On remedicalisation: male circumcision in the United States and Great Britain
Address for correspondence: Laura M. Carpenter, Department of Sociology, Vanderbilt University, VU Station B, Box 1811, 2301 Vanderbilt Pl, Nashville, TN 37235, USA
This paper compares the histories of male circumcision in the United States and Great Britain to explicate the theoretically important, yet inadequately specified, processes of demedicalisation and remedicalisation. Circumcision became medicalised to a similar extent, through similar processes, in both countries before World War II. However, by the 1960s, circumcision was almost completely demedicalised in Britain and almost universal in the US, where it became partially demedicalised after the 1970s. Medical professionals and insurance/healthcare systems drove demedicalisation in both countries; in the US, grassroots activists also played a critical role, while medical community ‘holdovers’ and parents resisted demedicalisation. Recent research linking circumcision to HIV prevention and deaths following religious circumcision are differentially likely to produce remedicalisation in the two nations, given differences in circumcision prevalence, HIV epidemiology, insurance/health systems, activism opportunities, and status of religious groups. Research on (de/re)medicalisation should theorise the life cycle of medicalisation, explore comparative cases, and attend more closely to medical holdovers from previous eras, prevalence and duration of medicalised practices, and barriers to promoting non-medical interpretations.
Since the late 19th century, an increasing number of human problems have been defined and approached in medical terms – from dying in the early 1900s to alcoholism in mid-century to erectile difficulties in the 1990s. This process, known as medicalisation, also works in reverse. Problems once under medical jurisdiction may come to be seen in other ways, as when late-19th century views of masturbation as a disease requiring medical intervention were supplanted in mid 20th century by understandings of masturbation as a normal part of sexual development. Yet, because instances of complete or nearly complete demedicalisation are rare, and examples of remedicalisation rarer still, the theoretically important concepts of demedicalisation and remedicalisation have not been adequately specified. What forces make demedicalisation more complete? Under what conditions, and for what kinds of problems, is remedicalisation likely to occur? Answering these questions is critical, given expanding medical costs, widespread concern that Western societies are becoming ‘overmedicalised’, and calls for health policy transformation.
This study compares the cases of male circumcision in the United States and Great Britain to delineate the conditions under which demedicalisation and remedicalisation are likely to occur. Historically circumcision was practised almost exclusively by Jews, Muslims, and certain African cultures for religious/ritual reasons. During the 19th century, British and US physicians increasingly came to see masturbation and the foreskin as disease-inducing – and circumcision as a potential cure (Gollaher 2000). By 1940, about 40 per cent of British boys and 60 per cent of US boys were circumcised as a preventive health measure (Darby 2005b, Laumann et al. 1997). After World War II, circumcision rapidly fell out of favour in Britain; today about six per cent of British boys are circumcised, most in accordance with Jewish or Muslim tradition (Roehr 2007). In the US, however, circumcision for preventive health and/or social reasons increased, reaching a rate of about 95 per cent in the late 1960s, then declining to about 65 per cent by 1999 (Gollaher 2000). These different trajectories – almost complete demedicalisation in Britain but only partial demedicalisation in the US – have set different stages for possible remedicalisation of circumcision and the foreskin, pursuant to recent studies linking circumcision to reduced HIV transmission and deaths following ritual circumcision.
This article asks: What factors contributed to the differential demedicalisation of circumcision in the US and Britain? To what extent may recent developments lead to remedicalisation of circumcision in the two countries? What general insights can this comparison offer into (de/re)medicalisation dynamics?
According to Conrad (1992: 211), ‘Medicalisation consists of defining a problem [not previously seen as medical] in medical terms, using medical language to describe a problem, adopting a medical framework to understand a problem, or using medical intervention to “treat” it’ [my emphasis]. At the conceptual level, medicalisation entails defining problems through medical vocabulary. Institutional-level medicalisation occurs when organisations adopt medical approaches to treating particular problems. At the interactional level, physicians may medically diagnose a patient’s problem or offer a medical treatment (e.g. tranquilisers) for a ‘social’ problem (e.g. unhappy family life).
In one sense, ‘medicalisation of circumcision’ refers to the processes whereby a procedure – cutting away most/all of the male foreskin – performed for ritual purposes was adopted as a preventive health measure. The increasing tendency of US and British Jewish parents to have their sons circumcised by medical rather than religious practitioners represents medicalised circumcision in this sense (Carlowe 2006). The medicalisation of circumcision can also refer to defining the foreskin in medical terms, as a potentially or inherently disease-inducing body part that may be treated/cured surgically (i.e. by circumcision). Nineteenth-century physicians medicalised circumcision in this manner. Circumcision has been medicalised primarily at the conceptual and institutional levels (similar to breast implants or medical birth control) rather than via one-on-one diagnoses in medical encounters (like Attention Deficit Hyperactivity Disorder), although individual physicians may propose circumcision to solve a patient’s ‘problems’.
Accordingly, demedicalisation of circumcision would entail reverting to an understanding of circumcision as a religious rather than a health practice and/or to a view of the penis/foreskin as not prone to disease (or in need of medical treatment). Remedicalisation denotes the revival of medical understandings of a condition that has previously been demedicalised.
Medicalisation, demedicalisation, and remedicalisation
From the late 1800s onward, the general tendency has been to shift from defining ‘problematic’ behaviours and attitudes as sinful to criminal to medical (Fox 1977). Some scholars contend that these processes have extended to virtually every aspect of human existence (Illich 1975), while others find such claims to be exaggerated (Fox 1977, Strong 1979). Clarke and colleagues (2003) argue that recent technoscientific changes have given rise to a new phenomenon, biomedicalisation. This concept has been critiqued as overly inclusive and for treating the expansion and morphing of medicalisation as quantitative rather than qualitative changes (Conrad 2005).
Individuals and groups benefit from medicalisation insofar as being ‘ill’ is generally viewed more sympathetically than being ‘sinful’ or ‘bad’. Medicalisation has also helped to relieve human suffering, as when medical definitions of childbirth enabled women to receive welcome pain relief (Riessman 1983). On the downside, medicalisation tends to pathologise everyday life and experiences (e.g. shyness), narrow the range of behaviour deemed acceptable, emphasise individual rather than social causes for problems, and enrich the pharmaceutical and biotechnology industries (Conrad 2007).
