Abstract

This entry provides some information about the rich history of male circumcision, distinguishes between four
clusters of reasons for male circumcision, and discusses shortly the differences and commonalities between male
and female circumcision. The ethics part focuses on the following four issues: (1) the (lack of) scientific evidence
regarding medical harms and benefits, (2) respect for the child’s and its parents’ rights, (3) the right on bodily
integrity, and (4) the moral weight of cultural considerations and its relation to global bioethics. It concludes that
in the debate about male circumcision, there is a tension between (1) general abstract principles such as
individual autonomy, self-determination, the child’s right on an open future, and bodily integrity, (2) evidence
based medicine that inspired scientific findings about harms and benefits, (3) cultural considerations, and (4)
practical and individual circumstances. In general, there seems to be a tendency toward a more skeptic stance
toward male circumcision, even within religious communities.

Introduction
Male circumcision (MC) is a controversial topic because it touches on strong cultural, religious, theological, and
philosophical convictions. It is probably the most commonly performed surgical procedure worldwide. Each
year around 13.3 million boys are circumcised (Denniston et al. 1999). Reasons to perform MC are of a medical
therapeutic, hygienic-preventive, religious, or cultural nature. Especially, the practices of hygienic preventive
and religious MC are subjects of debate. In various countries, there are ongoing discussions about the medical
and religious legitimization and moral acceptability of MC. Critics even plea for a ban on nontherapeutic
circumcisions. The bioethical dimension is complex.
History And Development
The early history of MC is lost in the mists of time. Before MC became a crucial practice in Jewish and Islamic
religion, it was already practiced for cultural, that is, not specific religious or medical reasons, for example, in
ancient Egypt (Gollaher 2000).

Cultural Circumcision
Since time immemorial, MC has been practiced in various tribes, e.g., in Africa and Australia. The reasons to
perform cultural MC are not always clear and may vary from culture to culture and tribe to tribe (Gollaher 2000).
However, this practice can generally be seen as part of an initiation ceremony or “rite de passage.” The mark of
circumcision symbolizes the individual’s permanent inclusion in a distinct tribal community. The initiation rite
of circumcision is essentially sacrificial. One small part of a member’s body (his foreskin) is sacrificed to the
divine powers to redeem the community. Why it is the foreskin and not another small body part like the earlobe
that is cut of is subject of psychoanalytic and anthropological research and speculation. Sigmund Freud spoke
of “cutting the penis” since he did not consider the foreskin a structure separated from the penis (Gollaher 2000,
p. 66). He considered circumcision to be a symbolic castration reinforcing the incest taboo and leading to
castration anxiety. This view, however, is not undisputed. The psychotherapist Bruno Bettelheim dismissed
Freud’s theory of primal castration. According to him, circumcision reflects a deep-seated ambivalence about
being confined to a single sex. The purpose of MC is not considered to exacerbate sexual anxiety but to palliate
it. According to Bettelheim, “circumcision developed as a result both of man’s desire to participate in the female
power of procreation, and of woman’s desire, if not to rob the male of the penis, at least to make him bleed from
his genital as women do” (Bettelheim in Symbolic Wounds; quotation in: Gollaher 2000, p. 69).

Religious Circumcision
MC is one of the earliest surgical procedures to have been performed in the practice of Judaism and Islam. The
ethos of circumcision in Judaism is complex. It has to do with personal and cultural identity and with the role of
man as guardian of his body. God did not complete creation. This was left for humankind to do. For Jews,
circumcision represents the covenant made between God and Abraham. The first reference to circumcision
appears in Genesis (17:10–14): “At the age of 8 days every male among you shall be circumcised throughout
your generations.” For Jews, circumcision is a commandment from God.

In early Christianity, the practice of circumcision was heavily debated. Opposition to circumcision was a crucial
element of the religious identity of the early Christians. In his letter to the Galatians, St. Paul explained that in
the process of instituting the new covenant between God and humankind, Jesus Christ subsumed the old covenant
between God and Abraham. Christ, St. Paul said, fulfilled the law, and this fulfillment rendered circumcision
irrelevant in the eyes of God. In other words, circumcision was not necessary in order to be a Christian (Gollaher
2000). St. Paul rather pointed to the “circumcision of the heart” and to baptism as the new symbol marking out
the people of the covenant from the rest of humanity.

