* Current national neonatal circumcision rates:
–Canada: <17% overall in 1996-97, with large regional variations. [see CIRP for provincial rates, data from Canadian Institute for Health Information]
–U.S.: 57.2% circumcised before leaving hospital in 1998. [data from CIRP, Solucient, CDC/NCHS]
–Australia: 12.1% circumcised in 2000. [data from CIRP and Australia's Health Insurance Commission]
* Every day in the United States, over 3,000 routine circumcisions are performed on infant boys: 1 every 28 seconds, 1.113 million yearly, at an annual cost to parents and health insurers of many tens of millions of dollars. [data extrapolated from CIRP]
* Over 80% of the world’s male population is genitally intact, with 20% being subjected to some form of childhood genital mutilation.
* The U.S. is the only country in the world to circumcise the majority of its newborn males for non-religious reasons.
* Over 90% of infant circumcisions performed in the U.S. are for non-religious reasons.
* 100% of infant circumcisions are done without the consent of the individual concerned.
* 0% of routine infant circumcisions are indicated. When referring to a medical intervention, the term “indicated” applies to a treatment/intervention that is required because a particular condition is present. Infant circumcision is performed only on healthy infants who do not have a condition requiring circumcision, so there is no “indication” to perform a circumcision. Routine infant circumcision has been called “cosmetic,” “prophyllactic,” “elective,”or “social” .
The problematic history of non-therapeutic (routine) male infant circumcision
* In the 19th century, British and American physicians thought it logical to perform genital surgery on both sexes to prevent or cure a long list of maladies. Just a few of these conditions included: paralysis, lunacy, curvature of the spine, epilepsy, fever, whooping cough, weight loss, tubercular meningitis, hernia, inflammation of the bladder and masturbation.
–Gollaher DL. From ritual to science: the medical transformation of circumcision in America. Journal of Social History 1994;28(1):5-36 . [Full Text]
* The current rationales/rationalizations for infant circumcision developed after the operation was in wide practice. Some of them include: to make sons resemble their circumcised fathers; to conform anatomically with peers (note: circumcised Canadian boys now find themselves in the minority); to improve hygiene; to prevent tight/non-retractile foreskin (which is normal in childhood); as prophylaxis against urinary tract infection (UTI), sexually transmitted diseases (STDs), and cancer of the penis, prostate and cervix. If circumcision were a new procedure being proposed today for any of the above conditions, it would not be acceptable based on insufficient medical evidence and/or medical ethics (it is against medical ethics to perform unnecessary surgery).
* With a clearer understanding of normal male genital anatomy, and the creation of the British National Health Service in 1948, infant circumcision in Great Britain quickly declined. Non-religious infant circumcision is now very rare. No exact figures are available, but from extrapolation of data from the Liverpool and Sefton health districts, it is estimated that 1.5% of boys would be circumcised by age 15, with <0.1% of those circumcisions done in infancy.
–Rickwood AMK, Kenny SE, Donnell SC. Towards evidence based circumcision of English boys: survey of trends in practice BMJ 2000;321:792-793. [Full Text]
The penile foreskin defined
* The foreskin (or prepuce) is a natural, retractile, protective covering for the glans (head) of the penis, and is the most erotogenic area of the penis in terms of the quantity, concentration, and quality of specialized nerve receptors and stretch receptors that it is endowed with, especially on its inner mucosal lining (which gets redeployed behind the glans during erection).
* The average adult foreskin consists of 1½ inches of outer skin, 1½ inches of inner mucosal lining – totaling a length of 3 inches – and is 5 inches in circumference when erect. This amounts to a surface area of 15 square inches, or a surface area equivalent to that of a 3" by 5" inch index card!
* The foreskin contains over 240 feet of nerves and over 1,000 nerve endings, as well as being a highly vascularized structure.
* The foreskin contains “junctional mucosa that appear to be an important component of the overall sensory mechanism of the human penis”
–J. R. Taylor et al. The prepuce: specialized mucosa of the penis and its loss to circumcision. British Journal of Urology (1996) 77, pp. 291-295.
* The foreskin is not vestigial or redundant tissue, in that no other part of the male body does what the foreskin does, or feels what the foreskin feels.
* The foreskin serves to protect the glans, thereby maintaining the glans-surface’s naturally-intended thinness, texture, and sensitivity.
* The foreskin has rich sensations in and of itself. The foreskin also plays a mechanical-lubrication role. It serves as a gliding sheath during masturbation or sexual activity, rendering the quality of the friction between the man and his partner more gentle, less abrasive. This is useful to the woman, especially with prolonged intercourse and especially with age, when she provides less liquid lubrication. With circumcision, this natural gliding mechanism is lost.
* The fact that the foreskin in infancy is usually non-retractile serves to protect the baby’s glans penis from urine and feces during the period that he is incontinent.
