Circumcision

In one of my recent classes, we had to research a subject that involved some degree of debate and present each side as unbiasedly as possible. I thought to look into some subject that I would have to research anyways to save myself time and to motivate myself to get a better grasp of the issues at hand. I chose routine neonatal male circumcision. I thought I would share because I think that both sides present some compelling arguments. I hope that in the end, you guys find this to be an entertaining, if not informative, read and take no offense at my closing opinion. Forgive any typos because this was my rough draft (my final was sadly lost somewhere in computerland).


Circumcision is a surgical procedure in which the skin (Along with mucosa, nerves, and small muscle) covering the end of the penis is removed (AAP, 2009). Although the exact frequency is unknown, it is estimated that 1.2 million newborn males are circumcised in the United States annually at a cost of between $150 and $270 million. This practice has been advocated for reasons that vary from symbolic ritual to preventive health measure (AAP, 2009).

Circumcision of males has been undertaken for religious and cultural reasons for many thousands of years. It probably originated as a hygienic measure in communities living in hot, dusty and dry environments. It remains an important ritual in several religious and cultural groups (RACP, 2009).

In the 1920s, for the first time in history, a majority of American males were to be circumcised. This was the beginning of a trend that increased over the years, and then leveled off to about 85 percent of newborn males by 1980 (Harrison, 2002). In the United States, many hospital-born male infants undergo circumcision regardless of the religious affiliation of their parents (Wallerstein, 2008). This is due in part to what is considered normal and also the belief that circumcision promoted cleanliness and disease prevention.

Documented health circumcision originated in the nineteenth century, when most diseases were of unknown etiology. During that time, a theory emerged that masturbation caused many and varied ills. It seemed logical to some physicians to perform genital surgery on both sexes to stop masturbation; the major technique applied to males was circumcision (Wallerstein, 2008). Ailments that were attributed to the foreskin included madness, muscle spasms, and sexual promiscuity.

For many who oppose neonatal male circumcision, the continuing practice of routine neonatal nonreligious circumcision in the United States represents an enigma. About 80 percent of the world's population do not practice circumcision, nor have they ever done so. Among the non-circumcising nations are Holland, Belgium, France, Germany, Switzerland, Austria, Scandinavia, Russia, China, and Japan (Wallerstein, 2008). Ironically, many pro circumcision groups argue that circumcision decreases chances for penile cancer, but incidents of penile cancer are at least .1% lower in countries that do not practice circumcision.
A number of medical societies in the developed world have published statements that do not recommend routine circumcision of male newborns. In its position statement, the Australian College of Pediatrics emphasized that in all cases, the medical attendant should avoid exaggeration of either risks or benefits of this procedure (AAP, 2009). Furthermore, many governments, including Australia’s, do not pay for neonatal male circumcision as a part of their social assistance programs.

Evidence regarding the relationship of circumcision to STD in general is complex and conflicting. Studies suggest that circumcised males may be less at risk for syphilis than are uncircumcised males. In addition, there is a substantial body of evidence that links non-circumcision in men with risk for HIV infection. There does appear to be a plausible biologic explanation for this association in that the mucous surface of the uncircumcised penis allows for viral attachment to lymphoid cells at or near the surface of the mucous membrane, as well as an increased likelihood of minor abrasions resulting in increased HIV access to target tissues (AAP, 2009). This said, the AAP goes on to state that behavioral factors appear to be far more important risk factors in the acquisition of HIV infection than circumcision status.

The following are some examples of sites representing both sides of the circumcision debate:

Medical video of the procedure (neither pro nor anti circumcision):
http://video.google.com/videoplay?docid=-6584757516627632617#

Pro (infant) Circumcision Sites:
http://www.gilgalsoc.org
http://www.medicirc.org

Anti (infant) Circumcision sites:
http://www.nocirc.org
http://www.circumstitions.com
http://www.mothersagainstcirc.org

Generally, those who endorse circumcision do so on either medical or religious grounds (or both). Those who are against routine male neonatal circumcision argue medical claims to the operation stating that no major health organization in the world recommends the surgery as a routine norm.

