the risk of a all incident cancers in the United States, thus ranking 43rd in inci-
dence among all site-specific cancers in US males’.54 In fact, penile
43
cancer ‘is not among the 10 most common malignancies in males in
 A AP Task Force on Circumcision, op cit. note 29, p. e756.
44
 A s the authors of the Canadian Paediatric Society statement on NNMC note, ‘urines
any national cancer registry; even in high-incidence regions of South
obtained via a midstream or catheter specimen from an uncircumcised male are America, Africa, and Asia, the risk of developing penile cancer before
commonly contaminated by organisms under the foreskin. Evidence for this is that 9% of
age 75 years is below 0.4%’.55 In line with this, the AAP estimates
uncircumcised and 0.5% of circumcised asymptomatic males had bacteruria later verified
by suprapubic urine collection to be falsely positive.’ Robinson et al., op cit. note 32, p.
8684, referring to Simforoosh, N., Tabibi, A., Khalili, S. A., Soltani, M.H., Afjehi, A.,
50
Aalami, F., & Bodoohi, H. (2012). Neonatal circumcision reduces the incidence of  The incidence of pathologic phimosis in intact males (0.5% to 1%) appears to be similar to
asymptomatic urinary tract infection: A large prospective study with long-term follow up the incidence of preputial stenosis/phimosis following circumcision (0.3-1.7%). See Shankar,
using Plastibell. Journal of Pediatric Urology, 8(3), 320–323. See also Van Howe, R. S. K. R., & Rickwood, A. M. K. (1999). The incidence of phimosis in boys. BJU International, 84,
(2005). Effect of confounding in the association between circumcision status and urinary 101–102; Kaweblum, Y. A., Press, S., Kogan, L., Levine, M., & Kaweblum, M. (1984).
tract infection. Journal of Infection, 51(1), 59–68. Circumcision using the Mogen clamp. Clinical Pediatrics, 23, 679–682; Stenram, A.,
45 Malmfors, G., & Okmian, L. (1986). Circumcision for phimosis—indications and results. Acta
 A AP Task Force on Circumcision, op cit. note 29, p. e767. Other credible estimates of
Paediatrica Scandinavia, 75, 321–323; Van Howe, R. S. (1997). Variability in penile
the number-needed-to-prevent range from 25 to 100—see Eisenberg, M. L., Galusha, D.,
appearance and penile findings: A prospective study. British Journal of Urology, 80, 776–782.
Kennedy, W. A., & Cullen, M. R. (2018). The relationship between neonatal circumcision,
51
urinary tract infection, and health. World Journal of Men's Health, 36(3), 176–182—to as  K ayaba, H., Tamura, H., Kitajima, S., Fujiwara, Y., Kato, T., & Kato, T. (1996). Analysis of
many as 195; see To, T., Agha, M., Dick P. T., & Feldman W. (1998). Cohort study on shape and retractibility of the prepuce in 603 Japanese boys. Journal of Urology, 156,
circumcision of newborn boys and subsequent risk of urinary-tract infection. Lancet, 352, 1813–1815; Øster, J. (1968). Further fate of the foreskin. Incidence of preputial
1813–1816. Some ‘lifetime’ estimates have been published including UTIs potentially adhesions, phimosis, and smegma among Danish schoolboys. Archives of Disease in
acquired between sexual debut and death, but these fall outside the scope of our Childhood, 43, 200–203.
analysis. 52
 In a large prospective study, a total of 1185 boys with a diagnosis of pathological
46
 Fisher, D. J. (2019). Pediatric urinary tract infection treatment and management. phimosis were treated with fluticasone proprionate. Successful results with no side
Medscape. Retrieved from https​://emedi​cine.medsc​ape.com/artic​le/969643-treat​ment effects were achieved in 1079 (91.1%) patients, including those diagnosed with mild
[accessed Nov 3, 2019]: ‘Most cases of uncomplicated UTI respond readily to outpatient balanitis xerotica obliterans. Zavras, N., Christianakis, E., Mpourikas, D., & Ereikat, K.
antibiotic treatments without further sequelae’. (2009). Conservative treatment of phimosis with fluticasone proprionate 0.05%: A
47 clinical study in 1185 boys. Journal of Pediatric Urology, 5(3), 181–185. Regarding
 What is more, ‘most children who have one UTI will not have another.’ American
preputioplasty, see e.g. Hotonu, S., Mohamed, A., Rajimwale, A., & Gopal, M. (2019). Save
Academy of Pediatrics. (2018). Recurrent urinary tract infections (UTIs) in children. From
the foreskin: Outcomes of preputioplasty in the treatment of childhood phimosis.
the AAP Section on Urology. Retrieved from https​://www.healt​hychi​ldren.org/Engli​sh/
Surgeon, in press. Available online at: https​://doi.org/10.1016/j.surge.2019.08.004
health-issue​s/condi​tions/​genit​ourin​ary-tract/​Pages/​Urina​r y-Tract-Infec​tions-in-Teens.
53
aspx [accessed Nov 3, 2019].  See, e.g., Larke, N. L., Thomas, S. L., dos Santos Silva, I., & Weiss, H. A. (2011). Male
48 circumcision and penile cancer: A systematic review and meta-analysis. Cancer Causes &
 Van Howe, R. S. (2007). Neonatal circumcision and penile inflammation in young boys.
Control, 22(8), 1097–1110. These authors note, however, that in two of the eight studies
Clinical Pediatrics, 46, 329–333. See also Escala, J. M., & Rickwood, A. M. K. (1989).
included in their analysis, ‘the protective effect of childhood/adolescent circumcision on
Balanitis. British Journal of Urology, 63(2), 196–197. According to these authors, balanitis
invasive cancer no longer persisted when analyses were restricted to boys with no
‘is usually associated with a prepuce which is partly or completely non-retractable. It
history of phimosis’.
does not cause phimosis and no single pathogen is involved. Most boys suffer a single
54
episode and circumcision is indicated only for those with recurrent, troublesome  Frisch, M. (2017). Penile cancer. In M. Thun, M. S. Linet, J. R. Cerhan, C. A. Haiman, &
attacks.’ D. Schottenfeld (Eds.), Cancer epidemiology and prevention (ch. 55), Oxford, U.K.: Oxford
49 University Press.
 NHS. (2017). Balanitis. UK National Health Service. Retrieved from https​://www.nhs.
55
uk/condi​tions/​balan​itis/ [accessed Nov 3, 2019].  Ibid: note 54.
8      | MYERS and EARP

that between 909 and 322,000 circumcisions would be required to Another problem with current conceptions of harm relating to
56
prevent a single case. NNMC is that anatomically normal and benign attributes of the foreskin
A similar analysis applies to most of the health benefits commonly are sometimes implied to have negative value. For example, according to
cited by NNMC advocates. We do not have space to cover them all the 2012 AAP statement, ‘Penile wetness (defined as the observation of
here. Instead, we refer the reader to more exhaustive critical surveys a diffuse homogeneous film of moisture on the surface of the glans and
of the claimed health benefits of NNMC that have recently been per- coronal sulcus) is considered a marker for poor penile hygiene and is
formed by others.57 Our point in this section has not been to imply that more prevalent in uncircumcised than in circumcised men’.59 In support
NNMC has no statistical health-related benefits. Rather, it has been to of this view, the AAP Task Force cites a study finding a higher rate of
emphasize that (a) the likelihood and magnitude of these benefits is ‘penile wetness’ among intact than among circumcised men.60 The study
scientifically controversial; (b) most medical bodies that have studied does not explain how penile wetness constitutes ‘poor penile hygiene’,
NNMC have failed to conclude that the health-related benefits out- nor does it define what is meant by the latter concept. It merely notes, as
weigh even the strictly health-related risks or harms; (c) most of the does the AAP Task Force, that other authors have used ‘penile wetness’
benefits cited by NNMC advocates do not apply until sexual debut, as a proxy for ‘poor penile hygiene’. Neither the authors of the study nor
which is typically at, near, or after the time at which the vast majority the AAP Task Force seem aware that penile wetness in genitally intact
of individuals could consent to circumcision if that is what they wanted; males is normal, just as labial wetness in genitally intact females is nor-
(d) the main health benefits said to apply before sexual debut have a mal. The glans penis, like the glans clitoris, evolved though natural selec-
low absolute risk of occurring, are typically non-serious, and can usu- tion to be an internal organ that is protected and lubricated by a prepuce,
ally be effectively treated without tissue loss; and (e) nearly all of the akin to the relationship of the eye to the eyelid.61
health benefits attributed to circumcision can be achieved in less inva-
sive ways that do not involve non-voluntary genital cutting.