* Women have a foreskin as well, which covers and protects their clitoris. It is alternatively referred to as the clitoral foreskin, clitoral prepuce, or clitoral hood.
Penile development
* Development of the foreskin is incomplete in the newborn male child, and separation from the glans, making it retractable, does not usually occur until some time between 9 months and 3 years.
* Tight non-rectractile foreskin (normal developmental non-retractability, or physiological phimosis) resolves by age 6 in 92% of boys, 94% by their teens. 1% of late adolescents will still have a non-retractile foreskin. (Gentle, systematic stretching is indicated to resolve this. Moreover, steroid creams are successful in resolving this in the vast majority of cases when this is a problem.)
* Infant circumcision interrupts natural penile development.
Hygiene easy
* The American Academy of Pediatrics (AAP) states: “The uncircumcised penis is easy to keep clean. No special care is required. No attempt should be made to forcefully retract the foreskin [of a child whose foreskin is as yet unretractable].”
* Simple overall hygiene can offer all the potential benefits of circumcision, without the sacrifice of the health benefits of the foreskin and of physical and functional integrity.
* Intact genital hygiene for a male is easy and takes very little time, certainly less time than shaving or brushing the teeth.
The basis of the (non-religious) circumcision decision
* Research has consistently shown that parents who decide to circumcise do so mainly for non-medical reasons. Social concerns are more important than medical ones according to one recent study. Reasons given for the procedure included perceived ease of hygiene, ease of infant circumcision compared with adult circumcision, father circumcised, to be like other boys, appearance, culture, and family pressure.
–Tiemstra JD. Factors affecting the circumcision decision. J Am Board Fam Pract 1999;12:16-20 [Full Text]
Immediate risks and possible surgical complications
* No accurate statistical records are kept of infant circumcision complications.
* According to the American Academy of Pediatrics, the exact incidence of post-operative complications is unknown.
* Complications are often overlooked or un(der)reported. They include: Lacerations, skin bridges, chordee, meatitis, meatal stenosis, urinary retention, glans necrosis, hemorrhage, meningitis, sepsis, gangrene, and penile loss requiring sex re-assignment. The literature abounds with reports of morbidity, and even death, from infant circumcision.
* A realistic complication figure is 2%-10%.
–Williams, N. Complications of Circumcision. British Journal of Surgery, vol. 80, October 1993, pp. 1231-1236.
* Infant circumcision excises normal, healthy, healthful, functioning erogenous tissue that belongs to someone else (i.e., to someone other than the one making the circumcision decision, and other than the one who will be affected by the decision), and leaves a scar.
Pain, trauma, and memory
* According to a comprehensive recent study, infant responses to pain are “similar to but greater than those observed in adult subjects.”
* Infant circumcision causes severe, persistent pain.
* Some infants do not cry because they go into shock from the overwhelming pain of the surgery.
* Infants rarely receive anaesthesia or post-operative pain management.
* No anesthetic has been found to be safe and totally effective in preventing circumcision pain in infants. [A man circumcised in adulthood will be given the benefit of general anaesthetic, post-operative pain management, choice and informed consent over the fate of his own genital integrity.]
* The persistence of specific behavioural changes after circumcision in neonates implies the presence of memory for the incident.
–Taddio A, Katz J, Ilersich AL, et al. Effect of neonatal circumcision on pain response during subsequent routine vaccination. Lancet 1997;349(9052):599-603. [Full text]
Maternal-infant interaction and breastfeeding affected
* A stressful, painful event such as circumcision affects feeding patterns. Infants feed less frequently and are less available for interaction after circumcision. Observed deterioration of breastfeeding after circumcision may potentially contribute to breast-feeding failure and changes in mother-infant interaction.
–Howard CR, Howard FM, Weitzman ML. Acetominophen Analgesia in Neonatal Circumcision: The Effect on Pain. Pediatrics, 1994; 93:641-646. [Full text]
–Dixon S. Snyder J. Holve R. Bromberger P. Behavioral effects of circumcision with and without anesthesia. J Dev Behav Peds 1984; 5: 246-250. [Full Text]
–Marshall RE, Porter FL, Rogers AG, et al. Circumcision: II effects upon mother-infant interaction. Early Hum Dev 1982; 7:367-374 [Full text]
* Breastfeeding has a protective effect against urinary tract infection (UTI) and other infant infections. There is a three-fold reduction in urinary tract infections during the first year of life in breast-fed infants according to the AAP. According to a recent study by Teresa To et al., 195 boys would have to be circumcised to prevent one hospitalization for UTI in the first year of life. By contrast, breast-feeding provides a three-fold reduction of the risk.
