Wednesday, June 3, 2015

Of Cats' Claws and Foreskins (or, An Open Letter to Linda B. Rosenthal, Assemblymember, New York State Assembly)

Of Cats' Claws and Foreskins
by David  Balashinsky

(or, An Open Letter to Linda B. Rosenthal, Assemblymember, New York State Assembly)

[Last January, Linda Rosenthal, a member of the New York State Assembly, introduced legislation that would ban the declawing of cats in New York State, absent a medical reason to do so.  The comparison was irresistible.  This, then, is the letter that I sent her last month.  It speaks for itself.  Since I have not received so much as an acknowledgment from the Assemblymember, I have decided to publish this as an open letter.]

26 May 2015

Dear Assemblymember Rosenthal,

I feel impelled to write to you having learned recently about your proposed bill to outlaw the declawing of cats in New York State.  For the record, let me state that I am a cat-lover and that none of my cats has been or ever will be declawed.

Although the matter that I am writing to you about today is not related directly to cat declawing or even to cats, from a philosophical and ethical standpoint it is very closely related, indeed.  In fact, it is no exaggeration to say that your anti-cat-declawing bill and the issue that I wish to bring to your attention stand on exactly the same philosophical, moral, and bioethical footing.  I am speaking of routine, forced infant male circumcision.  For, you see, I am writing as a victim and as a survivor of a medically unnecessary amputation of a normal, healthy, sensitive and fully functional body part that was performed without my consent.  It occurred to me, when I learned of your proposed bill, that what was done to me and what continues to be done to over one million infant boys and intersex infants annually in the United States has a lot in common with the practice of cat declawing.  Routine infant circumcision, just like cat declawing,  is a medically unnecessary surgery that is always performed without the victim's consent and that involves the amputation of a normal and functional body part.  In virtually all cases, infant male circumcision is performed not because there is a disease or illness that needs to be treated but for reasons of custom, cosmesis, convenience, and profit.  The human foreskin, like cats' claws, is not a useless appendage and it is not a birth defect.  Like claws in cats, the human foreskin has evolved and  been retained throughout millions of years of evolution as an integral part of the male genitalia because it serves  several important physiological functions.  Chief among these is providing protection for the glans in exactly the same way that the clitoral hood, its homologous counterpart in human females, provides protection for the clitoris.  (Anatomically, both the male foreskin and the female clitoral hood are identified as the prepuce.)   In addition, histological studies have demonstrated that the male prepuce contains specialized fine-touch nerve cells (called Meissner's corpuscles), and these studies thus tend to provide an objective validation of subjective reports that the male prepuce  provides the major portion of sensory response during intercourse.  (Studies have also demonstrated that the glans penis, in intact men, is less sensitive, hence less erogenous, than the prepuce itself.  And in circumcised men, once the prepuce has been amputated, leaving the glans penis without its natural protective covering, the glans becomes keratinized, hence, even less sensitive than it is naturally.)  In short, the male prepuce is not "just skin."  It has a function and its owner - the male born with it - has as much right to retain it as cats have a right to retain their claws.  Surgically amputating the prepuce in the absence of a compelling medical reason to do so - such as to save the life of the infant or to treat a serious medical problem for which conservative measures have failed or are unlikely to  succeed - is bad medicine, unethical, and a human-rights violation, just as cat declawing for the sake of mere convenience is unethical and a violation of the right of cats to retain their claws.