Circumcision is not mentioned in any form in the Koran. In Islam, the practice of MC is based on sunnah, that
is, the prophetic tradition marked by the Prophet Mohammed’s words and deeds. Circumcision is not an absolute
commandment but is strongly recommended. In practice, however, almost every Muslim boy will be
circumcised. While Jews speak only in terms of a commandment of God, Muslims also put forward hygienic
and medical reasons. In the prophetic traditions that enumerate the features of natural religion, MC is mentioned
under the heading cleanliness, together with the clipping of nails, the use of toothpicks, the cutting of moustaches,
etc.

Medical Circumcision
MC is also performed for hygienic and preventive reasons. In this regard, the USA is quite unique in the world.
Nowadays, the so-called routine neonatal circumcision (RNC) is the most frequently performed surgical
operation carried out in the USA. Although circumcision rates are steadily decreasing in most countries around
the world, including the USA, still around half of the newborn male infants in the USA are circumcised. The
modern history of RNC starts in the 1870s as a treatment for all kinds of signs and symptoms allegedly related
to genital irritation (Gollaher 2000). During the Victorian Era, a few American doctors, among them Lewis A.
Sayre, began to circumcise boys to prevent a wide range of conditions such as masturbation, enuresis, impotence,
epilepsy, and a variety of mental disorders. In the first half of the twentieth century, the practice of RNC spread
over the country, touted as a means to prevent diseases such as urinary tract infections, venereal diseases, and
penile cancer. With regard to RNC, there is a sharp distinction between the USA and Europe. While RNC is a
normal medical practice in the USA, the European medical establishment considers RNC an unnecessary
surgical procedure. RNC is an example of cultural diversity in the field of medicine and health care which
challenges the idea of interculturally shared values, methods, and practices.

Objections
Throughout history, there have been critics who object to religious MC. Although MC has a firm basis within
Judaism, there is some (marginal) opposition within this religion. It is argued, for example, that circumcision is
not as essential to Jewish identity as most Jews assume. Circumcision, then, is considered a violation of the
body’s integrity because a healthy, functional part of the body is excised. Other reasons to oppose circumcision
of newborns are the experience of pain, possible complications, a lack of presumed medical benefits, and
negative effects on the parents’ experiences. From such a critical perspective, circumcision has been described
as “a particular form of violence to children,” and uncircumcised boys have been described as “intact Jewish
boys” (Goodman 1999, p. 26). Nowadays, groups as Jews Against Circumcision exist and alternatives to the
excision of the foreskin are being proposed (Earp 2013). Also within Islam there is some opposition to male
circumcision. However, objections to MC derive largely from the practice of RNC.

Foreskin Restoration
As long as MC has been practiced, there have been attempts to restore the original anatomical structure. Jews,
for example, have practiced foreskin reconstruction for almost as long as they have practiced circumcision. In
the Hellenistic period, they were confronted with a culture that considered circumcision a barbaric mutilation of
the natural human body and a violation of common standards in Greek aesthetics. Greeks held athletic contests
in which the participants appeared nude. The Greek standard of modesty held that the foreskin should cover the
glans. The visible glans of a circumcised man was taken as evidence of sexual arousal and was thus considered
indecent within the arena (Gollaher 2000). Jews who wanted to meet the standards of Hellenistic culture tried to
restore their foreskin. During the Nazi regime in the Second World War, Jews were even more strongly motivated
to hide or undo their circumcision in order to conceal their Jewish identity.

Nowadays, it is especially men who have lost their foreskin due to RNC who try to undo the circumcision and
to restore the original anatomical structure as good as possible. This so-called foreskin restoration movement is
still growing. The term foreskin restoration can refer to any method of creating a facsimile of a foreskin to cover
the head of the penis. This can be done either by surgical means or nonsurgically by all kinds of stretching
devices. The National Organization of Restoring Men (NORM) is a nonprofit support group for men who have
concerns about being circumcised, who are considering foreskin restoration, or who are in the process of
restoring their foreskins. The aim of NORM is to help men regain a sense of self-directedness, physically as well
as emotionally.

