Social Work, Advocacy, & Childhood Genital Cutting

The following is an essay focused on social advocacy in the social work profession when it comes to the forced genital cutting of children. This was originally composed as part of my MSW graduate education, but I felt it was important to share publicly.

Social work is a profession based on Equality, social justice, and advocacy. As such, social workers should be at the forefront of advocacy efforts to ensure equal protection for all children at birth.

Social Work Advocacy and Childhood Genital Cutting

So often it seems that we can be overly critical of other’s cultural practices and traditions while lacking the ability to critically examine our own harmful cultural practices. For example, Western countries often criticize cultures who practice female genital cutting, while continuing to allow male genital cutting in their own country. This can be seen as hypocritical by members of female genital cutting cultures (Khaja, Barkdull, Augustine, & Cunningham, 2009). If we want to fight for human rights abroad, we need to be willing to address the hypocrisies within our own homes. Without this, alleviation efforts elsewhere will fail. The social issue that will be discussed in this paper is the forced genital cutting of children. Specifically, infant circumcision of male children will be discussed. Forced infant circumcision is most common in the Midwest region of the United States (Circumcision Rates, 2020). For that reason, this is the geographical area for which will be focused on in this assignment.

Population Affected

The issue of forced genital cutting in the United States mostly affects infants and young children who were born with male genitalia. This rarely affects female children in this area as female genital cutting was outlawed in the United States in 1996 (Macready, 1996). Most of the world does not circumcise their children with the exception of Muslim and Jewish families (Goldman, 1997). The United States is the only country that circumcises the majority of infant males without religious reasoning (Goldman, 1997). While many often site medical reasons for having a child circumcised, no major medical organization in the world recommends this procedure, and many criticize the procedure as causing serious damage (Goldman, 1997).

Demographic Context

The location where non-religious infant circumcision is most common is the Midwest region of the United States of America (Circumcision Rates, 2020). The Midwest US is roughly 51% female and 50% male and 23% are under age 18 (Census Reporter, 2018). Within this region, 75% of the population is white, 10% is black, and 8% is Hispanic (Census Reporter, 2018). Those who are Hispanic have been known to have lower circumcision rates (Rettner, 2013). The poverty rate in the Midwest is 12.5% with 17% of children living in poverty (Census Reporter, 2018). The social climate of the Midwest United States is part of the reason for the prevalence and continuance of infant circumcision. Infant circumcision is an accepted and often expected choice for parents of newborns in this region. Further, this is an option that is still offered to and sometimes even pushed onto parents in the hospitals shortly after their child’s birth. Medicaid programs are estimated to fund over a fourth of the circumcisions performed, costing taxpayers over $145 million dollars annually (Craig & Bollinger, 2006). Medicaid is meant to cover necessary medical services and infant circumcision is a medically unnecessary surgery often performed for social, religious, or cosmetic reasons (Craig & Bollinger, 2006). The politics of using taxpayer money to fund unnecessary surgery on infants and children is increasingly controversial.

Key Indicators

Infant circumcision is the forced amputation of healthy genital tissue of a non-consenting child. This is a clear human rights violation which can cause an array of negative effects throughout that child’s life. This includes immediate complications from the surgery, lasting psychological effects, adverse sexual effects, and even death. It is estimated that over 100 infant boys die in America every year as a direct result of infant circumcision (Bollinger, 2010). These deaths usually result from infection, excessive bleeding, or cardiac arrest (Elhaik, 2019). In addition to this, infant circumcision was found to be associated with a greater risk of sudden infant death syndrome (Elhaik, 2019). It is believed that this estimate is incredibly low, as there is currently no required reporting mechanism for circumcision deaths or complications resulting from the procedure (Bollinger, 2010). These deaths are completely preventable as infant circumcision is an elective cosmetic procedure.

The procedure of infant circumcision itself has been found to cause significant pain and distress with lead to considerable changes in hormonal, behavioral, and physiological parameters of the child (Elhaik, 2019). This includes both short- and long-term handing of stress, issues with adapting to the postnatal environment, breastfeeding issues, and interference with mother-child bonding (Frisch & Simonsen, 2015). One study found that those who undergo circumcision have a greater risk of being diagnosed with autism spectrum disorder before the age of 10 (Frisch & Simonsen, 2015). This risk increased especially for an autism diagnosis before age five (Frisch & Simonsen, 2015). The foreskin is often thought of as an “extra piece of skin” that simply causes infection. In reality, the foreskin is a specialized double layer of tissue that is essential for normal sexual functioning (Fleiss & Hodges, 2002). The male foreskin has many important protective, pleasurable, and sexual functions, including protecting from infection during the early years (Fleiss & Hodges, 2002). However, in American culture it seems that the functions and importance of the intact male genitals are overlooked, and the harm caused by circumcision is minimized.