Some conditions, like severe mental illnesses, are almost completely medicalised in the contemporary West, while others, like Chronic Fatigue Syndrome and gambling addiction are (respectively) only partly or minimally medicalised (Broom and Woodward 1996, Conrad 2007). Traces of previous, non-medical definitions may persist; competing definitions may exist; and certain aspects or cases of a condition may elude medical definition. For example, the holistic health movement encompasses trends consistent with both demedicalisation (placing responsibility for health primarily on individuals, flattening practitioner-client hierarchies) and medicalisation (framing health as pervading every aspect of life) (Lowenberg and Davis 1994). Medicalised categories can also expand and contract, as exemplified in attempts to extend biophysical sexual dysfunction diagnoses from men to women (Loe 2004).
Despite an overall trend towards medicalisation, the process is not unidirectional. Conditions that have come to be understood in terms of health and illness can (theoretically) be redefined again in non-medical terms. Fox (1977) conceptualises this as a cyclical ‘medicalisation-demedicalisation process’. Yet, homosexuality and masturbation are two of the only documented examples of complete demedicalisation (Conrad and Angell 2004). Partial demedicalisation occurs more often, as with disability, currently understood through both medical and social models (Linton 1998). Remedicalisation – reverting to medical understandings of an erstwhile-demedicalised condition – is rarer still.
Through most of the 20th century, medicalisation was driven primarily by three forces. The medical profession, already possessed of considerable power and authority, has worked to expand its influence and professional dominance, as when radiologists’‘discovery’ of child abuse enhanced their position and authority. Social movements and interest groups have promoted (and protested) the medicalisation of their experiences, as when the Alcoholics Anonymous movement lobbied reluctant physicians to view alcoholism as a disease. Competition and collaboration among inter- and intraprofessional groups has also encouraged medicalisation, as when discrediting midwives helped early 20th century obstetrician-gynecologists to secure authority over childbirth (Conrad 2005, Fox 1977).
Since the 1980s, major social and medical developments have activated several new engines of medicalisation. The rise of neo-liberalism, a free-market ideology promoting economic privatisation, has weakened public health and healthcare delivery infrastructures and encouraged deregulation (and expansion) of the pharmaceutical and biotechnology industries (Wills et al. 2008). The resulting emphasis on profit encourages medicalisation, as when new drugs become ‘treatments in search of illnesses’ (exacerbated in the US by legalised direct-to-consumer pharmaceutical marketing) (Conrad 2005). In the US, profit orientation led to managed care systems, which (dis)encourage medicalisation insofar as they reimburse some diagnoses and treatments while limiting coverage of others, typically based on cost effectiveness (e.g. directing psychiatric treatment from talk therapy to pharmaceuticals) (Conrad 2005). Some commentators predict that Britain’s National Health Service (NHS) will move in this direction. Neoliberal processes, with their ethics of active citizenship and maximisation of health/potential, have, moreover, helped produce new forms of collective identification – what Rabinow (1996) calls biosociality – around diseases/conditions, which in turn promote activism and changes in practices. In combination with changing demographic and epidemiological conditions, neo-liberalism fosters health consumerism, whereby ‘choice, self-management and active engagement in health become features of a restructured patient role’ (Bury and Taylor 2008: 201). Consumers’ increasing agency in demanding particular treatments (e.g. the cosmetic surgery boom; groups establishing websites demanding medicalisation of particular conditions), and companies’ and providers’ responses to those demands, have greatly encouraged medicalisation (Conrad 2005).
Factors that tend to constrain, or potentially reverse, medicalisation coexist with factors that encourage it (Fox 1977). These include lack of support from medical professionals; the erosion of medical authority; recognition that medical interventions do improve some human lives; group and individual challenges to medicalisation, including non-medical definitions of conditions; increasing power of groups whose experiences and/or identities have been medicalised (e.g. women, gays); non-availability and unprofitability of treatments; discovery of etiologies antithetical to medicalisation; and costs of medical care and limits on insurance coverage (Conrad 2007, Fox 1977, Strong 1979). Williams (2001: 144) in particular cautions against treating medicine ‘as a homogeneous body of “like minded” practitioners’ and assuming that all doctors and segments of the medical profession have ‘interest or enthusiasm about the possibilities of “expanding its empire” still further…particularly in the current clinical, economic, social and political climate’.
Medicalisation processes are shaped by gender, social class, and racial/ethnic relations. Women have arguably been more subject to medicalisation than men, given such factors as the greater visibility of female biological processes, which facilitates intervention and control (Riessman 1998). Yet, recent responses to erectile difficulties (Loe 2004) and baldness (Szymczak and Conrad 2006) suggest that men may be catching up. An early instance of male bodies being medicalised, circumcision offers an interesting case for exploring gender and medicalisation. Historically, racial/ethnic minorities have been disproportionately subject to medicalisation (Hickey 2006). Social class privilege enhances individuals’ and groups’ ability to embrace or resist medicalisation (Riessman 1998).
(Re/De)medicalisation empirically examined
Because demedicalisation seldom occurs, de- and remedicalisation are rarely studied and are undertheorised. One of the few detailed studies is Conrad and Angell’s (2004) analysis of homosexuality. Prior to the 1870s, people who had sex with same-sex partners were considered sinful and/or deviant and subject to punishment by church and state. In the late 1800s, Kraft-Ebbing and other physicians responded to such criminalisation and repression by arguing that homosexuality was not acquired but congenital, thus meriting therapeutic treatment (Conrad and Angell 2004). By the 1940s, many US Freudians viewed homosexuality as a mental illness curable through psychiatric treatment. Homosexuality’s inclusion in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM) in 1952 and 1968 marked the apex of its medicalisation.