Conceptual Clarification
Four Reasons For MC
If the ethical aspects of MC are at stake, it is important to distinguish between four clusters of reasons for a
circumcision: (1) medical therapeutic reasons, for example, in the case of phimosis or balanitis; (2) preventive-
hygienic reasons, as is the case in RNC; (3) religious reasons, as being practiced by Jews and Muslims; and (4)
cultural reasons, that is, circumcision for nonmedical, non-preventive, and nonreligious reasons, as is still being
practiced in some peoples as a “rite de passage.” These four categories do not exclude each other. There is often
a mix of reasons to circumcise. In Islam, for example, considerations of hygiene and health are mixed up with
strict religious convictions. Also the practice of RNC in the USA demonstrates how a procedure that once was
thought to have medical benefits can be transformed into a culturally based norm (Szasz 1996).

Genital Mutilation
One usually makes a sharp distinction between male and female circumcision. First, boys and men are mostly
circumcised for medical therapeutic, preventive-hygienic, or religious reasons. Female circumcision does not
occur for these reasons and is mostly based on cultural, that is, not specific medical, preventive, or religious
reasons. Second, the excisions in most female circumcisions are far more extensive than those in male
circumcision and can have dramatic negative medical side effects. Third, female circumcision is officially
forbidden in most countries, while there is no law that forbids male circumcision. For these reasons, female
circumcision is generally described as “female genital mutilation,” while the term “genital mutilation” is less
often used for MC.

Despite these differences, there are good reasons to consider male and female circumcision in the same context.
In both cases circumcision is an invasive intervention in the external genital organs for which – in most cases –
there is no medical indication. Further, a minimal form of female circumcision in the form of a small (nick)
incision may be less mutilating than a standard male circumcision. Moreover, the symbolic meaning is the same
in both cases. Generally speaking, being circumcised is considered a token of becoming a part of a community,
arising from a covenant with God or from a particular adult community. In addition to the nature of the
intervention itself and the symbolic meaning attached to it, there are also political justifications for emphasizing
the connection between the two practices. It is argued, for example, that female circumcision cannot be stopped
as long as male circumcision for nonmedical reasons is tolerated.

Ethical Dimension
The ethics part focuses on the following four issues which can be found in the literature: (1) the (lack of) scientific
evidence regarding medical harms and benefits, (2) respect for the child’s and its parents’ rights, (3) the right on
bodily integrity, and (4) the moral weight of cultural considerations and its relation to global bioethics (Benatar
and Benatar 2003; Dekkers 2009).

Harms And Benefits

Especially in the context of RNC, the scientific evidence (or the lack of it) for medical harms and benefits is
being discussed. Sometimes the discussion is expanded to nonmedical harms and benefits such as possible sexual
dysfunctions and the costs of the intervention. In the first decade of the twenty-first century, the relationship
between MC and HIV infection has reappeared on the agenda.

Harms
Although the literature occasionally reports horrifying complications of RNC such as a total destruction of the
penis, it is generally considered a simple procedure which, if properly performed, seldom leads to complications.
Possible medical harms of RNC are pain and complications such as bleedings and infections. The overall
complication rate associated with newborn circumcision is approximately 0.2 %.

Benefits
The benefits of RNC have been described in numerous studies using a wide variety of methodologies. Reported
benefits include reductions in the rates of urinary tract infections (UTIs), penile cancer, and some sexually
transmitted diseases (STDs). The extent to which circumcision decreases the risk of these outcomes has been
intensely debated. A consensus now appears to be emerging that there are some small protective benefits,
especially reducing the risk of UTIs. The protective effects of circumcision can be conveyed in terms of a so-
called number needed to treat (NNT). This number represents the number of male newborns who would need to
be circumcised to prevent one undesired outcome such as a UTI. It is known by now that around 100
circumcisions would be required to prevent one UTI. However, critics of RNC state that the incidence of UTIs
does not seem to be lower in the USA with high circumcision rates, compared with Europe with low circumcision
rates, that the evidence for clinically significant protection is weak, and that a UTI is generally no serious medical
problem and easy to treat (Frisch et al. 2013).

Circumcision And HIV

In the first decade of the twenty-first century, the RNC debate got a new stimulus. Observational studies had
shown that circumcised men appear less likely to acquire HIV than non-circumcised

men. The results of two experimental trials in Kenya and Uganda in 2007 showed that MC halves the risk of
adult males contracting HIV through heterosexual intercourse. Since then, several authors have stressed the need
of a large-scale circumcision campaign in order to prevent HIV infections. Many of their assertions remind us
of statements of fervent proponents of RNC in the USA, now and in the past, exaggerating the alleged
advantages, ignoring potential harms, and giving the impression that circumcision is no more than a simple
intervention comparable to a vaccination. Although there is some evidence of a protective benefit of
circumcision, factors such as the unknown complication rate of the procedure and negative behavioral
consequences still need to be taken into account. Pleas for preventive circumcision might also distract attention
from alternative ways of preventing the spread of HIV: lifestyle and sexual behavior, the use of condoms, and
the development of a vaccine.

