Welcoming children into this world peacefully
and enjoyably is every mother’s right.
Entering the world peacefully is every child’s right.
Tune in to what is natural and possible now.
I am thrilled to announce that the Journal of Sex Research is publishing an article I coauthored with ethicists Brian Earp and Lauren Notini, titled “Should Surgery for Hypospadias Be Performed Before an Age of Consent?” In this article, we explore the current literature regarding hypospadias and surgical outcomes, and then present a solid ethical framework under which to consider this situation.
If you are wondering whether hypospadias should be operated upon, the number one most important piece of advice I can give you is, Think outside the box. For years, the argument for hypospadias surgery has been that the condition prevents a child from living a “normal” life. For this reason, many parents have chosen to have their child operated upon, with the goal of protecting their children from pain and suffering.
I challenge you to reconsider the commonly held belief that surgery for hypospadias prevents pain and suffering. Hypospadias is diagnosed when a child is born with a penis that has not developed in what is considered the typical way. In most penises, the urethra opens at the end of the glans. The foreskin surrounds the glans circumferentially, and is closed at the tip, so the glans is not exposed to the outside world for some years. In hypospadias, the urethral opening is located on the underside of the penis at varying locations, depending on the degree of the condition (see image at left). The foreskin is usually not developed along the underside of the penis, and is sometimes described as having a hooded appearance.
Hypospadias may mean that a boy has so sit to urinate. It is often associated with curvature of the penis, which can range from mild to severe. In most cases, the urethra is widely open, but in a small percentage, the urethra is narrowed. Many people assume that all of these issues are “abnormalities.” Yet the only one of these that presents a threat to a child’s physical well-being is the uncommon scenario in which the urethra is narrowed and urine flow is obstructed. In the vast majority of cases, there is no threat to the physical health of the child.
But what about when the child grows up? Will his life be hard if he must sit to void? Will the curvature of his penis make sex difficult or painful, for him or his partner? Will he be teased in locker rooms? Many assume that all of these will be true, and decide to operate on the child before he can voice a memory of it, with the hopes that he will never face the difficulty of living life with a penis that is not “normal.”
One look at the reality of intersex, however, leads us to question these assumptions. Once one realizes that gender is not actually binary, that “normal” does not include only males or females, but an entire spectrum of development along a continuum, one begins to rethink this standard of “normal.” Today’s open awareness and acknowledgment of the range of sexual preferences held also helps us reconsider what is “normal” sexual behavior.
My years of training and experience as a urologist, as well as my personal interest in genital autonomy rights for children of all genders around the world, have led me to understand, beyond a doubt, that intersex conditions, or any differences in genital appearance, are not inherently always problematic and can in fact be desirable. In the vast majority of these situations, the primary problems are social and can be dealt with in other ways. Adults with these conditions who were and were not treated as children have been actively voicing for some time their belief that surgery should not be performed for these conditions on children who are not experiencing a threat to their physical health. Many of these adults have stated clearly that they would not have chosen surgery for themselves.
Instead, the recommendations center around accepting what is, embracing differences, and treating actual problems as they arise (not trying to prevent potential problems that do not currently exist).
I wholeheartedly believe this philosophy applies to boys with hypospadias. In our paper, we review data that show that 1) many adult males with hypospadias have no significant disruption to their life, and 2) the potential complications of operating are significant. If a person with hypospadias decides that he wants to have any or all aspects of it operated upon, he can make this decision as a fully informed adult. At this time and only at this time, can he ascertain for himself whether any voiding differences are problematic, whether he has any sexual difficulties, and what risks he is willing to take to address any problems he is experiencing.
Remember that we are all different, and those differences can often be embraced and enjoyed. Remember that surgery is a risky intervention and is best used with restraint. Remember to ask yourself what actual problem is occurring right now when considering any intervention that carries risk, for yourself or your child.
Above all, do your own research, and be willing to think outside the box.