The medicalisation of homosexuality was never undisputed, but demedicalisation did not begin in earnest until the late 1960s, when the gay liberation movement challenged the medical view by touting ‘gay pride’, publicly disrupting academic conferences, and actively negotiating with the committees revising the DSM (with some psychiatrist allies). In 1974, APA elected to remove homosexuality in the absence of distress/guilt from the DSM-III, effectively ‘vot[ing] the disease of homosexuality out of existence’ (Conrad and Angell 2004: 33). Decisive factors in this case of demedicalisation were medical professionals and grassroots activists allied against medical definitions and the growing power of the gay, lesbian, bisexual, transgender, and queer (GLBTQ) community.
Subsequent developments have had the potential to remedicalise homosexuality. Psychiatric professionals (including numerous holdovers from the medicalisation phase) have established the small but well-connected National Association for Research and Therapy of Homosexuality, which traces homosexuality to unhealthy childhood development and promotes conversion therapy, and developed the Gender Identity Disorder diagnosis. These developments have not yet led to remedicalisation, partly due to psychiatry’s increasing focus on conditions amenable to pharmaceutical therapies. Attempts to increase surveillance of gay and bisexual men in the wake of the HIV/AIDS epidemic also threatened to remedicalise homosexuality; in practice, however, this has not occurred, due largely to resistance from an increasingly powerful GLBTQ community. The shift from constructivist to biological explanations of homosexuality within GLBTQ circles and search for the ‘gay gene’ also pose the (unfulfilled) possibility of remedicalising homosexuality, part of a general shift from psychiatric to genetic rationales for medicalisation (Conrad and Angell 2004). Here, advocacy by a minority within medicine has failed to foster remedicalisation, not least because of resistance by the GLBTQ community, even as the rise of genetics retains the potential to reinvigorate medical understandings of homosexuality (Conrad and Angell 2004).
Medicalisation and demedicalisation of circumcision in two nations
The medicalisation of circumcision/the foreskin in Britain and the US occurred through similar processes and over the same period, but the timing and extent of demedicalisation have differed dramatically. Comparing the trajectories of circumcision in the two countries can, therefore, provide insight into (de)medicalisation dynamics.
My analysis draws on published histories of circumcision, materials from US and British medical associations and activist organisations from 1930 to the present, and news stories, editorials, and letters to the editor mentioning circumcision from ten US and ten British newspapers, chosen to represent diverse regions and editorial stances, from 1985-2007.1 (The news sample includes over 850 articles, 15 editorials, and 165 letters.) To analyse these data, I employed modified grounded theory (Charmaz 2006), allowing salient themes to emerge from repeated perusals of the data.
Medicalisation of circumcision: parallel developments in Britain and the US
Before about 1870, Britain and the United States followed the dictates of early theologians like Saints Paul and Augustine, who decreed that Christian men need not be circumcised, although Jesus was (Glick 2006).2 Eighteenth-century Britons associated circumcision with people from ‘alien’ cultures like Jews and Moors; regarded it as aesthetically disfiguring and emasculating; and were horrified by (well-documented) tales of Islamic captors circumcising British soldiers (Darby 2005b).
Eighteenth-century physicians’‘discovery’ that masturbation, already condemned by religious leaders, caused organic disease (e.g. Tissot’s Onanism ) and the belief that loss of sperm due to excessive ejaculation (spermatorrhea) compromised health were key preconditions for popularising circumcision in the 19th century (Darby 2005b, White 1993). Believing that secretions under the foreskin caused problem-provoking irritation, French physician Claude-Francois Lallemand became the first to promote pre-emptive circumcision in children, circa 1836-1842 (Darby 2005b). His advice went unheeded, however, until leading advocates of nerve force theory – which posited that irritation in one part of the body could produce pathologies in distant parts – applied their framework to the foreskin (Gollaher 1994). In 1870, US physician Lewis Sayre reported successfully treating hip-joint disease and paralysis, caused in his view by genital irritation, through circumcision (Gollaher 1994). His disciple, Norman Chapman, and physician/public health official Peter Charles Remondino subsequently touted circumcision as a preventive measure. Britain’s Nathaniel Heckford published results similar to Sayre’s in 1865, attracting little attention (Gollaher 1994); but leading British surgeons popularised Sayre’s work in the 1870s (Darby 2005b).
Even as circumcision came into medical favour, the rationale for performing it shifted. The rise of germ theory undermined arguments that circumcision could cure nervous disorders but recommended preventing disease by removing the ostensibly germ-harbouring foreskin (Darby 2005b). By the 1880s, physicians were treating venereal disease and cancer with circumcision (Gollaher 1994). In 1890, John Billings claimed that circumcision was responsible for lower rates of syphilis and cancer among Jews than Gentiles (Glick 2006). Victorian parents favoured circumcision’s purported ability to curb masturbation (Gollaher 1994).
Though few adult men chose to be circumcised (not surprisingly), circumcision in infancy/childhood became increasingly popular from the 1880s onward. Taking a preventive measure against disease and masturbation in youth seemed advisable, and infants could neither protest nor were thought to need anesthesia (Gollaher 1994). Moreover, it was widely (if incorrectly) believed that foreskins not retractable shortly after birth represented ‘congenital phimosis’, curable via circumcision (Darby 2005b). Performed by physicians for a fee, circumcision became a mark of class distinction. In Britain, public schools’ anti-masturbation campaigns popularised circumcision among upper-class boys (Darby 2005b). In the US, circumcision separated native-born Whites from southern and eastern European immigrants (Gollaher 2000) and expanded with the shift, primarily among well-off Whites, from home births with midwives to hospital births with physicians (Gollaher 1994).
Ironically, although virtually every medical theory supporting circumcision for preventive health was discredited after World War I, it continued to gain in popularity (Darby 2005b; Gollaher 1994). Child-rearing guides and social purity activists extolled circumcision (Darby 2005b). By the mid-1930s, nearly 60 per cent of US boys and 40 per cent of British boys were circumcised, with rates significantly higher among urbanites and the well-to-do (Darby 2005b, Laumann et al. 1997).