Advocates of RNC are using these new findings to support their case in favor of RNC, but it is questionable
whether these findings are relevant to the RNC debate. Taking into account the notion of a “prevention paradox,”
one might ask whether it is right to circumcise a whole population or a considerable part of it if many will not
benefit from the intervention, for example, because they do not engage in risky sexual behavior. Moreover,
although neonatal circumcision might be safer, less expensive, and easier to organize than adolescent or adult
circumcision, the child’s bodily integrity forms an additional argument against him being circumcised for an
issue that might not affect him for many years to come. Further, the medical, social, and cultural circumstances
in the USA and African countries such as Kenya and Uganda are distinctly different. The adult risk of HIV is
not high in the USA when compared with some African countries, and access to life-saving antiretroviral drugs
is widespread.

Continuous Debate
From a methodological perspective, the medical, psychological, and social benefits and harms of RNC are hard
to determine. There are some purported benefits of circumcision, but not all of them are supported by scientific
evidence. Moreover, there is no evidence that a possible minimal advantage of circumcision counterbalances the
disadvantages. And even if the advantages outweigh the disadvantages, it still remains to be seen whether RNC
should be applied on a large scale.

The American Academy of Pediatrics (AAP) released in 2012 a new Technical Report and Policy Statement on
RNC, concluding that possible health benefits now outweigh the risks and possible negative long-term
consequences (American Academy of Pediatrics 2012). Compared to earlier statements about RNC, the AAP
has now changed from a neutral to a more positive attitude toward circumcision. The AAP does not recommend
routine circumcision of all infant boys as a public health measure but asserts that the benefits of the procedure
are sufficient to warrant third-party payment. This conclusion seems to be strongly culturally biased, because it
is quite different from the opinion of physicians in other parts of the Western world, including Europe, Canada,
and Australia. In a recent commentary, it is stated that only one of the arguments put forward by the AAP has
some theoretical relevance in relation to RNC, namely, the possible protection against UTIs. The other claimed
health benefits, including protection against HIV/AIDS, genital herpes, genital warts, and penile cancer, are
considered questionable, weak, and likely to have little public health relevance in a Western context (Frisch et
al. 2013).

Children’s And Parents’ Rights

Routine Neonatal Circumcision
According to the AAP, scientific evidence demonstrates potential medical benefits in the long run of newborn
male circumcision. However, these findings are not considered sufficient to perform RNC without adequately
informing the parents as was previously often done. In cases such as MC, in which there are potential benefits
and risks, yet the procedure is not essential to the child’s current well-being, parents should determine what is
in the best interest of the child. To make an informed choice, parents of all male infants should be given accurate
and unbiased information and be provided the opportunity to discuss this decision. This view is an example of a
position which is much defended in the literature: because there is modest but not yet sufficient medical evidence
for RNC, the parents must decide on the circumcision of their son after being well informed about the pros and
cons. RNC is a discretionary matter. The decision whether or not to circumcise a child should be made by the
parents (Benatar and Benatar 2003).

Although good reasons exist to argue that parents should decide about circumcision, the question why
circumcision should be done on an age when the child cannot give his consent is still open. In order to question
the moral acceptability of nontherapeutic forms of circumcision, the focus is often on the protection of the child’s
rights, in particular his right on self-determination. The problem of entitlement brings some opponents of RNC
to the argument that circumcision must be postponed till the age of eighteen when the person himself can make
a well-informed and deliberate decision. This argument, however, can (partly) be counterbalanced by more
practical considerations: neonatal circumcision has less impact on the one whose foreskin is being removed, is
easier to organize, and is probably cheaper than circumcision at an adult age.