Before proceeding further, I think it worth taking a moment to clarify terms and to place this discussion in its proper context: genital mutilation more broadly.  After all, the more basic question  of the extent to which male circumcision and female genital mutilation are fundamentally more alike than dissimilar or more dissimilar than alike inevitably arises when considering the question of male circumcision.  The World Health Organization (WHO) defines female genital mutilation (FGM) as "all procedures that involve partial or total removal of the external female genitalia, or other injury to the female genital organs for non-medical reasons."  It further classifies FGM into four major categories: 1) Clitoridectomy (partial or total removal of the clitoris) or the prepuce (which, in the case of the latter, makes it identical to male circumcision); 2) Excision (partial or total removal of the clitoris and the labia minora with or without excision of the labia majora); 3) Infibulation (narrowing of the vaginal opening); and 4) Other (all other harmful procedures to the female genitalia for non-medical purposes, including pricking, piercing, incising, scraping, and cauterizing the genital area).  As is evident from these descriptions, while FGM is often worse than male circumcision in severity and damage (particularly because of the unsanitary conditions in which it is performed), it also includes procedures that are identical to and in many cases far less extreme and less damaging than that which occurs in infant male circumcision.  Hence, male circumcision, when judged by these same criteria, is male genital mutilation (MGM).  In contrast, the term "circumcision," I would argue, is merely a euphemism that is intended to downplay the severity of the harm done to the neonate's penis in this procedure.  Indeed, this is also why proponents of and apologists for FGM prefer to use the term "female circumcision."  It has been argued by some opponents of FGM (and I count myself among those who vigorously oppose FGM inasmuch as I oppose all genital cutting, regardless of the sex of the victim) that, because FGM generally constitutes so much more egregious a physical harm than male circumcision does, it is a misapplication of the term "mutilation" to apply it to male circumcision.  Yet, by the WHO's own definition of genital mutilation, male circumcision clearly falls within the ambit of that term, hence, it is no misapplication of the term, nor is it an exaggeration to call routine infant male circumcision what it is: male genital mutilation.  (The University of Oxford bioethicist Brian Earp opts for the more neutral term, "genital cutting."  Throughout this letter I use the terms "circumcision," "male genital mutilation," and "genital cutting" interchangeably because they all denote the same thing.)

What is noteworthy in the WHO's definition of FGM is the phrase "for non-medical reasons" and it is explicitly on the basis of this purported distinction - namely, that MGM is performed for medical reasons whereas FGM is not - that some opponents of FGM and some advocates of MGM object to the comparison of the two procedures and object to their being placed side by side within the same conceptual framework.  (Notwithstanding, incidentally, that it is not uncommon for physicians in those cultures that practice FGM to be just as certain of the medical benefits of female circumcision as the proponents of male circumcision are certain of its medical benefits in ours.)  Let us first consider, therefore, the historical-medical roots of circumcision as it is known and practiced in the United States today.  (I shall address the question of circumcision as part of the Jewish tradition separately.)

During the 19th century, circumcision was promoted as an effective remedy for a host of ailments including, but not limited to, rheumatism, epilepsy, asthma, skin cancer, insanity, and venereal disease.  However, it was as a remedy for "masturbatory insanity," which was believed to result from masturbation or "self-abuse," that circumcision was most widely promoted by its supporters during the 19th century.  (One of its most passionate Victorian advocates, none other than John Harvey Kellogg, the co-creator of Corn Flakes, also advocated putting carbolic acid on girls' clitorises for the same purpose: that is, to decrease sexual sensation and thus to inhibit masturbation.) Because it was widely pushed by its supporters both outside of and within the medical profession, infant male circumcision increasingly came to be accepted as normal and routine by a credulous public, even as the medical and sexually-repressive justifications for routine infant circumcision were debunked, one after the other.  Because, until recently,  it was seldom questioned, and because its continuation is supported by the sheer momentum of long practice, routine infant male circumcision has metamorphosed from pure pseudoscience to a cultural norm masquerading as a medical procedure: a cure in search of a disease.  These are the historical, pseudo-scientific and cultural roots of routine infant circumcision as it is practiced in the United States today.   Added to this are the current determined efforts by an entrenched and financially interested pro-circumcision lobby. Circumcision, it should be noted, is a $400 million per year industry.  This then, is how we have arrived at a state of affairs in which the United States is one of the few developed nations on Earth that practices routine infant circumcision. We are an outlier in this respect, and stand apart from the vast majority of other developed nations with comparable or superior health care systems.  Let us consider briefly, then, where the medical community at large actually stands on this issue.

