The subject of male circumcision has recently received considerable media attention as a result of publicity given to a previously unheralded group, based in the U.K., called the National Organization of Circumcision Information Resource Centres. This association recently bestowed an award on a McGill University ethicist, who had articulated that routine male circumcision was ethically objectionable because the surgery involved is typically performed without the consent of the infants or young boys involved. (Not that such subjects ever provide informed consent for any other parent-sanctioned procedure.)

Moreover, both the organization and its awardee apparently believe that routine male circumcision is as objectionable on ethical grounds as is so-called female circumcision or clitoridectomy. The latter practice involves the surgical removal of part of the clitoris and is enacted on pre-adolescent girls in some societies, for cultural and/or religious reasons, to limit sexual arousal and enjoyment in later life.

Any direct comparison between these two procedures on medical or other grounds is offensive. Indeed, the major ethical objection in this scenario is that a well-known academic would equate the sexual mutilation of young women, as practiced through clitoridectomy, with the virtually benign procedure that is practiced on very young males. Whereas male circumcision is probably the least complex of all surgical procedures, with the lowest rate of complications, clitoridectomy, by contrast, is a relatively complex operation that is most commonly practiced in rural areas in developing countries. Moreover, clitoridectomy is usually performed by unskilled individuals in settings remote from major medical centres, and often results in serious infection, hemorrage [sic] or even death. These considerations hold true, regardless of whether this procedure is performed for religious reasons or not.

A second major reason for taking umbrage at facile comparisons between circumcision and clitoridectomy is that the former confers an important protective effect against infection by HIV and probably against other viruses and bacteria as well. Not only are circumcised men less prone to HIV infection than their non-circumcised counterparts, they also have diminished incidence of urinary tract infections and ulcerative sexually-transmitted disease.

In the case of HIV, it is estimated that over 35 million people worldwide are currently infected by this virus. Of this total, over 90 per cent are inhabitants of developing countries in which anti-viral drugs are virtually not available.

It is inevitable, as things now stand, that the vast majority of these individuals will go on to develop AIDS and to die of this disease. Many of the countries of sub-Saharan Africa, such as Zimbabwe and Botswana, currently have HIV infection rates that exceed 25 per cent of the total population. In many urban centres, such as Harare, the capital of Zimbabwe, over 35 per cent of females, aged 13 to 18, are infected by HIV This underlines the need for highly efficient sex education and awareness programs that will inform the public in these countries of the dangers of HIV infection and of the need to take protective measures, such as the use of condoms, in order to protect against infection.

Unfortunately, such programs are insufficient, since HIV has continued to spread in spite of intense efforts in many countries to not only promote HIV awareness but also to distribute condoms for free. Many scientists and public-health officials have articulated a need for greater emphasis on female initiated measures in regard to protection against HIV, such as the development of vaginal douches, foams or jellies that women might employ either prior to or immediately after sexual relations to destroy HIV in the vaginal cavity, before it ever has a chance to cause infection. This is, in part, because women in developing countries are often not sufficiently empowered to insist on the use of a condom during sex. Therefore, the chain of HIV transmission must also be fought through a variety of non-condom-based intervention strategies that target males as well as females. High on this list is male circumcision.

Studies performed in Kenya by both Canadian and American scientists, in collaboration with their African counterparts, have shown that the proper use of condoms constitutes the most effective means of defence against HIV. In regard to protection of males, however, condom usage was followed by circumcision.

This is not to suggest, of course, that circumcised men cannot be infected by HIV. However, in the fight against AIDS we need all the help we can get. If circumcision provides a measure of protection against HIV through removal of highly susceptible target cells, without causing harmful effects, this practice should be promoted rather than discouraged, especially in HIV-endemic areas. It is absolutely untrue that the minimal risks involved in male circumcision outweigh any potential health benefits.

It has long been recognized that academic freedom gives individuals the right to express sincerely held opinions on a variety of subjects, as long as such expression does not harm others and is conducted as part of legitimate academic debate. Unfortunately the essays and speeches of well-known individuals on a subject such as circumcision are not limited to the ivory tower in regard to potential impact and will, in fact, promote confusion in regard to this procedure and its benefits.

Arguments aimed at limiting male circumcision in developed societies, on the grounds that the medical benefits of this procedure may not be as apparent as in developing countries, can have impact as well in those societies in which benefit may be the greatest. Thus, it is possible for well-meaning individuals, who opine on this subject without adequate understanding of the broader issues, to unwittingly contribute to the spread of HIV.

* Dr. Mark A. Wainberg is president of the International AIDS Society, a professor of medicine at McGill University and director of the McGill AIDS Centre at the Jewish General Hospital.
 
 
 

Even if circumcision could help protect against HIV infection—and the jury is out on that point—it still would not be necessary to circumcise unconsenting infants

MARGARET A. SOMERVILLE

It is a matter of real concern to have one's views misrepresented. And when the same error is made in the same newspaper, by three different people on three separate occasions within a short time span, despite a published correction after its first appearance, one needs to seek a reason.