However, even if one considers RNC a suitable matter for parental decision or for a decision by the child himself
when he is adult, there is still the fact that it is a medical procedure carried out by doctors. Critics of RNC inside
and outside the USA have therefore argued that it is not the question “who should decide” that is at stake but the
more fundamental question whether RNC is morally acceptable at all. What is the moral basis for cutting off a
part of the genitals of a healthy infant for dubious medical reasons? Also an adult’s decision to undergo
circumcision for medical preventive reasons is not morally neutral or uncontroversial.

For doctors, RNC is just a simple routine intervention, no more of an operation than a vaccination, to be carried
out in a few minutes. Others critically speak of “genital mutilation,” “amputation,” “child abuse,” or even “a
type of barbarism.” The language used in the RNC debate is far from being neutral. Whatever language is used,
however, at first sight RNC can be considered a violation of the Hippocratic principle of non-maleficence: first
do no harm. This does not mean that neonatal circumcision is morally questionable only because of harmful side
effects. Many generally accepted medical interventions do have negative side effects. What is crucial in the case
of RNC is the lack of a medical legitimization. It is, for example, argued in the commentary on the AAP report
that this report lacks a serious discussion of the central ethical dilemma with, on one side, parents’ right to act
in the best interest of their child on the basis of cultural, religious, and health-related beliefs and wishes and, on
the other side, infant boys’ basic right to bodily integrity in the absence of compelling reasons for surgery.
According to this commentary, bodily integrity is one of the most fundamental rights a child has. Physicians and
their professional organizations have a professional duty to protect this right. Physicians should discourage
parents from circumcising their healthy infant boys (Frisch et al. 2013).

Religious Circumcision
Children’s and parents’ rights and the principle of respect of individual autonomy also play a role in discussions
about the moral acceptability of religious MC. Defenders of religious MC, which is an ancient tradition,
sometimes suggest that “the sheer antiquity of the practice implies a kind of venerability” and that the
fundamental legal status of such an old religious custom cannot seriously be called into question (Earp 2013a).
In a recent introduction to a special issue of The Journal of Medical Ethics, Brian D. Earp points out that there
seems to be a tension or even an incompatibility between the implicit philosophical presuppositions of this
(pre)historical practice of MC, on the one hand, and the normative foundations of much of contemporary Western
law and custom, on the other (Earp 2013a). Elsewhere, he has argued that both the Jewish and Islamic practices
of MC are consistent with the norms of patriarchy: “both elevate the concerns of the community over the freedom
of the individual to make decisions about his own body in his own time; and both brand a child with a permanent
mark of religious belonging despite the significant possibility that he may one day fail to embrace the belief
system and/or cultural practices of his parents” (Earp 2013b).

By contrast, contemporary bioethics as well as the philosophical basis of many modern legal codes came to
fruition in a secular era that favors a very different set of values. In this context, Earp refers to such concepts as
autonomy, individual rights, informed consent, bodily integrity, the freedom to join (or to leave) a religion, the
“needfulness of protecting the vulnerable in society against the unwarranted exertions of the powerful,” and a
child’s interests in self-determination and an open future. This tension between “preand post-enlightenment
world views,” as described by Earp, can explain why there has been a revival of the debate on MC in the last
half-century, and why there may even be a growing opposition toward it (Earp 2013a).

Bodily Integrity
Much of the effort to regulate the use of the body is embedded in a moral language of terms such as sanctity,
dignity, and bodily integrity. These notions represent a fundamental view of the human body in Jewish, Christian,
and Islamic religions and also in (nonreligious) philosophical thinking, for example, in classic Greek and Roman
thought and in Thomas Aquinas’ and Kant’s philosophy. In the literature, three interpretations of “bodily
integrity” can be found which are relevant to the practice of MC: biological, subjective, and normative wholeness
(Dekkers 2009).

Biological Wholeness
The idea of biological wholeness means that although the human body consists of numerous body parts, organs,
tissues, cells, and subcellular components, it is still an anatomical and physiological unity, an integrated whole
which is more than the sum of its parts. Biological wholeness refers to the proper function of the body and its
parts. From this perspective, it is curious that there has been a lot of debate on the question whether the foreskin
is an essential body part. Some

Darwinism-oriented authors were of the opinion that the foreskin is nothing more than a vestige of the human
being’s evolutionary past. Most anatomists, however, consider the foreskin as an integral part of the sexual
organ. Nowadays, the foreskin is considered to have useful and valuable functions: protection, immunological
defense, erogenous sensitivity, and sexual functions in intercourse.