This is what the Royal Dutch Medical Association (KNMG) has to say regarding infant circumcision: "[N]on-therapeutic circumcision of male minors is a violation of children's rights to autonomy and physical integrity. Contrary to popular belief, circumcision can cause complications - bleeding, infection, urethral stricture, and panic attacks are particularly common. KNMG is therefore urging a strong policy of deterrence."   This is what the Canadian Paediatric Society has to say about it: "The overall evidence of the benefits and harms of circumcision is so evenly balanced that it does not support recommending circumcision as a routine procedure for newborns." Here's what the Royal Australasian College of Physicians has to say: "After reviewing the currently available evidence, the RACP believes that the frequency of diseases modifiable by circumcision, the level of protection offered by circumcision and the complication rates of circumcision do not warrant routine infant circumcision in Australia and New Zealand."  In fact, there is not a single professional medical organization on Earth that recommends routine infant circumcision.  Every research arm of every major medical organization ever tasked with assessing MGM has found insufficient evidence to warrant recommending it.  That holds even for its most ardent defender in the U.S. - the American Academy of Pediatrics. The AAP's own position statement on circumcision is that ". . . existing scientific evidence is not sufficient to recommend routine circumcision.  Therefore, because the procedure is not essential to a child's current well-being, we recommend that the decision to circumcise is one best made by parents in consultation with their pediatrician taking into account what is in the best interests of the child, including medical, religious, cultural, and ethnic traditions [my emphases]."   As is obvious, if the AAP's position statement professes to represent medical best practices, it manifestly lacks credibility for either there is a medical justification for routine circumcision or there is not.  To argue on behalf of MGM on the basis of "religious, cultural, and ethnic traditions" not only is inappropriate on the part of a medical organization but these are the very same justifications that have been used and continue to be used to defend the practice of female genital mutilation.

The AAP's position statement also includes the opinion that "evaluation of current evidence indicates that the health benefits of newborn male circumcision outweigh the risks and that the procedure's benefits justify access to this procedure for families who choose it. . . "   This conclusion has been roundly condemned by the international medical community.  For example, in a commentary signed by about 40 physicians and published in the Journal Pediatrics (the journal of the American Academy of Pediatrics, March 18th, 2013), entitled "Cultural Bias in the AAP's 2012 Technical Report and Policy Statement on Male Circumcision," the authors write: "Seen from the outside, cultural bias reflecting the normality of nontherapeutic male circumcision in the United States seems obvious, and the report's conclusions are different from those reached by physicians in other parts of the Western world, including Europe, Canada and Australia." The authors of this commentary conclude, "There is a growing consensus among physicians, including those in the United States, that physicians should discourage parents from circumcising their healthy infant boys because nontherapeutic circumcision of underage boys in Western societies has no compelling health benefits, causes postoperative pain, can have serious long-term consequences, constitutes a violation of the United Nations' Declaration of the Rights of the Child, and conflicts with the Hippocratic oath: primum non nocere: First, do no harm."   The President of Germany's Pediatric Society had this to say about the AAP's conclusions: "There is no reason from a medical point of view to remove an intact foreskin from underage boys or boys unable to give consent. . . . The statement from the AAP . . . has been graded by almost all other pediatric societies and associations worldwide as scientifically untenable."

The AAP's conclusion that the "benefits" of male genital cutting "outweigh the risks" has also been criticized by a group of psychologists who wrote to the CDC, after the latter issued a draft of updated recommendations in support of male genital cutting based on the AAP's position statement.  The authors of this letter noted not only the numerous methodological errors behind the AAP's position statement, but "the troubling fact . . . that the CDC completely ignored the psychological effects of genital cutting on male children."  Among the conclusions of these psychologists was that "circumcision causes significant psychological harm in children and adolescents" and that "by encouraging circumcision, medical professionals are shaming [intact] boys' bodies."

