Male Circumcision Research Paper

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Abstract

This entry provides some information about the rich history of male circumcision, distinguishes between four clusters of reasons for male circumcision, and discusses shortly the differences and commonalities between male and female circumcision. The ethics part focuses on the following four issues: (1) the (lack of) scientific evidence regarding medical harms and benefits, (2) respect for the child’s and its parents’ rights, (3) the right on bodily integrity, and (4) the moral weight of cultural considerations and its relation to global bioethics. It concludes that in the debate about male circumcision, there is a tension between (1) general abstract principles such as individual autonomy, self-determination, the child’s right on an open future, and bodily integrity, (2) evidence based medicine that inspired scientific findings about harms and benefits, (3) cultural considerations, and (4) practical and individual circumstances. In general, there seems to be a tendency toward a more skeptic stance toward male circumcision, even within religious communities.

Introduction

Male circumcision (MC) is a controversial topic because it touches on strong cultural, religious, theological, and philosophical convictions. It is probably the most commonly performed surgical procedure worldwide. Each year around 13.3 million boys are circumcised (Denniston et al. 1999). Reasons to perform MC are of a medical therapeutic, hygienic-preventive, religious, or cultural nature. Especially, the practices of hygienic preventive and religious MC are subjects of debate. In various countries, there are ongoing discussions about the medical and religious legitimization and moral acceptability of MC. Critics even plea for a ban on nontherapeutic circumcisions. The bioethical dimension is complex.

History And Development

The early history of MC is lost in the mists of time. Before MC became a crucial practice in Jewish and Islamic religion, it was already practiced for cultural, that is, not specific religious or medical reasons, for example, in ancient Egypt (Gollaher 2000).

Cultural Circumcision

Since time immemorial, MC has been practiced in various tribes, e.g., in Africa and Australia. The reasons to perform cultural MC are not always clear and may vary from culture to culture and tribe to tribe (Gollaher 2000). However, this practice can generally be seen as part of an initiation ceremony or “rite de passage.” The mark of circumcision symbolizes the individual’s permanent inclusion in a distinct tribal community. The initiation rite of circumcision is essentially sacrificial. One small part of a member’s body (his foreskin) is sacrificed to the divine powers to redeem the community. Why it is the foreskin and not another small body part like the earlobe that is cut of is subject of psychoanalytic and anthropological research and speculation. Sigmund Freud spoke of “cutting the penis” since he did not consider the foreskin a structure separated from the penis (Gollaher 2000, p. 66). He considered circumcision to be a symbolic castration reinforcing the incest taboo and leading to castration anxiety. This view, however, is not undisputed. The psychotherapist Bruno Bettelheim dismissed Freud’s theory of primal castration. According to him, circumcision reflects a deep-seated ambivalence about being confined to a single sex. The purpose of MC is not considered to exacerbate sexual anxiety but to palliate it. According to Bettelheim, “circumcision developed as a result both of man’s desire to participate in the female power of procreation, and of woman’s desire, if not to rob the male of the penis, at least to make him bleed from his genital as women do” (Bettelheim in Symbolic Wounds; quotation in: Gollaher 2000, p. 69).

Religious Circumcision

MC is one of the earliest surgical procedures to have been performed in the practice of Judaism and Islam. The ethos of circumcision in Judaism is complex. It has to do with personal and cultural identity and with the role of man as guardian of his body. God did not complete creation. This was left for humankind to do. For Jews, circumcision represents the covenant made between God and Abraham. The first reference to circumcision appears in Genesis (17:10–14): “At the age of 8 days every male among you shall be circumcised throughout your generations.” For Jews, circumcision is a commandment from God.

In early Christianity, the practice of circumcision was heavily debated. Opposition to circumcision was a crucial element of the religious identity of the early Christians. In his letter to the Galatians, St. Paul explained that in the process of instituting the new covenant between God and humankind, Jesus Christ subsumed the old covenant between God and Abraham. Christ, St. Paul said, fulfilled the law, and this fulfillment rendered circumcision irrelevant in the eyes of God. In other words, circumcision was not necessary in order to be a Christian (Gollaher 2000). St. Paul rather pointed to the “circumcision of the heart” and to baptism as the new symbol marking out the people of the covenant from the rest of humanity.