Those who are pro circumcision argue for many possible health benefits. It is common thought (particularly in America) that male circumcision promotes easier hygiene. This belief is based on the fact that there are fewer creases in the circumcised penis and that a man does not have to go through the hassle of manually retracting his foreskin in order to clean the area that normally lies underneath it. Those against circumcision maintain that it is simple to clean an uncircumcised penis, as well. Modern hygiene products make it quick and easy to cleanse under the foreskin.

Individuals who promote neonatal circumcision argue that medical research has indicated that indicated a decreased risk of urinary tract infections in circumcised males. The risk of urinary tract infections in the first year is low, but these infections may be several times as common in uncircumcised baby boys (AAP, 2009). Nonetheless, those against the operation argue that chances for the infection are still very low, at 0.9% of uncircumcised infants contracting an infection in the first year of life and rates decreasing from there.

Those who are in favor of circumcision argue for the prevention of penile problems. Occasionally, the foreskin on an uncircumcised penis may be difficult or impossible to retract (phimosis) (AAP, 2009). Those who argue against the operation state that most problems with phimosis either fade with time argue in favor of milder methods of treatment such as the forced retraction of the foreskin slightly every day over a period of months, which is reported to be painless.

Decreased risk of penile cancer is also something that is a reported benefit of circumcision. Although cancer of the penis is rare, it's less common in circumcised men (AAP, 2009). Oddly enough, in countries that do not routinely practice circumcision (Japan and most European nations), penile cancer rates are lower than in America (The Circumcision Reference Library, 2009). To further arguments, those who do not support circumcision also stress the extreme rarity of penile cancer.

The most avid circumcision supporters argue for the decreased risk of sexually transmitted diseases. Safe sexual practices remain essential, but circumcised men may have a slightly lower risk of certain sexually transmitted diseases — including HIV, the virus that causes AIDS (The Mayo Clinic, 2009). Studies have not been robust or conclusive enough for major health organizations to begin supporting the operation, which is the main counter-argument of those who are against it. Other arguments for circumcision include religious ones and the desire for a child to look like his father who is circumcised. Some parents fear that their child will be scorned for his uncircumcised penis.

Those who are against neonatal circumcision stress the surgical risks involved in the operation. Excessive bleeding and infection are uncommon, but possible. The foreskin may be cut too short or too long or fail to heal properly. If the remaining foreskin reattaches to the end of the penis, minor surgery may be needed to correct it. Complication rates ranging from 0.06% to 55% have been cited, though experts predict between 3 and 6 % actually experience true complications (Canadian Medical Association , 1996).

According to the American Academy of Pediatrics' 1999 Circumcision Policy Statement, “There is considerable evidence that newborns who are circumcised without analgesia experience pain and psychological stress.”(AAP, 1999) This is another focus of those against the operation. Local anesthesia can block nerve sensations during the procedure (Mayo clinic, 2009), but the infant still cries and it is unknown what he is actually feeling. The healing process after the surgery is also painful for the infant.

As stated before, those who are against routine male circumcision stress that no national or international medical association recommends routine circumcision as a worldwide norm. That said, the World Health Organization (WHO) does state “WHO/UNAIDS recommendations emphasize that male circumcision should be considered an efficacious intervention for HIV prevention in countries and regions with heterosexual epidemics, high HIV and low male circumcision prevalence. Male circumcision provides only partial protection, and therefore should be only one element of a comprehensive HIV prevention package.” (WHO, 2009)

Lastly, many believe that the foreskin is a normal, protective, functioning organ that should not be removed and that circumcision denies a male's right to genital integrity and choice for his own body.

Both arguments present facts that can be used to strengthen each case. Considering that this is a subject involving human infants, emotions run high and each argument has the potential to become unprofessional as a result.

The evidence that male circumcision at infancy is medically beneficial is debatable and inconclusive. It seems that each argument in favor of the procedure has an equally convincing counter comment from the opposing argument that makes points in favor seem less significant. Evidence against the procedure tends to be more emotional in nature but also present a valid argument.