BOX 3 A brief overview of the human prepuce

2.2 | Costs The prepuce is a ‘common anatomical structure of the male

and female external genitalia of all human and non-human
We turn next to the question of the costs or drawbacks to NNMC, primates’. In humans, the penile and clitoral prepuces are
which we have divided into three categories: general harms, medical identical in early foetal development and remain indistin-
complications and financial costs. These costs are discussed sepa- guishable in some intersex individuals. The prepuce is an
rately because in Anglophone Western countries, even those with ‘integral, normal part of the external genitalia that forms the
low or declining rates of NNMC, it is commonplace to discuss cir- anatomical covering of the glans penis and clitoris’, thereby
cumcision solely in terms of its medical benefits and surgical risks. internalizing each and ‘decreasing external irritation and
The prima facie value of the prepuce itself (see Box 3), the state of contamination’. In the case of the penile prepuce, an addi-
being genitally intact, and/or the ability to decide for oneself about tional function is to protect the urinary opening from abra-
whether to undergo an elective genital procedure—all of which are sion, as this runs through the penile, but not through the
necessarily lost to NNMC—are not typically given as much attention. clitoral, glans. In both cases, the prepuce is ‘a specialized,
But insofar as an individual does place a positive value on any of junctional mucocutaneous tissue which marks the boundary
those factors (the prepuce, genital intactness, or having a choice), between mucosa and skin … similar to the eyelids, labia mi-
NNMC is a harm to them even if there are no surgical complica- nora, anus and lips’. The ‘unique innervation of the prepuce
tions. 58
The magnitude of the harm, in turn, depends on the degree establishes its function as an erogenous tissue’.62
of value placed on these factors, which cannot be known in infancy
or early childhood and is likely to be highly individually variant.
2.2.1 | General harms
56
 A AP Task Force on Circumcision, op cit. note 29, p. e768.
57
 See, e.g., Dave, S., Afshar, K., Braga, L. H., & Anderson, P. (2018). Canadian Urological Circumcision removes one-third to one-half of the motile skin system
Association guideline on the care of the normal foreskin and neonatal circumcision in of the penis.63 This is tissue that many individuals consider to be erog-
Canadian infants (full version). Canadian Urological Association Journal, 12(2), E76–E99.
The authors fail to find that the health benefits of NNMC outweigh the medical risks, enous, as it provides a range of specific sensations that can contribute
concluding that from an ‘overall societal perspective, given our healthcare system and
the socioeconomic and educational status of our population, universal neonatal
59
circumcision is not justified based on the evidence available’. The most recent  A AP Task Force on Circumcision, op cit. note 29, p. e763.
evidence-based review from any non-partisan group or organization of which we are 60
 O’Farrell, N., Morison, L., & Chung, C. K. (2007). Low prevalence of penile wetness
aware is the one from Evidence Based Birth: Dekker, R., & Bertone, A. (2019). Evidence
among male sexually transmitted infection clinic attendees in London. Sexually
and ethics on: Circumcision. Evidence Based Birth. Retrieved from https​://evide​nceba​
Transmitted Diseases, 34(6), 408–409.
sedbi​r th.com/evide​nce-and-ethics-on-circu​mcisi​on/ [accessed Nov 3, 2019]. These
61
authors state: ‘After an extensive review of the literature, we’ve concluded that there is  Cold & Taylor, op cit. note 14.
62
no compelling evidence to justify routine male infant circumcision on medical grounds.’  Q uotations from Cold & Taylor, op cit. note 14.
58
 Svoboda, J. S. (2017). Nontherapeutic circumcision of minors as an ethically 63
 Taylor, J. R., Lockwood, A. P., & Taylor, A. J. (1996). The prepuce: Specialized mucosa of
problematic form of iatrogenic injury. AMA Journal of Ethics, 19(8), 815–824. the penis and its loss to circumcision. British Journal of Urology, 77, 291–295.
MYERS and EARP       9|
to the subjective experience of sexual enjoyment.64 The ‘gliding’ mo- pain-free circumcision’.70 A further consideration is that adults can
tion of the foreskin back and forth over the glans during sexual inter- communicate their pain levels clearly and manage their own pain con-
course or masturbation is permanently disabled by NNMC, changing trol needs as the circumcision wound heals. Pre-verbal infants, by
the very  mechanics of penile stimulation;65 and part or all of the contrast, whose wound—unlike that of an adult—will be exposed to
frenulum is often removed.66 Studies employing objective measures urine and faeces in a diaper, cannot as effectively communicate their
consistently show that the foreskin is the most sensitive part of the discomfort and must rely on others to change their bandaging, admin-
organ to light touch.67 Moreover, scar tissue may form around the cir- ister analgesic drugs, and so on, in a timely and appropriate manner.
cumference of the penis following circumcision, which apart from Most of the above outcomes, which may reasonably be judged
being unsightly in some cases, may also be less capable of supplying to constitute harms,71 could apply to circumcisions performed at
varied sensation.68 Finally, pain is an unavoidable consequence of cir- any stage of life. However, as with the pain issue, some potential
cumcision, not only during the procedure itself but also throughout harms of circumcision may be greater in infancy or early childhood
the healing process. Because general anesthesia is considered too compared with after an age of consent. First, on a psychological
risky for neonates, the most effective form of pain control is not avail- level, there is the sheer removal of choice concerning how an inti-
able to them (whereas it is available for adults). Instead, local anes- mate part of one’s body should look or function. Some individuals
thetics must be used. However, the best of these approved for use in regard this aspect of NNMC as harmful in and of itself.72 Second,
neonates still requires making injections into the base of the penis on a more physical level, because the infant penis is so small, the
prior to circumcision, which can itself be painful.69 As Bellieni et al. physician performing the circumcision may remove too much tis-
noted after a review of the literature, ‘there is no such thing as a sue, possibly contributing to tight or painful erections in adult-
hood, without being able to anticipate or fully account for this
64
 Ibid. See also Martín-Alguacil, N., Cooper, R. S., Aardsma, N., Mayoglou, L., Pfaff, D., & adverse outcome.73 It may also be more likely that the frenulum
Schober, J. (2015). Terminal innervation of the male genitalia, cutaneous sensory
receptors of the male foreskin. Clinical Anatomy, 28(3), 385–391; Ball, P. J. (2006) A
survey of subjective foreskin sensation in 600 intact men. In G. C. Denniston, P. G. Gallo, 70
 Bellieni, C. V., Alagna, M. G., & Buonocore, G. (2013). Analgesia for infants’
F. M. Hodges, M. F. Milos, & F. Viviani, (Eds.), Bodily integrity and the politics of circumcision circumcision. Italian Journal of Pediatrics, 39(38), 1–7. It is notable that a separate AAP Task
(pp. 177–188). New York, NY: Springer; Wong, D. P., Morrison, B. F., Mayhew, R. G., Reid, Force, charged with assessing the literature on infant pain rather than circumcision,
G. A., & Aiken, W. D. (2015). A delayed foreskin-sparing approach to the management of concluded that ‘exposure to repeated painful stimuli early in life is known to have short- and
penile fractures in uncircumcised Jamaican men. International Journal of Surgery Case long-term adverse sequelae [including] physiologic instability, altered brain development,
Reports, 17, 65–68; Kim, D., & Pang, M. G. (2007). The effect of male circumcision on and abnormal neurodevelopment, somatosensory, and stress response systems, which can
sexuality. BJU International, 99(3), 619–622. persist into childhood’, and recommended that ‘every health care facility caring for neonates
65
 For a demonstration, see MFN24. (2015). Gliding motion of the foreskin. Wikimedia should implement [a] pain-prevention program that includes strategies for minimizing the
Commons. Retrieved from https​://commo​ns.wikim​edia.org/wiki/File:Fores​kin_in_motion. number of painful procedures performed’. AAP Committee on Fetus and Newborn and
gif [accessed Nov 3, 2019]. Section on Anesthesiology and Pain Medicine. (2016). Prevention and management of
66 procedural pain in the neonate: An update. Pediatrics, 137(2): e20154271.
 See Shenoy, S. P., Marla, P. K., Sharma, P., Bhat, N., & Rao, A. R. (2015). Frenulum
71
sparing circumcision: Step-by-step approach of a novel technique. Journal of Clinical and  O f course, one and the same outcome may be judged to be—or experienced as—a harm
Diagnostic Research, 9(12), PC01–PC03. for one individual, while, for another individual with different preferences, it could be
67
 Sorrells, M. L., Snyder, J. L., Reiss, M.D., Eden, C., Milos, M. F., Wilcox, N., & Van Howe, judged to be a benefit. Once again, such disagreement weighs in favour of allowing the
R. S. (2007). Fine-touch pressure thresholds in the adult penis. BJU International, 99(4), individual to decide about their own genitals in terms of whether they should be
864–869; Bossio J. A., Pukall, C. F., & Steele, S. S. (2016). Examining penile sensitivity in permanently modified. For extensive discussions, see Earp, B. D, & Darby, R. (2017).
neonatally circumcised and intact men using quantitative sensory testing. Journal of Circumcision, sexual experience, and harm. University of Pennsylvania Journal of
Urology, 195(6), 1848–1853. For critical discussion and contextualization of these International Law, 37(2-online), 1–57; Earp, B. D. (2017). Gender, genital alteration, and
findings, see Earp, B. D. (2016). Infant circumcision and adult penile sensitivity: beliefs about bodily harm. Journal of Sexual Medicine, 14(5), Supp. 4, e225 (an associated
Implications for sexual experience. Trends in Urology & Men’s Health, 7(4), 17–21; Van video presentation entitled ‘Circumcision – a sexual harm?’ is available at https​://www.
Howe, R. S., Sorrells, M. L., Snyder, J. L., Reiss, M. D., & Milos, M. F. (2016). Re: Examining youtu​be.com/watch​? v=SB-2aQoTQeA).
penile sensitivity in neonatally circumcised and intact men using quantitative sensory 72
 Hammond, T., & Carmack, A. (2017). Long-term adverse outcomes from neonatal
testing. Journal of Urology, 196(6), 1824; Rotta, A. T. (2016). Re: ‘Examining penile
circumcision reported in a survey of 1,008 men: An overview of health and human rights
sensitivity in neonatally circumcised and intact men using quantitative sensory testing.’
implications. International Journal of Human Rights, 21(02), 189–218. Bossio J. A., & Pukall C. F.
Journal of Urology, 196(6), 1822–1823.
(2018). Attitude toward one's circumcision status is more important than actual circumcision
68
 Cold & Taylor, op cit. note 14. See also Fahmy, M. A. B. (2019). Nonaesthetic status for men’s body image and sexual functioning. Archives of Sexual Behavior, 47(3), 771–781.
circumcision scarring. In Fahmy, M. A. B. (Ed.), Complications in male circumcision (pp. 73
 Hammond & Carmack, op cit. note 72, pp. 199–200. See also Kaplan, G. W. (1983).
99–134). Amsterdam, The Netherlands: Elsevier. Complications of circumcision. Urologic Clinics of North America, 10(3), 543–549, referring
69
 Banieghbal, B. (2009). Optimal time for neonatal circumcision: An observation-based to skin bridges as a further potential complication of NNMC that may cause tight or
study. Journal of Pediatric Urology, 5(5), 359–362. The ring block injections administered painful erections. The size of the infant penis also may also explain why ‘partial glans
prior to circumcision in this study resulted in observable pain responses above a amputation, buried penis and total penectomies’ are complications that are primarily
pre-defined threshold in 31% of <1-week-old infants and 85% of 1–5-week-old infants. limited to early circumcisions. Ungar-Sargon, E. (2015). On the impermissibility of infant
That is, simply being administered the anesthesia was painful for many infants at a male circumcision: A response to Mazor (2013). Journal of Medical Ethics, 41, 186–190.
clinically significant level. Moreover, among 1–5-week-old infants, 71% experienced For supportive data, see PEPFAR. (2019). PEPFAR 2020 country operational plan
above-threshold pain during the actual circumcision. Some research suggests that infants guidance for all PEPFAR countries. PEPFAR. Retrieved from https​://www.state.gov/
experience pain, if anything, more acutely than adults: ‘The newborn is inexperienced in wp-conte​nt/uploa​ds/2019/11/2019-11-25-COP20-Guida​nce-Full-Conso​lidat​
filtering noxious stimuli, so the full impact of pain, without adaptive measures, is ed_Public-2-1.pdf [accessed Nov 3, 2019]. Likewise, deaths following circumcision
delivered. In older children and adults, pain is attenuated by filters developed with performed on infants are reported on occasion, including in developed countries,
experience by the nervous system. This difference in our perception may be explained by whereas deaths following the procedure performed under similar conditions on adults
older [individuals] who can articulate their level of pain, whereas infants are reduced to are virtually unheard of. See Earp, B. D., Allareddy, V., Allareddy, V., & Rotta, A.T. (2018).
screams that the circumcising physician may ignore.’ Van Howe, R. S., & Svoboda, J. S. Factors associated with early deaths following neonatal male circumcision in the United
(2008). Neonatal pain relief and the Helsinki Declaration. Journal of Law, Medicine & States, 2001– 2010. Clinical Pediatrics, 57(13), 1532–1540; Paediatric Death Review
Ethics, 36(4), 803–823. See also Fitzgerald, M. (2015). What do we really know about Committee: Office of the Chief Coroner of Ontario. (2007). Circumcision: A minor
newborn infant pain? Experimental Physiology, 100(12), 1451–1457. procedure? Paediatrics & Child Health, 12, 311–312.
 |
10       MYERS and EARP