Circumcision is not mentioned in any form in the Koran. In Islam, the practice of MC is based on sunnah, that is, the prophetic tradition marked by the Prophet Mohammed’s words and deeds. Circumcision is not an absolute commandment but is strongly recommended. In practice, however, almost every Muslim boy will be circumcised. While Jews speak only in terms of a commandment of God, Muslims also put forward hygienic and medical reasons. In the prophetic traditions that enumerate the features of natural religion, MC is mentioned under the heading cleanliness, together with the clipping of nails, the use of toothpicks, the cutting of moustaches, etc.

Medical Circumcision

MC is also performed for hygienic and preventive reasons. In this regard, the USA is quite unique in the world. Nowadays, the so-called routine neonatal circumcision (RNC) is the most frequently performed surgical operation carried out in the USA. Although circumcision rates are steadily decreasing in most countries around the world, including the USA, still around half of the newborn male infants in the USA are circumcised. The modern history of RNC starts in the 1870s as a treatment for all kinds of signs and symptoms allegedly related to genital irritation (Gollaher 2000). During the Victorian Era, a few American doctors, among them Lewis A. Sayre, began to circumcise boys to prevent a wide range of conditions such as masturbation, enuresis, impotence, epilepsy, and a variety of mental disorders. In the first half of the twentieth century, the practice of RNC spread over the country, touted as a means to prevent diseases such as urinary tract infections, venereal diseases, and penile cancer. With regard to RNC, there is a sharp distinction between the USA and Europe. While RNC is a normal medical practice in the USA, the European medical establishment considers RNC an unnecessary surgical procedure. RNC is an example of cultural diversity in the field of medicine and health care which challenges the idea of interculturally shared values, methods, and practices.

Objections

Throughout history, there have been critics who object to religious MC. Although MC has a firm basis within Judaism, there is some (marginal) opposition within this religion. It is argued, for example, that circumcision is not as essential to Jewish identity as most Jews assume. Circumcision, then, is considered a violation of the body’s integrity because a healthy, functional part of the body is excised. Other reasons to oppose circumcision of newborns are the experience of pain, possible complications, a lack of presumed medical benefits, and negative effects on the parents’ experiences. From such a critical perspective, circumcision has been described as “a particular form of violence to children,” and uncircumcised boys have been described as “intact Jewish boys” (Goodman 1999, p. 26). Nowadays, groups as Jews Against Circumcision exist and alternatives to the excision of the foreskin are being proposed (Earp 2013). Also within Islam there is some opposition to male circumcision. However, objections to MC derive largely from the practice of RNC.

Foreskin Restoration

As long as MC has been practiced, there have been attempts to restore the original anatomical structure. Jews, for example, have practiced foreskin reconstruction for almost as long as they have practiced circumcision. In the Hellenistic period, they were confronted with a culture that considered circumcision a barbaric mutilation of the natural human body and a violation of common standards in Greek aesthetics. Greeks held athletic contests in which the participants appeared nude. The Greek standard of modesty held that the foreskin should cover the glans. The visible glans of a circumcised man was taken as evidence of sexual arousal and was thus considered indecent within the arena (Gollaher 2000). Jews who wanted to meet the standards of Hellenistic culture tried to restore their foreskin. During the Nazi regime in the Second World War, Jews were even more strongly motivated to hide or undo their circumcision in order to conceal their Jewish identity.

Nowadays, it is especially men who have lost their foreskin due to RNC who try to undo the circumcision and to restore the original anatomical structure as good as possible. This so-called foreskin restoration movement is still growing. The term foreskin restoration can refer to any method of creating a facsimile of a foreskin to cover the head of the penis. This can be done either by surgical means or nonsurgically by all kinds of stretching devices. The National Organization of Restoring Men (NORM) is a nonprofit support group for men who have concerns about being circumcised, who are considering foreskin restoration, or who are in the process of restoring their foreskins. The aim of NORM is to help men regain a sense of self-directedness, physically as well as emotionally.