As for the risks of infant male genital cutting, when reaching their conclusion that infant circumcision is a relatively harmless procedure, the AAP, as has been pointed out by the noted Oxford bioethicist Brian Earp, ignored any and all complications after one month following a neonate's circumcision, despite the fact that the majority of complications that arise as a result of this procedure occur after that one-month post-operative period. This methodological bias allowed the AAP to reach its conclusion and allows it to misrepresent to the public the actual risks and deleterious effects - even when nothing goes "wrong" - of routine infant male genital cutting. Moreover, long-term studies have never established that infant circumcision is without harm to the adult.  Nor have any long-term studies ever even supported, let alone established, the claim that the benefits outweigh the risks. Even more inexcusable from a professional medical organization, the AAP position statement assigns no weight at all - none - to the inherent value to the individual himself of his prepuce - that is, to the part of his body that is to be or has been amputated without his consent.  Consider, by contrast, the case of Angelina Jolie, who elected to undergo a bilateral mastectomy on the basis of her statistically-established genetic predisposition to developing breast cancer.  Ms. Jolie, as an adult, was free and able to weigh for herself the relative costs and potential benefits of the surgery that she elected to have. Undoubtedly, she went through a wrenching process of weighing for herself the innate value of her breasts to her bodily self-image and sexual life against the risk to her health, statistically, that keeping her breasts posed.  It was a courageous decision that Ms. Jolie ultimately made but the point is that it was her decision to make - no one else's.  That is precisely the difference in the case of infant male circumcision: the individual himself is deprived of that choice.  He is denied the right of informed consent.  It is routinely asserted by its supporters that circumcision is justified on the basis of its health benefits but the weighing of costs versus benefits that supports this assertion just as routinely omits any consideration whatsoever of the innate value of the prepuce - for reasons of bodily self-image, for sexual sensation and response, or simply on the principle of bodily integrity and autonomy - to the person himself who is subjected without his consent to the circumcision. It would be as though Ms. Jolie, instead of having elected to have the prophylactic mastectomy on her own, had had her breast buds excised as an infant in accordance merely with her parents' wishes.  I do not think that there are many people in our society who would feel comfortable with the idea that such a momentous decision should have been taken out of the hands of Ms. Jolie herself, and that such decisions in similar cases should be made on behalf of women by someone else.  Yet this is exactly the position into which routine infant male circumcision places boys and men - like me - who have been subjected to this "prophylactic" amputation without our consent.

And what exactly are the specific medical justifications that are adduced in support of MGM?  A reduction in the risk of penile cancer, for one.  Yet the American Cancer Society has written that "circumcision is not of value in preventing cancer of the penis."  In fact, penile cancer is so vanishingly rare that a male is more likely to develop breast cancer than penile cancer yet, curiously, infant boys' breast buds are not routinely amputated along with their foreskins.  Another claim is that circumcision can reduce the risk of the adult male or his sexual partner's contracting an STD or the human papilloma virus (HPV).  But not only are there far more effective measures that can be taken to prevent these - the use of condoms (which should always be used anyway since a male's having been circumcised in no way obviates the need to practice safe sex) in the case of the former, and the administration of the HPV vaccine in order to prevent the latter - but these measures do not sacrifice an important part of the male genitalia.  Still another medical justification for MGM is that it reduces the risk of an infant's getting a urinary tract infection (UTI), but girls are ten times as likely as boys  to develop UTIs and, when they do, girls are routinely administered antibiotics as a remedy. Why is surgery indicated prophylactically in boys to lessen the mere risk of developing a UTI while the far less invasive and far less risky intervention of administering antibiotics is employed to treat UTIs in girls when they actually develop them?  The answer to that question, in part, is that, again, in a cost-benefit analysis of circumcision in boys, absolutely no value is assigned to the male prepuce.  But that is a manifestly subjective, cultural valuation of the male prepuce, not a medical one.  Yet another quasi-medical justification for MGM that its defenders offer is that of "hygiene."  To be sure, bacteria can accumulate within the fold of a male prepuce, but that can and should be addressed by the simple, less invasive, non-damaging, and less expensive method of practicing appropriate personal hygiene.  Moreover, with respect to the tendency of the genitalia to harbor bacteria, the very same can be said of the even greater number of skin-folds and recesses of the female vulva.  Does anyone suggest FGM as a remediation for the no-less innately bacteria-harboring environment of the female external genitalia?  We have seen, of course, that in FGM-practicing cultures, that is exactly what they do.  Here, in the United States, we rightly scorn such a suggestion.  Yet the extreme measure of genital cutting for precisely this reason not only is routinely advocated but routinely practiced on infant boys in the United States.  That is an unacceptable double-standard.  Indeed, in each of these cases, there is a double standard at work and, more broadly, this double standard is also what is behind the WHO's and the United Nations' condemnation of female genital mutilation on the one hand while failing to condemn and even advocating male genital cutting on the basis of its putative health benefits on the other.  But, as has been widely noted now, the AAP, as well as the CDC, which has basically echoed the AAP's position, and the WHO, are all out of step with the majority of professional medical organizations around the world, none of whom recommends routine infant male circumcision, and several of whom actively recommend against it.

