The debate on male infant circumcision in Europe: a challenge for Islamic biomedical ethics

Male circumcision is an ancient practice intimately linked to religious beliefs and ethnic identity but also shaped by medical considerations primarily related to hygiene. Recently, the practice has been the subject of increased criticism in Western European contexts where a range of concerns have been raised about the ethical and medical appropriateness of conducting surgical procedures for non-therapeutic reasons in minors.

In this article, we present a brief overview of the history of male circumcision. This is followed by a critical look at the range of approaches taken by European Muslims to respond to the increasingly hostile position being taken by advocacy groups, and some medical associations and governments opposing male infant circumcision. In doing so, we consider some of the unresolved aspects yet to be addressed from an Islamic bioethical viewpoint.

Finally, we discuss the need for Islamic bioethicists to reflect critically on approaches to advocating for practices such as male infant circumcision, as the current pragmatic strategies being pursued often lead to unforeseen challenges that may place communities in ethically and morally difficult positions.

The origins of male circumcision

Male circumcision involves surgical removal of the foreskin and is most commonly carried out during infancy. Although often associated with Judaism and Islam, circumcision is also performed in other communities worldwide for a range of religious, cultural or, less often, medical reasons. For example, male circumcision for cultural reasons are found among ethnic groups in sub-Saharan Africa, aboriginal Australasians, Aztecs and Mayans in the Americas, groups in the Philippines, and inhabitants of Pacific islands (World Health Organization 2007). Estimating the total number of males circumcised globally is difficult, but World Health Organization (WHO) figures compiled in 2007 suggest that approximately one-third of males worldwide are circumcised and that Muslims constitute 70% of these circumcised males (World Health Organization 2007).

From an Islamic point of view, male circumcision can be traced back to the time of Prophet Ibrahim (peace be upon him) who was commanded by Allah to circumcise himself, his son Ismael and his male family members (Rizvi et al. 1999). Male circumcision is not mentioned in The Holy Qur’an, but it is described in a number of Ahadith (sayings of the Prophet Muhammad). Some of these include male circumcision among the list of practices related to the Fitrah or the natural predisposition of mankind inclined towards submission to Allah (Mohamed 1996).

Abu Huraira narrated: “I heard the Prophet (peace be upon him) saying: Five practices are characteristics of the Fitrah: circumcision, shaving the pubic hair, cutting the moustaches short, clipping the nails, and depilating the hair of the armpits.”

(Khan 1996)

Ulama (Muslim legal scholars) have differing opinions on the compulsion of male circumcision within the Shari’ah (Muslim law) with some (the Maliki and the Hanafi schools) seeing it as Sunnah Mu’akkadah (not obligatory, but highly recommended) and others (Hanbal and the Shafi’i schools) maintaining that male circumcision is Fard (obligatory) for all Muslims.

For most Muslims, male circumcision is considered an act of obedience and submission to the will of Allah as well as a sign of belonging to the Muslim community. In addition, male circumcision constitutes an important ritual believed to carry a range of benefits in terms of personal hygiene, which is strongly endorsed within Islam (Gatrad and Sheikh 2008). In Muslim majority societies, male circumcision is thus an encouraged, accepted and valued religious practice often offered as part of routine pediatric care at public and private hospitals and clinics (Drain et al 2006). Little if any controversy is raised concerning the medical or ethical aspects of the ritual - a position in sharp contrast to the recent debates in a number of Western European countries with sizeable Muslim populations.

Male circumcision in Western Europe: from the 19th century to the present

Although male circumcision is deeply rooted in the history of monotheistic faiths, and thus has been present in Western societies for centuries, it only became a common medical procedure by the end of the 19th century (Darby 2003; Gollaher 2000). A range of medical problems and “social ills” were believed to be prevented or cured by male circumcision including masturbation, nervous system disorders and infections, and by the turn of the 20th century, infant male circumcision was nearly universally recommended by medical doctors in the UK (Alanis and Lucidi 2004).

With this, male circumcision in Europe moved from being primarily a religious ritual for specific religious communities (originally Jews and much more recently Muslims) to becoming justified by the believed beneficial health outcomes of the procedure thus expanding well beyond the religious communities engaged in this practice. After a period of mainstream acceptance and adoption of the procedure in medical practice, and sparked by the post-World War II reorganization of health systems, male circumcision became the subject of critical appraisal.