Conceptual Clarification

Four Reasons For MC

If the ethical aspects of MC are at stake, it is important to distinguish between four clusters of reasons for a circumcision: (1) medical therapeutic reasons, for example, in the case of phimosis or balanitis; (2) preventive-hygienic reasons, as is the case in RNC; (3) religious reasons, as being practiced by Jews and Muslims; and (4) cultural reasons, that is, circumcision for nonmedical, non-preventive, and nonreligious reasons, as is still being practiced in some peoples as a “rite de passage.” These four categories do not exclude each other. There is often a mix of reasons to circumcise. In Islam, for example, considerations of hygiene and health are mixed up with strict religious convictions. Also the practice of RNC in the USA demonstrates how a procedure that once was thought to have medical benefits can be transformed into a culturally based norm (Szasz 1996).

Genital Mutilation

One usually makes a sharp distinction between male and female circumcision. First, boys and men are mostly circumcised for medical therapeutic, preventive-hygienic, or religious reasons. Female circumcision does not occur for these reasons and is mostly based on cultural, that is, not specific medical, preventive, or religious reasons. Second, the excisions in most female circumcisions are far more extensive than those in male circumcision and can have dramatic negative medical side effects. Third, female circumcision is officially forbidden in most countries, while there is no law that forbids male circumcision. For these reasons, female circumcision is generally described as “female genital mutilation,” while the term “genital mutilation” is less often used for MC.

Despite these differences, there are good reasons to consider male and female circumcision in the same context. In both cases circumcision is an invasive intervention in the external genital organs for which – in most cases – there is no medical indication. Further, a minimal form of female circumcision in the form of a small (nick) incision may be less mutilating than a standard male circumcision. Moreover, the symbolic meaning is the same in both cases. Generally speaking, being circumcised is considered a token of becoming a part of a community, arising from a covenant with God or from a particular adult community. In addition to the nature of the intervention itself and the symbolic meaning attached to it, there are also political justifications for emphasizing the connection between the two practices. It is argued, for example, that female circumcision cannot be stopped as long as male circumcision for nonmedical reasons is tolerated.

Ethical Dimension

The ethics part focuses on the following four issues which can be found in the literature: (1) the (lack of) scientific evidence regarding medical harms and benefits, (2) respect for the child’s and its parents’ rights, (3) the right on bodily integrity, and (4) the moral weight of cultural considerations and its relation to global bioethics (Benatar and Benatar 2003; Dekkers 2009).

Harms And Benefits

Especially in the context of RNC, the scientific evidence (or the lack of it) for medical harms and benefits is being discussed. Sometimes the discussion is expanded to nonmedical harms and benefits such as possible sexual dysfunctions and the costs of the intervention. In the first decade of the twenty-first century, the relationship between MC and HIV infection has reappeared on the agenda.

Harms

Although the literature occasionally reports horrifying complications of RNC such as a total destruction of the penis, it is generally considered a simple procedure which, if properly performed, seldom leads to complications. Possible medical harms of RNC are pain and complications such as bleedings and infections. The overall complication rate associated with newborn circumcision is approximately 0.2 %.

Benefits

The benefits of RNC have been described in numerous studies using a wide variety of methodologies. Reported benefits include reductions in the rates of urinary tract infections (UTIs), penile cancer, and some sexually transmitted diseases (STDs). The extent to which circumcision decreases the risk of these outcomes has been intensely debated. A consensus now appears to be emerging that there are some small protective benefits, especially reducing the risk of UTIs. The protective effects of circumcision can be conveyed in terms of a so-called number needed to treat (NNT). This number represents the number of male newborns who would need to be circumcised to prevent one undesired outcome such as a UTI. It is known by now that around 100 circumcisions would be required to prevent one UTI. However, critics of RNC state that the incidence of UTIs does not seem to be lower in the USA with high circumcision rates, compared with Europe with low circumcision rates, that the evidence for clinically significant protection is weak, and that a UTI is generally no serious medical problem and easy to treat (Frisch et al. 2013).

