Category: Ethics

Evaluating the Genital Cutting Analogy

Catarina Dutilh Novaes has an excellent post on the comparison between male and female genital cutting.

 A heated discussion ensued from my post on circumcision last week, which in turn was essentially a plug to a thought-provoking post by Brian D. Earp at the Oxford Practical Ethics blog. The controversial point was whether circumcision is or is not to be compared to female genital cutting.

I’ve learned a lot from the different perspectives presented during the discussion; among other things, I’ve learned the terms ‘genital alteration’ and ‘genital cutting’, which now seem to me to be more adequate than either ‘circumcision’ or ‘genital mutilation’ to formulate the issue in a non-question-begging way (as argued here). And yet, I am now even more convinced that the analogy between male genital alteration and female genital alteration is a legitimate one – which (and let me say this again!) does not mean that there are no crucial differences to be kept in mind. That’s what an analogy is, after all.

I agree with this, and the bulk of the post. I recommend it with only a minor quibble and an additional piece of modern evidence.

My quibble:

It is well known that female genital cutting is practiced with different levels of severity, going from pricking and piercing to infibulation. …

I do not believe this is well known beyond academic knowledge. In my experience the average person hearing this comparison believes that female genital cutting is always a) the most severe form, b) performed to eliminate all sexual pleasure, and c) imposed at the insistence of males. Facts rarely correct that misunderstanding when presented. Most often the avoidance rests on imagined parental intent, as if that alone can dictate the outcome.

Modern evidence:

– Female genital cutting is embedded in a long history of oppression of female sexuality, and has as its main goal to diminish women’s sexual enjoyment. Male genital cutting in the form of circumcision has no such goal.

She is citing an objection from the comments of her original post rather than her opinion. She supports the challenge to the claim with the 19th century history of male circumcision in America. That is relevant, but there’s modern evidence that circumcision seeks to control male sexuality. Last year Rabbi Mark Glickman wrote (my post):

… Unlike female genital mutilation, Jewish circumcision is not a way to limit or control the child, and it does not destroy sexual desire.

Many find the practice troubling, I believe, because it so dramatically distinguishes religious values from commonly accepted modern American ones. America idealizes nature; Judaism and other religions try to control it and improve it. …

There are other examples. Religion still seeks to control the child and his sexuality through circumcision. A lack of ill intent does not negate the control from circumcision or its intentionality.

In a cultural rather than ritual context, circumcision is still about control. Parents circumcise so the boy will “look like his father”, regardless of what the child wants. Parents circumcise so that his sexual partners will not be repulsed. (This is an indirect form of control of his future sexual partners.) Parents circumcise to avoid STDs, even though condoms are still necessary. All of this controls the child and his sexuality. The control of males through non-therapeutic genital cutting is rarely as extreme as it is for females, but it is real and occurs now. There is no need to rely on history. The analogy holds up here.

Flawed Circumcision Defense: Rabbi Shmuley Boteach

Rabbi Shmuley Boteach has an opinion piece in The Wall Street Journal titled, “Germany’s Circumcision Police”. It starts off well.

There was a head-spinning moment in Germany last week: News emerged that a rabbi had been criminally charged for performing his religious duties. Rabbi David Goldberg of northern Bavaria, who shepherds a 400-member community, is the first person to run afoul of a ruling by a Cologne judge earlier this year that criminalized circumcision, a basic religious rite.

There is some precedent outside of Germany for such a ruling. …

Even though we disagree on policy, agreeing on basic facts is always good. But his essay slowly falls off the path.

… In the United States, a San Francisco ballot initiative tried last year to make circumcision an offense punishable by a $1,000 fine and up to a year in prison; it failed to get enough votes. …

That’s not an accurate summary of what happened last year. A court ruled that the local ballot initiative conflicted with an existing state law and struck it from the ballot. It had nothing to do with getting enough votes.

… But the circumcision ban deserves universal scorn.
…

Does the German government really want to get into a public battle over whether they are better guardians of the health and welfare of Jewish (and Muslim) children than their parents?

As long as parents continue to circumcise their healthy sons, I hope so. Obvious physical harm for subjective non-therapeutic benefits is unacceptable without the individual’s consent. Protecting the rights of all citizens is a legitimate role of the state.

The Los Angeles Times recently cited a study predicting that as the number of circumcisions goes down in the U.S., the cost of health care will steadily climb. Eryn Brown reported that “If circumcision rates were to fall to 10% . . . lifetime health costs for all the babies born in a year would go up by $505 million. That works out to $313 in added costs for every circumcision that doesn’t happen.”