Demedicalisation in Britain
Despite its growing popularity, circumcision never achieved unanimous support from British medicine (Darby 2005b). Prominent sceptics always existed, including cancer surgeon Herbert Snow, who denounced circumcision as ‘barbarity’ in 1890. Numerous physicians voiced concerns about excessive blood loss and complications due to poor surgical technique, prompting the development, by the 1930s, of non-surgical cures for congenital phimosis, a condition whose existence some doctors disputed (Darby 2005b). In 1932, a methodologically sophisticated study undermined another rationale for circumcision, finding similar rates of sexually-transmitted infections (STIs) across circumcision status (Lloyd and Lloyd 1934). Medical concern with masturbation was also dissipating, thanks to new views of sexuality as positive rather than as demanding control (D’Emilio and Freedman 1988). In 1935, the merits of childhood circumcision were debated in the Correspondence pages of the British Medical Journal (BMJ) ‘with almost religious fervour’ (5 October 1935). Nine authors primarily supported the procedure (e.g.‘I am unrepentant, for never have I had a complaint as regards ill after-effects’; 12 October 1935), twelve opposed it (e.g.‘Circumcision is, and always was, a tribal rite, and has no place in surgery’; 7 September 1935), and two took mixed/neutral stances.
When architects of the National Health Service (NHS) decided how funds should be allocated in 1948, they declined to cover routine circumcision, lacking definitive evidence of its medical efficacy (Gollaher 1994). The following year, BMJ published Gairdner’s (1949) landmark study demonstrating that separation and retraction of the foreskin usually occurred gradually – thus congenital phimosis was a myth – and noting that penile cancer was rare and evidence about syphilis inconclusive. An accompanying editorial declared that there was ‘little medical justification for routine circumcision of the infant’. Subsequent correspondence in the BMJ suggests that opposition to preventive circumcision had increased after 1935, with three physicians writing to support the practice, three taking mixed or neutral stances, and nine condemning it. One of the latter noted that ‘the NHS Act has “killed”, or at least largely reduced, routine circumcision. If so, that is one good mark for the Act’ (14 January 1950). The popular press showed little interest in these debates; neither the London Times nor Guardian published any articles about male circumcision between 1920 and 1960, despite regularly addressing female ‘circumcision’ (today called female genital cutting (FGC) or mutilation) in Britain’s African colonies. In 1985, Britain became one of the first Western nations to ban FGC (Boyle 2002).
Rates of circumcision fell rapidly, from 33-40 per cent of British boys in the 1930s, to 20 per cent by 1949, 10 per cent by 1963, and six per cent by 1975 (BMJ 1979). Many medical leaders contended that Gairdner ‘had a great deal to do with influencing opinion against routine circumcision, and his paper on this subject is still unexcelled’ (BMJ 1959: 445, see also BMJ 1979). Scholars such as Gollaher and Darby – as well as many activists – have attributed the decline in part to the NHS’s refusal to cover prophylactic circumcision.
Other factors also may have contributed to, or helped to perpetuate, demedicalisation. No British medical association formally recommended circumcision and, despite publishing numerous pro-circumcision articles from 1870-1949, neither the BMJ nor the Lancet endorsed the practice. (Granted, rank-and-file physicians do not always embrace government and professional associations’ pronouncements, see Williams and Calnan 1994.) Nor did British physicians reach agreement on the best technique or optimal timing for circumcision; early childhood was common but not universal (Darby 2005b). By contrast, in the US, circumcision immediately after birth in hospital – where 36.9 per cent of births occurred by 1935 and 75.6 per cent by 1944 (Devitt 1979) – rapidly became the norm (Gollaher 2000). (In Britain, one-fourth of births took place in hospital in 1937, two-thirds by 1960 (Beinart 1990).) The first wave of the British natural childbirth movement, from about 1933-60, implicitly discouraged circumcision by contending that ‘pregnancy and parturition were not pathological processes’ (Moscucci 2003: 169) and opposing overuse of technological interventions in childbirth (Kitzinger 1990); these tendencies were reinforced in the movement’s second wave, from the 1970s onward.
Currently, NHS covers circumcision only for medical reasons, in about one per cent of males; another five per cent of boys are circumcised for religious reasons (Roehr 2007). The 1996 British Medical Association (BMA) guidance on circumcision states: ‘To circumcise for therapeutic reasons where medical research has shown other techniques to be at least as effective…would be unethical and inappropriate’.
Partial demedicalisation in the US
In the US, by contrast, Gairdner’s paper was largely ignored and circumcision for preventive health grew in popularity. Critically, the private insurance system allowed individual doctors and parents to decide whether circumcision was warranted (and reimbursed those doctors performing it) (Gollaher 2000). Armed forces physicians promoted circumcision for STI prevention during World War II (Gollaher 2000) and medical professionals’ efforts, ongoing since the 1880s, to popularise circumcision among African Americans in order to reduce syphilis rates and alleged ‘promiscuity’ were stepped up after World War II (Hand 1949). By the mid--1960s, more than 90 per cent of US boys were circumcised (Laumann et al. 1997), almost all in infancy, making the medicalisation of circumcision far more complete – and uniformly executed – in the US than Britain.
American physicians began questioning the medicalisation of the foreskin/circumcision in the anti-authoritarian 1960s (Gollaher 1994). In 1963, an editorial in JAMA (Journal of the American Medical Association) asked why circumcision was so widely accepted, lacking empirical evidence of its effectiveness. In 1969, a New England Journal of Medicine article posited that routine circumcision and tonsilectomy both violated medicine’s ‘do no harm’ ethic, as neither had proven medical benefits (Bolande 1969). Responding to such critiques, in 1971, the American Academy of Pediatrics (AAP) released its first policy on circumcision, stating: ‘there are no valid medical indications for circumcision in the neonatal period’. Internal dissent prevented AAP from publicising this position, however; and other medical associations (e.g. American College of Obstetrics and Gynecology) took a ‘benefits and disadvantages’ approach (Gollaher 1994). In 1976, popular child psychologist Dr. Spock, once a circumcision proponent, condemned it (Gollaher 1994).
