Male Circumcision

The practice of male circumcision dates back as much as 15,000 years. While its origins are obscured by time, today the practice of circumcising male infants continues to be popular in many parts of the world. Why do cultures routinely remove healthy flesh from their infants? Let's explore the reasons and consequences of what has been described as the world's oldest planned surgical procedure.

We'll be focussing on infant male circumcision here. I've chosen those words carefully, as this practice is distinct not only from adult male circumcision, where consent is possible, but also from the completely distinct and unrelated procedure of female genital mutilation, which was once erroneously referred to as female circumcision.

The procedure can be done many ways, but in medical environments, straps are used to restrain the child while a device separates the foreskin from the glans, or "head" of the penis. In infants, these two tissues are attached, and don't come apart easily. Once this is complete, a scalpel will cut the foreskin away, or a clamp will be applied that will gradually cause the tissue to die and fall off. This latter procedure involves no cutting, but takes longer and can be upsetting to parents.

Though it had been in decline for many years, the rate of infant circumcision is rising in the United States, especially in the Midwest. In many other parts of the world, it's seen as an unusual and surprising thing to do. The decision to circumcise is in the hands of the parents, hopefully with the guidance of a qualified medical professional.

There are three main motivations for having the procedure done. Those are 1) religious ritual, 2) social norms, and 3) medical benefits.

Regarding religious rituals of circumcision, such as those found in Judaism, Islam, and some sects of Christianity, the case is simple: infants (or older children or converts) are circumcised because God said it was required. Specifically, Abraham was given this instruction directly from God, so some Abrahamic religions follow the instruction. Polynesian, Oceanic Aboriginal and some African traditions also practice circumcision, but not usually on infants. It is performed as a rite of manhood, with an emphasis on the strength demonstrated by enduring the extreme pain that follows from an incision in highly innervated tissue.

Most religiously prescribed circumcisions happen in a hospital environment, but others are performed using centuries old rituals involving holy knives, oral/genital contact, and other non-clinical conditions. If you believe God said you should cut off a part of your child's body, there's not much I can add to that except maybe to suggest that you ask the question "Why?" and only proceed when you have a satisfactory answer.

While religious tradition can lead to social norms, that's not always the case. In the United States, for example, circumcision is performed based on a tradition started by the anti-masturbation movement of the late 1800s. It was thought that removing the foreskin would prevent boys from "polluting themselves," also known as masturbating. Any circumcised man can tell you this is a completely ineffective approach. Still, the idea that it was the proper thing to do persists, and circumcision continues in part due to momentum from this movement.

When parents are asked if they want to circumcise their child or not, they often respond based on what they're familiar with. Some want their son to "look like Dad," or they don't want their child to be the "odd one" in the locker room. Others are concerned with hygiene and some are concerned that potential mates won't find an uncircumcised penis attractive. That feeling may come from their own of an uncircumcised penis as being somehow foreign or odd since they've never had any experience with one. Consider how the term "uncircumcised" is the most common way to refer to someone who is "intact."

There is also a concern about hygiene, which is separate from medical concerns. A circumcised penis had a dry head with no noticeable fluid or secretion build up. An intact penis has a moist head, and there can be a build up of sebum and skin cells known as smegma. While this is easily washed away, some people find the idea offensive and unclean. Ironically, the word "smegma" means "soap" in the original Greek. There is no evidence that the substance is harmful, and it may provide some benefit. Still, in cultures where circumcision is common, the idea that smegma is an unclean substance can be a motivation to circumcise.

Medical reasons for circumcision are complex and political. There are many medically indicated reasons to remove the foreskin of both adults and infants. These include cancers, chronic conditions, malformations, and other difficulties. Some studies have shown that the risk of penile cancer drops drastically in circumcised males. While that sounds like a good reason to have the procedure done, the incidence of penile cancer in intact males is 1:100,000. To gain any benefit, you'd have to circumcise 100,000 males to prevent one incidence of cancer. Accordingly, no widely-recognized medical organization recommends routine infant circumcision to combat penile cancer or other rare problems.

Things get trickier when sexually transmitted infections are considered. There is evidence, some of it strong, that certain infection rates are lower in circumcised males. Chief among these is HIV. HIV is a worldwide problem, killing many thousands of people each year. It's been hypothesized that intact men may harbor the virus under the foreskin, and that uncircumcised intercourse may cause more micro-lacerations to the penile skin, increasing the chance of sharing a blood borne illness. Some studies indicate other STIs such as cancer-causing HPV are more prevalent in intact men. It seems safe to say that there are some medical benefits to circumcision. It's also fair to counter that condom usage and the HPV vaccine can provide the same or better protection as circumcision.

And now we must weigh risk vs. reward. Are the presumed medical benefits worth the risks? There are medical benefits to appendectomy. If we performed routine infant appendectomy, incidents of the life-threatening condition known as appendicitis would be eliminated. And yet we don't do that, because the necessary calculation of risk and reward shows that the risks are not worth the reward. Abdominal surgery is far too dangerous to make it feasible when not in response to a serious condition.

When weighing the risks of infant circumcision, the rate of complications appears to be around 1.5%. That is, 1.5% of children undergoing the procedure will have unwanted side effects. While some of these might be as mild as bleeding, a small fraction of circumcised infants will have a serious complication which can include deformity, infection, and in extreme cases, amputation or death. These risks go up if the circumcision is performed outside of clinical conditions.