Concerns that risks of the procedure might outweigh the medical benefits were voiced e.g. by the British pediatrician Douglas Gairdner in 1949 (Gairdner 1949), and circumcision rates declined in Western societies most likely due to lack of coverage by national health insurance schemes care (e.g. in the United Kingdom) combined with the increasingly critical discussion amongst medical professionals and recommendations against routine infant circumcision (Alanis and Lucidi 2004).

Intensified debates on the permissibility of male infant circumcision in Europe

Whereas male circumcision in Muslim majority societies in present day continues to be widely accepted, and (medically as well as legally) appraised with reference to the Shari’ah as the primary tool for determining appropriateness of conduct, this frame of reference is lacking in Western societies placing Muslims and other religious and ethnic communities practicing male circumcision in a complex and challenging position with regard to justifying, and indeed being allowed to perform, this procedure.

Male infant circumcision performed for non-therapeutic reasons has invoked increasing controversy in particular in Denmark, Sweden and the Netherlands, and debates have intensified following a series of cases of severe complications of circumcision and a subsequent German court ruling deeming male circumcision equivalent to grievous bodily harm in June 2012 (Landesgericht Köln 2012; Morris and Tobian 2013). Overall, the lines of argument have centred on the four core principles of biomedical ethics governing physicians’ obligations towards patients - namely, autonomy, beneficence, non-maleficence and justice - that are ingrained into the overall legal framework regulating delivery and financing of healthcare services.

These principles are largely seen as detached from religious values and are therefore commonly framed within secular professional frameworks although they may, according to some scholars, be clearly identifiable in Islamic teachings (Beauchamp and Childress 2012; Chamsi-Pasha and Albar 2013; Padela 2013). More specifically, the practice of male infant circumcision is contested primarily based on ethical considerations related to protection of the child’s right to bodily integrity and self-determination, as well as on the medical risks associated with the procedure (Kristiansen and Sheikh 2013; Mazor 2013; Pinto 2012).

In the following, we present the main approaches taken by European Muslims to respond to the objections to male infant circumcision raised by advocacy groups, professional bodies and in some cases governments. Reference is made to developments and policies from the United States (US) when important for appraising the responses to male infant circumcision in Western Europe.

Medical risks and benefits

The most prominent stream of critique stems from clinicians and academics arguing based on their clinical experiences and scientific studies, that there is an elevated risk of a number of adverse health outcomes including bleeding, infection and decreased sexual functioning following male circumcision (Frisch et al 2013; Pinto 2012; Wheeler and Malone 2013). Opponents thus highlight the bioethical principles of non-maleficence and beneficence highlighting the obligation of doctors not to inflict evil or harm upon their patients; rather, their primary role is to preserve health and well-being of their patients (Beauchamp and Childress 2012; Chamsi-Pasha and Albar 2013). Evidence-based care is one of the most central pillars of contemporary discourses on medical interventions, and opponents argue that there is emerging evidence for more risks than benefits associated with the procedure which should have implication for clinical practice and policies.

This line of critique can be seen among a number of medical associations, including the British Medical Association and the Royal Dutch Medical Association that have engaged in a more critical discussion of the medical aspects of male infant circumcision for non-therapeutic reasons and revisions of their guidelines on the topic (Bates et al 2013; British Medical Association 2004; the Royal Dutch Medical Association 2010). The critique has also led to campaigns for a legal ban in several European countries and calls for withdrawal of health insurance coverage for male circumcision paralleling the development in several states in the US (Frisch et al 2013; Morris and Tobian 2013; Svobada 2014).

Although there is agreement on the part of medical professionals on the fundamental importance of appraising and incorporating emerging scientific evidence into healthcare policy and practice, there is at present considerable disagreement related to the quality and implications of the available scientific evidence pertaining to medical risks and benefits of male circumcision. The controversy revolving around the medical scientific rationale for male infant circumcision is reflected in intense debates in high-profile medical journals, and accusations have been made against medical associations who some find to be biased in their appraisal of the medical scientific rationale for male circumcision (Frisch et al 2013).

Different views of the evidence are reflected in the approaches taken by powerful international and national advocacy and professional bodies such as the WHO and the American Academy of Pediatrics that maintain that there is preventive and public health benefits associated with male circumcision (e.g. in reducing heterosexually transmitted human immunodeficiency virus infection) (Baker 2012; Morris et al 2014; Siegfried et al 2009; Singh-Grewal et al 2005; Task Force on Circumcision 2012). Muslim organizations, clinicians and academics of Muslim faith have joined in this line of reasoning by arguing for the health benefits of male circumcision (see e.g. Gatrad and Sheikh 2008), although the benefits in terms of hygiene and health outcomes are always presented as secondary to the religious aspects of the procedure.