The popularized Hironimus-Nebus legal case regarding a parental dispute about the circumcision of a 4-year-old boy has made headlines. Unfortunately, this legal battle has failed to address the core issue at hand.
In this case, what was actually deliberated by the judge and ruled upon is the fact that these parents once signed an agreement that their son would be circumcised. Years later, when the father decided to follow through on the agreement, the mother refused, giving concerns about the child now being older and having had a prior reaction to anesthesia. The dispute went before court, and a pediatric urologist testified that the child did not have any medical reason to undergo the removal of his foreskin. The judge, however, issued his ruling based upon the validity of the agreement signed between the parents, and stated that the mother must comply with the legally binding document.
The American Academy of Pediatrics Committee on Bioethics has clearly stated that physicians “have legal and ethical duties to their child patients to render competent medical care based on what the patient needs, not what someone else [such as the parent] expresses.” Yet, despite the strides made in this country to protect children’s autonomy, circumcision has escaped this oversight.
Proponents of circumcision (male and female) have long heralded a variety of benefits of the procedure. For more than a century, these have been made and later refuted, only to be replaced by new claims. Today’s claims are commonly and easily rebutted by other physicians and scientists, particularly those from cultures in which routine male infant circumcision is not performed or accepted as normal.
The harms of circumcision are undeniable. Genital surgery during childhood has long been recognized as psychologically traumatic within the medical profession. Meatal stenosis is recognized in urology texts as a complication that occurs almost exclusively after childhood circumcision. And the range of complications that have been reported during adulthood is vast.
In the Hironimus-Nebus case, however, even with the testimony by a pediatric urologist that the child did not have any medical need for circumcision, the issue considered was the prior legal agreement between the parents. The best interests of the child were not weighed, because too many in this country continue to mistakenly believe that removing healthy genital tissue from a child is not harmful (if the child is male) and is a valid choice for a parent to make for his or her child.
We will see change in this country when the issue of circumcision isn’t brought to court as a mediation between two parents but instead as a child needing protection from a harmful, non-therapeutic procedure being inflicted unnecessarily. In this and similar cases, our legal system has a real opportunity to protect and prioritize the rights of a child in a very meaningful way, in the same way many have called for to protect little girls in countries whose cultural norms are different from ours.
It is time for an ethical judicial body to truly reflect on what is occurring here, to look at the vast evidence worldwide that the removal of healthy genital tissue is harmful, and to change the way we treat our little boys for the better, for good.
The Centers for Disease Control has recently proposed making the recommendation that doctors inform parents, boys, and men that circumcision can reduce their risk of contracting HIV and other STDs. This proposal reflects a dangerous mix of bad science and strong cultural organization to support its harmful practices.
Imagine if a Somalian medical organization sent a group of researchers to the United States to recruit adult women to undergo removal of parts of their clitoral hoods (prepuces), labia minora, or some other part of their genitals. Then, they watched these women for a few months to see if they acquired HIV less often than their counterpart women who did not have their genitals altered. Very few Americans would consider this reasonable. We are blinded by our culture.
This “science” has never proved that circumcising is going to prevent a man from getting HIV. Firstly, we know that this claim is absolutely impossible. HIV is transmitted by sexual intercourse and the exchange of body fluids. Circumcision does not prevent this. Many circumcised men have HIV. That is simple and obvious. It is right in front of our eyes. These studies showed a less than 2% reduction in the rate of HIV acquisition in a very short follow-up after the surgery was performed. These African men had surgery on their penises with a mandatory minimum 6-week period of abstinence and visited health clinics in which they were getting sex education and condoms. It is no wonder they acquired less sexually transmitted diseases. No long-term follow-up has been done to show if these differences remained. And even if they had, it doesn’t matter. HIV can be prevented. But not by circumcision.
The promotion by our culture of the removal of healthy, functional, sexual, sensitive tissue makes it so clear that we are just as blind as the people in the other countries who are cutting their little girls. Look at the recommendations of all the other medical organizations in the developed world. They don’t recommend circumcision because it is harmful and it is not a valid medical procedure.