–Pisacane A, Graziano L, Mazzarella G, et al. Breast-feeding and urinary tract infection. J Pediatr 1992;120:87-89. [Full text]
–AAP Workgroup on Breastfeeding. Breastfeeding and the use of human milk. Pediatrics 1997;100: 1035-39. [Full text]
–To T, Agha M, Dick PT, et al. Cohort study on circumcision of newborn boys and subsequent risk of urinary-tract infection. Lancet 1998;352:1813-16. [Full text]
Long-term adverse outcomes
* An estimated minimum of 1.3 to 6.6 million males born in the U.S. between 1940 and 1990 carry some degree of physical complication from infant circumcision. Unknown numbers carry some form of sexual or psychological complication.
* Circumcision constitutes a subtraction, removing one- to two-thirds of the penile skin system.
* Long-term possible adverse outcomes (physical) include: skin tags; skin bridges; prominent scarring (keloid scar formation); tight, painful erections; bleeding of the circumcision scar during prolonged intercouse (constituting an efficient portal of entry for HIV among other viruses); penile curvature due to uneven skin loss; skin tone variance; progressive sensitivity loss (progressive keratinization of the glans-surface); excessive/painful stimulation or prolonged exaggerated thrusting needed to achieve orgasm; beveling deformities of the glans.
* Adverse outcomes of a psychological nature that have been reported and documented include: sexual dysfunction of various forms and degrees, including impotence; awareness of a loss of normal protective, sensory, and mechanical functioning; anger, resentment; feelings of parental petrayal; feeling (awareness) of being mutilated; feelings (awareness) of one’s right to a normal intact body having been violated and removed; feelings (awareness) of being unwhole and unnatural; addictions or dependencies; sense of anatomical and sexual inferiority to genitally intact (non-circumcised) men; foreskin (or intact penis) envy.
* The quality and quantity of long-term negative impacts on men from infant circumcision have never been investigated.
Involvement of Obstetricians/Gynecologists
* Ob/Gyn’s, specialists in female genitalia and practicing out of their field, perform most newborn male circumcisions.
* Ob/Gyn fees for circumcision range to $400, averaging $137 nationwide [U.S.]
* Circumcising 10 infants weekly for only 10 months of the year at $125 each (1987 U.S. rate), circumcisers earn at least an additional $50,000 annually.
* 74% of the Ob/Gyns surveyed perform circumcision.
* Ob/Gyns are generally not aware of preputial (foreskin) structure and function, or of the growing numbers of men undertaking foreskin restoration.
The questionable medical value of non-therapeutic (i.e. routine) male infant circumcision
Urinary tract infection (UTI)
* Worldwide, infant UTI is treated antibiotically, not amputatively.
* In the 1980s, retrospective studies by Wiswell et al. suggested that 98-99% of intact (non-circumcised) male infants will not develop UTI (compared with his finding of 99.9% in circumcised male infants). In 1989, the AAP (American Academy of Pediatrics) cautioned that Wiswell’s studies comparing the two groups may be methodologically flawed, and that the percentage of intact male infants who will not develop UTI may be even higher. Research in the 90s has since confirmed that Wiswell’s studies are flawed, as the AAP cautioned, and that the incidence of UTIs in intact male infants is significantly lower than the 1-2% he reported.
* Females have higher rates of UTI in childhood and throughout life than either intact or circumcised boys.
* European doctors cite American birthing practices, not the foreskin, as the cause of the U.S.’s allegedly higher rate of UTI in intact boys.
* UTI in males often results from a congenital abnormality which predisposes the child to bacterial infection. Such congenital abnormalities have nothing to do with the foreskin.
* Antimicrobial management of UTI in infants is routine, and the outcome generally good.
Penile Cancer
* Among intact (i.e., non-circumcised) males, 99.999% will not develop penile cancer [The rate of penile cancer is 1 in 100,000. It is one of the rarest cancers, rarer even than male breast cancer.]
* Testicular cancer strikes 1 in 300 males, prostate cancer 1 in 11. (Source: American Cancer Society)
* It has been suggested that performing 100,000 infant circumcisions – thus removing in 100% of those circumcisions 100% of the foreskin’s irreplaceable health benefits – in order to possibly prevent an otherwise preventable cancer in one elderly man is absurd.
* Annually, there are more infant deaths from infant circumcisions than deaths from cancer of the penis.
* It has been erroneously claimed that penile cancer virtually never occurs in men who have been circumcised in infancy.
* In a recent study on penile cancer, a full 20% of the study-group had been circumcised at birth.
Cervical cancer
* Scandinavian society (virtually non-circumcised) has a lower rate of cervical cancer than the U.S (a majoritarily circumcised society).
* Both cervical and penile cancer are now understood to be caused not by genital smegma (which both sexes produce), but by HPV (Human Papilloma Virus), a sexually transmitted virus.