The question of religious freedom often arises in discussions concerning MGM.  Furthermore, the question of anti-Semitism also arises in such discussions.  I will be the first to acknowledge that anti-Semitism does at times rear its ugly head when circumcision is discussed.  But I do not believe that the movement to ban MGM has any more than its "share" of anti-Semites than any other social movement, although the controversy surrounding circumcision, because of its centrality to Jewish tradition, inevitably gives rise to the charge of anti-Semitism against those who wish to ban the practice and, perhaps just as inevitably and just as unreasonably at the other end of the spectrum, to the anti-Semitic claim by some that Jews are the main defenders of the practice (unreasonable and anti-Semitic, I would argue, given that Jewish ritual circumcision constitutes a minuscule  percentage of the more than one million circumcisions that are performed in the United States annually).  Incidentally, and although it shouldn't matter to this discussion, I do think it worth mentioning here that I myself am Jewish.  Although I was not raised as a practicing adherent of Judaism, I am what I and my ilk consider a "secular Jew."  That is, I was raised and still identify culturally and ethnically as Jewish.  ( I was not circumcised in a bris but rather simply because my parents were swept along in the tide of routine infant male circumcision that was so prevalent around the time that I was born.)   Writing as a Jew, allow me to state categorically that it is my conviction that Jewish identity does not come from having part of one's penis amputated.  It comes from one's upbringing, one's values, one's cultural and ethnic heritage and, in the case of Judaism, it comes from one's religious beliefs.

Insofar as the religious rite of circumcision is concerned, I am encouraged to learn that a growing number of religious Jews are now abandoning, renouncing, and even condemning the practice of infant circumcision.  One such group, "Beyond the Bris," advocates a non-genital-altering ceremony known as a "brit shalom."  This movement has been endorsed by several rabbis.  One argument, however, that has been raised by some religious Jews against proposed legislative efforts to ban forced infant male circumcision, such as the proposed ballot initiative in San Francisco several years ago, is that such a ban would infringe upon the religious liberty of those Jews who want to practice circumcision.  To this, however, I would raise the counter argument that religious freedom does not extend beyond the believer to include the bodies of others, even his or her children.  The zone of freedom of belief may be infinite but the zone of freedom to do or act in accordance with one's beliefs is delimited by the right of others not to be harmed by those beliefs.   The law banning FGM in the United States, after all, does not allow for a religious exemption.   Certain pagan religions involve human sacrifice. Should the claim of religious liberty be invoked to permit killing other people?  Should Jehovah's Witnesses or Christian Scientists be allowed to withhold life-saving blood transfusions or medical treatments, respectively, from their children on the grounds that such treatments violate their religious beliefs?  Should there be a religious exemption to providing one's child with potentially life-saving vaccines?  In the current controversies surrounding gay rights and marriage equality (another basic human right that I wholeheartedly support) we frequently hear the claim of "religious liberty" being invoked by those who want to establish a right to legally discriminate against lesbians, gays, and transgendered persons simply on the basis of the believer's conviction that homosexuality is a sin.  But there is a great distance from a person's right to believe that homosexuality is an abomination to that person's being permitted, under the aegis of law, to discriminate against others on the basis of those beliefs.  By the same token, the right of the most devout Jew (or Muslim) to believe that circumcision is mandatory does not confer upon him or her the right to impose that belief on his or her child's body any more than a parent's religious beliefs outweigh a child's right to appropriate medical care.  Nor is the "right" to impose circumcision on a neonate any more compelling or sacrosanct than the "right" - whether for religious or cultural reasons - of a parent to subject her or his daughter to female genital mutilation.  If a Jewish boy wants to undergo a ritual circumcision, that is a choice that he should be permitted to make for himself when old enough to make the decision.  In infancy, a non-surgical and non-damaging ceremony should be employed as an alternative.  

