Intact America envisions a world where children are protected from permanent bodily alteration inflicted on them without their consent, in the name of culture, religion, profit, or parental preference.
Intact America works to protect babies and children from circumcision and all other forms of medically unnecessary genital alteration, whether carried out for cultural conformity or profit, in medical or non-medical settings.
We seek to achieve our goals through education, advocacy, public policy reform, and the empowerment of our supporters, partners, and volunteers.
Statement of Principles
The Prepuce – Facts and Function
The prepuce, or foreskin, is a normal part of both male and female genitalia, forming the anatomical covering of the glans penis in males and the clitoris in females. The prepuce is a specialized, junctional mucocutaneous tissue that marks the boundary between mucosa and epidermis; it is similar to the eyelids, labia minora, anus, and lips. The male prepuce also provides adequate tissue to accommodate a full erection. The unique innervation of the prepuce establishes its function as an erogenous tissue.
In infant males, the foreskin is attached to the glans (head of the penis); as a boy matures, and usually by the time he reaches puberty, the foreskin gradually detaches from the glans and becomes a movable, elastic structure that enhances sexual intercourse and sexual pleasure. In females, the prepuce (or clitoral hood) surrounds the clitoris.
Infant or childhood circumcision involves the removal of normal, healthy genital tissue from infants and children for religious, societal, or hypothetical medical benefits. Although the amount of genital tissue removed is variable, the penile prepuce is removed in nearly all male circumcisions, and the clitoral prepuce is removed in certain types of female circumcision.1
For purposes of this document the term “infant” and “child” or “childhood” are used interchangeably. Unless otherwise stated, “circumcision” refers to the surgical removal of the foreskin.
The Bioethics of Infant and Childhood Circumcision
Intact America’s position on infant and childhood circumcision adheres to basic bioethical principles, including autonomy, nonmaleficence, beneficence, and justice.2
Individual Autonomy, Parental Rights, and Informed Consent
In health care decisions, respect for the autonomy of the patient implies that the patient has the capacity to act and decide intentionally, with understanding, and without coercion or influences that would mitigate against a free and voluntary act. This principle is the basis for the practice of informed consent in the physician/patient transaction regarding medical care. In the case of medical procedures offered to infants or children, because the child has no understanding or capacity to freely and voluntarily consent, the right to decide is given to the child’s parent or guardian in a form of consent known as proxy consent. However, the scope of proxy consent is, by necessity, limited. Parents or guardians have the right to consent to medical intervention on behalf of a minor child in their custody if and only if that intervention is necessary to save the life or the health of the child. Because the foreskin is a normal, healthy anatomical structure, and because routine neonatal or childhood circumcision does not save the child’s life or health, the parent or guardian has no right to solicit or consent to circumcision on behalf of the child. Therefore, childhood circumcision, except in extremely rare cases where a pathological condition is present, violates the principles of informed consent and cannot ethically be performed by medical practitioners or in medical settings.
The principle of nonmaleficence requires that medical practitioners not intentionally create or cause to occur a needless harm or injury to the patient, through acts of either commission or omission. Childhood circumcision involves the permanent surgical removal of healthy, protective, erogenous tissue from a child who is unable to consent. The harms of circumcision are compounded by the fact that, often, no anesthetic or inadequate anesthetic is used for what is a prolonged and painful operation. Because it is not medically necessary, regardless of whether pain control is administered during the surgery, childhood circumcision violates the principle of nonmaleficience.
The principle of beneficence implies a duty upon health care professionals to not only provide a benefit to a patient but also to take positive steps to prevent harm from coming to the patient. It does not include the felt needs, concerns or cultural whims of anyone other than the patient. Because “routine” childhood circumcision does not seek to remedy an ill and, indeed, exposes babies and children to unnecessary risk, trauma and pain, it violates the bioethical principle of beneficence and should not be a part of medical practice.
The principle of justice in health care implies fairness, equal treatment and – by extension – equal protection. In the United States, girls of all ages are protected by federal and state laws from unconsented-to genital surgery practiced in medical or non-medical settings because of the health beliefs or religious or cultural preferences of their parents. Boys are accorded no such protection. There is no acceptable rationale for a distinction between female and male genital modification.
Tolerance for and even the promotion of forced genital surgery on male children, while at the same time condemning and prohibiting forced genital surgery on female children, violates the bioethical principle of justice.
In summary, because infant and childhood circumcision violates accepted principles of bioethics, it must not be tolerated.
Physician Solicitation of Circumcision
Intact America agrees with the American Medical Association’s position that states: “Physicians should not provide, prescribe, or seek compensation for medical services that they know are unnecessary.”3 Circumcision conducted in the absence of pathology is a medically unnecessary surgical procedure whose purpose is to permanently remove healthy issue. Therefore, it is a violation of the AMA’s Code of Medical Ethics for physicians to solicit, provide or seek compensation for such surgery.
It is the position of Intact America that all persons –male, female, or intersex – should be protected from coerced genital surgery. In cases of children born with anomalous genitalia, Intact America opposes gender assignment surgery on those too young to express their gender preference and to understand the risks, harms, and irreversibility of such surgery.
Intact America opposes the forced or coerced circumcision of persons of any age or gender. Should an adult choose to be circumcised or to undergo any other genital modification surgery or surgery on his or her reproductive organs, Intact America has no objection so long as that adult is fully informed of the permanent nature of the surgery, as well as all of the attendant risks and harms. In the case of a medically-indicated circumcision, informed consent includes information as to all possible alternative treatments, including the option of non-intervention. If full, informed patient consent is not possible due to age- or illness-related incompetence, proxy decision-makers must be provided with full information on all potential risks, harms, and options, including the option of non-intervention.