Male genital cutting is often seen in drastic contrast to female genital cutting. In the text, Human Rights and Social Justice in a Global Perspective, the author clearly stated their view that female cutting is not equivalent to male circumcision due to the extensive damage that female cutting can cause and the fact that it is often not performed in a medical setting (Mapp, 2014). This is just one example of how Western traditions are often accepted as right while other cultural practices are often judged against this norm (Ife, 2009). Views such as this only cause further damage to advocacy efforts to alleviate female genital cutting. Female cutting is typically thought of in its worst forms in the most unsterile of environments when these forms of cutting are rare (Earp, 2016). More common forms of female genital cutting are minor and done in sterile environments. Those who perform female genital cutting often cite health and hygienic benefits to the procedure (Earp, 2016). However, regardless of the intensity or reasoning, these practices are still criminal and viewed as a human rights violation.

This double standard of promoting the genital cutting of one sex while condemning the other only works to permit forced genital cutting of all children. This is because many forms of female cutting are done for similar cultural and hygienic reasons given for male circumcision (Earp, 2017). When we allow the genital cutting of male children for minor health benefits we have to open up the possibility that female cutting can have health benefits as well, and if that is the case, is it ethically permissible to then allow routine female circumcision? In addition to this, many forms of female cutting are less severe and remove less genital tissue than the typical American and Jewish circumcisions (Earp, 2017). When presented with legal cases of female circumcision cases, this leaves two possible outcomes. Either we must allow minor forms of female cutting that are less damaging then the male circumcision widely practiced, or male circumcision will need to be restricted (Earp, 2017). This has been seen to play out with the American Academy of Pediatrics releasing a policy statement suggestion that physicians consider minor forms of female circumcision procedures such as clitoral pricking (Louden, 2010) as well as in court cases where the laws against female circumcision were ruled to be unconstitutional and charges against doctors who performed female cutting were dismissed (Tacopino, 2018).

The Social Work Profession

At first it may seem that the issue of infant circumcision is not one that belongs in the social work field. However, according to the National Association of Social Workers (NASW), the primary mission of the profession is to help the vulnerable and promote social justice and social change (NASW, 2017). Humans have the right to self-determination and bodily autonomy. Many human rights are not extended to children and often the rights of parent’s clashes with the rights of children (Ife, 2009). Analyzing cultural practices of this nature through a human rights perspective is important as occurrence of human rights abuses has been excessive throughout history, especially for children (Cox & Pawar, 2013). This perspective promotes that all individuals have the right to make their own choices, so long as their behavior does not violate the rights of others (Cox &Pawar, 2013). This also focuses on the right to equality, the fact that everyone is born with equal rights (Cox & Pawar, 2013). Infant circumcision violates this right in a number of ways including that male children are not afforded the same rights as female children, and it would not be permissible to force a circumcision onto a non-consenting adult. With the issue of forced genital cutting, gender inequality comes into play as well. This is because females have had legal protection from forced genital cutting for over two decades while males are still routinely subjected to forced genital modifications (Macready, 1996). Those in the social work field have an obligation to advocate for the vulnerable and promote human rights of all. This would include advocating for male children to be afforded the same protection and rights to bodily autonomy that females have had for decades.

Intervention

Primary Elements

Intervention for a social issue this wide-spread and accepted will need to have multiple levels. The first level of intervention will need to be education and outreach to help bring increased awareness of this issue to the general public. There are many organizations currently working on this aspect of intervention. However, few are active in the Midwest region of the United States, where the circumcision rates are highest. Encouraging these organizations to expand and focus efforts where the issue is most common can help to alleviate the practice through decreasing social acceptance of the procedure. Education and outreach can help educate the public on the dangers and long-term implications of infant circumcision. This can also help teach parents proper care for intact (not-circumcised) children to prevent issues such as those associated with forced retraction. Increasing awareness can include public ad campaigns, providing informational materials at hospitals and pregnancy centers, educational outreach tables at local events, and even protesting.

In addition to this, the required reporting of circumcision deaths and complications throughout the life should be implemented. Currently, there is no required reporting of circumcision complications and many adverse effects are not known until later in life (Bollinger, 2010). This does not allow for the general public to know the true occurrence of circumcision related complications and risk of death resulting from the procedure. Without this information, it is impossible for parents to provide full informed consent for their child to undergo the procedure.