With respect to the question of religious freedom, it can also be argued, conversely, that allowing forced infant male circumcision is a violation of the religious liberty of the infant himself who is subjected to the circumcision. What of his rights to believe or not to believe?  What of his freedom of conscience?  What of his right to choose to subscribe to Judaism or Islam or rather to embrace another religion or no religion?  It is one thing, after all, for a parent to shape a child's mind in accordance with the parent's beliefs but it is quite another for a parent to shape or alter a child's body in accordance with those beliefs.  Forced infant male circumcision not only deprives the infant of the right of bodily integrity and of the right to consent to an irreparable amputation but, insofar as religion is concerned, it deprives him of the right to choose his own path in life.  No parent has the right to compel his children to follow any path throughout the child's life into and throughout adulthood all the way to the grave.  But because circumcision cannot be undone, the individual is condemned throughout his entire life to bear the scar of a ceremonial rite in which he may come, as an adult, not to believe.  Hence, permitting forced infant circumcision as part of a bris is every bit as much a deprivation of religious liberty as it is an accommodation of one.  That being the case - the two conflicting interests balancing one another, as it were - the law should add its weight to the right of the individual himself: the default should always be in favor of bodily integrity and in support of preventing an amputation that cannot be undone.  And, as I have said, a Jewish or Muslim man can always elect to undergo a voluntary ritual circumcision when he is old enough to make the choice for himself.

I began this letter to you by noting that I was impelled to contact you when I learned of your proposed legislation outlawing cat declawing. More particularly, in the article that I read about it (gothamist, January 14, 2015), on the subject of cat declawing you are quoted as follows: "There's no reason to do it unless the animal has [an] infection that is never going away, or if there is a cancer or tumor-related issue in the claw.  It's basically done because humans want it done, and I don't think it's our right to mutilate our animals for our own satisfaction."  When I read those words, I was struck by the realization that exactly those words could be said of infant male circumcision.  With your indulgence, I will paraphrase you using your quotation verbatim but merely substituting "infant" for "animal" and "prepuce" for "claw": "There's no reason to do it unless the infant has [an] infection that is never going away, or if there is a cancer or tumor-related issue in the prepuce.  It's basically done because humans want it done, and I don't think it's our right to mutilate our infants for our own satisfaction."  I think you must concede that, morally and medically, there is absolutely no difference between forced infant male genital cutting and cat declawing.  The fact that you so clearly articulated the ethical objection to cat declawing is precisely what encourages me to hope that you will be sympathetic to my claim on behalf of infant boys.  After all, you have a long resume and a distinguished legislative career of championing progressive causes and of defending the rights of the powerless.  What about infant boys and intersex infants?  They need a champion.  Since you are willing to defend the rights of cats, surely you are no less willing to defend the rights of human infant  boys and intersex infants.  I call upon you, therefore, Assemblymember Rosenthal, to do two things.  First, introduce legislation banning the use of Medicaid funds in New York State for non-therapeutic circumcision and, second, introduce legislation banning all non-therapeutic, non-medically- necessary genital surgery on any individual under the age of 18 in New York State.  Female genital mutilation has been illegal in the United States since 1996. Why shouldn't boys have the same legal protection against genital cutting as girls?  More to the point, shouldn't boys and intersex infants have at least the same rights as cats?


  1. This comment has been removed by a blog administrator.

  2. Well-written and well-argued. Will share on our Facebook page this coming Tuesday afternoon.