Subjective Wholeness
Jews and Muslims who have been circumcised for religious reasons seldom express feelings of not being
“whole” anymore (Dekkers et al. 2005). It thus appears that a violation of biological wholeness not necessarily
goes together with a feeling of a lack of subjective wholeness. However, a small portion of men who have been
circumcised for preventive-hygienic reasons later regret – under the influence of the ant circumcision movement
– being circumcised. There is a growing literature on negative feelings about bodily integrity in males
circumcised in infancy without religious motivation (Davis 2000–2001). The following comments have been
noted: “always thinking about foreskins,” “psychologically and physically damaged,” “desired to know what it
would be like with a foreskin,” “altered, not whole,” “mutilated,” “incomplete,” and “deformed” (Dekkers 2009).

Normative Wholeness
The biological and subjective wholeness of the human body is also a normative wholeness. This means that the
human body is characterized by dignity, sacredness, or intactness. It is often argued that a mutilation of the
human body is permissible only if it regards a nonessential body part and if the intervention is necessary to
preserve the whole body. According to Kant, we do not only have moral duties toward ourselves and other
persons but also toward our own bodies (Kant 1997). The foreskin can hardly be considered an essential body
part, but it is at least an integral part of the human body.

Bodily Integrity And MC

Biological, subjective, and normative wholeness do not necessarily coincide, but taken together they form a
strong argument for a reserved stance toward MC. Most opponents of any form of circumcision argue that (the
right to) bodily integrity and related concepts such as wholeness are incompatible with circumcision. It is striking
that the anti-circumcision movement speaks of “genital integrity” (Denniston et al. 1999). In terms of basic
human rights, circumcision without explicit consent may be considered to violate the individual’s right to bodily
integrity. This is a strong argument in favor of circumcision on an adult age, if circumcision is deemed necessary
at all. However, in order to show that also circumcision on an adult age is not uncontroversial, critics of
circumcision for nonmedical reasons emphasize a somewhat stricter interpretation of bodily integrity. From this
perspective, the notion of respect for bodily integrity has been opposed to the idea of personal autonomy and
self-determination over the body. It implies that the human body cannot (entirely) be owned or controlled,
because it has a moral value of its own. Even if people are considered to be the owners of their bodies, they are
not allowed to do everything with their bodies that they might want to. Respect for bodily integrity is an ethical
principle in its own right, closely connected with, but fundamentally different from the principle of personal
autonomy (Dekkers 2009).

The notion of bodily integrity is a key notion in many philosophical, theological, and religious considerations,
but it is not an absolute principle. First, it is ultimately based upon moral experiences. However, whether an
experience can be called a moral experience depends upon the context, culture, or tradition in which the subject
of that experience takes part. For many doctors the circumcision of male newborns is just a routine surgery to
be carried out in a few minutes. For many parents, however, witnessing a circumcision can be a distressing
experience. Also for people with a Jewish or Islamic background, witnessing a circumcision, although they feel
that it definitely needs to be done, is not a pleasant experience. These findings underscore that they intuitively
express feelings of ambivalence and hesitation that can be explained in terms of respect for the integrity of the
body (Dekkers et al. 2005).

Second, the principle of bodily integrity can be overridden by competing moral obligations, for example, to obey
God’s law, as is the case in Judaism and Islam, or to contribute to the health of the patient. Notwithstanding
critical differences between Jewish, Christian, and Islamic thinking, Jews, Christians, and Muslims generally
attach a high value to the integrity of the human body, while it is precisely in Judaism and Islam that male
circumcision is practiced. This seeming paradox could be explained by taking into account the specific traditions
in which this practice plays a role. It appears that Jews and Muslims regarding circumcision do not explicitly
think in terms of a violation of the integrity of the body. On the contrary, male circumcision is even considered
a step toward a perfection of the human body. The foreskin is considered an imperfection whose removal is
necessary to reveal the body’s ideal form.

Cultural Differences And Global Bioethics

MC for cultural reasons is an old prehistoric tribal tradition. Religious MC, dating back to the origin of Judaism,
was abolished in early Christianity but got a revival in Islam. Religious MC is based on strong religious and
theological norms and values. It is less recognized, however, that also the practice of RNC – although relatively
new – is also strongly culturally dependent. Its medical rationale developed after the operation was in wide
practice: to improve hygiene; to prevent phimosis, urinary tract infections, sexually transmitted diseases, and
cancer of the penis; but also to make sons resemble their circumcised father and to conform socially with their
peers. RNC is a medical and a social-cultural phenomenon as well.