Also, the foreskin is not just a useless piece of tissue (nor is the appendix). Foreskins protect the glans and also provide sexual sensation during intercourse. They also improve the mechanics of intercourse, making the need for artificial lubrication less necessary. While it's clear that circumcised men can and do enjoy sex, some argue that they are missing out on an even better experience, though studies have not yet shown this to be the case.

When there is some question as to a risk/rewards ratio, it's a good practice to look to experts and professionals for their opinions. In the case of circumcision, nearly all medical organizations sit firmly on the fence, tending towards not recommending the procedure be performed routinely on infants. Of these, only the American Academy of Pediatrics shows some support, as demonstrated by this 2012 statement:

After a comprehensive review of the scientific evidence, the American Academy of Pediatrics found the health benefits of newborn male circumcision outweigh the risks, but the benefits are not great enough to recommend universal newborn circumcision. The AAP policy statement published Monday, August 27 (2012), says the final decision should still be left to parents to make in the context of their religious, ethical and cultural beliefs.

So, the AAP states, the procedure appears to be valuable, but it's not explicitly recommended. That seems an odd position to take. Why not recommend a procedure if the benefits outweigh the risks?

Major medical organizations such as the AAP, the World Health Organization, and the Centers for Disease Control are good sources of reasoned information. They are also under political pressure. For the AAP, calling for an end to the practice could induce insurers to stop covering the procedure. While this would certainly lower the rates of circumcision, it could also adversely affect some families and doctors represented by the AAP.

While doctors and hospitals make money performing circumcisions, this is not just a financial consideration. If doctors stop doing routine circumcisions because of ethical or financial concerns, those who strongly believe their child should be circumcised may seek other, less safe means of having the procedure done. Thus, if the AAP decided to recommend an end to the practice, it's possible that more children would be harmed. This is similar to the argument used by pro-choice advocates who claim that people will have abortions no matter if it's legal or not, so we'd best make it legal so they can have them in safer conditions. This is just one possible argument. I can't be sure of the AAP's reasoning, and the statement remains controversial.

The WHO does recommend circumcision in areas of Sub-Saharan Africa where HIV is a serious health risk. In this region, the risk/rewards ratio is different because the reward of lowered incidence of HIV has a much bigger impact. They are in favor of the procedure for infants as well as adults, though they also say that condoms are effective. Why not just use condoms? The truth is that many people don't like them and don't use them, despite the very strong evidence that they significantly reduce the incidence of STIs. There are also religious proscriptions against their use.

And now another factor enters the conversation. If you agree that circumcision makes sense in Sub Saharan Africa, when should it be performed? It's a painful procedure for adults and infants. In infants, the risk of complications is lower than in adults, but there is some evidence to suggest that the pain of circumcision can negatively impact a person's reaction to pain for their entire life.

An adult may better be able to deal with the pain (which may be greater and last longer), and they have one thing that infants don't have: the ability to consent. And this is where much of the emotion surrounding this issue is focussed.

Many anti-circumcision groups believe that infant and childhood circumcision violates the principle of bodily autonomy, which states that a person has an unalienable right to dictate what changes are made to their body. It would be unconscionable to tattoo "I Love the Rolling Stones" on a child's forehead, and thus it should be unconscionable that a perfectly healthy part of their body be removed. If they choose to get that tattoo or be circumcised as an adult, that's completely fine as they're deciding what to do with their own body.

The problem with this argument lies in the fact that infants don't have bodily autonomy. Parents have the legal ability and duty to consent over changes to a child's body, with the requirement that such changes are made in the child's best interest. Children visit dentists, have their hair cut and get vaccines against their will. In cases of illness, they may have body parts removed or altered. It's up to the parents and medical professionals to decide which of these procedures should be performed. If parents go against medical advice, there can be legal consequences.

In the case of circumcision, if parents decide to circumcise their child, it can be viewed in the light of "doing what's best for the child." People may strongly disagree and present evidence to the contrary, but the argument can be made and it will be accepted by both the medical community at large and legal entities. This may change over time, but it is the current state of things.

There is a lot of information available from anti-circumcision groups that overstate the impact of circumcision. Some of these such as the Circumcision Information and Resource Pages and the National Organization of Circumcision Information Resource Centers (NOCIRC) present themselves as neutral information providers, while nearly all of the information provided is against the concept of circumcision, especially in infants. NOCIRC has a Circumcision Decision-Maker tool that encourages you to decide "No" regardless of what options you choose.

When confronted by studies indicating health benefits in circumcision, they respond with the tactic of pointing out that there is disagreement about the studies. This is a tactic commonly used by anti-vax groups and others whose beliefs fall outside the realm of scientific consensus. Their conclusion may very well be correct, but their tactics betray critical thinking and are firmly entrenched in emotion and activism. Studies have shown no difference in sexual satisfaction between circumcised and uncircumcised men, though there are anecdotes stating drastic differences. In an unscientific discussion with my male friends, none of them expressed any great regrets at having had the procedure done. I've known some intact men who needed to be circumcised for medical reason as adults. They all wish they'd had the procedure done as an infant. That argument could be made from people with appendicitis as well.

The impact of circumcision on adult life seems negligible for most people, though you can find strong arguments on both sides. Uncircumcised men can have the procedure done at any time, and circumcised men can undergo a lengthy process of regrowing a foreskin replacement if they choose to. This is arguably not a complete replacement, but it is an available option.

In conclusion, circumcision remains controversial. Infant male circumcision is largely motivated by social expectations.

If you're in a position of having to decide on the procedure for your child, you have things to consider. The main points are:

• Most medical organizations are either neutral or against the procedure
• Circumcision has risks, including disfigurement and death
• The consequences of circumcision are often overstated

By Jeff Wagg