Abortion and Other Surgery on the Reproductive Organs and Genitalia
Intact America opposes all forms of coerced surgery involving the genitalia or reproductive organs, including abortion, cesarean section, tubal ligation, hysterectomy, vasectomy, castration, or any other such interventions forced on persons of any age or gender. Intact America takes no position on legal, elective abortion performed upon the request of a fully informed, consenting woman.
Breastfeeding and Circumcision
Intact America supports breastfeeding as a beneficial practice for both mothers and infants. Breastfeeding enhances the infant-mother emotional bond and provides the infant with optimal nutrition, while children who do not breastfeed are at greater risk for many illnesses. Because the pain, shock, and trauma of circumcision have been shown to interfere with infants’ ability to breastfeed, it must not be performed in the absence of clear and immediate medical imperatives.
Tattooing, Piercing, and Scarification
Intact America opposes any forced cosmetic modification of the human body, and holds that any elective body modification that entails permanent disfigurement or decoration must never take place without the fully informed consent of the individual whose body would be permanently modified.
In the United States, federal and state laws prohibit any form of genital cutting on girls by health care professionals or laypersons, while the genital cutting of boys is not only currently tolerated but actually promoted in medical settings. Infant male genital cutting also is currently accepted as a legitimate expression of certain religious beliefs.
Intact America stands for equal dignity and rights for all, and is committed to advancing human rights for all people. Intact America believes that all children – boys, girls, and intersex children alike – must be protected from bodily harm. Intact America thus endorses the principle of equal protection regarding forced genital surgery, and supports legal efforts to protect all children from such genital modification.
Proponents of both male and female genital cutting use the same rationales to justify the practice. They say that genital cutting is traditional, culturally mandated, healthier, and cleaner; they say that the child will be more accepted by his or her peers and, as an adult, will be more marriageable.
Defenders of male circumcision often resist any comparison to female genital cutting on the basis that the former is less damaging and less invasive than the latter. A further contention is that female genital cutting deprives girls of their sexual pleasure, and some girls die, while male genital cutting still allows men to achieve orgasm, and is “less risky.” This reasoning is flawed, because it implies that, if female genital cutting could be modified, for example, to leave the clitoris in place,4 or made safer through the use of sterile instruments, it would be acceptable. However, both female and male genital cutting of children involve the forced removal of healthy genital tissue from unconsenting persons who are powerless to defend themselves and who will live permanently with the consequences. Therefore, any attempt to rationalize the practice for one gender while condemning it for the other reflects prejudice, ignorance, and cultural bias, and is an exercise in futility. Moreover, such claims distract from the universal truth that all children – male, female, and intersex – deserve and have equal right to be protected, safeguarded, and loved.
Circumcision and Sexually Transmitted Infections (including HIV)
Intact America opposes the promotion of circumcision as a method for the prevention of HIV/AIDS and other sexually transmitted diseases. Physicians and others who would promote circumcision have a long history of claiming medical benefits (that have all subsequently been disproven) to justify genital cutting of both males and females. HIV/AIDS is the latest in a long list of diseases that have been held out as a justification for circumcision.
It is socially irresponsible and dangerous to promote a message that circumcision offers protection from sexually transmitted infections, including HIV, when such protection – if it exists at all – is only partial, and comes at great expense and risk. Circumcised men can both contract and transmit sexually transmitted infections. The only way to prevent such infections is through abstinence or “safe sex” practices.
Intact America believes that all children – regardless of their race, ethnicity, or culture of origin – have the right to be protected from bodily harm.
Intact America recognizes the right of parents to raise their children in accordance with their own cultural and religious standards. However, this right is not limitless. Intact America holds that a child’s right to bodily integrity outweighs parental preference, cultural norms, and religious rituals. Therefore, parents may not (directly, or through the agency of a medical or religious practitioner) harm a child physically and irreversibly in the name of religion or culture.
The above Statement of Principles expresses the values and positions of Intact America on a variety of issues related to children’s bodies, and to bodily interventions. These positions may change over time, as do technology and circumstances, although the basic vision, mission and principles of Intact America are immutable.
© 2010 Intact America
1 The description of the features and functions of the male and female prepuce, and of their removal through circumcision, is taken from Cold, C.J. and J.R. Taylor, The Prepuce, British Journal of Urology, Volume 83, Suppl. 1: Pages 34-44 (Jan. 1999). See http://www.cirp.org/library/anatomy/cold-taylor/.
2 The discussion hereunder of bioethical principles borrows liberally from Beauchamp, TL and JF Childress, Principles of Biomedical Ethics. Fifth Edition. Oxford (2001).
3 Section 2.19, Unnecessary Medical Services. Code of Medical Ethics of the American Medical Association. Council on Ethical and Judicial Affairs.
Current Opinions with Annotations, 2008-2009 Edition.
4 Experts who have studied FGM typically divide it into several different types, depending upon whether the clitoris is removed wholly, in part, or not at all; whether the preputial hood is removed or left intact; whether the inner and outer labia are removed or cut; and whether the genitals are infibulated – i.e., sewn shut, with only a small opening left for urine and menstrual blood to escape. Just as female genital mutilation varies across cultures and practitioners in the type of instruments used, the amount of tissue removed, and the damage ultimately done to the girl, so does male genital mutilation (circumcision). It is generally recognized that the risk to the boy of catastrophic damage increases with the inexperience of the practitioner, the practitioner’s desire to remove a maximum amount of foreskin, the presence of risk factors in the infant, such as bleeding disorders, and exposure to infectious agents during or immediately following the surgery.