Why I didn’t circumcise my second son

As a practicing Jew, ARIEL KAGAN took circumcision for granted. As a medical ethicist, he couldn’t accept it.

At the moment of circumcision, most parents, have a panicky thought, “OMG, this is crazy!  Cutting the penis of an infant with a scalpel. Protect the child. You are the parent. Stop this now.”

I certainly had this feeling as our mohel (ritual circumciser) cut into the flesh of my elder son during his brit milah (Jewish circumcision ceremony).

Family and friends were gathered around. I wanted to be accepted by the community. I wanted to do the right thing. I wanted to honor my traditions. I was on autopilot.

Four years later, when our second son was born, I still felt guilty and conflicted over the experience with my first son. I still wondered if I had damaged him. I did not want to act on autopilot again.

I am trained as a psychiatrist and medical ethicist so, having had more time to think, I applied the framework of rational and moral analysis to the religious practice of circumcision before making a decision for my younger son.

Medical ethicists use three main moral principles to sort out whether a medical intervention is ethical:

Medical interventions must be in a person’s best interests and designed to genuinely help them (beneficence).

Medical interventions must not do anything to cause harm (non-maleficence).

The patient should make their own medical decisions about what happens to their bodies, to the greatest degree possible (autonomy).

Let’s examine how circumcision, a surgical procedure, lines up with these three ethical principles.

Beneficence

The motivation for performing circumcision is generally religious or cultural. Circumcision is rarely performed for medical benefit, but it may be performed when there is a clear medical reason, such as when the foreskin does not retract naturally.

There is weak data suggesting prophylactic health benefits from circumcision, e.g., a reduction in HIV transmission risk in endemic areas, but there is insufficient evidence to support routine circumcision of all boys for medical reasons.

Non-maleficence

You can see from the photos in this medical report that circumcision is a real operation and that its complications are awful.

Between  1.5% and 2% of may suffer serious complications. One study found that about 7.5% of visits to a pediatric urology service in Boston were for circumcision complications. Cases of circumcisers transmitting the herpes virus to infants have been reported. Deaths have occurred from complications of circumcision.

Early complications include pain, swelling, bleeding, death from bleeding, inadequate skin removal, and amputation of the tip of the penis (glans).

Later complications (weeks and months to years) include ongoing pain, wound infection, a skin bridge forming between the penile shaft and the glans, urinary retention, an ulcer at the penis opening or narrowing of the opening so that it’s hard to urinate, fistulas, sexual dysfunction and swelling of the glans.

Psychological trauma may also be associated with a perception of genital tampering. Men may feel less penile sensitivity, which is quite possible given that scar tissue has no nerves and that a large swathe of their foreskins was removed.

An increased risk of complications is correlated with less medical training. Many mohelim do not meet standards for medical training or continuing education.

The lack of anesthesia in many religious/cultural circumcisions also does not meet modern ethical standards for surgical procedures.

Given that circumcision is an elective procedure in a minor with no medical benefit, the only physical or psychological risk that is morally acceptable would be zero.

Autonomy

The ability to make medical decisions for infants is granted by proxy to their parents who are expected to make decisions in the best interests of the child.

For medical procedures a signed informed consent is considered essential. Yet, there is no real informed consent in ritual circumcision. Religious expectations override an open discussion of risks, benefits and alternatives parents are rarely asked to sign an informed consent document.

A better way

Pro-circumcisers are challenged to address circumcision’s ethical deficits through improving informed consent discussions with parents (risks, benefits and alternatives), using anesthesia, and better training and competency standards, including open tracking of complications and accountability for lay circumcisers.

Ethics committees, integral to every modern medical center, need to carefully consider a moral approach to children being circumcised under the rubric of their institutional care.

But it is also appropriate for Jewish parents to consider whether they really want to circumcise their sons. A sizable majority conform with the practice of circumcision because of the perception that it is a normative practice.

To them I would say, imagine you have friends who, because of their religious and cultural beliefs, want to remove their baby boy’s nipples without anesthesia using a lay nipplectomy practitioner.

Would you say, “That sounds like a fine idea” or would you raise an eyebrow? If your eyebrow went up, it is evidence of an ethical concern. Ethical questioning is a positive practice. It should be encouraged because it leads to reexamination and questioning of routine medical practices such as circumcision.

There ARE meaningful alternatives to surgical circumcision, which don’t involve surgically interfering with a child’s genitals.

One example is the Brit Shalom ceremony, a welcoming and naming ceremony used for Jewish girls and equally applicable to boys.

A Brit Shalom ceremony was our choice for our second son. It was a meaningful and joyous welcome to the tribe. I feel whole in our decision.

I still feel guilty and a bit sad for imposing ritual circumcision on our first son. I should have spoken up sooner.

We remain proud and committed members of our Jewish community. We were not ostracised. On the contrary, our ethical soul-searching was seen as courageous by our friends, family and perhaps even our rabbis.