The reason our little girls in this country remain intact is because our instincts to protect them have remained intact. The fact that scientific studies and organizational guidelines promoting male circumcision are being supported shows us how much our instincts to protect our boys have been lost.
It is unethical to use fear to coerce people into complying with social norms. It is not okay to cut your children’s healthy genitals. Period.
I see this question raised quite often–should a child with vesicoureteral reflux, congenital ureteropelvic junction (UPJ) obstruction, posterior urethral valves, or some other congenital problem making a UTI a potentially more serious threat to health be circumcised? Let’s explore a few facts around this scenario.
The medical profession has traditionally recommended male circumcision as a means to reduce the chance of acquiring UTIs in little boys who have a condition that predisposes them to harm from UTIs.* For example, if a child has vesicoureteral reflux and gets a bladder infection, that infected urine can reflux back to the kidney, potentially causing a more serious infection and long-term kidney damage.
There are two beliefs underlying this recommendation that we must examine. The first of these beliefs is that, in the past, circumcision has often not been recognized as harmful. However, many of us are now aware of the real harms experienced immediately and later by little boys undergoing infant circumcision, and of the growing numbers of adult men who are speaking out, saying they wish they hadn’t been circumcised.
The second belief is that removing the foreskin lowers the chance of acquiring a UTI. Though many have raised concerns about the methodology, there is data suggesting that this is true. (There is also some evidence contradicting this claim.) However, most of us who are truly aware of the harms of circumcision do not feel the lowered risk of UTI, even if the evidence is valid, justifies the harm of circumcision. We must therefore also rethink the recommendation for foreskin removal in the case of a child with a problem related to UTIs, as we carefully meet our responsibilities, as parents and physicians, who are making irreversible choices for a child.
If you are a parent who is aware of the harms of circumcision and wishes to keep your son intact, but your child has a condition for which circumcision is being recommended to mitigate an actual threat to his health, ask your doctor these questions:
1) What other preventive measures that are less harmful than circumcision can be tried?
2) If these other preventive measures are less effective and my child does get a UTI, how serious is the threat to his health and well-being, with proper treatment?
3) Are there other therapeutic measures (such as repairing a UPJ obstruction) that can be taken to make the health threat from a UTI smaller?
*Note that the reason we are not discussing this for little girls is because no one has published any studies to evaluate whether removing parts of their genitals lessens their UTI risk. It is hypothetically possible that measures such as removing the labia minora would work in a similar way as removal of the male foreskin to lower UTI risk, but these studies would be considered unethical, as would the treatment. Little girls with problems predisposing them to UTIs are typically treated with good toileting habits, preventive substances such as cranberry and low-dose daily antibiotics, therapeutic courses of antibiotics, observation, and surgery to correct anatomic abnormalities when it is believed that they will not improve with age. These treatments are also available for little boys.
I chose home birth because I value the advantages it offers that hospital birth cannot (such as the ability to move freely, to sink into the feelings of my body, to decide where and how my newborn is welcomed into this world, and to be surrounded by as many or as few other human beings of my choosing as I wish, to name a few). I also chose it because I acknowledge, value, and respect my freedom and responsibility over my own health and experience. If you don’t value these things, home birth may not be a good option for you.
If you want a physician to bear responsibility for you and your child’s safety, you should birth however they tell you to. That’s ok. If this is how you wish to live, then my work and message is not for you.
Doctors and patients all too often mistake quality of life (experiences) and quantity of life (survival and longevity). I value quality over quantity. If you see little value in quality and place far more value on quantity, home birth may not be for you.
There is no way you “should” give birth. I only recommend you educate yourself, examine your priorities, and choose for yourself how you wish to birth.
Yet the only time I ever used this knowledge set was to convince my midwife to give me 24 hours before doing lab tests for the elevated blood pressure and protein in my urine she detected on routine screening 1 week before my son was born.