Declining medical support for circumcision, combined with a natural childbirth movement that opposed most medical intervention in birth and infancy, and increasing immigration from countries where circumcision is uncommon, contributed to circumcision’s decline. The growing recognition, from the 1970s onward, of children’s rights to protection and self-determination may also have discouraged circumcision, although children’s rights organisations have not embraced it as an issue (Walker et al. 1999). Based on a survey of families in ‘natural’ childbirth preparation classes, 62 per cent of whom chose to circumcise their sons, primarily to resemble other males or for religious reasons, Brodbar-Nemzer et al. predicted ‘a gradual erosion of the social norm of circumcision’ (1987: 278). In effect, social and religious reasons persisted but medicalisation was on the wane.
Still, circumcision remained common enough in the mid-1980s to inspire organised opposition. The first US anti-circumcision grassroots group, National Organization of Circumcision Information Resource Centers (NOCIRC), was founded in 1986 by Marilyn Milos, a registered nurse who was ‘shocked’ by circumcised infants’ suffering (Atlanta Journal-Constitution, 13 May 1997). Hoping to put an end to routine circumcision throughout the US, NOCIRC and likeminded organisations worked to publicise circumcision-related accidents, such as an incident in which inappropriate techniques cost two Atlanta boys their penises (New York Times, 8 October 1985), and the results of scientific research refuting ‘conventional wisdom that newborn boys feel no pain during circumcision’ (Seattle Times, 8 December 1986). Activists also strove to frame circumcision in non-medical terms, as a gender equity or human rights issue, often comparing it to female genital cutting (FGC), a practice increasingly condemned in the 1980s and criminalised in 1996 (Boyle 2002). Anti-FGC activists have been reluctant to support anti-circumcision groups, however (Carpenter 2009). Starting in the mid-1980s, some major health insurers – arguably concerned primarily with containing costs – ceased coverage of circumcision.
Continued efforts by some physician-researchers to demonstrate circumcision’s benefits and lobby for policy changes led to a new AAP position in 1989, stating that ‘newborn circumcision has potential medical benefits and advantages as well as disadvantages and risks’. The current policy, from 1999, reiterates this renewed support for medicalisation, acknowledging ‘potential medical benefits’, but explicitly declining advocacy: ‘these data are not sufficient to recommend routine neonatal circumcision’. Thus, from a high of 95 per cent in the mid-1960s, circumcision rates fell to about 65 per cent by the late 1990s (Darby 2005a). Financial incentives to perform circumcisions persist, however, insofar as physicians receive compensation for each operation; these fees for service may be especially attractive to physicians whose income is limited by health maintenance organisations (HMOs). The partial demedicalisation of circumcision has been stemmed, but not reversed.
The potential remedicalisation of circumcision
Two recent developments have the potential to forestall further demedicalisation of male circumcision in the US and to promote remedicalisation in both countries: research linking circumcision to reduced rates of HIV transmission in Africa and highly-publicised deaths following circumcision by ritual practitioners.3
HIV/AIDS and circumcision
Early in the HIV/AIDS epidemic in Africa, researchers noticed that circumcised men were infected with HIV at lower rates than their uncircumcised brethren (Marx 1989). Some saw this as evidence that circumcision could prevent HIV, while others noted that circumcision was associated with other factors, such as Islamic beliefs, that prompted relatively conservative sexual behaviour – ostensibly the factor underlying observed differences. Randomised clinical trials of circumcision began in the early 2000s in Kenya, Uganda, and South Africa. In 2000, researchers discovered that the foreskin’s inner surface is dense with cells that facilitate HIV transmission, lending credence to claims that infection/circumcision patterns could result from biological factors (New York Times, 11 July 2000).
By 2005, the clinical trials were finding HIV rates 50-60 per cent lower among men in the circumcision groups than men in the control groups (Auvert et al. 2005).4 The medical community’s response was hopeful but guarded. At the 2006 international conference on AIDS, circumcision advocates argued that ‘new HIV infections in men could be substantially reduced and million of lives saved if [circumcision] were to be introduced’ while sceptics emphasised that ‘[circumcision] will not be the quick fix…unless cultural beliefs [about its acceptability] are included in the equation’ (BMJ 2006: 333, 439). Others cautioned that men might engage in riskier behaviour, thinking themselves fully protected by circumcision (i.e. disinhibition), and stressed the need to place circumcision in a comprehensive anti-HIV strategy.
Also in 2005, US-based activist group Mgmbill.org (founded in 2003; MGM stands for Male Genital Mutilation) began lobbying the United Nations (UN) to oppose circumcision as a human rights violation (the grounds under which it condemns FGC) unless it is chosen by a fully-informed, consenting adult. Mgmbill.org addressed the African findings:
Although some new studies suggest that circumcision may reduce susceptibility to HIV and penile cancer later in life, those findings are not a valid reason to amputate a healthy, functioning body part of a child…. Doctors don’t cut off the breasts of baby girls to help prevent breast cancer, either (http://mgmbill.org/faq.htm).
The UN did not respond. In fact, the World Health Organization (WHO) and UNAIDS, despite initially ‘refus[ing] to endorse [circumcision] as a prevention tool until more evidence is produced’ (BMJ, 26 August 2006), by March 2007 recommended ‘scaling up’ circumcision in countries with high rates of heterosexual HIV infection and low rates of circumcision. Kevin DeCock, WHO’s HIV/AIDS director, urged that circumcision ‘be recognised as an additional important intervention to reduce the risk of heterosexually acquired HIV infection in men’, provided adequate medical safeguards are offered at low/no cost as part of ‘a comprehensive package of HIV prevention’ (WHO/UNAIDS 2007).
Cautious optimism marked US medical and policy-maker responses as well. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, declared that adult circumcision ‘could be an important addition to an HIV prevention strategy…. However, it is not completely protective and must be seen as a powerful addition to…other HIV prevention methods’ (Roehr 2007). A 2007 editorial in PLoS Medicine said recommending circumcision for HIV prevention in the US was premature, given ‘the many differences between the underlying HIV epidemics in Africa and the US’ and lacking evidence that circumcision can prevent HIV transmission between men (a major vector in the US) (Sullivan et al. 2007). (Nor would circumcision prevent transmission through injection drug use.) HIV/AIDS activists expressed greater caution. Julie Davids, executive director of the Community HIV/AIDS Mobilization Project, said, ‘The US has a healthy HIV epidemic and high rates of circumcision, so I would caution against reading too much into the studies’ (Roehr 2007).
