It's a Boy! Unbiased Information About Circumcision
There is a skeleton in the back of my skeptic closet. A gnarly thing, decrepit and long dead. It lived when my daughter was but a babe. During that time, I came across a storm of information about how harmful vaccines could be.
Now, dear reader, I need to take a step back and let you know about the mindset that brought me to such misinformation and why I was gullible enough to swallow it. The women in my family are warriors of the natural health movement (otherwise known as medical pseudoscience). As a matter of fact, they've all worked in health food stores (myself included). They spend their hard earned money on homeopathic water tablets to fight the flu and consult their reflexology charts when they have a particularly nasty headache. My mother can swallow a dozen vitamins without a drop of water.
A distrust of the medical establishment is rooted deep in my brain and will probably never be fully eradicated. So when I started hearing things like "autism linked to MMR vaccine" in the hazy days of early (teenage) motherhood at a time when I had limited internet access, I freaked. I liked Dr. Sears' parenting books and decided to follow his modified vaccination schedule. My daughter would get her vaccines, just delayed a bit.
My family applauded my "informed" decision. Looking back, it was all confirmation bias and fear mongering. Thankfully, my atheism kicked in around that time and a skeptical worldview followed soon after. I know better now. Vaccines are safe and autism is probably not a disorder at all. I caught my baby girl up on her shots pronto. I still worry how much the vaccines' efficacy was hindered by my stubborn, misinformed self. Still, I have to admit that part of me cringes internally when we go to get flu shots. I guess the 'crunchy' is just too ingrained.
We did a lot of moving around at that point in life, and as a result, Boots had several pediatricians. One of the last she had before reason took hold was aghast that I would endanger my child's life in such a way. She was visibly angry and her tone was insulting. I understand now why she behaved in such a way, but I can't help but wonder if I would have seen the light a little sooner had she sat me down, showed me the evidence, and tried to convince me of the truth rather than getting emotional.
I might never have listened. Still, I wish she'd tried. With that in mind, I'd like to talk about something that I've been avoiding like the Black Death on this blog: circumcision. It hits a lot of major themes I muse on: kids, science, religion, society, and culture. The consequences of this post feel overwhelming in their reality. I am not facing the faceless billions of faithful, the ubiquitous media, or humanity at large. Oh no. I'm facing my friends, my family. The mothers, fathers, and sons that I know and love. Many are intelligent, informed individuals that disagree with me on this. Given the intimate nature of circumcision, tensions rise quickly.
For a while, I wondered if my views on circumcision would soften as my views on breastfeeding did. They didn't. (For the record, I think breastmilk and donor milk should be the norm. Those aren't always viable options in today's society, and I totally understand the many reasons mothers use formula. I just hope we keep improving our methods and lose the stigma on both sides.)
While I would prefer to leave this whole topic alone, I feel I cannot. When I was a mother to a daughter with a son on the way, I scoured the internet for a complete, unbiased post about circumcision. I never found one. Looking today, Google doesn't offer much. You either get a few measly sentences on a medical website, hit a pay-wall, or enter the staunch pro- or anti-circumcision sites. Those sites have reasons for existing and can be helpful. Still, I desired a comprehensive list of the risks and benefits. I hope this post can fill that gap.
Pregnant woman holding a sign which says its a boy photo via Shutterstock.
I have no desire to enter the 'mommy wars' arena that often pops up around posts about circumcision. I want to have an honest conversation about why we routinely circumcise infants and what science has to say about the practice. This article will be about non-therapeutic neonatal male circumcision unless specifically stated otherwise. Sources not linked to in the article can be found at the bottom.
-History of Circumcision-
Exactly when circumcision was first practiced is unknown. The earliest known evidence of circumcision are hieroglyphs in an Egyptian tomb dating back to 2400 BCE. Historians have come up with several possible reasons why our ancestors would have began the custom: as a rite of passage into adulthood, to signify higher social status, to humiliate defeated enemies while keeping them alive as slaves, to enhance sexual pleasure, to limit sexual pleasure, or for hygiene.
In more recent history, circumcision was spread by way of religion. In Judaism, the practice is done as part of a covenant with God when the infant is eight days old. Though it is not dealt with in the Quran, Muhammad reportedly prescribed it to ensure a man's moral and mental cleanliness, and males must be circumcised before they take an active part in worship. It is thought that the religious element is what initially spread the idea that circumcision hindered masturbation and enabled boys to remain more spiritually pure.
