Dr. Gro Harlem Brundtland
Director-General
World Health Organization

Dear Dr. Brundtland,

We are spokespersons for the Association for Genital Integrity, a Canadian group dedicated to protecting children from genital mutilation. We are writing to inquire about the position of the World Health Organization (WHO) on the emerging issue of male circumcision.

In recent months, news media have carried reports of hundreds of deaths and serious injuries from male circumcision, particularly in southern Africa. As a result of such deaths and injuries, the South African government plans to introduce legislation restricting the practice of circumcision in traditional ceremonies.

Legislation regulating ritual circumcision was passed earlier this year in Sweden. The Swedish move followed a series of incidents in which immigrant boys were seriously injured, including one case in which a three-year-old boy died after being circumcised by a licensed physician in Stockholm.

To assist us with our work in Canada, we seek clarification of WHO’s position on non-therapeutic circumcision of male infants and children. We submit the following questions for your consideration and response:

1. In light of the current initiatives in Sweden and South Africa (see enclosed press reports), does WHO believe that non-therapeutic male circumcision should be regulated?
2. WHO’s classification of genital mutilation includes only procedures performed on girls and women. Could you explain why WHO has not classified or commented upon any traditional procedures performed on males?

Thank you for your assistance. We would appreciate a response directed to D ennis H arrison at the above address.

Dear Mr. H arrison,

Thank you for your letter of 12 September 2001 addressed to Dr Gro Harlem Brundtland concerning male circumcision and enclosing the press reports of serious injuries resulting from circumcisions performed under unsafe conditions. These reports are worrying and the relevant national authorities are taking appropriate steps to ensure that male circumcision, where and when performed is done so safely. All who perform male circumcision are aware of the importance of minimising the potential risks and complications. National authorities will take steps which are appropriate and relevant for their country to ensure the safety of the procedure.

There is evidence the circumcised men are at lower risk of acquiring or transmitting infections, including the human immunodeficiency virus (HIV) (see Population Council News Release attached). At present it is unclear whether encouraging circumcision among boys and men who would not otherwise be circumcised actually has the desired impact on the rates of HIV infection. However, WHO is following the issue very carefully.

On the other hand, female circumcision which comprises all procedures involving partial or total removal of the external female genitalia, is associated with well-documented, long-term harmful effects on young girls and women. It is estimated that there are 100-140 million girls and women who have undergone some form of genital mutilation, and about 2 million girls are at risk from the practice each year. There are no health benefits of the procedure.

Yours sincerely,
 
[signed]
 
Dr Tomris Türmen
Executive Director
Family and Community Health

Dear Dr. Türmen,

Thank you for your correspondence dated October 11, 2001. We are writing to request further clarification of the World Health Organization’s position on genital mutilation.

First we would like to comment on a few of the points you made in your letter. We have some doubts about your statement that “all who perform male circumcisions are aware of the importance of minimizing the potential risks and complications.” If this were true, then there would have been no need for the Swedish government to pass legislation making circumcision safer. The continuing reports of deaths and serious injuries from male circumcision around the world suggest to us that not all who perform circumcisions are aware of the potential risks and complications.

In any case, good medicine is not just a matter of ensuring that procedures are carried out safely. Every procedure performed by a physician on a patient must be ethically and legally justified. Yet none of the authorities to whom we have written—and these have included the medical licensing board, the minister of health, and the minister of justice in every Canadian province—have been able to provide us with an ethical or legal justification for circumcising healthy boys. In a recent book, Dr. Margaret Somerville, the founding director of McGill University’s Centre for Medicine, Ethics and Law, describes her experience with Canadian officials this way:

When approached about the ethics and legality of infant male circumcision, [Canadian authorities] frequently fail to respond. If they do respond ... they often justify the practice with statements that are ethically and legally wrong. I have spent many hours replying to letters signed by ministers of justice or of health, or presidents of colleges of physicians and surgeons ... Sometimes, I do not receive any reply, but I have found that when I do receive a response, it rarely addresses the ethical and legal issues I have raised ...

