Circumcision is not a barrier to an individual's religious freedom

Was a German court justified in interfering with centuries of religious tradition?

A court in Cologne has ruled that circumcision, performed for religious reasons on male children below an age where they can meaningfully consent to the operation, amounts to an unwarranted and irreparable interference with their bodily integrity. Furthermore, it interferes with the right of a child "to decide for himself later on to what religion he wishes to belong".

The ruling, in a case involving a four-year-old Muslim boy who was injured in a botched procedure, has been strongly criticised by both Muslim and Jewish groups in Germany and beyond. In the UK Jonathan Arkush, vice-president of the Board of Deputies described it as "intolerant, ill-informed and deeply troubling."  Andrew Copson of the British Humanist Association, by contrast, supports it. He thinks it is "an open and shut case, ethically speaking" on the grounds that "respect for the autonomy of a person requires that they give consent for irreversible procedures affecting their body like cutting pieces off their genitals". And Pavan Dhaliwal, speaking publicly on behalf of the BHA, suggests that a ban on infant circumcision "would not constitute an attack on religious freedom, because boys would still be allowed to be circumcised when they reach an age to consent".

While Copson has some sympathy for Jews and Muslims who may interpret a ban as oppressive, he appears to locate the source of their discomfort in an emotional attachment to their traditions and, in the case of men, intimate feelings towards their own bodies. But this is more than a merely cultural or psychological issue. It would have especially serious consequences for Jewish religious practice. To ban the circumcision of infant boys would, in effect, be to ban Judaism itself, at least as it has been practised for almost three thousand years. Islam expects males to be circumcised but lays down no specific age for the procedure. Jewish law on the other hand requires circumcision on the eighth day after birth, an age at which even the most precocious infant would be unable to give informed consent. No uncircumcised boy would be able to celebrate his Bar Mitzvah at the traditional age of thirteen. It would be potentially catastrophic. That a German court should have produced such a ruling has only added to the disquiet. 

Along with the Sabbath and the rules of kosher, circumcision has always been one of the non-negotiable features of Judaism, indeed central to Jewish identity. The requirement is laid down in the book of Genesis (in chapter 17), which describes circumcision as the "token of the covenant" between God and Israel and goes on to warn that that "the uncircumcised man child whose flesh of his foreskin is not circumcised shall be cut off from the people; he has broken my covenant." 

The importance attached to the procedure is repeatedly stressed in the Hebrew Bible. In one incident recounted in Exodus, God threatens to kill Moses, apparently because the prophet's (non-Jewish) wife has not had their son circumcised. He is only saved when Zipporah takes the knife to her son's foreskin herself. The message is clear: so much does God care about circumcision that's he's prepared to kill the man without whom there would be no Judaism (nor any Christianity or Islam) at all rather than see one Israelite child in possession of a foreskin. It's that serious.

If circumcision were obviously a bad thing, then religious freedom could and should be overridden. No religious justification would suffice to permit human sacrifice, or indeed female genital mutilation (FGM), which most Western countries have specifically banned. But male circumcision is not obviously harmful, as FGM is. Performed properly, it is not dangerous. The World Health Organisation positively encourages it, the theory being that it protects against HIV and other sexually transmitted infections. The effect on sexual pleasure in later life is disputed. Men who are in a position to know offer differing opinions, with those who report improvement somewhat outnumbering those regretting the procedure. All agree, however, that even with anaesthetic during the operation it is very painful afterwards and it takes at least a month to recover.

This matters. If circumcision for religious reasons is restricted to adults, not only would this interfere with long-held custom (and in the Jewish case, Biblical law), it would also force men or older boys to undergo a painful procedure as a price of belonging to their ancestral religion. Uncircumcised male converts to Judaism or Islam already face this dilemma, of course, but it's not hard to see that the prospect would act as a deterrent to many men lacking in the zeal of a convert. At the same time, a circumcised man leaving the religion is not forced to be painfully uncircumcised. It's thus hard to follow the logic that sees the procedure as an interference with a boy's freedom to choose his religion later in life. Quite the reverse.

 

A young boy cries after being circumcised. Photograph: Getty Images
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A clinically-approved birth control app is changing the way we think about contraception

The particle physicist Elina Berglund has created an app that is 99 per cent effective. 

Women around the world using the contraceptive pill have long complained to their friends about its perceived side effects – weight gain, acne, mood swings to name a few. Some more recent studies have verified that anecdotal evidence – a Danish study from 2013 confirmed that there was a 40 per cent increased risk of depression for women who were on the pill, compared to those who weren’t.

Frustration around the inadequacy or ill-suitability of certain methods of contraception is rife. One woman, Elina Berglund, decided to do something about it.