Another aspect to address in intervention is the continued Medicaid funding of infant circumcisions. The American Medical Association, American College of Obstetricians and Gynecologist and other medical organizations consider infant circumcision to be a medically unnecessary cosmetic procedure (Craig & Bollinger, 2006). This not only uses tax dollars for a controversial and potentially harmful procedure, but it takes away from funds that can be used on other necessary services for the poor (Craig & Bollinger, 2006). Discontinuing Medicaid funding of infant circumcisions can help to decrease the number of infants subjected to the procedure while also increasing funding for needed services elsewhere. This leads into advocacy for policy change and legal considerations, which are major topics that need to be addressed in alleviation efforts. As mentioned previously, allowing male circumcision to continue while criminalizing female circumcision only works to make both permissible. To alleviate genital cutting for one sex, genital cutting for all children must be addressed. Legal and policy changes usually come after changing public perceptions, so most alleviation efforts at this point will be spent in the forefront working to change social norms that make infant circumcision a normal and accepted tradition.

Lastly, any intervention must also include support for victims of forced circumcision as well as for regret parents. Those who had their genitals altered without their consent as well as parents who consented to having a child undergo the procedure and regret their decision may need ongoing support or therapeutic interventions to deal with their feelings. However, this is something that is drastically lacking in America. One study found that those who sought therapeutic help for circumcision trauma and grift were met with being invalidated, their feelings minimized, grief dismissed, and feelings of being undervalued (Watson & Golden, 2017). Those seeking help need practitioners who will empathetically listen to concerns and help them through the grief they are feeling. Support can include further information for social workers and other mental health professionals when dealing with this specific population as well as the implementation of various support groups.

Stakeholders

Stakeholders involved in the issue of infant circumcision include the medical professionals performing the circumcisions, the medical organizations and establishments allowing the procedures to take place in their facilities, organizations who purchase the amputated foreskin tissue, parents signing consent forms for the procedure to take place, and the infants and children who are being subjected to the procedure. The medical professionals, medical establishments, and those purchasing foreskin tissue all have monetary interest in continuing the practice of infant circumcisions. Parents allowing the procedure to be done to their children may have a variety of reasons for this. This can include cultural, religious, sociological, pressure from friends and family, assumed benefits, and misinformation. Infants and children who have had circumcision performed on them do not have a say in the procedure, yet they are the ones who must live the rest of their lives with a choice that others made for them and whatever complications may arise as a result.

Challenges

Working to alleviate the forced circumcision of infants and children will come with many challenges as this is a widespread practice that has been continuing for centuries. Alleviation efforts are always met with a variety of pushback from those who wish to continue the practice. One major challenge will be the debate of parent’s rights vs children’s rights, especially when it comes to religious circumcisions. However, we need to ask ourselves at what point does a parent’s rights to practice religion or to make those decisions end and a child’s rights to self-determination and bodily autonomy begin? It seems reasonable to afford the child the basic right to keep the body they are born with and to allow them to be free from any forced modifications to healthy body tissue.

Another challenge will be combating the current misinformation and proposed medical benefits of circumcision. Many continue to circumcise under the impression that it is more hygienic and causes less issues later in life. As long as the intact child is cared for properly, these claims do not hold up. Education on proper intact care can help to address these concerns. It will also help to focus on the positives of intact male genitals rather than on the potential harms of circumcision. Framing the foreskin as important and essential will help others to see it less as an expendable piece of skin and rather one part to a whole unit that has a multitude of functions.

Ethics

The issue of forced infant circumcision cannot be examined or addressed apart from ethical considerations. Advocating for the equal protection of bodily autonomy for all children goes hand in hand with the social work code of ethics. The ethical value of social justice in particular calls social workers to pursue social change and challenge social injustice especially with vulnerable populations (NASW, 2017). Infants and children are a vulnerable population that often depends on others for survival and protection. They are unable to consent to a permanent body modification and must live with the multitude of negative outcomes that may occur as a result.

Cultural relativism is largely responsible for how circumcision is viewed in the Midwestern United States. In the Midwest, infant circumcision is viewed as a normal part of having a baby boy. However, female circumcision even in its mildest forms is viewed as a barbaric violation of human rights. Other countries that do not practice infant circumcision are often astonished to learn that this is common in certain parts of the United States. The intervention strategies mentioned previously work to empower parents and community members with knowledge to make more informed decisions. Ideally, this education will lead to decreased rates and less social acceptance of infant circumcision. These interventions also call for increased support and understanding for victims of circumcision.