I’m not impressed by Rabbit Boteach endorsing the idea that a child’s normal body – and by extension, his rights – has a price beyond which we’ll justify non-therapeutic intervention to remove parts of it. But, more importantly, the key in that is not $313. It’s predicting. Aaron Tobian and his co-authors used a data model to make a guess. There are many factors involved. They are not constant. Cost, availability, and need could be quite different in two decades. For the potential benefits against sexually transmitted infections, circumcision can be chosen later. That would match the ethics of the studies that used adult volunteers. This study seeks to “prove” that a specific, non-urgent solution should be applied now, regardless of ethics.

Why? Because circumcision has been proven to be the second most effective means—after a condom—for stopping the transmission of HIV-AIDS, with the British Medical Journal reporting that circumcised men are eight times less likely to contract the infection.

He gets credit for mentioning condoms, which puts him ahead of the AAP. Still, condoms provide greater protection than circumcision, and remain necessary after circumcision. So, cost-wise, it’s condoms or condoms and circumcision. The former is cheaper and ethical. Infant circumcision is not ethical, including when potential benefits against STDs are cited.

While the Germans decry the barbarity of circumcision for men, they also overlook the benefit to women who are the men’s partners. Male circumcision reduces the risk of cervical cancer—caused by the human papillomavirus, which thrives under and on the foreskin—by at least 20%, according to an April 2002 article in the British Medical Journal.

They overlook the potential benefit to women? Do they? They can agree that (voluntary, adult) circumcision may confer reduced risk to female partners while also finding it unacceptable to impose circumcision on infant males (i.e. not “men”). Rabbi Boteach ignores the ethical foundation for the court’s ruling.

While some attempt to equate male circumcision with female clitoridectomy, the comparison is absurd. Female circumcision involves removing a woman’s ability to have pleasure during sexual relations. …

Not necessarily. Yet, in spite of that, it remains unethical. At some point, the human rights principle(s) involved must factor. Equal protection is a human rights principle.

… It is a barbarous act of mutilation that has no corollary to its male counterpart. …

This is also not true. Within what he wrote, it is, because he limited himself to clitoridectomy. The scope of illegal female genital cutting/mutilation is much broader than that, including any cutting that is anatomically analogous to (or less harmful than) male circumcision. That’s relevant.

… Judaism has always celebrated the sexual bond between husband and wife. Attempts to malign circumcision as a method of denying a man’s sexual pleasure are ignorant. …

Male circumcision controls male sexuality, with a long history as an attempt to limit sexual pleasure. It is still used to reduce pleasure for males.

… Judaism insists that sex be accompanied by exhilaration and enjoyment as a bonding experience that leads to sustained emotional connection.

If we ignore explicit statements in favor of circumcision as a way to diminish male sexual pleasure, Rabbi Boteach’s claim here is not mutually exclusive from reduced sexual pleasure. Intent does not guarantee outcome.

We Jews must be doing something right in the bedroom given the fact that, alone among the ancient peoples of the world, we are still here, despite countless attempts to make us a historical footnote.

This is evidence that male circumcision does not eliminate male reproductive ability. No one has claimed it does. His statement is a non-sequitor. The ability to reproduce is not proof that circumcision is acceptable or that it does not affect sexual pleasure or inflict harm.

Related: From the Cut Podcast, a debate between Rabbi Shmuley Boteach and Cut director Eliyahu Ungar-Sargon.

AAP Task Force Member Douglas Diekama Maligns Circumcision Opponents

The Washington Post’s parenting blog has a new post, ‘Intactivists’ furious at new AAP circumcision policy, that contains a misdirection from Dr. Douglas Diekema. After quoting Ronald Goldman and a few commenters to an earlier post, this:

AAP officials expected such a reaction.

“For individuals who have decided that circumcision is wrong, no amount or quality of data will put these questions to rest,” Douglas Diekema, who served on the AAP task force that wrote the report, told me last week when I asked him about potential pushback.

Diekema implies that people who are against circumcision simply haven’t correctly considered the data, which means “reached his personal conclusion”. He implies that opponents have made a demonstrable error in judgment. This is nonsense. It’s consistent to accept every single piece of data the AAP considered, and to ignore the relevant information the AAP explicitly ignored in its consideration, yet reach the conclusion that non-therapeutic infant circumcision is unjustified medically (and ethically), contra the AAP’s biased and flawed statement. To quote Douglas Diekema himself:

… But it does have medical benefit. Not everyone would trade that foreskin for that medical benefit. …

No kidding. That’s the ethical issue, but it also shows that the benefits do not outweigh the risks for every individual. Diekema is engaging in propaganda, facilitated by The Washington Post. Both aspects of that are inexcusable.