I knew I was ok. I reassured the midwife that the nurse who worked in my office would recheck my blood pressure and urine in the morning. Then I went to the local farm where I was a member, picked up my veggie order for the week, and ate a lot of fresh spring greens. The next day, my blood pressure and urine were normal, and I had a long, peaceful, and easy labor 6 days later.
There is a role for obstetrics. In the case of a diseased pregnancy, their skills can be life-saving. But the way I learned about my healthy pregnancy and how to have a healthy delivery was by learning what my body was capable of and how it worked. And I learned this from other women. Some of these women were health care professionals, some were not, and all were mothers.
I never used my skills as a surgeon when I gave birth. I used my skills as a woman–skills I was born with and that I knew I had because of other women’s examples and encouragement.
Women, grab a mirror and take a good look at your clitoris. A really good look. Underneath the fold of skin, you can probably see a little knob of tissue. Try to peel the skin back so you can see this knob better. You probably can’t pull it back very much, and you probably don’t want to, because it probably would hurt to do so. This is exactly how the head of a newborn boy’s penis is attached to his foreskin.
The little knob of tissue you can see is the tip of the glans clitoris. If you could peel the skin back, you would see this structure looks like a very tiny penis. Under the skin, you can feel a ridge of tissue that is the continuation of this structure, hidden under the overlying skin.
What most people think of as the clitoris is actually the clitoral hood, which covers the glans clitoris. The clitoral hood is the prepuce, which is also the medical term for the foreskin of a man. Yes, women have a foreskin. During fetal development, the prepuce of the man and the woman arise from the same structure, as do the clitoris and glans (the genital tubercle). The prepuce develops in both sexes to form a hood over the glans. The crus clitoris (seen in the diagram) develops from the same fetal tissues as the corpora cavernosa in the man, which are the parts of the genitalia that fill with blood during arousal.
In little boys, with time, manipulation, and development, the prepuce (foreskin) naturally separates from the glans penis. In most women, however, the tissues remain firmly attached throughout life, and this protects the sensitive glans.
During a male circumcision, this tissue must be forcefully separated, and the natural adhesions torn, to release the foreskin so it can be amputated. This premature separation exposes the raw surface of the glans and leads to complications such as adhesion formation between the head of the penis and the circumcision scar, meatal stenosis (scarring of the urinary opening causing bladder dysfunction), and desensitization of penile tissues. Click this link to see real life images of these and other complications.
We are born with genitals the way they are meant to be, and they develop the way they are meant to develop. There is no need to interfere with the natural roles of the prepuce in healthy boys and girls, and doing so can lead to significant complications down the road.
I recently had the pleasure of attending a talk by Janet Heimlich about her book, Breaking Their Will: Shedding Light on Religious Child Maltreatment. She has done great work to break many barriers of silence, work that will hopefully lead to an end to much of the abuse that sadly is occurring today. Like religion, medicine can be quite helpful. There is no doubt medicine can save lives and relieve suffering. But children sometimes suffer in medicine’s hands as well. Religious authorities do not always promote that which is optimal for spiritual health, and medical authorities do not always promote that which is optimal for physical health.
On my personal journey described in Reclaiming My Birth Rights, I realized that many medical practices didn’t follow the standards of science, compassion, or ethics in which I believe. However, when I expressed a desire to choose practices for myself that did meet these standards, rather than what was the “norm,” I was met with a great deal of resistance in many forms. I never did understand this resistance, until I heard Heimlich’s talk.
Her work led me to realize that medicine functions in a way very analogous to religion, as a belief system that all too many follow with blind faith.
Among the harms caused by religious child maltreatment, Heimlich includes medical neglect. She gave some valid examples of this, but she also gave the example of religious exemption from vaccinations. As a physician who has thoroughly researched the science behind vaccines, I immediately recognized vaccine propaganda, not evidence-based truth, being used to support her arguments (unknowingly to her, I can only assume). I discuss the myths around vaccination in my book, but let me just say briefly that there is much more to the story than what most people are told. Recognizing how this propaganda gets accepted by the public, without questioning, felt eerily similar to the tales of harmful religious beliefs being perpetuated that Heimlich shared.