The late 1800s saw a rise in circumcision in the United Kingdom and the United States. The increase was due to the belief that it would cure a variety of ailments such as epilepsy, hernias, childhood fevers, nocturnal emissions, brass poisoning, and paralysis. In the mid-1900s, neonatal circumcision had become common in both the US and the UK. Even so, many doctors were skeptical and the call for evidence was renewed. In the 1950s, the UK National Health Service stopped paying for non-therapeutic neonatal circumcision. The American Academy of Pediatrics (AAP) concluded that there was no basis for routine circumcision in 1971 based on the information at the time. The AAP has changed their stance over the years, which I will address later.
One regularly reported benefit is the ease of cleaning a circumcised penis compared to an intact one. This is due to the fact that once a penis heals from surgery, cleaning is similar to washing a finger. Simply soap, rinse, and go. Before a circumcised penis is fully healed, cleanliness is an issue since correct post-surgery care is incredibly important to prevent complications. Aftercare requires bandage changes, dabbing of petroleum jelly on the wound, ensuring that diapers don't adhere to the healing area, and administering pain medication.
Washing an intact penis is also soap, rinse, and go until a foreskin naturally retracts which usually happens in early childhood. Once retraction begins the foreskin needs to be pulled up as far as comfortable then the tip of the penis is washed with mild soap and rinsed before the foreskin is replaced. It takes perhaps a few extra seconds. The foreskin protects the penis from abrasions, bacteria, and dryness. Like in the vulva of females, smegma can accumulate under foreskin which can lead to infections or adhesions, but this is prevented by basic washing as described.
-Urinary Tract Infections (UTIs)-
Reduced risk of UTIs is one of the most touted benefits of circumcision. Pain and fever are the most common symptoms of UTIs. Males are much less likely to have them in general because they have longer urethras so the bacteria has to travel farther. In the first year of life, intact males have a 1% chance of getting a UTI whereas circumcised males have about a .1% chance. Whether a baby is intact or not, UTIs are treated by taking antibiotics until the infection is clear, usually for about a week.
Foreskin amputation is clearly going to prevent any possible future foreskin infections, thus the benefit. There are two main infections that affect penile foreskins. Balanitis is an inflammation of the foreskin caused by poor hygiene and can be cleared by an over-the-counter hydrocortisone cream. Bacterial infections are the second type and usually occur when there is a cut on the foreskin. If a cut is properly cared for, there shouldn't be an issue. When bacterial infections do happen, oral or topical antibiotics are in order.
Paraphimosis can occur when a foreskin is in the retracted position for an extended period of time and swells until it cannot be unretracted. This is exceedingly rare as foreskins don't retract on their own. Paraphimosis is mostly caused by health professionals who do not return the foreskin to its proper position after penile examination or penile instrumentation (such as inserting a catheter). While it can be a bit of an ordeal, paraphimosis if usually treated without any long-term damage.
Phimosis describes a non-retractable foreskin. Since foreskins sometimes don't retract until puberty (or even after), circumcision is regularly suggested for males with non-retractable foreskin whether or not any problems are occurring. While about 99% of intact males have retractable foreskin, phimosis is not necessarily an issue. Medical problems only occur if the penis cannot be properly cleaned or the foreskin closes over the tip of the penis. In those cases, there are several treatments available, one of which is circumcision.
It is estimated that only 1/3 of circumcisions due to diagnosed phimosis are necessary. In the instances when phimosis is an issue, it is often at an age when the male can look at the options and decide which treatment is right for them. It is also worth mentioning that boys can be born with a penile web or buried penis. In these cases, circumcision can actually create phimosis.
Put bluntly, we just don't have enough information to make claims about penile cancer and its relationship to circumcision. There is one American study that found that men circumcised as children had a lower rate of penile cancer while men circumcised as adults had a higher rate. Penile cancer is exceedingly rare among both intact and circumcised males. When we look at statistics from around the globe, there is no clear link between circumcision and penile cancer.
-STDs and STIs-
As the media has informed many of us, several studies conducted in high risk areas of Africa showed a significant decrease of HIV contraction in heterosexual, circumcised males. In the studies where risk factors were lower, the results were significant but not as impressive. The studies had some issues and those that carried it out wanted further research.
Many have since stated that the results cannot be applied to the U.S. or other populations where maintaining good hygiene and access to condoms are not issues. HPV and cervical cancer has been shown to be somewhat less prevalent in circumcised males and their partners if they were non-smokers in a monogamous relationship and had a low number of sexual partners in general. Condom usage does significantly more to prevent STDs and STIs than circumcision.