I believe that most parents want what they feel is best for their child and that parenting comes along with many decisions that can be quite difficult to make. Furthermore, I think that it is a staple of good parenting to make any and all decisions based on research, gathered facts, and evaluation. The opinions of a single health care provider or family members should play a lesser role. Practices need to be questioned because in spite of their popularity, common decisions are not always the right decisions.

While researching this issue, I focused on finding empirical articles and governmental/health sites that would give me access to the most accurate information. Warning signs that indicated that perhaps I should not include the site in my analysis were an abundance of emotion, accusations, and opinionated remarks. These sites were avoided.

I found the AAP (and other governmental equivalents such as Australia’s RACP) to have the most accurate and trustworthy information. They seemed generally unbiased and provided facts that influenced my final decision. Their closing statement on the subject of circumcision was that “Existing scientific evidence demonstrates potential medical benefits of newborn male circumcision; however, these data are not sufficient to recommend routine neonatal circumcision.” This statement helped me to solidify my opinion on the matter.

I cannot say that this research has swayed my beliefs either way. I knew quite a bit from my own personal internet meanderings when I was trying to decide about whether or not to circumcise my own son. Before that, however, I assumed there was a good reason behind the operation—I just didn’t know what it was. Now that I have more information, I have made my own decisions through my own research and that makes me more confident about my decisions as a parent.
After researching the different positions surrounding routine male circumcision at infancy, I think that each side has made some legitimate points. There are some slight health benefits to male circumcision. I do, however, agree with those who say that the risks involved in the operation, the trauma associated with it, and lack of solid evidence as to the validity of some purported health benefits al serve to tip the balance against the operation.

Furthermore, I find moral issues with neonatal male circumcision. It is the removal of an entire body part and the child has absolutely no say in whether or not he wants it to be done. In fact, videos that I downloaded which showed the operation indicate that the infant doesn’t agree with the process of foreskin removal at all.

In the end, I understand that there are benefits and risks associated with both sides of the argument and that it can feel like a no win situation for parents. I wouldn’t look down my nose at a parent making an educated decision about what to do with his or her child. As I stated previously, however, I do not believe that any practice should go unquestioned. Parents should know the facts before making their decisions.

Works Cited

American Academy of Pediatrics (AAP). (2009). Circumcision: Information for Parents. Retrieved November 21, 2009 from http://www.circumstitions.com/AAP-bro.html

American Academy of Pediatrics (AAP). (2009). Circumcision Policy Statement. Retrieved 21 November 2009 from http://aappolicy.aappublications.org/cgi/content/full/pediatrics;103/3/686

DeLaet, D. L. (2007). Framing Male Circumcision as a Human Rights Issue?: Contributions to the Debate Over the Universality of Human Rights. Retrieved on 21 November 2009 from http://www.allacademic.com/meta/p179332_index.html

Fetus and Newborn Committee. (1996). "Neonatal circumcision revisited". Canadian Medical Association Journal 154 (6): 769–780. Retrieved on 29 November 2009 from http://www.cps.ca/english/statements/FN/fn96-01.htm

Harrison, Daniel. (2002). Rethinking Circumcision and Sexuality in the United States. Vol 5. Sage Publications. Retrieved on 21 November 2009 from http://sexualities.sagepub.com.pegleg.park.edu/cgi/reprint/5/3/300

The Circumcision Reference Library. (2008). United States Circumcision Incidence. Retrieved on 21 November 2009 from http://www.cirp.org/library/statistics/USA/

The Mayo Clinic. (2009). Pros and Cons of Circumcision. Retrieved on 22 November 2009 from http://www.mayoclinic.com/

The Royal Australasian College of Physicians (RACP). (2009). Policy Statement On Circumcision. Retrieved on 29 November 2009 from http://www.racp.edu.au/index.cfm?objectid=D7FAA93E-E091-4209-15657544BA419672

Wallerstein, E. (2008). Circumcision: The Uniquely American Medical Enigma. Retrieved on 21 November 2009 from http://www.cirp.org/library/general/wallerstein/

World Health Organization (WHO). (2009). Retrieved on 29 November 2009 from http://www.who.int/hiv/topics/malecircumcision/en/index.html