There have also been attempts to challenge the comprehensiveness of existing scientific evidence by highlighting then need to expand the gaze beyond the physiological, preventive and sexual effects of circumcision to also include the psychological and social effects of male infant circumcision e.g. in terms of identity processes and feeling of belonging to religious communities (Kristiansen and Sheikh 2013; Mazor 2013; Yavuz 2012).

Arguing for male infant circumcision within a medical scientific paradigm does however present some challenging questions for Muslims to grapple with. If Muslims argue for the merits of male circumcision based on a scientific perspective, they need to decide on an appropriate and consistent line of response if emerging evidence shows either no overall benefit or finds that there is net harm of the procedure as currently practiced. In addition, and touching upon the bioethical principle of justice, is it reasonable to advocate that male infant circumcision should be available as a state provided service, in particular in the context of austerity and cost-containment within tax-based health systems?

Respect for religious diversity and human rights

A second stream of criticism against male infant circumcision highlights the child’s rights to bodily integrity and self-determination thus touching upon the biomedical principle of autonomy. These opponents of male infant circumcision have argued that the practice violates a number of international declarations and conventions including the Universal Declaration of Human Rights, the Convention on the Rights of the Child, the International Covenant on Civil and Political Rights, and the Convention Against Torture (Svoboda 2013).

In response to this second line of reasoning, and also drawing heavily upon human rights principles related to religious and cultural diversity, Muslims and others have pointed to the imperative of respecting individual values, autonomy and freedom of religious practice (see e.g. Collier 2012; Gatrad et al 2002; Kristiansen and Sheikh 2013; Mazor 2013). From this perspective, banning male infant circumcision is a violation of the United Nations Convention on the Rights of the Child Article 14 (2) stating the rights of parents to exercise parental choice on behalf of their child as well as Articles 8 and 9 of the European Convention on Human Rights stating the right to respect for family and private life and the freedom of thought, conscience and religion (Bates et al 2013; European Court of Human Rights 1950; United Nations Convention on the Right of the Child 1989).

Jewish communities have joined in this line of response by voicing their concern for a violation of the right to religious freedom. Examples of this consist of a letter sent from Shimon Perez to the president of the Council of Europe following their resolution entitled “The Children’s Right to Physical Integrity” as well as reactions from the Simon Wiesenthal Center condemning a Norwegian cartoon depicting male infant circumcision as a gross maltreatment of an infant boy (The Guardian 2013). In addition, an alignment between European-based Jewish and Muslim communities has been established based on an initiative by the Gathering of European Muslim and Jewish Leaders representing imams and rabbis in 25 European counties. This has resulted in a meeting between a delegation of Jewish and Muslim clerics and representatives of the Council of Europe discussing concerns for the rights to religious freedom (YNetNews 2014). Moreover, interfaith initiatives have discussed establishment of a public relations campaign addressing misunderstandings about male circumcision in Europe (The Hareetz 2012).

There are a number of unresolved issues for Muslims and other faith groups arguing for the permissibility of male infant circumcision from a religious diversity and human rights perspective. For example, what tensions may arise between parental choice vis-à-vis the child’s rights to religious freedom? Would postponing male circumcision to the age of maturity/adulthood be more ethically appropriate? And what are the grounds for opposing parental choice in relation to female genital mutilation (FGM) that is also practiced by some Muslims (and other communities) and which is equated by some critics with male circumcision?

Legal aspects and risk-reduction strategies

A final line of argument has sought to address the legal aspects of male infant circumcision and the likely implications of banning the practice. This reasoning acknowledges that the renewed debate over male circumcision in the West may have implications for millions of Muslims if legislation against male circumcision is adopted. This is no longer an unlikely outcome judging from the emotionally charged debates in certain countries with a small and/or new Muslim presence and the widespread attention of the general public, medical practitioners and politicians with strong voices (e.g. non-governmental organizations in Denmark, the Swedish Ombudsman for Children, Save the Children, and the Danish Medical Association) advocating for a legal ban on non-therapeutic male infant circumcision (Danish Medical Association 2014; Jurist 2013). Muslims have argued that the current discussions seem to fail to acknowledge the importance of practices building on deeply personal beliefs about the existential meaning with the human condition, and their resistance to change (Gatrad et al 2002; Kristiansen and Sheikh 2013).

