Undue Suffering Circumcision for Non-Medical Reasons Is Wrong
A Commentary By Dr. Maximilian Stehr
As the debate over the medical ethics of circumcision rages in Germany, some have argued that the practice provides health benefits. But many in the medical community disagree. Circumcision is not in the best interest of boys who undergo the procedure.
In July 2011 a mother took her 2-year-old son to a pediatric clinic in Munich. Up to that point he had been the picture of health. There was absolutely nothing wrong with him. His parents simply wanted him to be circumcised at a medical facility on religious grounds.
But something went wrong when the boy was anesthetized, and the surgical team suddenly couldn't ventilate him anymore. The oxygen levels in his blood dropped, and his heart stopped beating. A dramatic scene unfolded in the minutes that followed, as the doctors tried to reanimate him, eventually calling in the emergency pediatric specialist. By the time the specialist arrived, the boy's body had been starved of oxygen for at least 10 minutes. The team finally managed to resuscitate the boy, and he was taken to our hospital by ambulance. But the child never regained consciousness. The lack of oxygen had caused too much damage to his brain.
I'm not telling this story to be sensationalist. I'm telling it because it moved me deeply. A healthy child that had probably happily crawled out of his bed that very morning had been anesthetized unnecessarily a few hours later, and by midday he lay in our intensive care unit, severely disabled for the rest of his life.
This shocking tale makes one thing absolutely clear: We doctors must never unnecessarily endanger the patients entrusted to our care. After all, had this boy not been circumcised, there would have been no emergency during his anesthetization. Every surgical intervention and every anesthesia is associated with a certain amount of risk. In this case the risk is not very great, but should nevertheless be taken only when justified. Under no circumstance should the dangers be overlooked because we think "It's only a minor operation." It's not.
'First, Do No Harm'
Munich's university hospital, the Klinikum Grosshadern, stopped circumcising boys without medical indication back in 2001. Many renowned pediatric hospitals had taken similar steps even before the Cologne Regional Court recently declared religious circumcision of children illegal. The medical community has been debating the issue for almost a decade. It's only thanks to the judges in Cologne that the matter has been brought to the attention of the public.
One of the fundamental principles of medical ethics is that no one should be harmed. The oath formulated by Hippocrates (approx. 460-370 BC) and sworn by all doctors includes the following statement: "I will prescribe regimens for the good of my patients according to my ability and my judgment and never do harm to anyone." Another key idea lies at the heart of all ethical behavior by medical personnel: "Primum nihil nocere," or "First, do no harm," a phrase coined by Scribonius Largus, a doctor at the court of the emperor Tiberius Claudius. The treatment of patients must be with their welfare in mind, and must therefore have priority over other interests, such as science, financial gain or profit.
Medically unnecessary circumcision causes damage because it results in an irreversible loss of healthy bodily tissue. Some people may consider it insignificant because the foreskin serves no discernible purpose. But the foreskin does indeed have a number of functions, although very few of the people engaging in the debate are aware of them.
No Medical Benefit
After birth, the foreskin protects the head of the penis (the glans) and prevents the external urethral orifice from abrasion and drying out. Following circumcision, the surface of the glans regularly thickens and calluses. This can lead to a constriction of the opening of the urethra, the most common complication associated with circumcision in infancy, occurring in up to 30 percent of cases. It's not unusual for several operations to be required before affected children can empty their bladder properly.
The foreskin also plays a role in arousal. In contrast to the glans, which has deep sensitivity, the foreskin has what are known as tactile corpuscles which can only be found in similar density in the tips of the fingers, the lips and the eyelids. It's therefore hardly surprising that the foreskin is considered a male erogenous zone. A significant majority of men who are circumcised in adulthood, and are therefore in a position to make comparisons, say they are less sensitive in this area after surgery. But that's not the only reason why circumcision affects sexuality: Couples in which the man is circumcised uniformly report a loss of male secretions during sex and therefore greater friction and resulting pain. It can therefore be assumed that circumcision can indeed have a negative impact on sexuality and the sex life of both circumcised men and their partners. These findings are not new. Major studies and surveys have been conducted and published as far back as the 1990s.
But the direct consequences of an operation must also be considered. Post-surgical complications occur in between 0.19 and 2 percent of circumcisions, but rise to 11 percent for patients circumcised in infancy. These complications primarily involve secondary bleeding or infection. In rare cases the urethra or the glans may be damaged or even need to be amputated. I see such complications time and again at our clinic, even though they occur in less than one percent of medical procedures. They mean painful surgery for the child.
Often enough, circumcision is deemed to be of medical benefit, for instance in preventing infectious diseases or cancer. But it's worth taking a closer look at the figures and the findings of related studies: Circumcised infants may have only a tenth as many urinary tract infections in their first year, but these infections generally occur so rarely that 100 circumcisions would be needed to prevent a single urinary tract infection. This doesn't make sense in otherwise healthy babies. There is no medical benefit to routine circumcision.
Wait For Consent
Nor does it reduce the likelihood of passing on or contracting sexually transmitted diseases. As early as 1855, a study suggested a possible link between circumcision and the transmission of venereal diseases. Since then, more than 30 studies have been published on the matter. However, the findings of these studies are extremely inhomogeneous. In effect, circumcision doesn't have any effect on the incidence of most sexually transmissible diseases (gonorrhea, syphilis, herpes and AIDS).
In 2007, the World Health Organization recommended circumcision as a prophylactic measure against HIV infection. This recommendation was based on studies from Kenya and Uganda that suggested that the risk of infection with HIV was 50 percent lower in circumcised heterosexual men than in non-circumcised ones. But demands for routine or blanket circumcision don't take into account the fact that the WHO considers circumcision only for adult males who can decide for themselves and are at a high risk of infection.
From an epidemiological perspective, the practice makes no sense for Germany. Furthermore, circumcision for this purpose could also be carried out at an age at which the person in question can make their own decisions. The same concern also applies to the supposed preventative nature of circumcision with regard to penis carcinoma or even cervical cancer: If circumcision had an unambiguously positive influence -- and not all scientists agree it does -- this operation would only make sense at an age when the man is sexually active, in other words at an age when the young man can consent himself.
A Chance For Dialogue
Medically, there is no evidence of advantages for boys. Therefore non-medically indicated circumcision is not in the child's best interests either. This is the key argument against the inadmissible comparison of circumcision with a recognized vaccine. The effectiveness and therefore the utility of the vaccine for the child have been scientifically proven.
Doctors have to weigh potential risks and benefits. There are no medical benefits to circumcision on religious grounds. For this reason it's all the more significant that it's a serious surgical procedure fraught with risks and complications. Whether it's carried out under local or general anesthetic, circumcision causes boys undue suffering. This procedure must therefore be rejected from both a medical and an ethical perspective.
As a devout Catholic, I have great respect for the concerns of religious communities. As a scientist, I feel discredited by Chancellor Angela Merkel's comments about how the circumcision ruling makes Germany "a laughing stock." The Cologne Regional Court presented us with an opportunity to work together with the various religious communities to consider the rights of physical inviolability and religious freedom. Some Muslims have already shown a willingness to accept that boys be circumcised only when they are old enough to give their consent. But in Berlin the debate is at risk of being stifled politically, robbing us of the chance for dialogue.
Translated from the German by Jan Liebelt