Formerly a particle physicist at CERN (and a member of the team responsible for the discovery of the Higgs Boson particle), Berglund co-founded Natural Cycles, a contraceptive app, with her husband Raoul Scherwitzl. Approved as a contraceptive app earlier this year, it is downloadable on a smartphone and relies on a relationship between body temperature and fertility to tell women when they're fertile.

But contraception campaigners have viewed the concept with caution. Widespread use of the pill, condoms, and diaphragms comes after decades of campaigns against reliance on "natural methods" – not to mention the opposition of religious organisations like the Catholic church. 

At first glance, Natural Cycles might not seem all that different from the Vatican-approved "rhythm method", which is based on observing the exact stages of a woman's fertility cycle and avoiding sex during ovulation. This can be, according to the NHS, up to 99 per cent effective – but in reality it is closer to 75 per cent, because "people can make mistakes". 

Users of Natural Cycles take their temperature daily and input it into the app (which costs £6.99 a month). The app then compares the figure to its own dataset and uses an algorithm based on Berglund's days from CERN. It also asks for other data, such as the dates of user's periods and whether they are planning for a pregnancy or not, to create a personalised calendar.

If it’s safe to have unprotected sex, then the in-app calendar will show up as green. If not, the in-app calendar will show up as red. On those red days, users should find methods of contraception if they aren’t seeking pregnancy.  

Menstrual tracking apps are all the rage (there are around 1,000 of them on the current Apple app store). But recent studies have shown that those apps are often inaccurate and lack any scientific basis. 

Natural Cycles, by contrast, carried out three clinical trials, each time expanding the dataset to reduce errors. The most recent, written up in Contraception, involved 22,785 women across 37 different countries in settings that mimicked real life. The co-authors pointed out that in instances of perfect use, one out of 100 women become pregnant accidentally. However, in instances of typical use, seven out of 100 women had the same result.

When Natural Cycles first gained publicity, Berglund pointed out to the press that “now they (women) have a new, clinically verified and regulatory approved option to choose from”. Berglund and Scherwitzl are looking into getting Natural Cycles prescribed on the NHS, like the pill.

So is Natural Cycles the future of family planning? The first thing to make clear is that the app cannot actually function as physical contraception – on “red” days, the app advises users to use a condom if they’re having sex and don’t want to get pregnant. It cannot prevent the transmission of sexually transmitted diseases either. 

Nor is the app really marketed to those who may benefit from the most information about their sexual health – 16 to 25-year-olds, who are also the age group most likely to engage in risky sexual behaviour. 

A spokesperson for Marie Stopes, the reproductive health NGO, said: "Apps to track fertility are a high-tech version of what women have been doing for years with a diary and a thermometer.

"For anyone trying to get pregnant, they might well help. However, if you want to avoid pregnancy, it’s much better to choose a reliable, long-acting modern method of contraception like an IUD or implant. Traditional methods, including tracking fertility, carry a much higher risk of unintended pregnancy."

The app relies on an algorithm, meaning it is only as effective as the data that it receives from users. It is also not free, which may exclude its usage by certain sections of society. A blog written for NHS Choices emphasised that the data collected in all the trials was collected from women who were already signed up for the product, making it likely that they had an incentive to continue with this specific additional contraceptive, as opposed to looking elsewhere. Even so, a third of users who had signed up still dropped out, potentially because of the maintenance required to get results from it. 

All the same, Natural Cycles has 380,000 users and counting. It has received clinical approval to be marketed as a medical device, and it seems to be meeting a need – 70 per cent of Natural Cycle's users come from hormonal contraception, according to Berglund. In her account of Natural Cycles in the Evening Standard, Kate Wills highlighted that the Apple Watch had all sorts of health inputs, but no way to track periods.  All kinds of apps exist to make modern life easier – why has it taken so long for one that addresses a concern for so many women to make its way into the mainstream?

The history of contraception is littered with examples of women being ignored. Early birth control studies vastly underplayed the potentially debilitating side effects of hormone fluctuations on women’s mental health and physical appearance, often treating users as though they were hysterical. Add into the equation the stigma around accessing contraceptives safely and non-judgementally, and it’s easy to see why a relatively painless and private form of contraception might be appealing. 

Natural Cycles may well work for some women – those who are in stable relationships, hoping to get pregnant and fastidious enough to note their temperature every morning. But it doesn’t prevent diseases, requires a steady commitment and – here's the clincher – can't take measurements when you’re hungover as alcohol can affect your temperature. There's also a big difference between the "perfect" use of the app, and the likelihood of pregnancy when used in a "typical" fashion. So long as that's the case, old-fashioned contraception seems unlikely to be swept away by a digital revolution.