would be cut away with those devices most commonly used to 2.2.2 | Medical complications
perform neonatal or infant circumcisions (e.g. the Gomco clamp,
Mogen clamp, or Plastibell), which less discriminately remove tis- The strictly medical complications of circumcision are often said to
sue around the diminutive infant glans. In voluntary circumcisions, be fewer and less serious in infancy, especially in the neonatal pe-
by contrast—that is, when the penis has reached its full size—it is riod, than at any other stage of life. As ‘strong’ NNMC advocates
easier for the physician to cut around the frenulum, leaving it (see Box 2) Brian Morris et al. state in a review, ‘Evidence clearly
mostly or entirely intact.74 shows that circumcision in infancy carries fewer risks of complica-
In terms of data collection and estimation of complications, prob- tions than circumcisions performed in childhood or later in life’.76
lems associated with NNMC may be less likely to be recognized or Somewhat incongruously, however, they go on to argue (emphasis
reported: some individuals may go their entire lives thinking that a added):
negative outcome is normal, or fail to associate the problem with
their circumcision, because this occurred prior to their ability to A recent systematic review found a median complication
make a conscious before-and-after comparison. Finally, the infant frequency of 1.5% among studies of neonatal or infant
foreskin is normally fused to the head of the penis by a membrane, circumcision, compared to 6% among studies of children
whereas the foreskin of a fully developed penis is more likely to be aged one year or older … In the large RCTs of adult MC,
detached. The authors of a study comparing neonatal circumcision complications were seen in 1.7-3.8%; these were virtu-
with that of older boys—to be discussed further below—explain the ally all mild or moderate and were effectively treated.77
surgical significance of this distinction:
In other words, according to these authors, while complications
In the neonatal period, irrespective of the applied from circumcision in early childhood (ages 1 year and older) occur
method of circumcision, a forced and traumatic deglov- about 4 times as frequently as in the neonatal or infant period—assum-
ing of the foreskin from the meatus, glans, and sulcus ing that the cited data are correct; more on this below—there does not
cannot be avoided … Initially, the inner surface of the appear to be a very large absolute difference between complications
prepuce and the epithelium of the glans are fused, and arising from such neonatal or infant circumcision and adult circumci-
separation of these two surfaces develops progres- sion, which is the more ethically relevant comparison in terms of the
sively [which] explains the need for forceful and trau- capacity to consent. In fact, even the relative difference in complica-
matic degloving in neonatal circumcision. Degloving tion rates appears to be modest: the complication rate for adult cir-
leads to a perimeatal inflammation, which can result in cumcision, according to the authors, is between 1.13 and 2.53 times
meatal deformity with eventual stenosis. Development that of NNMC, with ‘virtually all’ of the complications associated with
of scar tissue with meatal deformity and stenosis [in the adult form being ‘mild or moderate’ and ‘effectively treated’. If that
our study] was secondary to the traumatic excoriation is the case, then the marginally greater alleged complication rate in
and was not merely due to exposure and irritation by adults (in absolute terms, between 0.2% and 2.3%) is arguably of lit-
the diaper of the fragile and under-keratinized glans tle medical or ethical significance, whereas the capacity of the adult,
75
epithelium. compared with the infant, to consent to the procedure is of enormous
ethical significance.
Even from a purely technical perspective, then, there are at least Even so, the evidence cited by Morris et al. in support of their
some costs to performing circumcision on a small and underdeveloped claims regarding an increased risk for adults does not come from
penis that do not apply to circumcision performed on a penis that has well-controlled studies. Instead, it comes from studies of non-con-
reached its full size and final configuration. Moreover, any long-term current populations circumcised with different techniques and
complications that are incurred in infancy or early childhood will affect
the individual for a longer period of time and hence a greater propor- 76
 Morris et al., op cit. note 13.
77
tion of their life compared with the same complication incurred in ad-  Ibid. Apart from this article by Morris et al., one of the most common sources of the
claim that circumcision is more risky after infancy is the study by El Bcheraoui, C., Zhang,
olescence or adulthood. X., Cooper, C. S., Rose, C. E., Kilmarx, P. H., & Chen, R. T. (2014). Rates of adverse events
associated with male circumcision in US medical settings, 2001 to 2010. JAMA Pediatrics,
168(7), 625–634. These authors claim that compared with boys circumcised at <1 year,
74
 O n the importance of allowing the penis to reach its full size more generally, consider the incidences of probable adverse events were "approximately 20-fold and 10-fold
the analogous case of elective labiaplasty in females. According to the Royal College of greater for males circumcised at age 1 to 9 years and at 10 years or older, respectively."
Obstetricians and Gynaecologists (RCOG), ‘Even though children aged 16 or over can However, these estimates were indirectly inferred from a retrospective comparison of
consent to surgical procedures’, medically unnecessary female genital cutting procedures hospital billing claims that did not distinguish between voluntary/non-
‘should not normally be carried out on women and girls under 18 years of age, voluntary or therapeutic/non-therapeutic circumcisions nor adjust for potential
irrespective of consent, because full genital development is not normally achieved confounding with concurrent procedures. Moreover, the window of analysis
before the age of 18’. RCOG Ethics Committee. (2013). Ethical opinion paper: Ethical employed was likely too short to capture one of the most common late-
considerations in relation to female genital cosmetic surgery (FGCS). RCOG. Retrieved occurring complications associated with newborn circumcision, namely, meatal stenosis,
from https​://www.rcog.org.uk/globa​lasse​t s/docum​ents/guide​lines/​ethics-issues-and- such that "the observed low frequency of urethral strictures (0.01%) – and therefore the
resou​rces/rcog-fgcs-ethic​al-opini​on-paper.pdf [accessed Nov 3, 2019]. low overall frequency of complications for boys circumcised in infancy (0.4%) – most
75
 Machmouchi, M., & Alkhotani, A. (2007). Is neonatal circumcision judicious? European likely reflects a combination of insensitive research data and insufficient
Journal of Pediatric Surgery, 17(04), 266–269, p. 268. follow-up" (Frisch & Earp, op cit. note 21, p. 633).
MYERS and EARP |
      11