Circumcision And HIV

In the first decade of the twenty-first century, the RNC debate got a new stimulus. Observational studies had shown that circumcised men appear less likely to acquire HIV than non-circumcised

men. The results of two experimental trials in Kenya and Uganda in 2007 showed that MC halves the risk of adult males contracting HIV through heterosexual intercourse. Since then, several authors have stressed the need of a large-scale circumcision campaign in order to prevent HIV infections. Many of their assertions remind us of statements of fervent proponents of RNC in the USA, now and in the past, exaggerating the alleged advantages, ignoring potential harms, and giving the impression that circumcision is no more than a simple intervention comparable to a vaccination. Although there is some evidence of a protective benefit of circumcision, factors such as the unknown complication rate of the procedure and negative behavioral consequences still need to be taken into account. Pleas for preventive circumcision might also distract attention from alternative ways of preventing the spread of HIV: lifestyle and sexual behavior, the use of condoms, and the development of a vaccine.

Advocates of RNC are using these new findings to support their case in favor of RNC, but it is questionable whether these findings are relevant to the RNC debate. Taking into account the notion of a “prevention paradox,” one might ask whether it is right to circumcise a whole population or a considerable part of it if many will not benefit from the intervention, for example, because they do not engage in risky sexual behavior. Moreover, although neonatal circumcision might be safer, less expensive, and easier to organize than adolescent or adult circumcision, the child’s bodily integrity forms an additional argument against him being circumcised for an issue that might not affect him for many years to come. Further, the medical, social, and cultural circumstances in the USA and African countries such as Kenya and Uganda are distinctly different. The adult risk of HIV is not high in the USA when compared with some African countries, and access to life-saving antiretroviral drugs is widespread.

Continuous Debate

From a methodological perspective, the medical, psychological, and social benefits and harms of RNC are hard to determine. There are some purported benefits of circumcision, but not all of them are supported by scientific evidence. Moreover, there is no evidence that a possible minimal advantage of circumcision counterbalances the disadvantages. And even if the advantages outweigh the disadvantages, it still remains to be seen whether RNC should be applied on a large scale.

The American Academy of Pediatrics (AAP) released in 2012 a new Technical Report and Policy Statement on RNC, concluding that possible health benefits now outweigh the risks and possible negative long-term consequences (American Academy of Pediatrics 2012). Compared to earlier statements about RNC, the AAP has now changed from a neutral to a more positive attitude toward circumcision. The AAP does not recommend routine circumcision of all infant boys as a public health measure but asserts that the benefits of the procedure are sufficient to warrant third-party payment. This conclusion seems to be strongly culturally biased, because it is quite different from the opinion of physicians in other parts of the Western world, including Europe, Canada, and Australia. In a recent commentary, it is stated that only one of the arguments put forward by the AAP has some theoretical relevance in relation to RNC, namely, the possible protection against UTIs. The other claimed health benefits, including protection against HIV/AIDS, genital herpes, genital warts, and penile cancer, are considered questionable, weak, and likely to have little public health relevance in a Western context (Frisch et al. 2013).

Children’s And Parents’ Rights

Routine Neonatal Circumcision

According to the AAP, scientific evidence demonstrates potential medical benefits in the long run of newborn male circumcision. However, these findings are not considered sufficient to perform RNC without adequately informing the parents as was previously often done. In cases such as MC, in which there are potential benefits and risks, yet the procedure is not essential to the child’s current well-being, parents should determine what is in the best interest of the child. To make an informed choice, parents of all male infants should be given accurate and unbiased information and be provided the opportunity to discuss this decision. This view is an example of a position which is much defended in the literature: because there is modest but not yet sufficient medical evidence for RNC, the parents must decide on the circumcision of their son after being well informed about the pros and cons. RNC is a discretionary matter. The decision whether or not to circumcise a child should be made by the parents (Benatar and Benatar 2003).

Although good reasons exist to argue that parents should decide about circumcision, the question why circumcision should be done on an age when the child cannot give his consent is still open. In order to question the moral acceptability of nontherapeutic forms of circumcision, the focus is often on the protection of the child’s rights, in particular his right on self-determination. The problem of entitlement brings some opponents of RNC to the argument that circumcision must be postponed till the age of eighteen when the person himself can make a well-informed and deliberate decision. This argument, however, can (partly) be counterbalanced by more practical considerations: neonatal circumcision has less impact on the one whose foreskin is being removed, is easier to organize, and is probably cheaper than circumcision at an adult age.