Another example of religious child maltreatment Heimlich uses is male and female circumcision, stating that the practices are motivated by cultural and religious beliefs. In the United States, however, these practices are also motivated by medical beliefs. Male circumcision rates are dramatically higher in this country than in most of the rest of the world, despite the majority of this population not being Jewish, Muslim, tribal African, or any other culture that advocates routine genital cutting for religious reasons. It is only because doctors support genital cutting that this medically unnecessary procedure with an unacceptable complication rate is so common here.
Yet another example of medical child maltreatment is the surgical alteration of intersex children to conform to a gender “norm,” which continues today, even though adults who underwent these surgeries have been speaking out for over twenty years, saying that these surgeries harmed and did not help them. Despite this incredible evidence, these practices continue because of long-standing beliefs taught to physicians by physicians before them. Adult patients, those who were supposed to be helped, have long been calling for physicians to choose another model of care, but instead the old, harmful model is held on to, with minor adjustments made as some form of reconciliation.
In Heimlich’s presentation, she defined religious child maltreatment and the organizations that perpetuate it, and I immediately saw that medicine could meet most of these definitions. I encouraged her, and I encourage you as well, to consider what she says in her book as it may apply to medicine as well.
I am not anti-religion, nor am I anti-medicine. Both religious leaders and medical authorities are humans, capable of good and bad decisions. Because of their vast influence, both sets of authorities must uphold their duty to meet incredibly high ethical standards as they guide others. Although it can certainly be difficult, I urge us all to look at the facts before us, specifically the cries of those who have been harmed as children and are now speaking out, and reconsider what we are doing. When we know what has been done is harmful, we need to choose another model. We can do better.
Today, I am reviewing a recently published article in a major medical journal, in which the authors erroneously state that circumcision can “prevent” HIV and that it reduces the rate of HIV acquisition by 50-60%. In truth, as I have written before, these studies show a much lower reduction in the rate of acquisition of 1.25% (the “reduction” of 60% refers only to a statistically derived number, not actual numbers of human beings).
It is common knowledge among the public and medical professionals that circumcision does not and cannot prevent HIV (or any STD) from being caught or transmitted to a sexual partner. However, major medical organizations have jumped on this inaccurate science and obvious propaganda, and they are now promoting the mass circumcision of African men rather than measures that could actually prevent HIV, such as education.
I am also reading a book titled Dissolving Illusions, in which authors Suzanne Humphries, MD, and Roman Bystrianyk review the history of vaccination. The historical truths shared in this book are incredibly similar to what is occurring now with circumcision and HIV in the medical world. A small suggestion of benefit is translated into a “cure” and propagated, when, in fact, other measures such as improved sanitation had a far greater impact on health and well-being and disease transmission. So much of these myths have been spread, that people now believe vaccines led to the elimination of the numerous disease epidemics present at the turn of the 20th century, when, in truth, many epidemics ended because of public sanitation and hygiene measures. There weren’t even vaccines available for many of the diseases we rarely see today, such as typhus, typhoid, and scarlet fever. (There is much more in this book, and if you are interested in knowing the truth, I suggest you read Dr. Humphries and Mr. Bystrianyk’s work!)
The parallels between these two circumstances, in which medical authority and weak science is used to scare people into conforming with medical interventions that carry a risk of harm is astounding.
I am often asked why, if the ethics of childhood genital cutting seem so simple and obvious to me, are there so few other physicians who agree. If male infant circumcision is so clearly wrong, why do physicians continue to support this practice?
I have a deep desire to understand why this is occurring, because I believe that by understanding, we will be able to solve the problem as a society. As I reflect on this question, images of my father keep popping into my mind.