evaluated with disparate methodologies, using inconsistent defini- A final study, from Saudi Arabia, had a relatively well-controlled
tions and thresholds for identifying complications. Very few stud- prospective cohort design, and found a significantly higher rate of
ies have made a direct comparison between the complication rates ‘serious complications’ for neonatal circumcision compared with cir-
of neonatal versus later circumcision within a single population, cumcision of older infants, regardless of the method used (bone cut-
and those that have have yielded mixed results. One study from ter, Gomco clamp, Plastibell device). The authors concluded from
Iran, for example, found no statistically significant difference in this that ‘neonatal circumcision should not be recommended’.81
late complications (defined as excessive residual foreskin, exces- However this study, too, did not compare neonatal (or infant) cir-
sive foreskin removal, meatal stenosis, granuloma, penile rotation, cumcision with circumcision after an age of consent: the maximum
and secondary chordee) when comparing circumcisions performed age in the comparison group was 5 months old.
by medically untrained personnel in the neonatal period (5.68%) No studies to our knowledge have yet been performed comparing
with those performed in later childhood (7.44%). However, more the circumcision of neonates or infants with that of consenting
than 70% of the latter circumcisions took place between the ages older  adolescents or adults in the same population, properly con-
of 2 and 12, with 12 being the maximum age of any child included trolling for the experience of the surgeon, the method used, the set-
in the study. Because this is below the age of consent in most ju- ting, and the reason for circumcision. This last factor is perhaps the
risdictions, it is also below the age range of the relevant compari- most important. Because it is unusual, especially in the developed
son class for our purposes.78 world, for adults to request a circumcision unless they have a pre-exist-
Two other studies from Pakistan found a lower overall complica- ing medical condition relating to their penis, some of the greater appar-
tion rate in neonates than in older children, but similarly failed to make ent burden of complications in adults (on average) may be related to
the ethically relevant comparison: the maximum age at which the cir- this factor. NNMC, by contrast, is usually performed on a normal,
cumcisions took place across both studies was 5 years old.79 healthy penis. Some complications that do occur may be missed by the
Nevertheless, in one of the studies, the authors reported a greater per- parents, and the infant will be in no position to recognize or to report
centage of buried glans cases (3.21%) in neonates (mean age 15 days) these. The only other party who might report any complications arising
than in infants (mean age 3 months) or older children (mean age 2.3 from NNMC is the medical practitioner (who has an interest in not
years) (1.24% and 1.92% respectively), ‘which may be due to the small doing so). That being said, recent findings from a relatively controlled
size of [the neonatal] penis and adhesions’.80 Again, these findings sug- comparison based on millions of cases, with all circumcisions per-
gest that different kinds of complications may occur at different rates formed as part of the ongoing VMMC program described above, sug-
depending on the age of the individual, with some being higher (or gest the very opposite of the conclusion drawn by Morris et al. in their
more serious) at a given age and others being lower (or less serious). review. According to the U.S. President's Emergency Plan for AIDS
Relief (PEPFAR), ‘Complications continue to be reported more com-
78
monly among those under age 15 at VMMC, especially in infants’. In
 Yegane, R.-A., Kheirollahi, A.-R., Salehi, N.-A., Bashashati, M., Khoshdel, J.-A., &
Ahmadi, M. (2006). Late complications of circumcision in Iran. Pediatric Surgery particular, fully 100% of glans injuries and 90% of fistulas reported
International, 22, 442–425. A similar limitation applies to a later Turkish study, which had through their Notable Adverse Events (NAEs) reporting system oc-
a maximum age of 14 years: Bicer, S., Kuyrukluyildiz, U., Akyol, F., Sahin, M., Binici, O., &
Onk, D. (2015). At what age range should children be circumcised? Iran Red Crescent curred in children circumcised at ages 14 and younger. And the overall
Medical Journal, 17(3), e26258. These authors found no statistically significant difference ratio of NAEs to circumcisions performed was 5 times higher in infants
in surgical complication rates between children circumcised at ages <1 year, 1-7 years,
and 7-14 years. There were, however, fewer recorded complications due to anaesthesia
(15.3 per 100,000) than in young adolescents (2.9 per 100,000), which
in the <1 year group, but these children were circumcised with local anaethesia only, in turn was about twice the ratio for individuals circumcised at ages 15
whereas general anaesthesia was used among the older children, with the
years and above (1.6 per 100,000). As a result of these findings,
majority complication being the temporary experience of double vision. We discuss the
ethical significance of the use of local versus general anaesthesia elsewhere in the paper. PEPFAR announced in late 2019 that it will no longer fund infant cir-
79
 Moosa, F. A., Khan, F. W., & Rao, M. H. (2010). Comparison of complications of cumcisions as a part of the VMMC program, citing the ‘NAE review, the
circumcision by ‘Plastibell device technique’ in male neonates and infants. Journal of the
severity of glans injuries and fistulas when they occur, and expected
Pakistan Medical Association, 60, 664–667. Razzaq, S., Mehmood, M. S., Tahir, T. H.,
Masood, T., & Ghaffar, S. (2018). Safety of the Plastibell circumcision in neonates, timing of pubertal development’. The minimum eligibility criteria for
infants, and older children, International Journal of Health Sciences, 12(5) 10–13. Similar
VMMC have been updated to 15 years of age or Tanner Stage 3 sexual
findings, with similar limitations (e.g., maximum age of 8.5 months in the non-newborn
comparison group) were reported in a retrospective study of 130 circumcisions development.82
performed by a single pediatric urologist based in the United States: Horowitz, M., & Even in developed countries, severe complications associated with
Gershbein, A. B. (2001). Gomco circumcision: When is it safe? Journal of Pediatric Surgery,
36(7), 1047–1049. More recently, a complication rate of 1.5% was reported for neonates NNMC may be more common than suggested by its proponents’ con-
over a five-year period compared to 2.9% in non-neonates; but again, the study was servative estimates. At a single children’s hospital in Birmingham,
retrospective and poorly controlled, and the non-neonate group was not old enough to
consent (max age <5 years): Hung, Y. C., Chang, D. C., Westfal, M. L., Marks, I. H.,
England, for instance, cases of ‘life threatening hemorrhage, shock or
Masiakos, P. T., & Kelleher, C. M. (2019). A longitudinal population analysis of cumulative sepsis’ resulting from infant circumcision ranged from 0 to 11 per year
risks of circumcision. Journal of Surgical Research, 233, 111–117. A prospective Indian
study also reported a 4.16% complication rate in neonates circumcised with the Plastibell
device compared to 20% in infants, with the same wrong-comparison-group
problem (max age 1 year): Shinde, N. D., Moinuddin, M., & Danish, A. O. (2018). Plastibell
81
circumcision in neonates and infants at tertiary care centre. International Surgery Journal,  Machmouch & Alkhotani, op cit. note 75, p. 266.
5(4), 1488–1491. 82
 PEPFAR, op cit. note 73, pp. 171–172, emphasis added. For further discussion, see Earp
80
 Ibid: p. 12. & Darby, op cit. note 71.
12       | MYERS and EARP

between 2002 and 2011.83 Because these figures were obtained as a ($800+ on the high end, including a facilities fee) and that of an older
result of a special freedom of information request and otherwise would adolescent who could at least potentially consent ($850 up to age 17),
not have been made public, it is unclear whether the complication rates could be $50 or less in at least some contexts. But even if the compari-
in the published literature reflect the full scope of the problem. Finally, son is between newborn and adult (age 18+) elective circumcisions, the
it has been suggested that ‘the severity of complications is far more difference could be as little as $700 if local anesthesia is used. For a
important than the rate. Although necrotizing fasciitis, amputation of point of comparison, the U.S. national average cost of adult (elective)
the penis and death are incredibly rare’, they may be more common in labiaplasty is $2,924 according to the American Society of Plastic
infancy than in adulthood (provided a similar clinical context  and a Surgeons.87 In either case, the cost of the adult procedure would be
healthy organ); and ‘some would consider it unethical [to] advocate for borne exclusively by the small minority of individuals who had an ex-
an elective procedure that may or may not benefit an individual plicit, robust desire to undergo a genital-altering procedure, whereas
[non-consenting] patient yet has any potential to result in such devas- those who did not have such a desire would pay nothing.
tating outcomes’.84 Morris et al. also argue that individuals circumcised as adults may
need to take time off work. Any lost earnings that result from this
would need to be taken into account as well. However, similar to the
2.2.3 | Financial costs labiaplasty example, this financial loss would be moderated by the
fact that it was voluntarily incurred to achieve a desired outcome,
Morris et al. point to a lower financial cost of performing circumcision except in those rare cases where the procedure was medically nec-
in infancy, estimating in 2012 a cost of between $165 and $257 in in- essary.88 We discuss the ethical implications of these observations
fancy, compared with $1,800–2,000 for circumcision in adolescence or in a later section.
adulthood. They acknowledge, however, that the cost for older males
‘can be reduced by insisting on a local anesthetic, since a general anes-
thesiologist’s fees can be considerable’.85 As noted, general anesthesia 3 | E TH I C A L I S S U E S
is typically contra-indicated in neonates, which appears to be the main
reason why neonatal circumcisions are generally less expensive over- In the previous sections, we explored a range of empirical questions re-
all. Morris et al. state that if adolescent and adult males opted for cir- lating to the potential benefits and risks of circumcision before versus
cumcision under local anesthesia, the discrepancy in cost would not be after an age of consent. We argued that the evidence for the medical
as great. Consistent with this, a more recent, informal estimate sug- benefits of circumcision is much less compelling than its strongest ad-
gests that when the procedure is not covered by health insurance, ‘cir- vocates claim. We also noted that only a few of these alleged benefits
cumcision for a newborn infant typically costs $150–$400 for the would apply to children below the age of consent. We then highlighted
doctor fee, and possibly an additional facility fee, which can increase a number of problems with the arguments that neonatal circumcision
the total to $800 or more’, whereas ‘circumcision for an older child or carries fewer costs or disadvantages, whether general, medical, or fi-
adult male typically costs $800–$3,000 or more’. As a characteristic nancial. In the following section, however, we will simply grant for the
example, the fees from one circumcision clinic are listed as ‘$850 for sake of argument the claim of NNMC proponents that the greatest bal-
children 1 to 17 years, $1,500 for adults if local anesthesia is used and ance of medical benefits over risks applies to circumcisions performed
$3,000 for adults if general anesthesia is used’.86 Assuming for the in infancy, and especially in the neonatal period, compared with cir-
sake of argument that these figures are in the right ballpark, the differ- cumcisions performed later in life. We argue that even if one grants this
ence in cost between a medically unnecessary newborn circumcision claim despite the contrary evidence surveyed above, it does not follow
that NNMC is a morally acceptable practice.
83
 Checketts, R. (2012). Response to freedom of information request, FOI/0742.
Birmingham Children’s Hospital, NHS Foundation Trust. Retrieved from http://www.
secul​arism.org.uk/uploa​ds/foi-bch-respo​nse-recei​ved-260612.pdf [accessed Nov 3,
2019]. For a recent discussion of some of the challenges in obtaining freedom of
3.1 | Benefits
information data on circumcision complications, see Fox, M., Thomson, M., & Warburton,
J. (2018). Non-therapeutic male genital cutting and harm: Law, policy and evidence from
UK hospitals. Bioethics, 33(4), 467–474.
3.1.1 | Circumcision before sexual debut
84
 Robinson et al., op cit. note 32, p. 8684, emphasis added. Against this view, it could be
argued that certain risks associated with a lack of circumcision, such as penile cancer, The AAP was prompted to update its policy statement on NNMC
may also be devastating. However, these typically already-low risks can almost always be
in light of the three aforementioned RCTs in sub-Saharan Africa
reduced or eliminated without genital surgery, which carries its own risks, whereas the
most devastating injuries that may be caused by circumcision (e.g. partial or complete that reported a reduced risk of female-to-male HIV transmission
amputation of the glans) are typically more directly attributable to the surgery itself.
following VMMC. Based on the inadequately supported
85
 Morris et al., op cit. note 13, p. 8.
86
 See https​://health.costh​elper.com/circu​mcisi​on.html [accessed Nov 3, 2019]. We do
not suggest that the estimates from this source are reliable or nationally representative; 87
 See American Society of Plastic Surgeons (ASPS). (2019). Vaginal rejuvenation surgical
we use them purely for the sake of illustration. Please note that the most recent fees
options. ASPS. Retrieved from https​://www.plast​icsur​gery.org/cosme​tic-proce​dures/​
listed at the example clinic, Gentle Circumcision of California, are $900 for teens up to
vagin​al-rejuv​enati​on/labia​plasty [accessed Nov 3, 2019]. The data cited are from 2018.
age 17 and $1600 for adults (18+). See http://www.gentl​ecirc​umcis​ion.com/ [accessed
88
Nov 3, 2019].  Ungar-Sargon, op cit. note 73.
MYERS and EARP |
      13