The answer on the question why RNC is still practiced in the USA at a time when evidence based medicine
(EBM) is the global standard must be sought in psychological, social, and cultural explanations. Although
advocates of RNC accuse opponents of RNC of opinion-based arguments and do their best to present scientific
figures that support their view, they often fail to recognize that their own view is also based on social-cultural
beliefs and values. Advocates of RNC focus on the alleged medical advantages, but the so-called medical aspects
of RNC also appear to be largely culturally based. RNC is recommended on medical or quasi-medical grounds
but is for a great deal legitimized in and through the social context. The medical rationalization of RNC is one
of the most obvious illustrations of the acculturation to the ideology of the “therapeutic state,” the political order
in which social control is legitimized through an ideology focused on health (Szasz 1996). The practice of RNC
demonstrates how a procedure that once was thought to have medical benefits can be transformed into a culturally
based norm.

The question is how global bioethics should treat cultural differences such as RNC and religious MC. Should
these practices be stimulated, tolerated, criticized, discouraged, or even prohibited? The single fact that RNC is
disapproved in European culture and that religious MC is not part of Christianity is not a sufficient reason to
disapprove that practice in another culture and religion. At stake are culturally dependent norms and values
which necessitate an open view toward other cultures. RNC and religious MC should be discussed in the context
of an ethics of multiculturalism. The significance of the notion of multiculturalism primarily lies in a favorable
and open attitude toward other cultures. In the context of the MC debate, there is value in trying to step back
from one’s cultural assumptions and to view RNC and religious MC from another cultural perspective.

The problem, however, is that multiculturalism is often associated with a form of ethical relativism, that is, the
claim that morality is relative to the norms of one’s culture and – in a more stringent interpretation – that there
are no common moral principles shared by all cultures (Baker 1998). In Against Relativism, Ruth Macklin states
that ethical relativism can be sustained for some cultural practices and traditions but that it should be rejected
for others as a “pernicious doctrine” (Macklin 1999, p. vi). The question is whether RNC and religious MC are
a suitable subject for an “anything goes” or laissez-faire attitude. Can some form of ethical relativism be
sustained for RNC and religious MC, or must these practices be discussed in the context of a global and
intercultural bioethics? Taking into account the current debate on MC, there appear to be good reasons to argue
that for both practices ethical relativism must not be sustained.

Conclusion
MC is a controversial subject. The debate about the medical, moral, theological, legal, and cultural justifications
for MC is still going on. In this debate, there appears to be a tension between (1) general abstract principles such
as individual autonomy, self-determination, the child’s right on an open future, and bodily integrity, (2) evidence
based medicine that inspired scientific findings about harms and benefits, (3) cultural considerations, and (4)
practical and individual circumstances such as conscientious objection in a clinical context (Ahmad 2014).

In the current debate about the pros and cons of RNC, proponents focus on medical-scientific arguments and
considerations about evidence based medicine, while opponents base their view predominantly on moral notions
and principles such as children’s and parents’ rights and bodily integrity. It is important to realize, however, that
scientific arguments are also based on moral arguments and that moral arguments cannot be considered
separately from scientific reasoning.

It appears, moreover, that abstract principles such as bodily integrity are ambiguous. It is only within a particular
moral narrative that one can determine whether specific uses of the body are to be praised, condemned, or
regarded as morally neutral. What is meant by “bodily integrity” must be explored by analyzing specific practices
in which the integrity of the body is at stake. Although the human body may generally be seen as having an
integrity which must be respected, every alteration or apparent violation of the human body must be considered
in its own medical, religious, and cultural context.

In the literature, one can still find strong defenses of RNC and religious MC as both morally and legally
permissible, alongside contrary arguments that circumcision is an unambiguous affront to human rights. The
debate is far from over. Nevertheless, as Earp argues, “the overall balance of opinion may be shifting toward
one of general skepticism concerning circumcision, even within religious communities” (Earp 2013a).
Increasingly, individual writers with a Muslim or Jewish background point out that there are alternatives to
religious MC and that the involuntary excision of children’s foreskins may not be necessary for contemporary
religious observance (Earp 2013a).