Being from England, I reached adulthood without even knowing that there was such a thing as the routine circumcision of newborn boys. In Europe it is rare, and it is estimated that between 80 and 95 percent of men worldwide are uncircumcised. But when I married an American and gave birth to a boy in the Hudson Valley, I learned that most boys are circumcised as a matter of course in the US. I informed my husband that I was against it for our child and he agreed. A few decades ago this would have been a radical choice: 85 percent of American boys in the 1980s were routinely circumcised. But that has fallen to an average of 55 percent nationwide, with just 23 percent in the western states. This decrease is partly a result of immigration from countries where it is not practiced but may also be due to factors such as a gradual change in our perception of the custom and a greater awareness of medical facts.
Ninety percent of circumcisions in the US are done electively for nonreligious reasons, and it is these nonreligious ones that this article largely addresses. Still, it is worth noting that this ancient practice is often entwined with culture, ritual, and emotion. For Jews and Muslims, it represents a covenant with God. Traditionally, these faiths interpret the Bible to require boys to be circumcised, whether as infants, or later as a rite of passage.
J.P. of New Paltz (who asked that we use only his initials) is of Jewish heritage, yet he decided that he would “never allow” his son to be circumcised either for religious or medical reasons. “For me it was a no-brainer” he says. “I encountered a lot of protest from my family and in-laws. But to me, circumcision is a hold-over from less enlightened times.”
Circumcision in the United States
Circumcision first appeared here during the puritanical Victorian era, often within the context of Christian fervor, as an attempt to curb masturbation. The aim was to create postoperative soreness and tight skin to make manipulation more difficult, and erections uncomfortable. Dr. John Harvey Kellogg, a prominent medical doctor, wrote in 1888: “A remedy [for masturbation] which is almost always successful in small boys is circumcision...without administering anesthetic, as the pain attending the operation will have a salutary effect upon the mind, especially if connected with the idea of punishment.” And in a time before the causes of disease were understood, doctors of the 1800s claimed it could prevent all manner of conditions, from bed-wetting and asthma to epilepsy and even polio. Gradually, other reasons to circumcise came into vogue. Today’s rationale for circumcision (other than religious ones) includes fears that an intact foreskin makes a penis difficult to clean and more prone to infection.
Paul Mark Baker, MD, a pediatrician with Hudson Valley Pediatrics in Middletown observes that, of the parents who have their sons circumcised, “usually it’s cosmetic, and Junior is to have it because Daddy did.” Indeed, a father may be very resistant to a son who does not resemble him. In any case, in America we have grown accustomed to the appearance of a circumcised penis and as a result many people seem to prefer its aesthetics. For reasons such as these, many parents in the United States take it for granted that a son will be circumcised. As such, they may not investigate what the procedure entails and assume it to be a quick “snip,” attended by little discomfort and no side effects. In reality, it is an invasive, painful operation.
More Than a Snip
With the advent of YouTube and anticircumcision websites, parents can easily see the procedure for themselves. It is not pretty. To summarize a common hospital method: The baby is strapped to a board for the duration of the procedure, which lasts up to15 minutes. The foreskin is clamped and a probe is repeatedly forced between it and the glans (head of the penis) to break the secure bond that, in infants, attaches the foreskin to the glans. Once loosened, the foreskin is cut open to expose the glans. A bell-shaped instrument is fitted over the glans while the surrounding foreskin is finally cut off, removing at least 50 percent of the penile skin system (the foreskin being a continuation of the shaft skin and not merely a small flap at the end). The wound is cleansed, covered with Vaseline and gauze, and usually heals in one to two weeks.
While some doctors inject a local anesthetic into the base of the penis before the procedure (itself very painful), it is almost never used because it is risky for an infant, and actually considered unnecessary by some doctors. Topical numbing creams are sometimes applied but are woefully inadequate. Because the foreskin is highly innervated, babies typically scream and struggle throughout the operation. A few will exhibit signs consistent with shock, thus the reduced outward response in some babies. Several studies have recorded a markedly elevated heart rate and cortisol levels, intense crying, and other measures that indicate severe pain. A study as long ago as 1983 in the Journal of Pediatrics concluded, “This level of pain would not be tolerated by older patients.” Another study was ended early because babies were so obviously traumatized (Journal of the American Medical Association, 1997). The pain does not end with the procedure. With a raw wound, urination stings, contact with (and changing of) diapers is uncomfortable, and being held closely can hurt.