Reactions in US popular media have been more enthusiastic. One typical editorial – ambiguous as to whether African interventions should extend to the US – read: ‘AIDS policy makers should be discussing how to promote circumcision so they can be ready to act immediately if the Kenya and Uganda studies confirm the good news in South Africa’ (New York Times, 15 October 2005). In popular discourse, the African studies are being used to justify the existing medicalisation of circumcision. Anti-circumcision activists have responded by emphasising human rights and other non-medical arguments, as well as disinhibition and limits to protection. Some critics have denounced circumcision campaigns as an attempt to medicalise Black men’s bodies (Ferris n.d.): ‘[A]re poorer African men more expendable to such research and easier to coerce into needless surgery? This can easily be viewed as a colonial undercurrent.’ Some journalists criticised ‘anti-circumcisionists’ for their continued opposition:
When [HIV-prevention] evidence from Africa defied them, they changed the subject to Europe. When evidence from Europe defied them, they changed the subject again.... The strongest argument against circumcising babies to prevent HIV is that they’re too young to consent. But we vaccinate babies all the time (Washington Post, 20 August 2006).
Findings from the African trials (and lobbying within the medical community) helped prompt AAP’s 2007 decision to reevaluate its 1999 policy (Konrad 2007). Were the AAP to declare definitively that circumcision was medically beneficial, or were enough parents/consumers to raise enough commotion, insurers who have stopped covering circumcision might reinstate coverage – effectively rolling back one source of demedicalisation.
British medical and policy communities have supported circumcision in Africa but expressed little interest in pursuing circumcision in Britain. The National Aids Trust’s Deborah Jack allowed that ‘the promotion of voluntary circumcision can play an important role in reducing the risk of HIV transmission’, but stressed ‘any awareness campaign would have to be extremely careful not to suggest that [circumcision]…is an alternative to using condoms’ (Laurance 2006). Peter Baker of Men’s Health Forum emphasised the ‘important human rights issue about circumcising babies or boys who are clearly unable to give informed consent’ (Roehr 2007). Many commentators noted that high circumcision rates had not prevented HIV from spreading in the US – implying that (re)adoption of circumcision might have little effect in Britain.
Not all Britons are so cautious, however. A longtime circumcision advocate, London Times health columnist Dr. Thomas Stuttaford framed the HIV-circumcision studies as cause for (re)popularising circumcision in Britain, as did the Orchid Cancer Appeal’s Tim Oliver (Sunday Times, 11 November 2007). Yet, calls to revamp British policy based on the African findings have otherwise been absent from British newspapers. In 2006, when WHO’s senior UK adviser, urologist Tim Hargreave, mused that ‘the presumption against [circumcision] in Scotland should be lifted’, the public responded with what one commentator called a ‘flurry of NORM-like activity’ (Independent, 13 November 2007) – NORM-UK being Britain’s chief anti-circumcision organisation. (NORM-UK is not an acronym (http://www.norm-uk.org/faq.html); founded in 1994, the organisation provides information about foreskin restoration and alternatives to medically indicated circumcision.) As of June 2009, none of the British medical associations nor the NHS was reported to be reconsidering its stance on circumcision.
Research on circumcision and HIV/AIDS has activated two engines of remedicalisation. It offers a new etiology for HIV, positing the foreskin as a disease vector and circumcision as the treatment. It also provides an avenue to influence for medical professionals concerned with HIV/AIDS and/or who are circumcision advocates seeking reasons to maintain the practice. Anti-HIV activists have approached (re)medicalisation of circumcision with ambivalence, eager to curb the spread of HIV but also to maintain current prevention regimes (where they dominate). Circumcision foes have denounced this new impetus to medicalisation, emphasising non-medical interpretations of circumcision. Britain and the US provide very different contexts for these developments, given the different prevalence of circumcision and HIV in the two countries. If HIV were more prevalent in Britain, circumcision might be more appealing. Conversely, if circumcision were rare in the US, calls to expand it might inspire greater outcry.
Deaths following ritual/religious circumcision
Concern that ritual/religious circumcision could transmit, rather than prevent, disease has waxed and waned among US and British physicians since the 1890s (Darby 2005b; Gollaher 1994). Efforts to bring religious circumcision under medical jurisdiction – often prompted by accidental deaths following ritual circumcision – represent a form of remedicalisation.
Periodically, since the 1985 circumcision-related death of a two-year-old London Muslim boy (Times, 11 September 1985), the British press has reported deaths following religious circumcision. In 1991, a nine-year-old Muslim boy died from an overdose of painkiller administered by the West Midlands physician who circumcised him (Guardian, 8 April 1993). Increasing hospital admissions of boys with serious complications after ritual circumcision were also reported. Doctors in heavily Muslim regions protested against the NHS’s 1989 decision to prohibit religious circumcision in hospitals because it competed with medically necessary procedures (Independent, 8 January 1991). Writing in the BMJ, Madden and Boddy (1991) noted that hospital care for circumcision-related complications cost far more than circumcision. Others questioned ‘the legitimacy of having the operation done at home’ (Independent, 30 April 1991). Muslim practices have been singled out, in part because the timing, training, and type of practitioner used are varied and unregulated, whereas ritual Jewish circumcision is performed by mohels (traditional practitioners) trained and regulated by the 200-year-old Initiation Society, and in part because the rapid growth of the Muslim population created tremendous demand (Independent, 30 April 1991). Whether NHS should provide religious circumcision is still debated today (International Symposium on Genital Integrity 2008).