This is an issue that many anti-circumcision advocates feel is common sense, but research is murky. There isn't a lot of research on comparative sexual satisfaction because so few males have been circumcised as adults. What little there is seems to indicate that when the foreskin is amputated, sensation decreases. Several small studies showed a severe decrease and participants reported being unhappy with the results. Two larger studies literally contradicted each other. Erectile dysfunction has been reported as an side effect of circumcision.
Contrary to popular thinking, anesthesia is still not always used during circumcision. When anesthesia is used, it often involves putting needles directly into the penis. Topical anesthesia is not usually used since the time it needs to take full effect is approximate. Myths about infants' ability to feel pain have perpetuated, but we know that even the newest humans feel pain. Pain and discomfort can occur during a circumcision and during the recovery period.
-Complications of Circumcision-
I'll start with the scariest one first: death. Since circumcision related deaths are not reported that way, the numbers are uncertain. Blood loss, a complication from an unknown health condition, an allergy to anesthesia, or a mistake during the procedure can have fatal consequences. Anti-circumcision sources estimate that up to 117 deaths in the U.S. can be attributed to circumcision. Unless the CDC begins to list circumcision as a cause and fatalities are tracked as such, there is no way to get a definitive answer.
The estimated complication rate is placed anywhere from .1% to 35%. One major study placed it at 1 in 476 while another said it was 1 in 100. Infection, bleeding, and failure to remove 'enough' skin are the most common issues. Phimosis, chordees, hypospadias, epispadias, and urethra fistulas are all rare complications that require further surgery. Penile tissue death, partial or full penile amputation, and necrotizing fascitis (flesh eating disease) have been reported. Other complications include adhesions/skin bridges, inclusion cysts, abnormal healing, meatitis, meatal stenosis, urinary retention, and an excessive amount of skin removal. A well-sourced list of reported complications can be found here.
I'd be remiss if I didn't state that these statistics are for circumcisions performed in clinical settings. Circumcision is still primarily a cultural ritual in many areas and is not preformed in medically sterile environments. Complication rates and devastating accidents are much more common in cases where sanitation is uncertain. Many people will remember New York City's tragedy when an ultra-Orthodox Jewish ritual led to 11 baby boys contracting herpes, killing two of the boys.
Many people choose circumcision because it is the norm in their area or the other men in the family are circumcised. Since circumcision rates are trending downward, this is not as much of a factor as it once was.
Circumcision as a rite of passage continues to be one of the main reasons circumcision is practiced worldwide. As I stated earlier, religion was a driving force of circumcision in the early days and it continues to be a primary factor in many cultures. If religion is the deciding factor in the decision to circumcise an infant, there is a clear issue of consent: there is no guarantee that a child will grow up to accept the same beliefs as his parents. This fact has led to many reconsidering religious circumcision, even in Israel.
By definition, non-therapeutic neonatal circumcision is amputating healthy tissue from infants that are unable to consent. Ethically, all benefits have to be weighed against this fact. Complication rates are higher when the surgery is preformed later in life and the UTI benefit is completely lost after the first year of life. All the other benefits are applicable to older males who can weigh the pros and cons for themselves and make an informed decision, taking away all consent issues.
There are a growing number of adult men that are unhappy with their unconsensual circumcisions. A non-profit organization called NORM acts as a support group and has been in operation for almost twenty years. Many of its members choose to attempt foreskin restoration, and report beneficial physical and emotional results.
-The United States vs The World-
In 2007, the American Academy of Pediatrics released a policy statement that made headlines around the world. Their initial and subsequent statements announced that after reviewing hundreds of studies, their stance was that the benefits of male neonatal circumcision outweighed the risks, citing the ones I have discussed. They didn't go so far as to recommend the procedure.
Many pediatricians welcomed their new stance while others disagreed. A worldwide group, known as Doctors Against Circumcision, released a statement before the AAP's announcement, accusing them of making the stance change based on financial reasons. They later released a detailed Genital Integrity Policy Statement. Another coalition of doctors published their disagreement via the AAP's medical journal. A prominent medical ethics blog issued a special release recently regarding events since then.
Many of the dissenting voices argued that the AAP has a conflict of interest. The AAP is not a governmental organization. It is comprised of pediatricians and according to their mission statement, they seek to "attain optimal physical, mental, and social health and well-being for all infants, children, adolescents and young adults [by] support[ing] the professional needs of its members." Anti-circumcision activists often say that the "professional needs" are often financial and worry that the shift in stance is due to the compensation doctors receive for performing circumcisions, as well as the thousands of dollars hospitals can be paid when selling a foreskin to cosmetic companies.