I’ve sent an e-mail to the Washington Post blogger, Janice D’Arcy, asking for comment on Diekema’s problematic quote. I will update if I receive a response.

Brian D. Earp on the AAP’s Flawed Circumcision Policy Statement

If you read only one analysis on the AAP’s revised policy statement on infant circumcision, make it this fantastic deconstruction by Brian D. Earp. It’s almost too perfect to excerpt. This is a great sample, but his entire post is required reading.

Here they depart from their 1999 statement in asserting that (1) the benefits of the surgery definitively outweigh the risks and costs and (2) that it is therefore justifiable to perform the operation without the informed consent of the patient. This does not follow. In medical ethics, the risk/benefit rule was devised for therapeutic procedures aimed at treating an extant pathological condition, and for minor prophylactic interventions such as vaccination. It has no relevance to nonessential amputative surgery, especially when it involves the painful removal of healthy, functional erogenous tissue from the genitals, and when safer, more effective substitute strategies exist for achieving the same ends.

You may be surprised to learn that the word “condom” does not appear even once in the 28 page AAP report.

In making their risk/benefit calculations, then, the AAP simply leaves out a critical bulk of factors relevant to the equation, including the existence of a range of proven healthcare tools like condoms, vaccines (including an effective HPV vaccine), and antibiotics. If they had bothered to consider human rights and bodily integrity issues, the function of the foreskin, its value to the individual, and his possible wishes in later life, as well, their computations would quite plainly yield a very different answer.

Seriously, it’s worth the time. And share it far and wide.

The AAP Worsens Its Flawed Circumcision Position

A lot has already been said about the AAP’s revised policy statement on non-therapeutic circumcision on non-consenting male children.

More will be said today and beyond. Much of it will be uncritical regurgitations of the AAP’s revision by news organizations. There will also be analysis from those who recognize and highlight the glaring deficincies and oversights in the policy. I expect to contribute my own thoughts. For now, I’ll highlight one key aspect from my initial read-through before going into what I think is a more important consideration to this apparent-but-not-really temporary setback.

The short version of the statement ends with this (emphasis added):

Parents ultimately should decide whether circumcision is in the best interests of their male child. They will need to weigh medical information in the context of their own religious, ethical, and cultural beliefs and practices. The medical benefits alone may not outweigh these other considerations for individual families.

That’s so close to the ethical stance. Remove families and focus on the individual and it would be ethical¹.

The way the promoted portion of the new “finding” within the revised statement differs from this conclusion is the key takeaway to challenge the supposed change from the AAP, which is really more-or-less just an exercise in urging politicians to permit circumcision on Medicaid. Here, the AAP demonstrates that its evaluation of the net benefit, that possible benefits outweigh the risks, is subjective and determined only by individuals. This directly contradicts the supposed proof based on their review of research that the potential benefits outweigh the risks (and the costs – the direct harm in every case – that they ignore). We should repeatedly emphasize that as often as necessary.

My concern is that we’ll get stuck in this low-level, short-term portion of the larger debate. It’s clear from European medical associations and courts that the eventual destination is public policy against non-therapeutic circumcision. The AAP and American society, in general, are (inexcusably) behind. But both will get there. Activists for the rights of children can make that happen sooner than it otherwise might happen.

The key is that we must give people the opportunity to save face, to avoid digging in to protect their egos. The problem is their stance, not necessarily their character. It should be obvious to them that their stance is incorrect. It isn’t. To address that, do we want to express an irrelevant, limited sense of superiority or convince others that we’re correct because facts and ethics demonstrate the case we’re making? If we impugn their motives and/or character by choosing the former, we may extend the period during which this policy statement stands or encourage people who can be influenced either way to choose the inferior stance of the AAP.

Edit note: I changed “it’s” to “their stance” to avoid possible confusion.

¹ The existing societal view treats certain basic human rights – for boys only – as a buffet from which parents may pick and choose for their own reasons. This is the problem merely expressed within the AAP’s policy statement.