Arguments revolve around the likelihood that banning practices stemming from deeply-held religious beliefs and identities may drive the practices underground, and that this may be associated with higher risks of adverse medical outcomes for infants. The rationale from a risk-reduction point of view is that by allowing male infant circumcision to be performed in the confines of established, high quality healthcare services, there is a better chance of ensuring appropriate management of risks associated with pain and complications following circumcision which will overall minimize adverse effects. By cautioning against a legal ban of male circumcision from a more pragmatic, risk-reduction approach, such voices seek to bring the complex decision-making processes of Muslim (and Jewish) families into the debates and thereby challenge the efficacy and rationale of legislation against religious practices based on an assumed shared interest in protecting the well-being of the individual child. Again, this line of reasoning raises a number of questions which need to be considered from an Islamic bioethical perspective. For example, should pragmatism be a first-line defense against restrictions on religious freedom? Would the same line of reasoning be appropriate when discussing FGM where one could argue that parents may find strategies to overcome the legal ban in many countries?

Islamic bioethics in the context of Muslim minority societies

As shown above, a range of criticisms have been raised in the course of the current debates on male infant circumcision in Europe. Muslims (and other faith groups) have responded with arguments resting on the assumed medical benefits, respect for religious diversity and human rights, and finally, arguments for risk-reduction strategies. Common to all these approaches is a reactionary and at times apologetic response rather than a more principled, proactive approach. The Muslim response thus seems to be lacking a coherent line of argument – be it medical, rights-based or legal – of how to continue male circumcision.

With Muslims dispersed across a range of countries that now rely on essentially secular frameworks when appraising the ethics and legal aspects of human behavior, Muslims in general and Islamic bioethicists in particular are faced with the complex task of speaking within as well as beyond the borders of the Muslim Ummah (community). Male circumcision represents a deeply rooted Muslim practice, but it is facing increasing criticism in particular in parts of Western Europe. Medical societies, policymakers and the general public most of whom are drawing on either secular frameworks or belonging to different faiths, are stakeholders within current debates which may – if not adequately engaged with – end in either a legal ban against male infant circumcision or severe restrictions on access to safe, high quality performance of the procedure within healthcare facilities.

Padela (2013) has called for a more clear distinction between Islamic bioethics concerned with the ethico-legal traditions of Islam based on studies of texts and doctrines on the one hand, and what he calls Muslim bioethics focusing on how Muslims engage with texts and doctrines when encountering medical challenges relating to core Islamic beliefs. We would add that more attention should be paid to the particularities of the situation faced by Muslims living within Western societies. The decision-making processes and behaviors of Muslim minorities are confined by legal frameworks which may be discouraging or even banning Islamic rituals/behaviors, such as male circumcision, thereby placing Muslims in particularly challenging positions with regard to their freedom of religious practice.

Even if no legislation against male circumcision is ultimately passed, encounters with medical practitioners are shaped by professional and societal discourses, and will therefore likely be shaped by perceptions running against what some perceive to be an unnecessary health risk (some even considering it to be child neglect or worse still abuse) rooted in religious beliefs that may seem strange and “foreign” in a secular, Western context (Kristiansen and Sheikh 2013). Adequately understanding and engaging with such lived experiences in Western European countries with sizeable Muslim populations requires continuous effort by Muslim scholars, medical practitioners as well as Muslim citizens who remain vital in ensuring respect for religious diversity and freedom of practice including the right to maintaining religiously engrained behaviors.

Healthcare delivery is framed by a range of contextual factors including public discourses on religious diversity, legislation regulating permissibility and financing of healthcare services, and negotiation of medical care in everyday clinical encounters. As such, it is a dynamic field comprised of various actors drawing on different – and at times – conflicting paradigms – in their appraisal of religious practices and their place within healthcare services. To adequately and coherently respond to the challenges arising in this diverse field, particularly in the context of non-Muslim societies, there is a need for a broad approach to Islamic bioethics encompassing all relevant ethical, legal and medical perspectives as well as the more anthropological dimensions of human behavior. Ethicists, lawyers, clinicians, academics and other stakeholders, need therefore to collaborate on developing lines of arguments and discuss responses that are firmly grounded in Islamic bioethics and that more proactively address the case of male circumcision than those sued hitherto as well as future challenges emerging in the field of biomedicine.

Conflict of interest

Both authors have published within the field of ethical and medical permissibility of male infant circumcision in Europe.




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