However, even if one considers RNC a suitable matter for parental decision or for a decision by the child himself when he is adult, there is still the fact that it is a medical procedure carried out by doctors. Critics of RNC inside and outside the USA have therefore argued that it is not the question “who should decide” that is at stake but the more fundamental question whether RNC is morally acceptable at all. What is the moral basis for cutting off a part of the genitals of a healthy infant for dubious medical reasons? Also an adult’s decision to undergo circumcision for medical preventive reasons is not morally neutral or uncontroversial.

For doctors, RNC is just a simple routine intervention, no more of an operation than a vaccination, to be carried out in a few minutes. Others critically speak of “genital mutilation,” “amputation,” “child abuse,” or even “a type of barbarism.” The language used in the RNC debate is far from being neutral. Whatever language is used, however, at first sight RNC can be considered a violation of the Hippocratic principle of non-maleficence: first do no harm. This does not mean that neonatal circumcision is morally questionable only because of harmful side effects. Many generally accepted medical interventions do have negative side effects. What is crucial in the case of RNC is the lack of a medical legitimization. It is, for example, argued in the commentary on the AAP report that this report lacks a serious discussion of the central ethical dilemma with, on one side, parents’ right to act in the best interest of their child on the basis of cultural, religious, and health-related beliefs and wishes and, on the other side, infant boys’ basic right to bodily integrity in the absence of compelling reasons for surgery. According to this commentary, bodily integrity is one of the most fundamental rights a child has. Physicians and their professional organizations have a professional duty to protect this right. Physicians should discourage parents from circumcising their healthy infant boys (Frisch et al. 2013).

Religious Circumcision

Children’s and parents’ rights and the principle of respect of individual autonomy also play a role in discussions about the moral acceptability of religious MC. Defenders of religious MC, which is an ancient tradition, sometimes suggest that “the sheer antiquity of the practice implies a kind of venerability” and that the fundamental legal status of such an old religious custom cannot seriously be called into question (Earp 2013a). In a recent introduction to a special issue of The Journal of Medical Ethics, Brian D. Earp points out that there seems to be a tension or even an incompatibility between the implicit philosophical presuppositions of this (pre)historical practice of MC, on the one hand, and the normative foundations of much of contemporary Western law and custom, on the other (Earp 2013a). Elsewhere, he has argued that both the Jewish and Islamic practices of MC are consistent with the norms of patriarchy: “both elevate the concerns of the community over the freedom of the individual to make decisions about his own body in his own time; and both brand a child with a permanent mark of religious belonging despite the significant possibility that he may one day fail to embrace the belief system and/or cultural practices of his parents” (Earp 2013b).

By contrast, contemporary bioethics as well as the philosophical basis of many modern legal codes came to fruition in a secular era that favors a very different set of values. In this context, Earp refers to such concepts as autonomy, individual rights, informed consent, bodily integrity, the freedom to join (or to leave) a religion, the “needfulness of protecting the vulnerable in society against the unwarranted exertions of the powerful,” and a child’s interests in self-determination and an open future. This tension between “preand post-enlightenment world views,” as described by Earp, can explain why there has been a revival of the debate on MC in the last half-century, and why there may even be a growing opposition toward it (Earp 2013a).

Bodily Integrity

Much of the effort to regulate the use of the body is embedded in a moral language of terms such as sanctity, dignity, and bodily integrity. These notions represent a fundamental view of the human body in Jewish, Christian, and Islamic religions and also in (nonreligious) philosophical thinking, for example, in classic Greek and Roman thought and in Thomas Aquinas’ and Kant’s philosophy. In the literature, three interpretations of “bodily integrity” can be found which are relevant to the practice of MC: biological, subjective, and normative wholeness (Dekkers 2009).

Biological Wholeness

The idea of biological wholeness means that although the human body consists of numerous body parts, organs, tissues, cells, and subcellular components, it is still an anatomical and physiological unity, an integrated whole which is more than the sum of its parts. Biological wholeness refers to the proper function of the body and its parts. From this perspective, it is curious that there has been a lot of debate on the question whether the foreskin is an essential body part. Some

Darwinism-oriented authors were of the opinion that the foreskin is nothing more than a vestige of the human being’s evolutionary past. Most anatomists, however, consider the foreskin as an integral part of the sexual organ. Nowadays, the foreskin is considered to have useful and valuable functions: protection, immunological defense, erogenous sensitivity, and sexual functions in intercourse.