Social Work Practitioners' Roles

Social workers can be a leading force in the fight to end forced circumcision. On a macro level, social workers can advocate for education and policy change. They can work writing letters to legislators and hospitals and lead the way in changing Medicaid funding for unnecessary circumcisions. Social workers can also work for non-profit organizations that aim to eliminate routine circumcision. On a micro level, social workers can work with the victims or survivors of forced circumcision and regret parents in a therapeutic setting. This can include providing individual therapy as well as support groups. In working on multiple levels and in a variety of aspects social workers provide help to struggling victims, decrease the number of those subjected to forced circumcision, and hopefully someday provide legal protection for future generations.

References

Bollinger, D. (2010). Lost Boys, Boyhood Studies, 4(1), 78-90. Retrieved Jul 24, 2020, from https://www.berghahnjournals.com/view/journals/boyhood-studies/4/1/bhs040106.xml

Census Reporter. (2018). Census profile: Midwest Region. Retrieved July 26, 2020, from https://censusreporter.org/profiles/02000US2-midwest-region/

Circumcision Rates. (2020). Retrieved July 25, 2020, from https://worldpopulationreview.com/state-rankings/circumcision-rates-by-state

Cox, D. R., & Pawar, M. S. (2013). International social work: Issues, strategies, and programs. (2nd ed.). Thousand Oaks, CA: SAGE.

Craig, A., & Bollinger, D. (2010). Chapter 20: Of Waste and Want: A Nationwide Survey of Medicaid Funding for Medically Unnecessary, Non-Therapeutic Circumcision. In A. Craig (Author), Bodily integrity and the politics of circumcision: Culture, controversy and change (pp. 233-246). New York, New York: Springer.

Earp, B. D. (2017). Does female genital mutilation have health benefits? The problem with medicalizing morality. Practical Ethics (University of Oxford). Available at http://blog.practicalethics.ox.ac.uk/2017/08/does-female-genital-mutilation-have-health-benefits-the-problem-with-medicalizing-morality/

Earp, B. D. (2016). Boys and girls alike: The ethics of male and female circumcision. In

E. C. H. Gathman (Ed.), Women, Health, & Healthcare: Readings on Social, Structural, &

Systemic Issues (pp. 113-116). Dubuque, IA: Kendall Hunt Publishing Company

Elhaik E. (2019). Neonatal circumcision and prematurity are associated with sudden infant death syndrome (SIDS). Journal of clinical and translational research, 4(2), 136–151.

Fleiss, P. M., M.D., & Hodges, F. M., D.Phil. (2002). What your doctor may not tell you about circumcision: Untold Facts on America's Most Widely Performed- and Most Unnecessary-Surgery. New York, New York: Warner Books.

Frisch, M., & Simonsen, J. (2015). Ritual circumcision and risk of autism spectrum disorder in 0- to 9-year-old boys: national cohort study in Denmark. Journal of the Royal Society of Medicine, 108(7), 266–279. https://doi.org/10.1177/0141076814565942

Goldman, R., Ph.D. (1997). Circumcision, the hidden trauma: How an American cultural practice affects infants and ultimately us all. Boston, MA: Vanguard.

Ife, J. (2009). Human rights from below: Achieving rights through community development. Port Melbourne, Vic.: Cambridge University Press.

Khaja, K., Barkdull, C., Augustine, M., & Cunningham, D. (2009). Female genital cutting. International Social Work, 52(6), 727-741. doi:10.1177/0020872809342642

Louden, K. (2010, June 02). AAP Retracts Controversial Policy on Female Genital Cutting. Retrieved July 26, 2020, from https://www.medscape.com/viewarticle/722840

Macready N. (1996). Female genital mutilation outlawed in United States. BMJ (Clinical research ed.), 313(7065), 1103. https://doi.org/10.1136/bmj.313.7065.1103a

Mapp, S. C. (2014). Human Rights and Social Justice in a Global Perspective An Introduction to International Social Work (2nd ed.). Oxford: Oxford University Press.

National Association of Social Workers. (2017). NASW code of ethics. Retrieved Month, Day, Year, from https://www.socialworkers.org/About/Ethics/Code-of-Ethics/Code-of-Ethics-English

Rettner, R. (2013, August 22). U.S Circumcision Is On The Decline. Retrieved July 26, 2020, from https://www.huffpost.com/entry/circumcision-rate-drops_n_5107637

Tacopino, J. (2018, November 21). Ban on female genital mutilation ruled unconstitutional. Retrieved July 26, 2020, from https://nypost.com/2018/11/20/ban-on-female-genital-mutilation-is-unconstitutional-judge/

Watson, L., & Golden, T. (2017). Male Circumcision Grief: Effective and Ineffective Therapeutic Approaches. New Male Studies: An International Journal, 6(2), 109-125.