Circumcision is most prevalent in the Muslim world and least prevalent in Latin America. Africa, the U.S., the Philippines, Israel, South Korea, and parts of Southeast Asia have the highest rates. Low rates are found in Europe, parts of Southern Africa, and most of Asia and Oceania. Like the U.S., Canada, New Zealand, Australia, and the U.K. have seen declines in the circumcision rate. Overall worldwide rates are said to be between 10% and 33%.
Many posts about male circumcision identify female genital cutting (FGC) as a ghastly horror. I tend to agree, but I am going to try to look at this without my cultural biases. There are different types of FGC, the lesser forms nick the skin surrounding the clitoris or remove the clitoris. The most severe form and what is often referred to as female genital mutilation is pharoanic circumcision (PC) which entails removing the labia and stitching closed the opening.
There are four reasons typically given for FGC: to preserve cultural identity, to help maintain cleanliness and health, to preserve virginity and family honor and prevent immorality, and to further marriage goals including enhancement of sexual pleasure for men. As horrific as FGC seems to most of us, many African women have lamented Westernized feminism for mistaking their joyous rite of passage for a dangerous, oppressive practice.
Because the practice is so stigmatized, there is very little research on any potential benefits. Like with male circumcision, when FGC or PC is preformed in unsterilized environments, complication risks are high. However, two studies suggested that there may be a strong protective effect against HIV and a 2007 study suggested that the less invasive types of FGC do not inhibit sexual pleasure in circumcised females.
Vaginal plastic surgery is preformed in the U.S.A. in the form of labiaplasties, clitoral hood reductions, or a combination of both. These and other vaginal surgeries are preformed to enhance sexual function or change aesthetics and are in many ways comparable to FGC. A small 2009 study found that over 90% of women who had vaginal plastic surgery were pleased with the results.
Much like when the AAP changed its stance on male circumcision, they made headlines in 2010 when they published an article on FGC which stated: "Most forms of FGC are decidedly harmful, and pediatricians should decline to perform them, even in the absence of any legal constraints. However, the ritual nick suggested by some pediatricians is not physically harmful and is much less extensive than routine newborn male genital cutting."
There were few who agreed with the AAP's statements about FGC even though their stance is congruent with their stance on male circumcision. Given the fact that the type of FGC they are giving credence to is said to not cause physical harm and be "much less extensive than routine newborn male genital cutting," I wonder at the lack of research. The AAP feels the benefits of male circumcision outweigh the risks so why not look into an even less invasive surgery that could have similar benefits for girls? Law bars pediatricians from performing FGC on minors, but researchers could look at girls and women that have already been circumcised. Are cultural norms stopping science or even influencing policy?
I'd venture that most of us can't imagine a world where we circumcise infant girls routinely, but is it really so different than what we do to infant boys? If the research that is available is correct, we could give our girls less risk of STDs and STIs, make their vulvas easier to clean, as well as remove any potential clitoral infections or issues. It could lower cancer risk in the same way that it may lower HIV risk. What if it led to less yeast infections? Would we remove portions of our girls' genitalia without consent the way we remove portions of our boys? I don't know, but if the answer is no we must reevaluate why we say yes to our boys now.
My goal was to remain unbiased, but if you guessed that my son remained intact you are correct. The statistics failed to sway me toward preemptive amputation and the issue of consent made it an easy decision. I know many people look at the same information and decide differently. In the end, I feel like most of the information out there is either too biased or too muddled and I hope this article is an exception. I did my best to find trustworthy sources as a lot of circumcision posts rely on misleading sources. I've included more links below for those interested.
In the end, the most important thing is that we love our children and the we offer them our best. Just because we have the same information does not mean we will make the same choices, but our best decisions are usually the ones based on reason.
Originally published at Wary Wonderlust
Nerve Endings and Sexual Pleasure
Complications of Circumcision
Penile Cancer Statistics
Penile Cancer Risk Factors
HIV Circumcision Studies
HPV, UTIs, and other statistics related to circumcision
Condoms Save Lives
More on Condoms
Study Researching STD, STI, and HIV Risks and Possible Circumcision Benefit
Preventing Penile Cancer
Penile Cancer Stats in US vs Other Parts of the World
AAP's Circumcision Information
AAP's Circumcision Info
Care of an Intact Penis
Overdiagnosis of Phimosis in Intact Males / Second Study
Normal Ballooning of Intact Penises
Photos of Botched Circumcisions
Prevalence of Circumcision
World Health Organization-Circumcision Overview
How Circumcised Foreskins are Used
AAP Mission Statement
Videos of Circumcisions
Differing Jewish Views on Circumcision
Recent German News about Circumcision
Tanzanian Study Discussed FGC