My father is a retired law enforcement officer. An ethical law enforcement officer. As a child, I knew the dangers he faced and how critical the situations he placed himself in were. And I also knew the great care and restraint he used when facing these criminals, so he could deal with the situation in a just manner. With the increase in videotaping abilities, more and more scenes of questionable law enforcement behavior are visible to the public, and these usually feel as bad to me as medicine’s perpetuation of harmful practices. However, I am slow to judge because of my insider’s understanding of what it is like to be a law enforcement officer.
The practices of medicine and law enforcement are both very difficult. Physicians are overworked, overburdened with mindless systems of accountability such as insurance paperwork and government-required documentation, and threatened with lawsuits and career loss if they make an honest mistake. Health outcomes are unpredictable and not entirely within any physician’s control. Being a physician is emotionally and physically taxing. Law enforcement officers are also under significant emotional and physical stress, and are generally underpaid, misunderstood, and underappreciated. Violent situations are quite unpredictable and can quickly become life-threatening.
That said, there is no excuse for unethical behavior. Rather than excuse it, I would like to understand why it happens by understanding those who choose not to engage in it. So I asked my father a few questions about his approach to volatile situations. He didn’t know why I was asking or that I intended to share it. Here is some of what he said:
“It was ok [to shoot], but I took extraordinary risk in my career. I strived to end [conflicts] without gunfire which put me in extremely dangerous situations.”
“I didn’t want to take anyone’s life on a split second decision. The dynamics of being involved in a bad situation are something no one can even come close to understanding. It’s very quick. So fast sometimes that you can’t think that fast. So it was best for me to risk [my own life] to have peace that I never made a bad mistake.”
“In my mind, I justified being hurt before I made a bad decision.”
“It made me proud when all the young guys would say, ‘Where’s Carmack?’ in the bad situations. It made them more comfortable and able to perform under pressure with a clear mind having me up front. I liked that.”
He told me he always exercised the least aggressive options possible, and I asked if he was taught this in school or self-taught. He replied that he was mostly self-taught:
“I put in more hours training than I did on the clock, so I was able to alleviate the fear factor for myself because I was comfortable with how I could respond to any situation.”
“Most of my training was from my own desire to be the best I could be at my job. Budgets are always low for training, but to me it was the most important aspect of law enforcement.”
“The people I swore to protect were going to get the best I could possibly become, even with it being at my own expense.”
Like my father, I always had a strong desire to do the best I could, to know what I was talking about so I did not make a mistake. I take the responsibility I have for my patients quite seriously, and I realize this trust is a gift. I researched circumcision on my own time, by myself, so that I would be more confident in patient encounters, and it was through this research that I learned that what our medical societies were saying was not actually what was best for our patients’ well-being.
One commonality between the fields of medicine and law enforcement is that, though they are both considered service industries, they are both also positions of authority because of the advanced skill set and decision-making powers necessary for both. However, the service side of this often comes second, because doctors and law enforcement officers are not actually accountable to those they serve, but rather to systems. They are not even paid by those they serve, most of the time, but rather by insurance or government money (taxes). The accountability is extremely indirect, so the satisfaction of the patient and public can take a back seat when those in charge of their paychecks have other standards.
When faced with situations in which the public (law-abiding citizens and patients) are questioning activities they are seeing, we as professionals need to respond by listening and considering why this is happening. We need to hear them when they say they are not ok with what we are doing. When we recognize a behavior that is inappropriate, however, it is important to do more than condemn it.
One reason this doesn’t happen from within the professions often enough is that we do care about our peers, even if some of their behaviors are unethical. Though we are aware of the “bad” behaviors, we are usually also aware of the good they do. In punitive systems, mistakes can ruin careers and lives, and we usually would prefer that our partners choose new standards rather than lose their livelihood. However, their fear of having their careers and lives ruined often creates a great deal of resistance to hearing critiques, and it is hard to be heard when you raise one.