Subjective Wholeness

Jews and Muslims who have been circumcised for religious reasons seldom express feelings of not being “whole” anymore (Dekkers et al. 2005). It thus appears that a violation of biological wholeness not necessarily goes together with a feeling of a lack of subjective wholeness. However, a small portion of men who have been circumcised for preventive-hygienic reasons later regret – under the influence of the ant circumcision movement – being circumcised. There is a growing literature on negative feelings about bodily integrity in males circumcised in infancy without religious motivation (Davis 2000–2001). The following comments have been noted: “always thinking about foreskins,” “psychologically and physically damaged,” “desired to know what it would be like with a foreskin,” “altered, not whole,” “mutilated,” “incomplete,” and “deformed” (Dekkers 2009).

Normative Wholeness

The biological and subjective wholeness of the human body is also a normative wholeness. This means that the human body is characterized by dignity, sacredness, or intactness. It is often argued that a mutilation of the human body is permissible only if it regards a nonessential body part and if the intervention is necessary to preserve the whole body. According to Kant, we do not only have moral duties toward ourselves and other persons but also toward our own bodies (Kant 1997). The foreskin can hardly be considered an essential body part, but it is at least an integral part of the human body.

Bodily Integrity And MC

Biological, subjective, and normative wholeness do not necessarily coincide, but taken together they form a strong argument for a reserved stance toward MC. Most opponents of any form of circumcision argue that (the right to) bodily integrity and related concepts such as wholeness are incompatible with circumcision. It is striking that the anti-circumcision movement speaks of “genital integrity” (Denniston et al. 1999). In terms of basic human rights, circumcision without explicit consent may be considered to violate the individual’s right to bodily integrity. This is a strong argument in favor of circumcision on an adult age, if circumcision is deemed necessary at all. However, in order to show that also circumcision on an adult age is not uncontroversial, critics of circumcision for nonmedical reasons emphasize a somewhat stricter interpretation of bodily integrity. From this perspective, the notion of respect for bodily integrity has been opposed to the idea of personal autonomy and self-determination over the body. It implies that the human body cannot (entirely) be owned or controlled, because it has a moral value of its own. Even if people are considered to be the owners of their bodies, they are not allowed to do everything with their bodies that they might want to. Respect for bodily integrity is an ethical principle in its own right, closely connected with, but fundamentally different from the principle of personal autonomy (Dekkers 2009).

The notion of bodily integrity is a key notion in many philosophical, theological, and religious considerations, but it is not an absolute principle. First, it is ultimately based upon moral experiences. However, whether an experience can be called a moral experience depends upon the context, culture, or tradition in which the subject of that experience takes part. For many doctors the circumcision of male newborns is just a routine surgery to be carried out in a few minutes. For many parents, however, witnessing a circumcision can be a distressing experience. Also for people with a Jewish or Islamic background, witnessing a circumcision, although they feel that it definitely needs to be done, is not a pleasant experience. These findings underscore that they intuitively express feelings of ambivalence and hesitation that can be explained in terms of respect for the integrity of the body (Dekkers et al. 2005).

Second, the principle of bodily integrity can be overridden by competing moral obligations, for example, to obey God’s law, as is the case in Judaism and Islam, or to contribute to the health of the patient. Notwithstanding critical differences between Jewish, Christian, and Islamic thinking, Jews, Christians, and Muslims generally attach a high value to the integrity of the human body, while it is precisely in Judaism and Islam that male circumcision is practiced. This seeming paradox could be explained by taking into account the specific traditions in which this practice plays a role. It appears that Jews and Muslims regarding circumcision do not explicitly think in terms of a violation of the integrity of the body. On the contrary, male circumcision is even considered a step toward a perfection of the human body. The foreskin is considered an imperfection whose removal is necessary to reveal the body’s ideal form.

Cultural Differences And Global Bioethics

MC for cultural reasons is an old prehistoric tribal tradition. Religious MC, dating back to the origin of Judaism, was abolished in early Christianity but got a revival in Islam. Religious MC is based on strong religious and theological norms and values. It is less recognized, however, that also the practice of RNC – although relatively new – is also strongly culturally dependent. Its medical rationale developed after the operation was in wide practice: to improve hygiene; to prevent phimosis, urinary tract infections, sexually transmitted diseases, and cancer of the penis; but also to make sons resemble their circumcised father and to conform socially with their peers. RNC is a medical and a social-cultural phenomenon as well.