assumption that this reported benefit can be meaningfully extrap- sion—at any age—prevents HIV in this subset of the population.93 It is
olated to NNMC in the United States, the AAP 2012 Task Force thus very different from the epidemic in sub-Saharan Africa.94
claimed that waiting until an age of consent to offer circumcision Even granting, therefore, that a tiny fraction of the annual cases
may be medically disadvantageous insofar as a certain percentage of female-to-male transmission of HIV in the United States (and rel-
of U.S. adolescents become sexually active before they can legally evantly similar contexts) may occur in adolescents under the age of
89
consent to sex. But this claim needs to be put in context. Using 15, likely engaged in unprotected sex, it is unclear how this could jus-
data from the U.S. Centers for Disease Control and Prevention tify the non-voluntary removal of a psychosexually significant part
(CDC) concerning female-to-male HIV transmission—and assuming of an individual’s body long before sexual debut. Neonatally circum-
for the sake of argument that the African data could be directly cised homosexual males—or heterosexual males who practice safe
applied to the United States—the researcher Sarah Bundick has sex—will receive virtually no HIV-related benefit whilst bearing the
argued as follows: burden of unsafe choices made by others. It is also worth remem-
bering that circumcision is not a failsafe intervention: it does not
If we assume that all 5,250 men who get HIV from a female prevent HIV (or any other sexually transmitted infection). Rather, it
sexual partner [per year] are not circumcised (though this is may merely reduce one’s risk of contracting the virus by around half
certainly not the case), the data suggest that about half of per coital act, assuming (for the sake of argument) that the African
these infections—around 2,625 infections or ~5% of new findings are both accurate and generalizable.
infections—may have been prevented if the men had been A more appropriate solution, then, would be to allow individu-
circumcised. If we then factor in the number of men who als to decide for themselves whether or not to undergo circumci-
are circumcised when they are infected (approximately sion when they are old enough to understand what is at stake. If
70–80% of American men are already circumcised), the most decline to undergo the procedure even after being informed
number of infections that could have been prevented by of its purported benefits, it is not safe to assume, as some circum-
circumcision drops considerably. Taken together, the data cision proponents do, that this is only because they want to avoid
suggest that the number of HIV infections that could be the pain and disruption that accompany the procedure in later
prevented in the US by promoting infant male circumcision life.95 Rather, these individuals may place a positive value on their
is likely to be only in the hundreds per year—a tiny fraction foreskins or on the state of being genitally intact, or prefer alter-
90
of the estimated 50,000 new HIV infections. native, less invasive, more effective means of preventing sexually
transmitted infections (STIs). Consider that if adult men were forc-
With respect to the specific claim of the AAP Task Force, it should ibly circumcised to lower their risk of STIs, even on the paternalis-
be emphasized that the sub-population of males that is both (a) sexu- tic assumption that this was best for them, this would be seen as an
ally active before a legal age of sexual consent and (b) at a meaningful
risk of becoming infected with HIV (i.e. from either a similarly underage 93
 A 2008 meta-analysis performed by the CDC and the five largest studies exploring
female sexual partner or an older female committing statutory rape) is whether there was a link between circumcision status and HIV prevalence or incidence in
men engaging in homosexual activities failed to find an association that was statistically
much smaller than the sub-population analysed by Bundick: a CDC significant. Millett, G. A., Flores, S. A., Marks, G., Reed, J. B., & Herbst, J. H. (2008).
study cited by the AAP Task Force shows that only 84 males aged Circumcision status and risk of HIV and sexually transmitted infections among men who
have sex with men. Journal of the American Medical Association, 300, 1674–1684 (Errata
13–19 were infected with HIV via heterosexual contact in the entire JAMA (2009), 301, 1126–1129); Solomon, S., Mehta, S., Srikrishnan, A. K., Vasudevan, C.
United States in 2010.91 Indeed, the main driver of the HIV epidemic in K., Mcfall, A. M., Balakrishnan, P., ... Celentano, D. D. (2015). High HIV prevalence and
incidence among MSM across 12 cities in India. AIDS, 29, 723–731; Gust, D. A., Wiegand,
the United States is still homosexual sex between males (63% of all
R. E., Kretsinger, K., Sansom, S., Kilmarx, P. H., Bartholow, B. N., & Chen, R. T. (2010).
new infections),92 and there is no consistent evidence that circumci- Circumcision status and HIV infection among MSM: Reanalysis of a Phase III HIV vaccine
clinical trial. AIDS, 24, 1135–1143; Jozkowski, K., Rosenberger, J. G., Schick, V.,
Herbenick, D., Novak, D. S., & Reece, M. (2010). Relations between circumcision status,
sexually transmitted infection history, and HIV serostatus among a national sample of
men who have sex with men in the United States. AIDS Patient Care & STD, 24, 465–470.
Oster, A. M., Wiegand, R. E., Sionean, C., Miles, I. J., Thomas, P. E., Melendez-Morales, L.,
89
 A AP Task Force on Circumcision, ‘Cultural bias and circumcision’, op cit. note 28, p. ... Millett, G. A. (2011). Understanding disparities in HIV infection between black and
803. The Task Force cites CDC data from 2011 showing that sexual debut had already white MSM in the United States. AIDS, 25, 1103–1112. Subsequently, a 2019
occurred by the age of 13 in 6.2% of high school students. meta-analysis calculated that circumcised men were at lower risk, but their findings are
90
 Bundick, S. (2009). Promoting male circumcision to reduce transmission of HIV: A of questionable value considering the analysis also found evidence of between-study
flawed policy for the US. Harvard Health and Human Rights Journal (online). Retrieved heterogeneity and significant publication bias. Yuan, T., Fitzpatrick, T., Ko, N.-Y., Cai, Y.,
from https​://www.hhrjo​urnal.org/2009/08/promo​ting-infant-male-circu​mcisi​ Chen, Y., Zhao, J., ... Zou, H. (2019). Circumcision to prevent HIV and other sexually
on-to-reduce-trans​missi​on-of-hiv-a-flawed-policy-for-the-us/ [accessed Nov 3, 2019]. transmitted infections in men who have sex with men: A systematic review and
91
 Centers for Disease Control and Prevention. HIV surveillance in adolescents and young meta-analysis of global data. Lancet Global Health, 7, e436–47. When adjusted for these
adults, p. 7. Retrieved from https​://web.archi​ve.org/web/20120​72400​1848/www.cdc. two factors, the difference was no longer seen: Van Howe, R. S. (2019). Is circumcision
gov/hiv/topic​s/surve​illan​ce/resou​rces/slide​s/adole​scent​s/slide​s/Adole​scents.pdf an answer for HIV prevention in men having sex with men? Lancet Global Health, 7(8),
[accessed Nov 3, 2019]. The AAP Task Force (op cit. note 28, p. 803) misleadingly cites e1011.
94
the total number of HIV infections for this age group (2,266), which comprises data for  For reasons already discussed, this is not to say that NNMC would necessarily be
both sexes and all vectors of infection. justified in those settings (where the circumcision programs were originally framed as
92
 Centers for Disease Control and Prevention. HIV in the United States: At a glance. being voluntary); only that it may be particularly unjustified in the United States and
Retrieved from http://www.cdc.gov/hiv/stati​s tics/​basic​s/atagl​ance.html [accessed Nov epidemiologically similar countries.
95
3, 2019].  Morris et al., op cit. note 13, p. 10.
14       | MYERS and EARP

impermissibly coercive public health strategy, amounting to However, this argument is problematic, even if it is stipulated that
state-sanctioned assault and battery. On the other hand, when ne- the underlying empirical assumptions (about ridicule, etc.) are
onates or infants—who are unable to offer any effective resis- sound.100 First, an argument of this form could be applied to any cul-
tance—are forcibly circumcised, this is framed as a legitimate tural practice—no matter how unjust or harmful—upheld by social
means of promoting personal and/or public health by advocates of norms that stigmatize noncompliance. Second, whether NNMC really
96
NNMC. does confer a (net) cultural benefit depends on how the affected indi-
Let us turn finally to the question of the legal age of consent. vidual personally relates to the culture or sub-culture of their birth.
NNMC proponents seem to assume that the age of consent for cir- Some may only identify with certain aspects of that culture; others
cumcision must be the same as the age of legal majority (18 years in may wish to reform it or leave it altogether. Even if one accepts (which
most jurisdictions). By contrast, we argue that the age of consent for seems unlikely in the modern world) that most individuals will not
circumcision should be no earlier than the age of consent to sexual question the cultural commitments of their parents’ generation, it is
relations, which ranges from 16 to 18 across U.S. states, often with far from clear that the remainder will have been socially benefited by
close-in-age exemptions (so-called ‘Romeo and Juliet laws’). Such ex- NNMC.101
emptions allow for even lower age limits when, for example, both
partners are minors.97 Alternatively, in discussing the age at which a
child might be expected to provide their own fully informed consent 3.2 | Costs
for certain medical or surgical interventions, the AAP’s Committee on
Bioethics suggested 14 years as a reasonable age.98 Depending on 3.2.1 | Impact on sexual function
the maturity, or perhaps the degree of sexual experience (if any) of
the minor, something approximating this age might well be appropri- As discussed earlier, proponents of circumcision are generally dismiss-
ate as a lower limit for consenting to circumcision, consistent with the ive of claims that removing the sensitive foreskin may affect sexual
recent change in eligibility criteria for VMMC set by PEPFAR. The experience in a negative way or in a way that an individual might rea-
underlying point is simply that the person whose sexual or reproduc- sonably resent. For example, in a review paper cited frequently by
tive organ would be permanently affected by the procedure should these proponents,102 Morris and Krieger rate studies purporting to
have at least some reasonably well-informed say in whether or not show that circumcision has no effect on sexual pleasure (or even a
they want to undergo the procedure. This is impossible in the neona- positive effect) as being of higher quality, whilst they deem studies
tal period. suggesting otherwise to be of lower quality.103 But as Bossio et al.
point out, the coding scheme employed by Morris and Krieger can be
used in a questionable manner: for example, Morris and Krieger
3.1.2 | Cultural benefits