Though a high degree of accountability is extremely important for those in positions of power, it is equally important to provide those fallible human beings in these fields with alternatives that are actionable. We must recognize that we are all people who make mistakes, and though I am not against legislation to require appropriate behavior, when a system is purely punitive with no opportunity for rehabilitation, those who are confronted with their mistakes will naturally exhibit resistance because of their fear and desire to protect their own livelihood. Allowing open dialogue and admission of mistakes allows us to hear why the ethical action wasn’t taken in the first place and truly offer a replacement action that is more desirable. We must create a system that allows rehabilitation and evolution.
In addition to enacting standards that do not permit behavior that is unethical, we need to reward strong leadership of ethical behavior. As my father’s example shows, strong leadership is not only better, but also desired by those who want, but don’t know how, to achieve the highest standards themselves. Political lobby organizations are not designed to act in the best interest of those receiving the services of the professionals they represent, but rather to promote their professional members’ own best interests.
We also need to provide quality education on alternatives that are more appropriate. For circumcision, examples include proper foreskin care teaching, teaching on true preventive measures such as not smoking and other healthful behaviors, and alternatives to religious rituals such as brit shalom. I am extremely thankful to intactivist groups for providing this education for me when I needed it, and for so many others who have benefited from this education as well.
Most importantly, we, as a society, need to insist upon high standards so that we can truly trust these authorities–physicians and officers–when we need them. Choose to see doctors who answer to patients rather than insurance companies and government agencies. Support programs that encourage and train law enforcement officers in less harmful ways to end confrontations. Stand up for what you believe in, and support educational efforts to enact improved standards.
We must begin to expect, support, encourage, and reward ethical behavior.
Having spent years as a physician with expertise in male and intersex genitalia, and performing extensive research on the practice of female genital mutilation, the double standard here is obvious. In regions practicing female genital mutilation, they do not call it mutilation. They call it female circumcision, and they do not agree it is mutilation. They believe it is best for the child and the woman she will become, and it does offer many cultural and psychosocial benefits. The practice is usually done under the guise of good intentions, not as punishment, torture, or intentional trauma.
Female circumcision is practiced in more than 29 countries in the world, and it is estimated that there are 125 million women living who have undergone this procedure. Male circumcision remains common in many places, and an estimated 661 million men living today have been cut. Estimates of the number of intersex children (in which their biology does not conform to medical ideals of male or female biology) are at least 1 in 2000 (about 3.5 million of this world’s approximately 7 billion population), and, depending on definitions, may be as high as 1 in 150. A significant number of these intersex children undergo gender-conforming surgery during childhood, which is surgery designed to make the appearance of the genitals match the gender of rearing decided upon by the care team.
The World Health Organization defines genital mutilation as intentionally altering the genitals for non-medical reasons. Male circumcision is widely recognized as being medically unnecessary. Gender-conforming surgery in intersex individuals is performed for psychosocial reasons, not medical issues. I agree with the World Health Organization’s choice to call female circumcision for what it is, mutilation to genitals, and out of respect for the severity and harm of this practice, I will use the phrase “female genital mutilation” rather than “female circumcision.” Because the discussion here is on medically unnecessary alteration of genitals, I will also use the phrases “male genital mutilation” rather than “male circumcision” and “intersex genital mutilation” rather than “gender-conforming surgery” in the remainder of this article.
Female genital mutilation occurs in many forms. These can include pricking, scraping, incising, cauterizing, piercing, removing the prepuce of the clitoris, removing part or all of the clitoris, removing parts or all of the labia minora and labia majora, and narrowing the vaginal opening.
Male genital mutilation involves forcibly separating the foreskin from the glans to which it is firmly attached in infancy, incising it, removing the foreskin in its entirety, partially removing the foreskin and attaching a device designed to restrict its blood flow and cause it to fall off after several days, and cauterizing. The foreskin is a multi-layered tissue (not skin), with moisturizing, gliding, protective, and sensory functions, and the foreskin has the densest concentration of nerve endings of the entire male genitalia.