Circumcision under Scrutiny
The American Medical Association issued this reminder in its 1999 Report of the Council on Scientific Affairs: “Virtually all current policy statements from specialty societies and medical organizations do not recommend routine neonatal circumcision.” The American Academy of Pediatrics (AAP) official policy statement states similarly that the medical evidence “is not sufficient to recommend routine neonatal circumcision.” Dr. Baker used to quote this when trying to dissuade parents from having it done, but says “after a while I just gave up, since it was clear they were going to anyway. If the babies themselves had a vote in Washington, it would never be done.”
Many eminent doctors and scientists advocate for a complete ban on routine circumcision on the grounds of pain, trauma, and complications. Famous pediatrician Benjamin Spock did a u-turn from his original support of circumcision to declare in 1976: “It is at least mildly dangerous. There is also a danger of emotional harm.” Some researchers have theorized that the trauma becomes imprinted in newly forming pleasure centers of the brain, so that sex is associated with pain later in life.
Dr. Baker has not personally seen many complications but admits, “There are horror stories, such as when a trainee obstetrician did a circumcision incorrectly and it had to be redone, including a skin graft.” Circumcision does have surgical risks and at least 20 documented short-term or long-term side effects, including ulceration at the site of surgery (in as many as half of circumcised babies), painful urination; abnormally shaped or shortened penis; loss of the entire penis due to infection; permanent pits and scars on the glans; painful swelling from severed lymph vessels; breathing difficulties and injury to internal organs from intense, prolonged crying; failure to breastfeed and interrupted parent-infant bonding when shock causes the infant to withdraw and pain affects his mood; and longer term psychological and nervous system damage. Death from circumcision is rare but does occur, and is usually due to uncontrollable bleeding or systemic infections. A 1979 edition of Sexual Medicine Today reported 229 fatalities per year. Although that reference is relatively old, the fact that iatrogenic deaths are known to be under-reported means that the figure may be more accurate than we would like to believe.
Official medical organizations in Canada, Australia, New Zealand, Finland and Britain all have statements opposing routine circumcision; the British Medical Association describes it as “unethical and inappropriate.” Thomas J. Ritter, a surgeon and coauthor of Doctors Re-examine Circumcision, reminds his colleagues who still perform it: “You are violating the major tenet of medical care, ‘First do no harm,’ and all seven principles of the Medical Association Code of Ethics.”
Cancer and Infections
It is widely believed that circumcision can help prevent cancer and sexually transmitted diseases (STDs). The American Cancer Society “does not consider routine circumcision to be a valid or effective measure to prevent cancers” and finds that “penile cancer rates in countries which do not practice circumcision are lower than those found in the United States.” Penile cancer is rare; Ritter posits that a man has a greater chance of dying from breast cancer or from the circumcision itself. And while circumcision was suggested to help prevent cervical cancer in women because Jewish women had a lower incidence, non-Jewish partners of circumcised men do not have a lower incidence. Also, European women do not have a higher rate than American women, even though most European men are uncircumcised.
Although some studies indicate that circumcision reduces the spread of STDs and urinary tract infections, the AAP discredited them as flawed in its 1999 policy statement, which it reaffirmed in 2005. The AMA acknowledges that some studies have linked circumcision to a lower rate of UTIs in the first year of life, but that such infections are rare in any case (0.4 to 1 percent). Whether circumcision reduces likelihood of HIV infection or transmission continues to be debated. A 1999 meta-analysis of HIV/circumcision correlation studies published in the International Journal of STD & AIDS concluded, “Recommending routine circumcision as a prophylactic measure to prevent HIV infection in Africa, or elsewhere, is scientifically unfounded.” A trio of recent controlled studies in Africa found lower female-to-male transmission rates among circumcised men—a result underlying a wave of voluntary circumcision among some African men. But the design of these studies and their relevance in a complex cultural setting are being questioned by some HIV/AIDS experts, and regions of Africa where circumcision is already common do not all have correspondingly low HIV infection rates.