Not all claimed benefits of circumcision before an age of consent re- 100
 It is not clear that such a stipulation would be justified. Advocates of NNMC do not
late to the medical aspects of the practice. Some have pointed to po- typically cite any evidence that a child will in fact suffer psychologically if they end up
being different from their peers in this particular respect. There is also a question about
tential cultural or even spiritual benefits: in some cultures, for who the relevant peers are, depending on the context. In most Western countries where
example, circumcision is commonly embraced as a means of initiation penile circumcision occurs, for example, it is usually limited to a minority sub-group,
whereas most individuals in the larger society (of which the circumcised child is
that allows individuals to be regarded as full members of the group in
ostensibly also a part) are not circumcised. Assuming that the child is not entirely isolated
which they are raised.99 Such sociocultural benefits, it is proposed, from their non-circumcised peers, then, it could just as easily be predicted that they will
be teased for being circumcised. In short, the teasing argument only works under an
are denied to those children who are not circumcised as early as pos-
assumption of cultural homogeneity with high rates of circumcision; yet this is not the
sible: although they will be able to choose circumcision for them- situation in most multi-cultural Western societies where the ethical debate about NNMC
selves—later on—if that is what they desire, they will first have to go is primarily taking place. Even in the U.S. state of Iowa, which has a relatively high rate of
circumcision even for the United States—and where the only empirical study on ‘locker
through childhood wondering why they look different from their room’ teasing that we are aware of has been conducted—the data suggest that (1) penile
peers, possibly being subject to ridicule in the proverbial locker room, size, not circumcision status, is the main source of teasing, and (2) even if a boy is teased
for not being circumcised, this does not seem to cause much distress. In fact,
and so on. ‘experiencing teasing or witnessing others being teased about penile appearance did not
have an effect on the desire for a different penile appearance [and] being uncircumcised
did not increase the rate of personally experienced teasing’. Alexander, S. E., Storm, D.
W., & Cooper, C. S. (2015). Teasing in school locker rooms regarding penile appearance.
96
 Morris, op cit. note 36. Journal of Urology, 193(3), 983–988, p. 985.
101
97
 See https​://www.ageof​conse​nt.net/states [accessed Nov 3, 2019].  Ungar-Sargon, op cit. note 73; The Pew Forum on Religion & Public Life. (2008). US
98 religious landscape survey religious affiliation: Diverse and dynamic. Washington, D.C.: Pew
 Committee on Bioethics. (1995). Informed consent, parental permission, and assent in
Forum on Religion & Public Life.
pediatric practice. Pediatrics, 95, 314–317.
102
99  Morris, B. J., & Krieger, J. N. (2013). Does male circumcision affect sexual function,
 Benatar & Benatar, op cit. note 22, pp. 43–45. See also Schlegel, A., & Barry III, H.
sensitivity, or satisfaction? —A systematic review. Journal of Sexual Medicine, 10(11),
(2017). Pain, fear, and circumcision in boys’ adolescent initiation ceremonies.
2644–2657.
Cross-Cultural Research, 51(5), 435–463. Note that circumcision performed as a rite of
103
passage into adulthood—i.e. around puberty—could in principle conform to our proposed  Boyle, G. J. (2015). Does male circumcision adversely affect sexual sensation,
consent threshold, i.e. if the child were mature enough to appreciate what was at stake in function, or satisfaction? Critical comment on Morris and Krieger (2013). Advances in
the initiation. Sexual Medicine, 5(2), 7–12. The author reply is available at the journal website.
MYERS and EARP |
      15

assigned the highest possible quality rating to a study of which one of exceedingly difficult, and as such has never been done.108 So the ques-
104
them (Krieger) was the lead author, despite the seemingly clear con- tion might best be put in terms of the burden of proof. Arguably, this lies
flict of interest involved in assessing one’s own work, while also failing with those who propose to excise healthy tissue from the penis, espe-
to engage with or even mention the published criticisms of the study’s cially when the person who would undergo this procedure is unable to
materials.105 Even more questionably, they assigned the highest possi- provide their own consent.109 We suggest that the arguments and
ble quality rating for a study of its kind to a single paragraph in a popu- evidence of NNMC advocates fall far short of meeting this burden. For
lar book by Masters and Johnson, referring to an experiment purporting one thing, proving a negative claim about adverse sexual outcomes is
to show no difference in penile glans sensitivity between circumcised practically impossible: an absence of evidence is not the same thing as
and non-circumcised individuals.106 Yet the study was never subjected evidence of absence unless one has accurately, robustly and systemat-
to peer review, and the paragraph provided no details of the tools, ically measured all such possible outcomes with sufficient statistical
methodology, or statistical procedures used, when this information is power to detect them, should they exist.110 Obviously this has not oc-
107
absolutely required for properly evaluating claims of a ‘null effect’. curred. Moreover, there are many aspects of the foreskin that are not
But even if one simply accepts the ratings assigned by Morris yet fully understood,111 and increasing evidence that circumcision
and Krieger, their own interpretation of the evidence does not sup- likely does alter subjective sexual experience in a variety of ways.112
port NNMC. This is because the studies they judge to be of the These alterations might not always be judged negatively: some men
highest quality, which according to them ‘suggest that medical male circumcised as adults, for instance, have indeed reported no differ-
circumcision has no adverse effect on sexual function, sensitivity, ence or even an increase in sexual satisfaction, while other men have
sexual sensation, or satisfaction’, concern consensual, adult circum- noted a clear decrease.113 The point is that no one other than the
cision, not circumcision of newborns. If anything, then, the review by owner of the penis is better positioned to determine whether they
Morris and Krieger supports the performance of voluntary circum- wish to assume the risk that circumcision might permanently compro-
cision after an age of consent: for it is circumcision of this kind for mise their sexual enjoyment. A person who seeks circumcision in
which the evidence against adverse sexual outcomes is, by their own adulthood also has the advantage of being able to explain to the sur-
account, the strongest. geon exactly how they want the procedure performed. They are able
Of course, comprehensively assessing both the objective and sub- to choose the ‘style’ of cut that conforms to their own aesthetic pref-
jective sexual outcomes of NNMC in a nuanced, scientific way is erences (e.g. ‘high and tight’ or ‘low and loose’),114 and because their
penis is fully grown, the surgeon will be able to determine with preci-
sion its final or stable anatomy, vasculature and innervation.115 In in-
fancy, the penis is very small and the surgeon cannot know how big the
organ will grow or exactly where to do the cutting in order to obtain
the desired cosmetic result. Because this is essentially a guess, too
104
 K rieger, J. N., Mehta, S. D., Bailey, R. C., Agot, K., Ndinya-Achola, J. O., Parker, C., & much tissue is sometimes removed, as we noted earlier; or indeed too
Moses, S. (2008). Adult male circumcision: Effects on sexual function and sexual
satisfaction in Kisumu, Kenya. Journal of Sexual Medicine, 5, 2610–2622. According to
little tissue, such that re-operation may be pursued.116
Frisch (2011), ‘it should be recalled that a strong study design, such as a randomized
controlled trial, does not offset the need for high-quality questionnaires. Having
obtained the questionnaires from the authors … I am not surprised that these studies
provided little evidence of a link between circumcision and various sexual 108
 Johnsdotter, S. (2013). Discourses on sexual pleasure after genital modifications: The
difficulties. Several questions were too vague to capture possible differences between
fallacy of genital determinism (a response to J. Steven Svoboda). Global Discourse, 3(2),
circumcised and not-yet circumcised participants (e.g. lack of a clear distinction between
256–265. See also Darby, R., & Cox, L. (2008). Objections of a sentimental character: The
intercourse and masturbation-related sexual problems and no distinction between
subjective dimensions of foreskin loss. Matatu, 37, 145–168.
premature ejaculation and trouble or inability to reach orgasm). Thus, non-differential
109
misclassification of sexual outcomes in these African trials probably favored the null  Adler, P. (Mar 30, 2016). Resolving circumcision controversies: The burden of proof
hypothesis of no difference, whether an association was truly present or not.’ Frisch and the benefit of the doubt. Circumcision and the Law Blog (blog). Retrieved from https​://
(2012). Author's Response to: Does sexual function survey in Denmark offer any support circu​mcisi​onand​thela​wblog.wordp​ress.com/2016/03/30/resol​ving-circu​mcisi​on-contr​
for male circumcision having an adverse effect? International Journal of Epidemiology, overs​ies-the-burden-of-proof-and-the-benef​it-of-the-doubt/​[accessed Nov 3, 2019].
110
41(1), 312–314.  Boyle, G. J. (2018). Proving a negative? Methodological, statistical, and psychometric
105
 K rieger also appears to have a patent pending for a circumcision device of which he is flaws in Ullmann et al. (2017) PTSD study. Journal of Clinical and Translational Research,
the lead inventor: https​://paten​t s.google.com/paten​t /WO201​31738​0 4A1/ko [accessed 3(Suppl. 2), 375–381.
111
Nov 3, 2019].  Martín-Alguacil et al., op cit. note 64.
106 112
 Masters, W., & Johnson, V. (1966). Human sexual response. Boston, MA: Little Brown &  See for instance Sorrells et al., op cit. note 67, cited above. See also Frisch, M.,
Co., pp. 189–191. The only study information provided is as follows: ‘A limited number of Lindholm, M., & Grønbæk, M. (2011). Male circumcision and sexual function in men and
the male study-subject population was exposed to a brief clinical experiment designed to women: A survey-based, cross-sectional study in Denmark. International Journal of
disprove the false premise of excessive sensitivity of the circumcised glans. The 35 Epidemiology, 40(5), 1367–1381; Earp, op cit. note 67, and Martín-Alguacil et al., op cit.
uncircumcised males were matched at random with circumcised study subjects of similar note 64.
ages. Routine neurologic testing for both exteroceptive and light tactile discrimination 113
 K im, D., & Pang, M. G. (2007). The effect of male circumcision on sexuality. BJU
were conducted on the ventral and dorsal surfaces of the penile body, with particular
International, 99(3), 619–622.
attention directed toward the glans. No clinically significant difference could be
114
established between the circumcised and the uncircumcised glans during these  Savulescu, J. (2013). Male circumcision and the enhancement debate: Harm reduction,
examinations.’ not prohibition. Journal of Medical Ethics, 39, 416–417.
115
107
 See Harms, C., & Lakens, D. (2018). Making 'null effects' informative: Statistical  E arp & Darby, op cit. note 71.
116
techniques and inferential frameworks. Journal of Clinical and Translational Research,  K rill, A. J., Palmer, L. S., & Palmer, J. S. (2011). Complications of circumcision. Scientific
3(Suppl 2), 382–393. World Journal, 11, 2458–2468.
 |
16       MYERS and EARP

