Men are entitled to their penis … all of it.
These are our positions on the various aspects of genital cutting of newborn boys. The following principles express the values and positions of Intact America on a variety of issues related to children’s bodies and 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.
Georganne Chapin, April 2015
Physician Solicitation of Circumcision
Intact America’s principles agree with the American Medical Association’s position, which states: “Physicians should not provide, prescribe, or seek compensation for medical services that they know are unnecessary.”1Section 2.19, Unnecessary Medical Services. Code of Medical Ethics of the American Medical Association. Council on Ethical and Judicial Affairs. Child genital cutting conducted in the absence of pathology is a medically unnecessary surgical procedure whose sole 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.
Medicaid and Private Insurance Payment for Child Genital Cutting
Intact America opposes the use of public and private health insurance funds for medically unnecessary surgery on children’s natural genitals.
Health care resources are finite. Whether funded by government-collected tax revenue (as for Medicaid and Medicare services) or by privately insurance premiums, health insurance funds are pooled to spread risk and maximize equitable distribution of benefit. Federal rules prohibit the expenditure of government funds for medically unnecessary services, but even for private insurance, it is generally accepted that only medically-necessary services shall be paid for by pooled funds; medically unnecessary procedures such as aesthetic enhancements (cosmetic surgery) performed in the absence of pathology or medical indication shall be the financial responsibility of the person requesting the service. (Bioethical rules of consent also apply, of course, whatever the payment source; thus, discretionary procedures may only be performed upon individuals who have the legal capacity to consent to them, and who have given such consent.)
Because there is no medical indication for removing a child’s natural, healthy foreskin, and because a child does not have the legal capacity to consent to this intervention, neither public nor private insurance funds should be used to pay for this procedure, or for the cosmetic alteration of any child’s genitals.
The Bioethics of Infant and Childhood Circumcision
Intact America’s position on infant and childhood genital cutting adheres to basic bioethical principles, including autonomy, nonmaleficence, beneficence, and justice.2This discussion of bioethical principles borrows liberally from Beauchamp TL, Childress JF. Principles of Biomedical Ethics. Fifth Edition. Oxford (2001).
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 underlies the concept of informed consent in the physician/patient transaction. 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 to medical interventions undertaken 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” CGC 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 genital cutting (CGC) involves the permanent surgical removal of healthy, protective, erogenous tissue. The harms of CGC are compounded by the fact that, often, no anesthetic or inadequate anesthetic is used for what is a prolonged and painful operation. Regardless of whether pain control is administered during the surgery, however, because it is not medically necessary, CGC circumcision violates the principle of nonmaleficience.
The principle of beneficence says that health care professionals have a duty to not only provide a benefit to a patient, but also to take positive steps to prevent harm to the patient. It does not include the felt needs, concerns or cultural beliefs of anyone other than the patient. Because “routine” CGC 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. A consensus is also growing that children who are born intersex (i.e., those whose genitalia have both male and female characteristics) should not be “treated” with genital surgery until they are old enough to express their sexual identity. Boys are accorded no such protection. There is no acceptable rationale prohibiting genital cutting on some children, while tolerating (and even promoting) it for others. Male CGC violates the bioethical principle of justice.
It is the position of Intact America that all persons—male, female, and 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 or to understand the risks, harms, and irreversibility of such surgery.
Intact America opposes forced or coerced genital cutting on persons of any age or gender. Should an adult choose to be circumcised or to undergo any other genital modification surgery or surgery on that adult’s reproductive organs, Intact America acknowledges their right to choose such surgery, so long as they are fully informed of its risks, harms and permanent nature. 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 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 elective abortion performed upon the request of a fully informed, consenting woman.
Breastfeeding and Circumcision
Tattooing, Piercing, and Scarification
Intact America opposes any forced cosmetic modification of the human body and holds that any medically unnecessary 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.
Intact America stands for equal dignity and rights for all and is committed to advancing human rights for all people. Intact America holds that all children—boys, girls, and intersex—must be protected from bodily harm. Intact America thus endorses the principle of equal protection regarding forced genital surgery.
In the United States, federal and state laws prohibit any form of genital cutting upon girls by health care professionals or laypersons, while the genital cutting of boys and some intersex children is not only tolerated but is actually promoted in medical settings. Infant male genital cutting also is currently accepted as an expression of certain religious beliefs.
Proponents of female CGC use many of the same rationales put forth by cultures that practice male CGC. 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 (or attractive to the opposite sex).
Those who vociferously oppose female CGC often resist any comparison to male CGC on the basis that the former is more damaging and invasive than the latter. They contend that female CGC deprives girls of their sexual pleasure and puts girls at risk of death, while male CGC still allows men to achieve orgasm and is “less risky.” This reasoning is flawed because it implies that if female CGC could be modified—for example to leave the clitoris in place3Experts 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 of catastrophic damage to the boy 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.—or could be made safer through the use of sterile instruments, it would be acceptable.
However, female, male and intersex CGC all involves the forced removal of healthy genital tissue from unconsenting children who are powerless to defend themselves and who will live permanently with the consequences. Therefore, any attempt to rationalize the practice for some children while condemning it for others reflects prejudice, ignorance, and cultural bias, and flies in the face of the universal truth that every child has the right to be protected, respected, and loved.
Circumcision and Sexually Transmitted Infections (including HIV)
Intact America opposes the promotion of male CGC as a method for preventing sexually transmitted infections, including HIV. It is socially irresponsible and dangerous to disseminate a message that the removal of normal genital tissue offers protection from sexually transmitted infections. Individuals can both contract and transmit sexually transmitted infections regardless of whether their genitals are intact or surgically altered. The only way to prevent such infections is through abstinence or “safe sex” practices.
Intact America recognizes the right of parents to raise their children in accordance with their own values and beliefs. However, this right is not limitless. A child’s right to bodily integrity outweighs parental preference, cultural norms, and religious mandates. Therefore, parents must 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.