Dr. Baker is among those who do not condone AIDS prevention as a reason for circumcision, noting that “while there is evidence that it could reduce the rate in Africa, it does not seem to make any difference here in the US.” Indeed, the United States has the highest percentage of sexually active circumcised men in the Western world, one of the highest rates of AIDS, and an epidemic of STDs.
Hygienic and Sexual Considerations
A circumcised penis is often thought of as more hygienic, but an intact penis is easy to keep clean. Moreover, the foreskin of an uncircumcised penis acts as a protective covering that maintains the glans as an internal organ, shielding it and the urinary opening from abrasion and germs. The foreskin’s inner surface is a mucous membrane similar to the underside of the eyelid or inside of the cheek. It produces lubricants, cleansing secretions, and antimicrobial proteins (such as lysozyme, also found in tears and breastmilk). It also maintains ideal pH balance and temperature. In infancy, the foreskin lips dilate only enough to allow for the passage of urine, protecting the developing glans from exposure.
The foreskin produces a natural emollient (smegma), as do female genitals. Pediatrician Paul M. Fleiss describes it as “the most misunderstood, most unjustifiably maligned substance in nature.” Once thought by physicians of the 1800s to be a germ-trapping substance that was also unclean itself, this natural secretion helps to keep the glans clean and healthy, just as tears cleanse and lubricate the eyes. Accumulation of smegma can be prevented by simply rinsing it away on a regular basis.
As a movable sheath, the foreskin allows the penis to glide more smoothly in and out of the vagina within its own sleeve. Movement of the foreskin itself also contributes to a man’s pleasure. With more specialized nerve receptors than any other part of the penis, it is a major erogenous zone. A removed foreskin takes with it about 240 feet of nerves and 20,000 nerve endings. Circumcision may also remove the highly erogenous frenulum. And since the foreskin keeps the glans moist, the glans is more sensitive in an intact male. A circumcised penis exposes the glans to constant abrasion from clothing; together with the loss of its moist environment, this toughens the skin.
J.P. laments, “Circumcision is a physiological alteration of our most private parts for life. I will never get to experience that part of myself in its natural state.” Many men feel the same. Wishing to experience an intact penis, some are using specialized products to gradually stretch shaft skin over the glans to re-create (after months) a sheath-like covering.
The Future of Circumcision
Circumcision is gaining momentum as a human rights issue. Increased condemnation of female circumcision (or “female genital mutilation”), which cuts away some or all of a girl’s external genitalia, has added a new perspective on male circumcision. Though the two differ in various ways, people are realizing that they are both attended by pain and loss of function. Some men have even filed lawsuits against their circumcisers and the first cases have already been settled. Examples include the case of William Stowell, who waited until the age of 18 when he was legally able to sue the doctor and Long Island hospital where he was circumcised, and Shane Peterson of Australia who was awarded $360,000 for a circumcision that was botched.
Ritualized circumcisions often differ from routine hospital procedures in technique and intentions, but similar pain and health issues apply. Religious rationale for circumcision is beyond the scope of this article, but readers interested in the controversy about circumcision on that basis will find fascinating perspectives and resources at Jews Against Circumcision (www.jewsagaintscircumcision.org) and in the books Questioning Circumcision: A Jewish Perspective by Ronald Goldman PhD, and Male and Female Circumcision among Jews, Christians and Muslims, by Sami Awad Aldeeb Abu-Sahlieh.
In the end, the decision to circumcise or not is in the hands of the parents. Still, the fact that a baby cannot give his own informed consent bothers activists such as Georganne Chapin, a health care executive and attorney who has taught bioethics. She is leading the formation of Intact America (www.intactamerica.org), a new organization, based in Tarrytown, dedicated to abolishing infant circumcision. Ms. Chapin’s own prediction is that “it will only be a short time before we realize that circumcision cannot cure our ills, and coercing vulnerable people to give up a critical part of their anatomy is a bioethical travesty.”