3.2.2 | Ignoring consent cost-effective—with a shorter healing time, and so on—than la-

biaplasty performed on a consenting adult. Would any of these
NNMC proponents, both ‘strong’ and ‘weak’ (Box 2), argue that the considerations, alone or together, make non-voluntary neonatal
requirement for consent should not apply to the person being circum- labiaplasty permissible, either morally or legally, in Western soci-
cised, but instead to their parents. Parents are regularly required to eties? It seems unlikely. As one of us has argued elsewhere, even if
make decisions for their children, this argument holds; why should cir- health benefits of some kind or degree do one day become reliably
cumcision not be one of them? As noted, we agree that parents should associated with neonatal labiaplasty, it is almost certain that oppo-
(or may) make many decisions on behalf of their children, but there are nents of the practice (which include the WHO, the United Nations,
also certain decisions that parents may not make on their behalf. The all Western democracies, and the present authors) would continue
question is: to which category does the circumcision decision belong? to see clear moral problems:
One might attempt to answer this question by considering other kinds
of bodily alterations that are already seen as off-limits in Western soci- First, they would argue that healthy tissue is valuable
eties, and then triangulating between these cases and circumcision to in-and-of-itself, so should be counted in the ‘harm’ col-
see where the latter falls. Consider the example of tattooing. In many umn simply by virtue of being damaged or removed.
Western jurisdictions, it is illegal to tattoo a child’s body, presumably Second, they would point to non-surgical means of pre-
because this permanently alters their body in a way that the child may venting or treating infections, and suggest that
later reasonably regret or resent, before they are able to offer any these should be favored over more invasive methods.
117
meaningful consent. In such jurisdictions, therefore, it would be il- And third, they would bring up the language of rights: a
legal to tattoo a child’s foreskin. Yet if a parent wanted to cut off the girl has a right to grow up with her genitals intact, they
foreskin entirely, and then tattoo it, this would be permitted under cur- would say, and decide for herself at an age of under-
rent norms and standards. NNMC therefore seems anomalous when standing whether she would like to have parts of them
compared with other medically unnecessary child body modifications. cut into or cut off.118
Against this view, it might be argued that NNMC, but not tattooing,
carries at least some medical benefits (even if it is not clear that these The same arguments, we suggest, apply to NNMC.
benefits outweigh even the strictly medical risks, as previously dis-
cussed). This, then, could explain why the former is forbidden but the
latter is not. So let us consider a different example, that of labiaplasty. 3.2.3 | Irreversibility
Labiaplasty is similar to circumcision in that it removes genital tissue
that is not necessary for sexual enjoyment but which nevertheless has What about non-physical ways of shaping of a child? Eldar Sarajlic
certain properties—sensitivity to touch, elasticity, independent manip- has contrasted circumcision with religious indoctrination. He
ulability, and so forth—that allow for particular subjective sensations, notes that while parents are permitted to raise their children
during sex or foreplay, for example, that many people value positively. within a particular religion, there is nothing inherently irreversible
It is also similar to circumcision in that the genital tissue it removes is about religious indoctrination (he argues, however, that religious
often warm and moist and may trap bacteria, can become infected or indoctrination is only acceptable if certain efforts are made to ex-
even cancerous, may be injured or torn during sexual activity, and re- pose children to other ways of thinking outside the home).119 In
quires regular washing to maintain good hygiene. Removing the labia, any event, a great many people raised within a particular religious
therefore, likely does confer at least some statistical health benefits or cultural tradition later abandon certain associated beliefs and
in that it reduces the surface area of genital tissue that is not essential practices.120 With circumcision, however, no such abandonment is
for sexual function (in some narrow sense) but which may on occa- possible. As an analogy, imagine that Christian parents wanted to
sion pose a problem of one kind or another for its owner. In addition, tattoo ‘a Christian cross on their child’s body; the fact that the
it may plausibly confer at least some psychological or social benefits child can later distance himself from Christianity does not make
for some women, insofar as they prefer the aesthetics of a vulva that the tattoo legitimate and we could understand his upset about
has been subjected to labiaplasty, or if it helps them to avoid negative having to carry this religiously imposed, permanent mark, which
judgments from potential sexual partners (however inappropriate such [he] might understandably perceive as overstepping a boundary
judgments may be). Indeed, the World Health Organization (WHO) in- (and therefore as abuse)’.121
cludes such broader psychosocial factors in its definition of health, so
perhaps these potential outcomes should be counted as ‘health bene- 118
 E arp, B. D. (2017). Does female genital mutilation have health benefits? The problem
fits’ as well. with medicalizing morality. Journal of Medical Ethics Blog. Retrieved from https​://blogs.
Now, let us assume for the sake of argument that perform- bmj.com/medic​al-ethic​s/2017/08/15/does-female-genit​al-mutil​ation-have-health-benef​
its-the-probl​em-with-medic​alizi​ng-moral​ity/ [accessed Nov 3, 2019].
ing labiaplasty in infancy is technically simpler, safer and more 119
 Sarajlic, E. (2014). Can culture justify infant circumcision? Res Publica, 20(4), 327–343.
120
 The Pew Forum, op cit. note 101.
121
117
 Chegwidden, J. (2009). Response: Tasmanian Law Reform Institute Issues Paper No. 14:  Möller, K. (2017). Ritual male circumcision and parental authority. Jurisprudence, 8(3),
Non-therapeutic male circumcision, 1–79. 461–479, p. 472.
MYERS and EARP |
      17

This irreversibility is a cost that must be taken seriously. Some There are other differences as well. As McIntyre et al. note, ‘vacci-
NNMC proponents compare this with the cost that a genitally intact nation satisfies ethical criteria for preventive interventions in children:
person must bear if they decide to undergo circumcision later in it is effective, minimally invasive, and associated with significant socie-
life,122 but a fundamental asymmetry remains. Any person who was tal benefits’.125 We take ‘effectiveness’ here to refer to an improve-
not circumcised, but wishes to be, can undertake the surgery volun- ment to the individual’s health. As already argued, the prevailing
tarily. A person who was circumcised without their consent and who opinion of international medical authorities is that the potential, statis-
resents what was done to their body, by contrast, has no ethically tical health benefits of NNMC, especially for individuals in developed
comparable recourse.123 countries, fail to outweigh the risks and harms of the procedure.
It is true, as discussed earlier, that choosing circumcision in later Circumcision does not prevent any diseases or maladies; at most, it
life is not cost-free: one must take time off school or work and refrain may reduce the (typically already low) absolute risk of these, and it is
from sexual activity for a number of weeks. However, older children rarely the least harmful or the most effective available means of reduc-
and adults currently seem willing to take time off work for other val- ing this risk. This stands in stark contrast to the measles vaccine, for
ued projects (e.g. going on a vacation) or to refrain from sexual activity example, which immunizes 95% of those who receive it against a dis-
after other elective surgeries (e.g. a vasectomy or a labiaplasty). It is ease with notable morbidity that can spread quickly through inciden-
unclear why circumcision should be treated as a special kind of burden. tal, unknowing contact with infected air particles in public spaces.126
Moreover, NNMC proponents do not account for comparable disrup- (Compare this with the diseases that circumcision is said to protect
tions in the neonatal period. The developmental needs of an infant are against, which are primarily spread slowly through intimate, knowing
very different from those of an adult. However, because the infant contact in private spaces.) Given that circumcision involves cutting into
cannot report on these needs, there is an epistemic asymmetry. Adults and removing healthy tissue from a sensitive, sex-specific organ—­
are in a position of being much more aware of—or more easily able to versus a sex-neutral needle-prick that does not remove tissue from any
imagine—the kinds of disruptions they would incur. Such disruptions part of the body, nor even typically leave a very salient lasting mark—it
are therefore easier to identify and perhaps to measure. But this does does not pass the minimally invasive test for prophylactic interven-
not entail that disruptions for the infant are any less significant; there is tions. Indeed, imagine  a vaccine that could  only  be  administered  to
simply not enough quality research into the question. non-consenting girls and which required the removal of a sizable por-
tion  of healthy  tissue from their vulvas in order  for  it to work. Such
a vaccine would rightly not be allowed. As Somerville points out, it is
3.2.4 | Vaccination analogy not enough to show that NNMC can decrease one’s likelihood of con-
tracting various diseases: because it is a non-voluntary surgical proce-
NNMC proponents often liken the procedure to a vaccination, which dure, it must also be ‘the only reasonable way to obtain these
as Morris et al. point out, is ‘similarly performed before the child is benefits’.127 If there are less invasive means of obtaining the benefits,
old enough to consent and which carr[ies] similar risks of complica- as indeed there are (e.g. basic hygiene and safe-sex practices, or indeed
tions’.124 However, even if the likelihood of complications is similar actual vaccinations), these should be preferred.
between the two procedures (we are not suggesting that this is actu- Benatar and Benatar argue that just because one intervention
ally the case), the kind of complications will often be dissimilar—for is more invasive than another, it does not follow that it is exces-
example, an allergic skin reaction versus a genital laceration—and sively invasive.128 They note, for instance, that oral vaccinations
different people may assign different weights to such variable com- are not as invasive as those by injection, which are in turn not as
plications. Moreover, in the case of circumcision, the risk is concen- invasive as circumcision. Notice, however, that neither of the first
trated on a particular part of the body—namely, the penis—that is
widely seen as having a special kind of value or significance com-
125
pared with many other body parts, including the typical sites of vac-  McIntyre, P., Williams, A., & Leask, J. (2003). Refusal of parents to vaccinate:
Dereliction of duty or legitimate personal choice? Medical Journal of Australia, 178(4),
cine administration such as the arm or thigh. 150, citing Hodges, F. M., Svoboda, J. S., & Van Howe, R. S. (2002). Prophylactic
interventions on children: Balancing human rights with public health. Journal of Medical
Ethics, 28(1), 10–16.
122 126
 Benatar & Benatar, op cit. note 22, p. 37.  See Centers for Disease Control and Prevention (CDC). Measles cases and outbreaks.
123
 They may attempt one of the various techniques of so-called foreskin restoration CDC.gov. Retrieved from http://www.cdc.gov/measl​es/cases-outbr​eaks.html [accessed
(whereby weights, tapes, or other devices are attached to the remaining penile shaft skin Nov 3, 2019]. Or consider the flu vaccine. While it is not as effective from year to year as
over several months or years to attempt to stretch it forward) but this is really a is the measles vaccine (according to the CDC, it ‘reduces the risk of flu illness by between
misnomer. The foreskin is not actually restored; nor are the specialized nerve endings 40% and 60% among the overall population during seasons when most circulating flu
that were excised with it. Rather, a pseudo-foreskin is at best created, which some viruses are well-matched to the flu vaccine’), it is the best available option for reducing
individuals evidently judge to be better than no foreskin at all. See Schultheiss, D., Truss, the risk of a highly contagious illness that simultaneously satisfies the minimally invasive
M. C., Stief, C. G., & Jonas, U. (1998). Uncircumcision: A historical review of preputial criterion. See CDC. Vaccine effectiveness: How well do the flu vaccines work? CDC.gov.
restoration. Plastic and Reconstructive Surgery, 101(7), 1990–1998. For evidence from Retrieved from https​://www.cdc.gov/flu/vacci​nes-work/vacci​neeff​ect.htm [accessed
sales records that more than 500,000 men in the English-speaking world are likely Nov 3, 2019].
127
engaged such burdensome foreskin ‘restoration’, see Earp, B. D. (2016). Between moral  Somerville, M. (2000). The ethical canary: Science, society and the human spirit. Toronto,
relativism and moral hypocrisy: Reframing the debate on ‘FGM’. Kennedy Institute of Canada: Viking, p. 205.
Ethics Journal, 26(2), 105–144 (p. E-9 of the supplementary material). 128
 Benatar, D., & Benatar, M. (2003). How not to argue about circumcision. American
124
 Morris et al., op cit. note 13. Journal of Bioethics, 3(2), W1–W9.
18       | MYERS and EARP

