Parents can legally authorize surgical procedures in the best interests of their children.14, 57, 58, 59, 60 The AAP’s ethics committee and others support this contention,61, 62 as does Article 14(2) of the United Nations Convention on the Rights of the Child (UNCRC) 44/25 of November 20, 1989.63 Exceptions include failing to act in the interests of children and situations in which a medical procedure or withholding a medical procedure might cause serious harm. Because infant male circumcision is not prejudicial to the health of children but instead is beneficial, it also does not violate Article 24(3) of the UNCRC. This document does not refer to childhood male circumcision. If it did, then it is unlikely that the UNCRC would have as signatories almost all the Islamic states and Israel.64 Article 24(1) of the UNCRC calls on parties to agree to “recognize the right of the child to the enjoyment of the highest attainable standard of health and to facilities for the treatment of illness and rehabilitation of health. States Parties shall strive to ensure that no child is deprived of his or her right of access to such health care services.”63
Although some argue that a child has a right to “bodily integrity” and, thus, that circumcision of boys should be banned, discouraged, or at least delayed until he can decide for himself,65, 66, 67 others disagree64, 68, 69, 70, 71 based on several reasons, some of which are discussed later herein. One author argues that being circumcised boosts autonomy more than constraining it.72 Article 24(3) of the UNCRC seeks to abolish traditional practices prejudicial to the health of children.63Because infant male circumcision is not prejudicial to the health of children but rather is beneficial, it does not violate Article24(3).64 In fact, one commentator construed Article 24(3) as requiring circumcision.64 He pointed out that the tradition in countries that abstain from circumcision can, in fact, be judged as being prejudicial to the health of children.64 He used as an example the increased risk in sexually active minors of acquisition and transmission of potentially fatal oncogenic human papillomavirus genotypes and HIV.
Most parents care deeply for their children and try to do what is best for them. The AAP recommended development of unbiased educational material and that physicians routinely discuss the circumcision decision with parents early in a pregnancy. Fully informed parents might likely choose to have their baby boy circumcised.73 It has been argued that parents who are opposed—even after being fully informed—would seem to place greater value on preserving the foreskin than in protecting their child against the harms, to the boy and his future sexual partners, of the uncircumcised state.64Nevertheless, some parents may refrain out of respect for cultural traditions or perhaps religion; others out of a philosophical position of opposing anything other than the natural state or the acceptance of the alternative views of opponents. Regardless, the decision of parents who refuse should be respected and accepted.
Arguments by opponents start with the premise that circumcision of males has no benefits, only harms, or that the benefits only apply later in life when the male can make the circumcision decision for himself.66, 74 Table 4 shows that benefits apply in the early pediatric period and extend all the way through life to the geriatric period. Problems in uncircumcised elderly men, especially in nursing homes, are underrecognized and need more attention and research. Another claim is that circumcision diminishes sexual function, sensitivity, and pleasure.67, 74, 75 A recent exhaustive systematic literature review76and a meta-analysis77 found either no adverse effect or an improvement in these parameters as a result of circumcision.
Parents and physicians each have an ethical duty to the child to attempt to secure the child’s best interest and well-being.78Because the benefits outweigh the risks and the procedure is safe (Table 4), circumcision might be seen in the same light as other interventions that parents must choose for their child. It is the duty of states to create conditions necessary for the fulfillment of rights to good health by facilitating the availability of interventions that are beneficial. Logically it can be argued that should include male circumcision.79 Ethically, infant male circumcision seems to fall within the prerogative of parental decision making.71 A landmark review a decade ago noted that most decisions made by parents for their children will likely have a more profound effect on them than the presence or absence of a foreskin.80
The timing of circumcision is crucial. Medical and practical considerations strongly favor the neonatal period (Table 4).16Surgical risk is, thereby, minimized and the accumulated health benefits are maximized.14, 16 If circumcision is not performed, one of the benefits potentially lost is protection against urinary tract infections that in infancy may lead to kidney damage (see the recent review by Morris and Wiswell17). Those who argue that circumcision can be delayed so that the boy can make up his own mind when older might not have considered that the operation on mature genitalia is not as simple as the surgery on a baby boy’s penis. Delay may result in increased cost, a higher risk of complications, anesthesia risk if a general anesthetic is used (as is more likely), a longer healing time, a poorer cosmetic outcome should sutures be used, a requirement for temporary sexual abstinence, interference with education or employment, and loss of opportunity for, or delay in, the achievement of protection from STIs for those who become sexually active early and for those who ignore advice on abstinence, thereby exposing them to increased risk of STIs during the 6-week healing period.14, 16 Thus, it is disingenuous to suggest that the procedure is comparable at both ages.64 Furthermore, an adult cannot consent to his own infant circumcision.64
Many nations that condemn childhood male circumcision are not as quick to condemn other comparably invasive and dangerous procedures that have no medical benefit,64 eg, cosmetic orthodontia, correction of harelip, surgery for tongue-tie, growth hormone injections for treatment of dwarfism, and removal of supernumerary digits.64 Thus, as stated byJacobs,64 it seems odd that neonatal male circumcision is regarded by some as controversial.
As far as the law is concerned, there is a view that the legal system has no place interfering in medical practice when it is based on evidence except to ensure that professionals always act responsibly.