Dr. Mark Wainberg has devoted a major part of his article headed "Circumcision Helps in AIDS Fight" (Comment, Oct. 12) to the same error made by the columnist Catherine Ford (Comment, Aug. 16) and repeated in a Gazette news report on Sept. 12. They all wrongly claim that I believe that infant male circumcision is as ethically wrong as female genital mutilation, Wainberg describing my alleged belief to this effect as "offensive ... and a reason for taking umbrage."

I can only assume that this must be an attempt to set up a straw man in order to justify infant male circumcision on the grounds that it is much less harmful than female genital mutilation. As I explained before, the fact that this is true in the vast majority of, although not all, cases does not, in itself, ethically justify infant male circumcision.

The usual ethical and legal justification for any parent-sanctioned surgical wounding of a child is that this must be undertaken with a therapeutic intent.

As the Canadian Paediatric Society has recognized, routine infant male circumcision is not therapeutically necessary. Parents cannot give an informed consent to non-therapeutic interventions on their children that involve any more than the most trivial harm. Infant male circumcision does not fall within this description, despite Wainberg's description of it as a "virtually benign procedure ... the least complex of all surgical procedures with the lowest rate of complications."

WHAT EVIDENCE?

I raise two queries in this respect: First, on what evidence did Dr. Wainberg rely in making this statement? As an eminent scientist, he would not make it without such evidence. And did he examine the evidence to the contrary? Second, is Wainberg's statement true for the vast majority of circumcisions carried out in developing countries, the context in which he is most concerned to promote the practice?

I am not competent to address the protective effect of circumcision against HIV infection, although I am familiar with the literature on this. It would seem that there are credible experts on both sides of the debate and, therefore, that the jury is out. This raises four points:

First, in Canada, the physician has the burden of proof of therapeutic necessity and likely effectiveness of a surgical intervention when these count as ethical and legal justifications for the surgery. Therefore, even assuming that reducing the risk of HIV transmission could be a justification for infant male circumcision, this justification would not be available until it became at least more likely than not that circumcision would reduce the risk of HIV transmission.

Second, even assuming that circumcision could help to protect against HIV infection, it would not be necessary to carry it out on unconsenting infants. One could wait until the person was about to become sexually active and could decide for himself.

Third, one is ethically required to use the least harmful, least invasive means of achieving a good, the achievement of which involves harm. Consequently, a surgical intervention aimed at preventing the spread of HIV could only be justified if there were no other reasonable way to achieve this. And, even if circumcision helped to protect people in developing countries from the spread of HIV, we would not be justified in carrying this out for this purpose in developed countries, where other, better means of protection are much more readily available.

Fourth, there is evidence that some men in developing countries who are circumcised believe that this gives them protection against HIV infection. As a result, they are less likely to use other safe-sex practices. In short, even assuming that circumcision could reduce the rate of HIV infection, it could be a double-edged sword.

The thrust of Wainberg's argument is that I should not speak against infant male circumcision being carried out on children in Canada or other similar Western countries, because to do so could discourage circumcision in developing countries where this could reduce HIV transmission. This argument is based on an approach that accepts that we are justified in harming the individual child in order not to deliver a message that could cause harm to a group of other children when they later become sexually active. For a physician to carry out circumcision under such a justification would mean that the physician would be putting the interests of others ahead of the interests of his patient, a breach of the physician's primary obligation of personal care to the child. This would indeed be unethical.

HARMFUL EFFECTS

Where Wainberg and I fundamentally disagree is whether infant male circumcision does have harmful effects. I believe that it does, including the irreversible loss of healthy, erogenous tissue, the risks involved in the procedure itself and the pain that this procedure involves.

I can only query the basis on which Wainberg can say that "it is absolutely untrue that the minimal risks involved in male circumcision outweigh any potential health benefits" when the Canadian Paediatric Society has not come to this conclusion.

Finally, the professional positions which Wainberg and I hold (in his case, he is an eminent AIDS researcher and President of the International AIDS Society and I am an ethicist) can give our opinions weight far beyond that which they would carry if we were acting simply in a private capacity.

We need to keep in mind an old saying in human rights: "Nowhere are human rights more threatened than when we act purporting to do good". This is true because when we are seeking to do good, we can be insensitive to the fact that our conduct also involves doing harm.

Even if circumcision could reduce the transmission of HIV, the benefits of promoting it for this purpose would need to be balanced against any interference with children's human rights in the context of infant male circumcision.

Respect for these rights requires that we must have very substantial justification for subjecting a child to any risk through a surgical intervention, causing him pain or intervening to alter his body permanently, other than to provide necessary therapy for the child himself.

In summary, as matters stand, if we are to justify infant male circumcision, this justification must be sought elsewhere than on the protection-of-health ground that Wainberg seeks to use.

* Margaret A. Somerville is Gale professor of law and a professor in the faculty of medicine at the McGill Centre for Medicine, Ethics and Law.