Intersex genital mutilation often includes removal of functional phallic tissue (“clitoral” reduction), reconstruction of the phallus to bring the urethra to the tip (hypospadias repair), scrotoplasty and labioplasty (plastic surgery on the scrotum or labia), and gonadectomy (removal of the testicles, ovaries, or mixed gonads if they do not match the sex of rearing decided upon by the medical team).
Some believe that female genital mutilation is not performed for health benefits, while male and intersex genital cutting are. In truth, male, female, and intersex genital mutilation are all performed by health care practitioners. Male and female genital cutting are also common cultural rituals in many parts of the world. Practitioners of genital cutting in all its form, including female genital mutilation, claim health benefits.
Hypotheses of health benefits change throughout time, and the most frequently cited benefit of male genital mutilation today is a reduction in HIV transmission. In one of these studies, this reduction was reported to be from 2.9% to 1.2%. The theorized reason for this is the removal of foreskin mucosa, through which HIV may be transmitted. Female circumcision, of course, also removes mucosal tissue and also promotes monogamy, both of which are likely to lower HIV transmission rates, perhaps even more than the 1.7% difference found in the HIV studies on adult men being circumcised in Africa. Since most medical research comes out of developed nations that consider female genital mutilation unethical, it is unlikely the studies will ever be done to prove the “health benefits” of genital mutilation in women as has been done in men. If these studies were done, and it was found that female genital mutilation victims had a 1-2%, or even a 5%, reduction in the rate of HIV transmission, would this justify the procedure?
Some circumcised men do not feel that the genital mutilation they underwent has caused problems in their lives. Similarly, it is usually women who have undergone genital mutilation, who are grateful they had it done, who choose it for their daughters. (I am not aware of any intersex individuals who are calling for the genital mutilation of future intersex children.)
Many proponents of female genital cutting do so because of myths about what women will do if their birth genitals are unaltered. We know in our country that these myths are not true, and we are speaking out to share this message and enact change in their practices. Similarly, many proponents of male genital cutting in the United States support it because of fears about what will happen to boys if they keep the foreskins they are born with. Yet if we look at disease rates in countries in which circumcision of male infants is not routine, we can easily see that these fears are similarly unfounded. A common reason given for genital mutilation in intersex children is that it will make life easier for them, avoiding all of the fears of what life will be like as a child growing up with different genitalia. Yet adult victims of intersex surgery and adults with intersex who did not have surgery are saying these fears, too, are not founded in fact.
All genital tissue, in males, females, and intersex individuals, is sensitive and functional. Surgery always creates scarring, which interferes with sensation and function in unpredictable ways. Genital cutting is traumatic, whether done in a hospital or not and whether done with anesthesia or not. It is not medically necessary, and it is mutilation.
In 2008, the World Health Organization called for the elimination of female genital mutilation and to uphold the rights of girls and women. Many countries, including the United States, have laws prohibiting the practice of female genital mutilation. Sweden passed the first law banning female genital mutilation in 1982, and the United States enacted its law in 1997. Female genital mutilation remains a widespread practice. Similarly, adult survivors of male and intersex genital cutting have called for legislation and international standards to end it, but both practices remain common.
Female genital mutilation is a horrific practice. The genital cutting of children across all genders is far more similar than it is different. It is great that the world is recognizing the harms of female genital mutilation and is enacting protection to help end it. But boys and intersex children are being mutilated, too, and that mutilation is being justified by the medical profession.
Wake up, world. No one deserves to have their genitals cut, removed, or altered in any way without their consent.
World Health Organization, Male circumcision: global trends and determinants of prevalence, safety, and acceptability
World Health Organization, Fact sheet on female genital mutilation
OII Intersex network, What is intersex?
Full Frontal Activism, Compelling statistics on the number of intersex individuals
World Health Organization, Eliminating female genital mutilation: an interagency statement
Wikipedia, Female genital mutilation