Flawed Circumcision Defense: Yair Rosenberg, Part 2

In response to the AAP’s pending release of its revised policy statement on non-therapeutic male child circumcision, Yair Rosenberg repeats the mistakes in his prior analysis. He perpetuates appeals to authority, omits relevant information, and ignores inconvenient facts. One might even say he’s being obscurantist.

This isn’t just an issue of religious freedom—it’s a basic question of public health. That’s because according to the National Institutes of Health and the World Health Organization, among others, circumcision is one of the global health community’s best HIV prevention techniques. As Eric Goosby, the U.S. AIDS coordinator, has said, “Male circumcision is a highly significant, lifetime intervention. It is the gift that keeps on giving. It makes sense to put extraordinary resources into it.” To that end, anti-AIDS organizations are partnering to circumcise 20 million African men by 2015. …

Until now, the scientific consensus surrounding circumcision has driven policy in Africa, but not the United States. Today, that changes.

Individual humans make up “public health”. What is – and is not – acceptable to do to individual bodies in the name of public health is the question of ethics that Rosenberg, Goosby, the AAP, and every other circumcision advocate ignores. This is especially true because circumcision is not the least invasive or the most effective method available for reducing HIV (or any other) risk. It’s also still not particularly useful in contexts outside of parts of Africa. As I wrote in my prior post, the risk reduction is in female-to-male HIV transmission in high-risk populations. That isn’t compelling within the scope of the AAP’s focus. Context matters. Obscurantist journalists ignore that.

The importance of this [updated policy] cannot be overstated. …

It can be. Rosenberg’s post is proof.

… The AAP is a driving force behind health policy in America, and the experts involved in its new statement are already going on record in major media outlets to advocate that circumcision be covered on public health plans like Medicaid. The statement solidifies the scientific consensus behind the advisability of infant male circumcision (noting that complications are more likely to arise when the procedure is performed later in life) and places the traditional practice squarely within the realm of sound medical science.

This is only true if ethical considerations are not a part of sound medical science. It’s fine if Rosenberg or others do not wish for ethics to be applied to their own bodies. But not everyone shares that odd, limited view. Some of us appreciate the basic concept of human rights, including those of physical integrity and self-determination, and wish they had been applied to us. It’s too late for too many males, but there is never a bad time to stop violating human rights.

Also, the question of possible benefits and their applicability to any particular individual is separate from the public policy question of paying for non-therapeutic surgical interventions on non-consenting individuals. Non-therapeutic infant circumcision is an irresponsible use of funds in pursuit of subjective goals via unethical means. There is nothing good about it, regardless of how “prestigious” an organization promoting the idea is irrationally perceived to be. An organization that advocates violating human rights deserves no prestige.

This is not just good news for the United States, where obscurantist anti-circumcision groups have sought to completely ban this medically beneficial practice rather than allow families to choose whether to perform it. …

Rosenberg’s prior essay was obscurantist propaganda. Unlike his writing, I’ve acknowledged the arguments offered in favor of circumcision. I’ve explained why they’re inferior in the debate as it pertains to individuals. Mr. Rosenberg has not done the same. Instead, he offers condescending evasions:

… It’s also a powerful rebuttal to the flawed reasoning of the German court in Cologne, which ruled that circumcision generally constitutes “bodily harm,” yet made allowances for circumcisions performed for “medical reasons.” Thanks to the AAP, we can now state that all circumcisions are medically beneficial. …

The German court in Cologne ruled that non-therapeutic circumcision on non-consenting children violates their rights to physical integrity and self-determination. There is no flaw in that expression of basic human rights. The are the same rights that form the basis for prohibitions on FGC/M.

The court’s finding that circumcision constitutes bodily harm, no quotes, is consistent with permitting circumcision for medical need. The existence of a problem necessitates considering interventions. Ethically proxy consent will choose the least invasive, most effective solution. That is rarely circumcision when there is a need. But where it is necessary, the goal is an objective net benefit, that the surgery will remedy the problem. The outcome is presumed to outweigh the harm imposed to achieve it. The key is the outcome can be measured immediately and directly. Is the malady resolved?

With non-therapeutic circumcision, there is no objective net benefit because there is no malady. There is only objective harm for subjective benefits. The subjective benefits may not be valued or desired by the individual. In that case it’s objective harm to the individual for the subjective preferences of another. That is unethical. Because surgery on children involves proxy consent, medical need is required. The court was correct and consistent. The AAP is incorrect and encouraging unethical rights violations.