two interventions, though somewhat invasive, irreversibly alters maintain, then the relative difference between the risks should not be
one’s gross anatomy and external physical appearance—much less considered a morally weighty factor.134 In the case of an  adult, any
a physically and symbolically salient, psychosexually significant complications that do occur are the result of a procedure that was vol-
aspect thereof.129 The immediate side effects and any long-term untarily undertaken, after the adult had been informed about the na-
complications of a vaccination may be regretted, but in the ab- ture and likelihood of these very risks. This is not possible in the case of
sence of these, it difficult to explain how one could reasonably the neonate or young  child. Generally speaking, risks imposed on a
come to regret the vaccination per se. By contrast, hundreds of person who is aware of the risks and agrees to assume them in light of
thousands of individuals seem to resent the non-voluntary re- their own considered preferences and values are much less morally ob-
moval of their foreskins even in the absence of clinically significant jectionable than risks imposed on a person who is not aware of the
130
complications. risks and/or does not agree to assume them.
As for the last condition of significant societal benefits, based on
our earlier discussion, this too would not be met by NNMC in devel-
oped countries (and the jury is still out with respect to sub-Saharan 3.2.6 | Financial costs
Africa). Lyons has observed that a number of ‘parents are already
skeptical about the risk-benefit ratio of conventional vaccines’. The The claim that NNMC is generally less expensive than adult circumci-
‘possible misrepresentation of a surgical procedure [especially one sion is plausible and we do not wish to dispute this. However, the cost
as controversial as NNMC] as an effective vaccine seems unlikely to for individuals between ages 14 and 17 is in some cases far less than for
131
improve trust’. In fact, not only might this fail to encourage more those aged 18 and older (see above discussion), and we have suggested
people to circumcise their infants, he argues; it could lead to fewer that these individuals, in contrast to infants, may at least in principle be
parents vaccinating their children.132 able to provide their own informed consent. As stated earlier, one of
the main reasons that adult circumcision tends to cost so much is that
it is usually performed under general anesthesia, which is more effec-
3.2.5 | Medical complications tive than local anesthesia in preventing the pain associated with the
procedure. Neonates receive either local anesthesia (which could in-
As noted previously, assuming that the figures provided by Morris et al. clude something as mild as a topical cream) or none at all, and are in no
about the medical complications of NNMC versus circumcision later in position to communicate their pain levels explicitly. Even among
life are correct (contrary to the more recent evidence from PEPFAR), NNMC defenders, it is usually accepted that infants experience signifi-
the relative risk does not appear to be much greater, if it is greater at all. cant pain both during and after the procedure.135 This remains the case
And according to NNMC advocates, the absolute rate of complications under local anesthesia, because even the most effective form, dorsal-
in both cases is ‘low’, with ‘virtually all’ being mild and treatable if and penile nerve block, is itself painful to administer and sometimes fails.136
133
when they do occur. But if the medical risks in both cases are ‘low’ in From an ethical perspective, using less effective anesthesia on a more
absolute terms and otherwise mild or treatable, as NNMC advocates vulnerable individual—who cannot refuse the procedure—in order to
drive down costs should be called into question.
Finally, the cost comparison between neonatal and adult cir-
129
 E arp & Steinfeld, op cit. note 6. cumcision is in one sense misleading. One must also consider the
130
 See Earp, ‘Between moral relativism’, op cit. note 123. The figure reported there (at
cost comparison between either neonatal or adult circumcision, on
least 500,000) is the best available, conservative estimate of the number of males in the
English-speaking world actively engaged in ‘foreskin restoration’. As this is a very the one hand, and no circumcision on the other. The latter option
burdensome and time-consuming process that, if successful, creates a pseudo-prepuce has no procedural costs tied to it, and it appears to be the default
only, it stands to reason that these individuals are/were highly resentful of having had
their foreskins removed. More recently, a demographically diverse (albeit not nationally preference of the vast majority of genitally intact individuals. If a
representative) survey of 999 U.S. American men—carefully designed to avoid particular individual does choose to be circumcised absent med-
oversampling of individuals who might have concerns about circumcision—found that of
the 771 respondents who reported being circumcised, 105 (13.6%) reported wishing
ical necessity in adulthood, this will likely cost more to them in
they were the opposite circumcision status, with a quarter of that sub-group stating that strictly financial terms than it would have cost their parents if the
they would ‘seriously consider’ changing their circumcision status if it were possible (i.e.
same individual had been circumcised in the neonatal period. But
through a foreskin restoration process). Please note that a similar percentage of genitally
intact individuals (15.9%) reported wishing they were the opposite circumcision status; in this case, the (incalculable) moral costs of NNMC will have been
however, as we argue, such individuals still have an option open to them, whereas those
avoided.
who reported resentment about being circumcised have no comparable recourse. See
Earp, B. D., Sardi, L., & Jellison, W. (2018). False beliefs predict increased circumcision
satisfaction in a sample of US American men. Culture, Health & Sexuality, 20(8), 945–959.
For further evidence of resentment among circumcised individuals and related
discussions, see Hammond & Carmack and Bossio & Pukall, op cit. note 72.
131
 Lyons, B. (2013). Male infant circumcision as a ‘HIV vaccine’. Public Health Ethics, 6(1),
90–103, p. 99.
134
132
 Ibid.  C armack, A., Notini, L., & Earp, B. D. (2016). Should surgery for hypospadias be
133
performed before an age of consent? Journal of Sex Research, 53(8), 1047–1058.
 Morris, B. J., & Green, E. C. (2014). Circumcision, male. In W. C. Cockerham, R.
135
Dingwall, & S. R. Quah, (Eds.), Blackwell encyclopedia of health, illness, behavior, and society  See Benatar & Benatar, op cit. note 22.
136
(pp. 253–256). Hoboken, NJ: Wiley-Blackwell.  See Frisch & Earp, op cit. note 21, for references and discussion.
MYERS and EARP |
      19

4 | CO N C LU S I O N of their intimate anatomy removed, resent this, and still have a re-
course. Accordingly, from a moral point of view—which includes a
In this paper, we have interrogated the common view that NNMC medical cost–benefit analysis as only one part of the overall ethical
carries fewer risks and confers greater benefits than circumcision analysis—we find that medically unnecessary circumcision should
later in life. We have shown that NNMC proponents who advance not be performed on minors who are too young to  provide valid
this view are usually thinking only in terms of a narrow analysis of consent to the procedure.
the medical benefits (disease prevention) and risks (surgical compli-
cations). When one considers potential benefits and risks in a more C O N FL I C T O F I N T E R E S T
comprehensive manner, including in light of more recent evidence, The authors declare no conflict of interest.
this view is less compelling.
Circumcision removes healthy genital tissue that is prima facie ORCID
valuable, while imposing the risk of a number of surgical complica- Alex Myers  https://orcid.org/0000-0002-6760-5683
tions, ranging from mild to severe, the full extent of which is under- Brian D. Earp  https://orcid.org/0000-0001-9691-2888
137
studied and unknown. The favourable attitude of NNMC
proponents towards the procedure appears to be at odds with that AU T H O R B I O G R A P H I E S
taken towards medically unnecessary surgeries more generally, es-
pecially when the affected person cannot consent.138 As a California Alex Myers specialized in applied ethics at the University of
Appeals Court stated in 2006, it ‘seems self-evident that unneces- Cape Town and later worked as a public health researcher at the
sary surgery is injurious and causes harm to a patient. Even if a sur- University of the Witwatersrand, Johannesburg, South Africa.
gery is executed flawlessly, if the surgery were unnecessary, the
surgery in and of itself constitutes harm.’139 Brian D.  Earp is the Associate Director of the Yale-Hastings
There are a number of reasons to prefer circumcision after an Program in Ethics and Health Policy at Yale University and The
age of consent, as we have discussed. The most important, how- Hastings Center, and a Research Fellow at the Uehiro Centre for
ever, is that it preserves freedom of choice. Those who were not Practical Ethics at the University of Oxford.
circumcised in childhood, but wish they had been, still have the
option of circumcision available to them; whereas those who were
circumcised in childhood, but wish they had not been, cannot undo
what has already happened. In our view, the concerns of those who How to cite this article: Myers A, Earp BD. What is the best
have had a healthy part of their intimate anatomy removed, resent age to circumcise? A medical and ethical analysis. Bioethics.
this, and have no adequate recourse, should be taken more seri- 2020;00:1–19. https​://doi.org/10.1111/bioe.12714​
ously than the concerns of those who did not have a healthy part

137
 A AP Task Force on Circumcision, op cit. note 29, p. e772.
138
 This is beginning to be recognised, however. See the Case No. LJ13C00295: Re B and
G (Children) (No 2) [2015] EWFC 3, p. 69, in which Judge James Munby ruled that
‘circumcision’ of male, as well as of female, children ‘amounts to significant harm’.
Retrieved from https​://www.famil​ylaw.co.uk/news_and_comme​nt/re-b-and-g-child​
ren-no-2-2015-ewfc-3 [accessed Nov 3, 2019].
139
 Tortorella v. Castro, 43 Cal. Rptr. 3d 853 - Cal: Court of Appeal, 2nd Appellate Dist.,
3rd Div. 2006, emphasis added.