Public officials have no difficulty addressing the ethical and legal issues raised by female circumcision. It is only in the context of male circumcision that these issues are avoided. Yet any medical intervention on a patient must be ethically and legally justified, regardless of the sex of the patient. To argue differently is to be guilty of discrimination based on sex.

On a point of terminology, you state in your letter that female circumcision has no health benefits. We think you may mean rather that female circumcision has no medical justification. There are health benefits to removing virtually any normal part of the body, since a missing body part can never become diseased or injured. Removing healthy breast tissue prevents breast cancer, amputating a toe prevents nail fungus, and so on. Even female circumcision has health benefits, since anyone whose clitoris and labia have been cut off will never suffer from vulvar agglutination, lichen sclerosus, or cancer of the labia.

An intervention is medically justified, on the other hand, if the benefits from the procedure outweigh the associated risks and harms. It is the test for medical justification, not the test for medical benefit, that determines whether or not a medical intervention can be ethically and legally carried out on a person incapable of giving informed consent.

In your letter you refer to evidence that circumcised men are less likely to acquire or transmit infections, including HIV. However, there is also evidence to the contrary. For example, a large and well-controlled American study found that circumcision provided no discernible prophylactic benefit. In fact, this study found that circumcised men were slightly more likely to have contracted both a bacterial and a viral sexually transmitted disease in their lifetime. For chlamydia, the difference between circumcised men and non-circumcised men was quite striking. While 26 of 1033 circumcised men had contracted chlamydia in their lifetime, none of the 353 intact men reported having had it.

Using circumcision as a weapon in the fight against AIDS raises a number of medical, ethical, legal, and human rights issues. The protective effect of circumcision, assuming it exists at all, is only partial. Circumcised men are still capable of acquiring or transmitting HIV. Touting circumcision as a preventative for HIV infection could encourage high-risk sexual behaviour among circumcised men, by giving them and their partners a false sense of security.

Medical ethics demand that patients should, to the greatest extent possible, be free to choose among medical alternatives without coercion or manipulation. Most circumcisions, however, are performed on individuals who are too young to give informed consent. These individuals are also too young to be sexually active; hence they are not at immediate risk for sexually transmitted diseases such as AIDS. Is AIDS prevention a valid reason for circumcising a person who is not yet sexually active, and who is incapable of giving informed consent? An analogy would be removing some of a young girl’s breast tissue to reduce her risk of developing breast cancer.

The Association for Genital Integrity believes that all childhood genital surgery performed without medical justification is a violation of human rights. In our opinion, elective genital surgery should be postponed until the person undergoing the procedure is old enough to give informed consent. We support South African legislation prohibiting the performance of traditional circumcision on boys under 18 years of age.

We also believe that public health is closely allied to human rights. In our view, public health officials have a responsibility not only to promote public health, but also to protect human rights. It is inconsistent with human rights to remove a healthy part of a normal organ from a person too young to give informed consent.

We would like to know if the World Health Organization agrees with us on these points. That is, does WHO accept that all children should be protected from surgical operations which are not medically justified?

We would appreciate a response directed to D ennis H arrison at the above address. Thank you for considering this matter.

Dr. Tomris Türmen
Executive Director
Family and Community Health

Dear Dr. Türmen,

We are spokespersons for the Association for Genital Integrity, a Canadian group dedicated to protecting children from genital mutilation. We are writing to request clarification of a statement in a publication entitled, Female Genital Mutilation: An Overview, World Health Organization, Geneva, 1998.

Under the heading “Definitions and classifications,” this publication describes the difference between male and female circumcision in the following terms:

The most important difference is that even the most minimal form of female circumcision can affect a girl’s normal sexual function.

We would appreciate a reference for the above statement. According to WHO’s classification scheme for FGM, the minimal forms of female circumcision include:

• pricking, piercing or incising of the clitoris and/or labia
• stretching of the clitoris and/or labia

Is WHO aware of evidence showing that the above interventions “can affect a girl’s normal sexual function?” Also, can WHO cite any evidence suggesting that male circumcision does not affect a boy’s normal sexual function?

We still await a response to our previous letter, a copy of which is enclosed for your review.

Thank you for your assistance. We look forward to your reply.

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