So, can we really state that all circumcisions are medically beneficial? Including the ones where the boy suffers a complication? If he loses his glans, is he still benefited? What about his entire penis? What about the thankfully rare instances where the boy loses his life? At least the benefits accrued over his short lifetime? Since all of these scenarios happen, even if we ignore my focus on individuals who suffer only the expected harm, isn’t it a bit obscurantist to state that all circumcisions are medically beneficial?

… If German courts continue to prosecute Jews and Muslims for practicing circumcision, then we will know that this animus is rooted not in science or fact, but in ignorance and prejudice.

I won’t say I expected his screed to end with something other than a preemptive ad hominem attack. It’s still pathetic.

Update: Walter Russell Mead uncritically endorses Rosenberg’s flawed post and makes a request:

Hopefully anti-circumcision zealots will take a deep breath and rethink their fevered stance on the issue. Beyond the fact that their bans impinge on the rights of Jews and Muslims to practice their religion as they see fit, they ought to consider that there is legitimate science pointing to the practice being beneficial to infant male health.

The only legitimate science involving infants is on UTIs, and possibly penile cancer. The former are uncommon in intact males in the first year (1%) and almost always easily treatable. The latter is more reasonably associated with other causes, with U.S. rates similar to those in mostly intact Europe. Everything else involves adult volunteers. The possibility of health benefits, or even religious benefits, does not render non-therapeutic circumcision on a child ethical.

No court in the United States endorses a right to practice one’s religion as members “see fit”. There are limits that may be imposed based on constitutional tests. Non-therapeutic child circumcision should fail that test because it is physical harm.

One Unremembered Trauma: Emphasize Trauma, Not Unremembered

Here’s a report from Jezebel on the Johns Hopkins study. It’s maddening.

Personally, I don’t give a care what kind of a penis any grown man currently has, because I am not in the business of telling people what to do with their genitals, or judging whether anyone’s genitals are “right” or “wrong.” That said, if I had a boy-baby, I think I would probably circumcise him (not, like, with my bare hands, but you know), because I can’t imagine one unremembered trauma could be more painful than a lifetime of a nasty, unfair, pervasive stigma. But that’s just me.

Did you catch that? She’s not in the business of telling people what to do with their genitals, except she would probably have her son’s normal genitals permanently altered. That is definitely tell someone exactly what he can’t do with his genitals.

That also reads like judging “right” and “wrong” to me. What someone else might say to her son could direct her to parent with a scalpel. Thinking with assumptions like this – that a parent can’t educate their children that the problem rests with the person who would stigmatize – creates the self-perpetuating cycle that parents “have” to cut to make their sons normal common to protect them from possible ridicule. This is especially ridiculous if we’re honest, because children will find ways to taunt, and about anything. If it’s not genitals, it’s hair color or fashion or ears or pimples or freckles or weight or whatever. We don’t expect parents to surgically alter other aspects of their children to avoid this temporary, not-guaranteed harassment. Normal genitals should be no different. Non-therapeutic genital cutting is an abdication of parental responsibility.

**********

Post Script: The predictable chaos ensued in the comments, apparently. I didn’t read them because I don’t read comments sections. But it’s obvious since the first comment addresses it. The Jezebel writer, Lindy West, replied:

Hey, screaming people. First of all, male circumcision and female genital mutilation are not equivalent. …

Ms. West is wrong.

(Advocates for genital integrity should not be screaming, literally or figuratively, in comments sections. I wish that didn’t need to be repeated.)

Infant Male Circumcision and Current Human Rights Disparities

Another focused post for a story on which I’ll have more to say.

In a study published Monday in the Archives of Pediatric and Adolescent Medicine, a team of economists and epidemiologists estimated that every circumcision not performed would lead to significant increases in lifetime medical expenses to treat sexually transmitted diseases and related cancers — increases that far surpass the costs associated with the procedure.

I strongly suspect the study is flawed because it makes estimates. I’ll withhold further comment until I know more. For now, there’s enough to discredit the embarrassingly incomplete approach used to justify the study and its estimates.

That sentiment [that Medicaid should cover non-therapeutic child circumcision] was echoed in an editorial accompanying the study. UCLA health economist Arleen Leibowitz wrote that by failing to require states to cover circumcision in Medicaid plans, the U.S. reinforces healthcare disparities.

“If we don’t give poor parents the opportunity to make this choice, we’re discriminating against their health in the future,” she said in an interview. “If something is better for health and saves money, why shouldn’t we do it? Or at least, why shouldn’t we allow parents the option to choose it?”