Some have opposed efforts to medicalise ritual/religious circumcision. In 1996, NORM-UK asked the General Medical Council (GMC), Britain’s medical ethics authority, to consider forbidding doctors from performing ritual circumcision on the grounds that children are too young to consent.5 In 1997, the GMC issued a guidance declaring that ‘doctors performing the operation must be skilled in it, keep up to date…and discuss the issue carefully with the parents’ but remaining silent on the ethics of religious and cosmetic circumcision (Independent, 22 September 1997). In 2003, after a divorced White mother and Nigerian father sued one another over their son’s circumcision, the BMA published ‘good practice’ guidelines for circumcision in infancy/childhood. To ensure that circumcision is ‘in the child’s best interest’, BMA ‘now advises that both parents must give consent before a “non-therapeutic” circumcision can be performed’.
In the US, by contrast, calls for medicalisation have focused on Jewish practices. In the 1980s, with Jewish parents increasingly opting for circumcision by physicians rather than mohels, Reform Jewish leaders founded a programme to recruit mohels ‘from the existing ranks of physicians’ (Los Angeles Times, 11 January 1986) – effectively deploying medicalisation for religious ends. The 1990s saw some isolated proposals, as when Sanford Kuvin, MD, wrote in the New York Times, ‘It is unsettling that with today’s global blood-borne epidemics…there is no public health regulation…of circumcisers outside the hospital’ (25 May 1996). AAP (1999) finds it ‘legitimate for parents to take into account cultural, religious, and ethnic traditions’ when making decisions about circumcision and has made no move to regulate ritual circumcision.
The chief incident spurring demands for medicalising Jewish circumcision occurred in 2004-05, when a New York rabbi/mohel allegedly transmitted type-1 herpes to several infants through ‘a practice little known outside ultra-Orthodox communities called metzizah bi peh, in which the mohel uses his mouth’ to ‘draw blood from the circumcision wound to remove impurities’ (Daily News, 2 February 2005). Herpes is serious in infants; several died. After repeated attempts to get Rabbi Fischer voluntarily to stop performing circumcision, the New York City Health Department filed a court order compelling him to cease. Health officials also urged Orthodox leaders to ‘switch to suctioning the blood through a tube’ (New York Times, 26 August 2005). The Orthodox leadership responded by accusing the city of interfering with religious freedom and insisting on self-regulation.6 Rabbi David Niederman, of the United Jewish Organization, declared: ‘The Orthodox Jewish community will continue the practice that has been practiced for over 5,000 years’. In October 2005, the city dropped the restraining order and ‘passed the matter onto a Jewish religious court’ from the Central Rabbinical Congress (Daily News, 18 October 2005). Health Commissioner Dr. Thomas Frieden insisted that New York ‘did not intend to ban or regulate oral suction’ but, in an open letter, urged Orthodox parents ‘to consider other religiously viable options’ (New York Times, 14 December 2005). Anti-circumcision activists used this incident as an opportunity to advocate alternative bris ceremonies (involving symbolic circumcision only).
Examining this potential impetus to remedicalisation reveals the authority of medicine competing with the power of religious groups to insist on self-regulation (and cultural values favouring religious self-regulation).7 British medical associations appear more able or willing to take action than their US counterparts, consistent with Nathanson’s (2007) findings about public health policy in general. Insurance/healthcare delivery systems also matter. Unlike the NHS, US health insurers rarely distinguish among religious, social, and health reasons when covering circumcision – eliminating much of the cost disincentive to remedicalising ritual circumcision. Circumcision currently costs about $300 for US newborns (Summers 2009) and £300-700 for British non-infant children (Bristol Children’s Hospital 2006). The fact that British Muslims are disproportionately poor, and thus more likely to resort to less-qualified practitioners and/or less able to mount a campaign on their behalf, may also shape remedicalisation processes.
Discussion and conclusion
Several factors contributed to the differential demedicalisation of circumcision cross-nationally. In Britain, the chief engines of demedicalisation were lack of support from the medical community and a health insurance/delivery system that limited costs and mandated practices on a national basis. Decades later, US physicians’ declining interest in circumcision fostered partial demedicalisation, although a significant segment of the medical community continued to favour it (for clinical and financial reasons). Private insurance/healthcare systems helped perpetuate medicalised circumcision in the US after World War II; however, insurers’ recent cost-cutting measures could contribute to demedicalisation in the long run. Grassroots activists played a paramount role in (partial) demedicalisation in the US, via medically-oriented critiques and non-medical framings of circumcision. In Britain, anti-circumcision activism began decades after demedicalisation, focusing on foreskin restoration and reducing the number of ‘medically necessary’ circumcisions; British activists have thus helped perpetuate demedicalisation and forestall remedicalisation. These findings are consistent with Nathanson’s (2007) conclusion that British health policy is affected more powerfully by state actors and medical elites than by grassroots activists, whereas in the US the obverse holds true.
My analyses suggest that the prevalence and duration of a medicalised practice affect the likelihood of demedicalisation. Circumcision was not common enough, for long enough, that British physicians and lay people became unfamiliar with uncircumcised penises, as happened in the US (Darby 2005b). Fear that anti-circumcision efforts might offend the Jewish community may also have limited demedicalisation in the US.
These different national histories of demedicalisation, combined with different current contexts, make remedicalisation differentially likely in the two countries, pursuant to research linking circumcision to HIV prevention and deaths from ritual/religious circumcision. The US will probably embrace remedicalisation of circumcision, whereas Britain will not. Still, only partial demedicalisation in the US will be easier to reverse than almost complete demedicalisation in Britain. Also critical is the differential impact of HIV in the two nations; Britain’s low infection rates disincentivise remedicalisation.
Furthermore, given the recent vintage of demedicalisation in the US, that medical community includes more pro-circumcision ‘holdovers’ to promote remedicalisation. Even before the HIV-circumcision studies, these holdovers had succeeded in adding ‘benefits’ to AAP’s position on circumcision. Insurance/healthcare delivery systems play important roles as well, insofar as the choices of many individuals in a private, for-profit insurance system can produce society-wide remedicalisation. Neither US insurers nor the NHS are likely to welcome the additional expense of circumcising all newborn males, barring evidence that the cost of treating circumcision-preventable conditions would be higher; however, this disincentive to remedicalisation is greater in Britain, where the NHS currently pays to circumcise less than five per cent of boys, while US insurers already pay to circumcise about 60 per cent of infant boys.