The answer on the question why RNC is still practiced in the USA at a time when evidence based medicine (EBM) is the global standard must be sought in psychological, social, and cultural explanations. Although advocates of RNC accuse opponents of RNC of opinion-based arguments and do their best to present scientific figures that support their view, they often fail to recognize that their own view is also based on social-cultural beliefs and values. Advocates of RNC focus on the alleged medical advantages, but the so-called medical aspects of RNC also appear to be largely culturally based. RNC is recommended on medical or quasi-medical grounds but is for a great deal legitimized in and through the social context. The medical rationalization of RNC is one of the most obvious illustrations of the acculturation to the ideology of the “therapeutic state,” the political order in which social control is legitimized through an ideology focused on health (Szasz 1996). The practice of RNC demonstrates how a procedure that once was thought to have medical benefits can be transformed into a culturally based norm.

The question is how global bioethics should treat cultural differences such as RNC and religious MC. Should these practices be stimulated, tolerated, criticized, discouraged, or even prohibited? The single fact that RNC is disapproved in European culture and that religious MC is not part of Christianity is not a sufficient reason to disapprove that practice in another culture and religion. At stake are culturally dependent norms and values which necessitate an open view toward other cultures. RNC and religious MC should be discussed in the context of an ethics of multiculturalism. The significance of the notion of multiculturalism primarily lies in a favorable and open attitude toward other cultures. In the context of the MC debate, there is value in trying to step back from one’s cultural assumptions and to view RNC and religious MC from another cultural perspective.

The problem, however, is that multiculturalism is often associated with a form of ethical relativism, that is, the claim that morality is relative to the norms of one’s culture and – in a more stringent interpretation – that there are no common moral principles shared by all cultures (Baker 1998). In Against Relativism, Ruth Macklin states that ethical relativism can be sustained for some cultural practices and traditions but that it should be rejected for others as a “pernicious doctrine” (Macklin 1999, p. vi). The question is whether RNC and religious MC are a suitable subject for an “anything goes” or laissez-faire attitude. Can some form of ethical relativism be sustained for RNC and religious MC, or must these practices be discussed in the context of a global and intercultural bioethics? Taking into account the current debate on MC, there appear to be good reasons to argue that for both practices ethical relativism must not be sustained.

Conclusion

MC is a controversial subject. The debate about the medical, moral, theological, legal, and cultural justifications for MC is still going on. In this debate, there appears to be a tension between (1) general abstract principles such as individual autonomy, self-determination, the child’s right on an open future, and bodily integrity, (2) evidence based medicine that inspired scientific findings about harms and benefits, (3) cultural considerations, and (4) practical and individual circumstances such as conscientious objection in a clinical context (Ahmad 2014).

In the current debate about the pros and cons of RNC, proponents focus on medical-scientific arguments and considerations about evidence based medicine, while opponents base their view predominantly on moral notions and principles such as children’s and parents’ rights and bodily integrity. It is important to realize, however, that scientific arguments are also based on moral arguments and that moral arguments cannot be considered separately from scientific reasoning.

It appears, moreover, that abstract principles such as bodily integrity are ambiguous. It is only within a particular moral narrative that one can determine whether specific uses of the body are to be praised, condemned, or regarded as morally neutral. What is meant by “bodily integrity” must be explored by analyzing specific practices in which the integrity of the body is at stake. Although the human body may generally be seen as having an integrity which must be respected, every alteration or apparent violation of the human body must be considered in its own medical, religious, and cultural context.

In the literature, one can still find strong defenses of RNC and religious MC as both morally and legally permissible, alongside contrary arguments that circumcision is an unambiguous affront to human rights. The debate is far from over. Nevertheless, as Earp argues, “the overall balance of opinion may be shifting toward one of general skepticism concerning circumcision, even within religious communities” (Earp 2013a). Increasingly, individual writers with a Muslim or Jewish background point out that there are alternatives to religious MC and that the involuntary excision of children’s foreskins may not be necessary for contemporary religious observance (Earp 2013a).

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