We shouldn’t do it or allow it because non-therapeutic genital cutting on a non-consenting child is unethical. Male circumcision on a healthy child violates his basic human rights to bodily integrity and self-determination. It is indefensible, even if it’s possibly “better” for his health in someone else’s subjective evaluation or because it saves money when individuals are considered statistics rather than human beings with their own rights and preferences.

The abstract makes it clear the study is speculative. Yet, we already have rights-based law for females without absurd exemptions we refuse to touch for males, so the idea that rights trump speculative benefits isn’t foreign. The ability to do something or to possibly achieve some population-level result without concern for the individuals involved cannot – must not – be viewed in a bubble that contains only the factors one is interested in (e.g. male circumcision is currently practiced, so it’s acceptable).

There are no doubt many non-therapeutic surgeries we could perform on children that might result in some decreased prevalence of disease x, y, or z. Infant mastectomies to remove breast bud tissue might reduce the risk of breast cancer. Shouldn’t we study that, at least, since it might reduce cancer? Reducing cancer is “good”, whatever the means, right? No one is foolish enough (yet?) to think such a thing, which highlights the flaw in thinking by those making excuses for circumcision, such as Ms. Leibowitz here. Society should stop ignoring the costs to the individual who must bear the outcome of the decision. Ignoring them is unacceptable. The ethics of circumcision are not divisible from any other basic human rights consideration or proper medical analysis based on therapeutic need, or lack thereof.

Finally, that non-poor families can afford to violate their children’s sons’ rights is not a reason to use taxpayer funds to let poor parents violate their children’s sons’ rights. That’s a political question rather than a medical question. It is inexcusable to sacrifice the bodies of male children (only!) because we’re too cowardly to honestly evaluate the mistake of non-therapeutic circumcision on non-consenting individuals. This is the same idiotic approach Dr. Edgar Schoen pushed in his 2005 propaganda book, “Ed Schoen, MD on Circumcision”. Somehow, not using public funds to violate a child’s body and rights is discrimination. It isn’t because circumcision is not a valid parental choice. UCLA health economist Arleen Leibowitz is wrong.

None of this is a surprise, based on the editorial by Ms. Leibowitz and Katherine Desmond, “Infant Male Circumcision and Future Health Disparities”. The first two sentences reveal so much.

The health benefits of male circumcision (MC) have been extensively documented in observational studies and by randomized controlled trials in Africa showing that MC reduces heterosexual transmission of human immunodeficiency virus (HIV) infection from women to men by 55% to 76% …

The trials showed that voluntary, adult male circumcision reduces female-to-male HIV transmission in high risk populations with a heterosexual epidemic and a low rate of circumcision among adult males. That’s quite different, since it doesn’t describe the United States. It also fails to describe the circumcision they’re advocating. Children are not adult volunteers. That’s the ethical flaw in their analysis.

… and provides significant protection against human papillomavirus infection. …

Gardasil is approved for girls and boys. Circumcision is unnecessary for this possible benefit, as it is for nearly every possible benefit.

… Male circumcision is negatively associated with prostate cancer in men and with cervical cancer in female partners of men infected with human papillomavirus.

Negatively associated. Correlation is not causation. The study’s authors acknowledged this when they stated that it was an observational study. “Negatively associated” is not sufficient.

Doctors Aren’t Cultural Actors

I may have more to say on this story about circumcision as “the ultimate parenting dilemma. Understood, it isn’t a dilemma. But we have to deal with reality, not the world we should have. For now, this:

“You are doing a procedure on someone who cannot make a decision for himself – it’s a difficult choice for both parents and physicians,” says Dr Marvin Wang, co-director of the Newborn Nurseries at Massachusetts General Hospital, who has conducted hundreds of circumcisions.

It is, he says, more a “cultural decision” than a medical one, and therefore, for parents to decide, while he advises on the pros and cons.

Wang says most parents come in with fervent beliefs – and what a doctor says makes little difference.

“The bottom line is… they stick to their guns. They choose the pieces of information that bolster their argument and run with that.”

What a doctor says makes little difference. Having conversed with people who support circumcision for irrational reasons, I am not surprised. However, what a doctor does can make all the difference. Or, rather, what a doctor does not do. There is no obligation to participate in non-therapeutic circumcisions on minors. There is an ethical duty to not participate. If doctors refused to perform the surgeries, the numbers would decline. Not to zero, but it would signal a critical truth to parents who intend to make their son’s choice.