Activists’ efforts will probably matter more in the US than Britain, partly because of activists’ generally greater role in US health policy (Nathanson 2007) – although health-related activism in Britain is on the rise (e.g.Boyce 2007) – and partly because of contextual factors, especially only-partial demedicalisation in the US. US activists’ ability to reframe circumcision in non-medical terms that the general public finds convincing is crucial. But non-medical groups that might ‘own’ circumcision, such as human rights and anti-FGC groups, have largely refused to join the anti-circumcision fight (Carpenter 2008). HIV activists’ desire to maintain their own influence in prevention efforts may work in circumcision foes’ favour. Alternate ‘owners’ are less critical in Britain, since remedicalisation would have to start virtually from scratch.
Regarding the medicalisation of religious circumcision, affected groups’ ability to resist or encourage (de/re)medicalisation of circumcision, which depends on their social power, is key. British Muslims are not only a religious minority, in a country with an established (Christian) church, but also, on average, poorer and less well educated than other Britons, and typically racial/ethnic minorities and/or recent-generation immigrants. The same social deprivation that makes British Muslims more likely to rely on less competent circumcision practitioners ironically facilitates social control of their practices. In the US, the relatively powerful Jewish community, well represented in medical circles, has successfully blocked medical intervention in ritual circumcision. (That said, religious minorities have an incentive to favour (re)medicalisation of circumcision for preventive health because it normalises and justifies their ritual practices.)
Gender, social class, race, and age powerfully affect (de/re)medicalisation dynamics. Circumcision represents an early effort to medicalise male bodies. My analysis suggests that this effort succeeded largely because the males in question were boys, possessed of little social power, and because middle- and upper-class parents initially supported medicalisation. In the present-day US, it has been difficult to convince men (the dominant gender) that circumcision is not in their best interests, while in Britain the opposite is true, suggesting that the local prevalence of a medicalised practice interacts with gender. The intersection of race/ethnicity, social class, and religion are fostering the remedicalisation of Muslim circumcision in Britain, while deterring remedicalisation among US Jews.
Comparing the trajectories of homosexuality and circumcision illuminates (de/re)medicalisation dynamics. Medical organisations’ official policies helped to demedicalise both practices (with rank-and-file physicians’ co-operation). But where holdovers promoting medicalisation of homosexuality have been relatively unsuccessful, pro-circumcision holdovers in the US have been highly influential. Conversely, grassroots circumcision opponents have been less effective than gay rights activists at resisting remedicalisation. The GLBTQ movement is considerably more powerful – gaining momentum from a broader range of issues – and has a constituency of adults who perceive their own lives to be directly affected by medicalisation.
Finally, the case of male circumcision indicates that remedicalisation represents a fundamental – if rare – stage in the medicalisation-demedicalisation process. Fox (1977) contended that social forces tend to correct overmedicalisation. My research suggests something more complex. After a phenomenon has been demedicalised, subsequent rounds of medicalisation do not start from scratch, but rather are facilitated by lingering medical definitions and medicalisation proponents, although long delays between rounds of (re)medicalisation may limit these factors’ effectiveness (as with circumcision in Britain).
This comparative analysis has indicated that (de/re)medicalisation processes, and the engines driving them, may differ across social contexts, thus highlighting the utility of cross-national research. The case of circumcision recommends theorising the life cycle of medicalisation and argues for carefully considering the prevalence and duration of specific medicalised practices. My findings moreover suggest that medical professional ‘holdovers’ from previous phases of medicalisation be attended to more closely. Whether the ‘owners’ of non-medical interpretations of a practice embrace or reject those interpretations merits further study, too. Finally, scholars should consider whether phenomena that are medicalised because of their ostensibly preventive effects represent a new category of medicalisation.
US sources include New York Times, Washington Post, Los Angeles Times, USA Today, Atlanta Journal-Constitution, Bismarck (ND) Tribune, NY Daily News, Minneapolis Star Tribune, Seattle Times, and San Francisco Chronicle. British sources include London Times/Sunday Times, Guardian, Independent, Telegraph, Daily Mail, The Sun, Mirror, Glasgow Herald, Edinburgh Scotsman, and Daily Record.
The trajectory of circumcision in Canada, similar to the US and Britain up to the 1930s, has since fallen in between.
In the US, where the pain of unanesthetised circumcision is a major anti-circumcision argument, the development of safer pain relievers might also foster remedicalisation. Since 1999, AAP has maintained ‘if a decision for circumcision is made, procedural analgesia should be provided’. Activists have countered by (re)framing circumcision as a human rights issue. The use of discarded foreskins to create artificial skin and the declining popularity of natural/non-hospital childbirth in the US might also spur remedicalisation.
Subsequent analyses found smaller reductions in HIV transmission (Talbott 2007) and higher rates of HIV infection among circumcised than uncircumcised virgins, suggesting significant levels of non-sexual transmission (Brewer et al. 2007).
Ethical standards allow parents to consent to medical necessity but not elective surgery for their children.
Conversely, Yeshiva University’s Moshe Tendler argued that metzitzah b’peh violates the Torah rule ‘that you cannot expose or accept a risk to health unless there is true justification’ (New York Times, 26 August 2005).
In 2001, Sweden medicalised ritual/religious circumcision via a law requiring circumcision ‘to be performed only by a physician or another person with appropriate training’ and with pain relief (Seattle Times, 2 October 2001). Prompted primarily by injuries to Muslim boys, the law was criticised by Jewish groups ‘as an unnecessary restriction on freedom of religion’.
The author would like to thank Charles L. Bosk, Monica J. Casper, Peter Conrad, Heather Kettrey, Michael Kimmel, Meika Loe, Kasie Luttrell, Dan Morrison, Constance A. Nathanson, Harmony Newman, the Social Science Research Council – Sexuality Research Fellowship Program, and the National Science Foundation (Grant No. 0816678).