By Karen Burka
Issue 132, September/October 2005
Routine infant circumcision continues to be the most commonly performed surgery on children in the US, with about 1.2 million newborn boys circumcised each year.1 The US also continues to be the only industrialized nation that circumcises the majority of its newborn baby boys for nonreligious reasons. The health-based reasons have been criticized and are controversial.2
Despite these facts, the rates of routine infant circumcision (RIC) in the US have steadily declined for more than a decade, and dropped more than 11 percent in just two years (2001-2003), according to the National Center for Health Statistics. Nationally, the average RIC rate fell to 55.9 percent in 2003, the latest year for which statistics are available. The largest decline was in western states, where the rate dropped 23 percent and seven out of ten boys remained genitally intact.3
Several factors are driving this decline, including parents-to-be who are better informed, more doctors and childbirth educators willing to speak out against circumcision, and an influx of immigrants from Asia, South America, and Europe—where RIC is anything but routine—who are not circumcising their newborn sons.
Perhaps most important, grassroots efforts to expose the medical myths and highlight the ethical concerns surrounding circumcision are becoming more widespread and mainstream. Here's what you need to know about circumcision to make an informed decision that can enhance your son's self-esteem and sexual health for the rest of his life.
What is circumcision?
Circumcision is the cutting off of the fold of skin that normally covers the glans, or head, of the penis. This double layer of skin, the prepuce, is commonly known as the foreskin. In a circumcision, a baby boy is spread-eagled on his back on a board or table; his arms and legs are strapped down so that he can't move. The baby's genitals are scrubbed and covered with antiseptic. The foreskin is torn from the glans and slit lengthwise so that the circumcision instrument can be inserted. The foreskin is then cut off.4 Years ago, doctors believed—and told new parents—that babies didn't feel pain, and that therefore circumcision didn't hurt and would be forgotten as the child matured. Today, experts both within and outside the medical community agree that babies do feel pain, and that circumcision is extremely painful for them. Many circumcisions are performed without anesthesia. Most doctors and childbirth educators agree that the administering of the available painkillers—including the most effective, the ring block, which requires four injections—can itself be extremely painful for an infant. And even when anesthesia is administered, it does not completely eliminate the pain.
Increasingly, the trauma experienced by the infant during circumcision is being linked to later childhood intolerance of pain. According to an article by British researchers Dr. Maria Fitzgerald and Dr. Suellen Walker, "One important study shows that boys who have been circumcised at birth show increased pain responses to vaccinations at four to six months compared to those who have not. . . . In a follow-up, prospective study of 87 infant boys, uncircumcised infants were found to have the lowest pain scores at vaccination four to six months later, followed by those circumcised after treatment with lidocaine-prilocaine cream (EMLA), while those circumcised after placebo cream showed the greatest responses."5
As with any surgery, circumcision comes with serious risks, such as excessive bleeding, infection, complications from anesthetics, and even death.
One-month-old Ryleigh Roman Bryan McWillis died in August 2002 after suffering severe hemorrhage from his circumcision.6 The Canadian-born baby had a normal-term birth, with no complications or problems. In August 2003, a four-week-old Irish infant named Callis Osaghae died of severe blood loss just hours after a routine circumcision.7 Complications from the circumcision of three-week-old Dustin Evans of Cleveland, Ohio, led his doctors to perform additional surgery to unblock the baby's urethra. Unfortunately, he never made it to the actual surgery, instead dying as anesthesia was administered.8
The sad conclusion of one story that made international headlines came in May 2004, when David Reimer, whose penis had been destroyed during a nontherapeutic infant circumcision, committed suicide at age 38. After the circumcision, Reimer's doctors had castrated him and convinced his parents to raise their son as a girl. He was renamed Brenda, and at puberty given feminizing hormones to promote breast development while he waited for sex-reassignment surgery. Reimer was confused and depressed; his suicide attempts began in his teens, when he was told the truth about his sexual identity and surgery. He later renamed himself David and had a double mastectomy and reconstructive penile surgery. A book about his tragic experience, As Nature Made Him: The Boy Who Was Raised as a Girl, was written by John Colapinto.
The value of the foreskin
The foreskin itself is gaining the respect it deserves as an incredibly rich and useful sexual and sensory organ. A large, double-sided tube of skin, nerves, blood vessels, and muscle, the foreskin comprises 80 percent or more of the penile skin covering,9 or at least 25 percent of the flaccid penis's length.10 According to Dr. John R. Taylor, coauthor of two anatomical studies of the prepuce, the foreskin's location and structure indicate that it is the most important sensory tissue of the penis.11
The key to the foreskin's sexual function is the ridged band, a zone of corrugated tissue just inside its tip. First described by Dr. Taylor in the British Journal of Urology, the ridged band contains thousands of specialized, highly erogenous nerve endings that enhance sexual pleasure.12 Because circumcision removes almost all of these nerve endings, circumcised men never feel the sensations those nerves can provide.
The foreskin also serves as a vital defense against infection. Just as the eyelids protect the eyes, the foreskin covers and protects the urinary opening, helping to maintain the sterility of the urinary tract. It also keeps the surface of the glans soft, moist, and sensitive. Thus it maintains optimal warmth, pH balance, and cleanliness.13 Between the foreskin and glans, an antiviral, antibacterial substance called smegma accumulates. Smegma contains several protective substances, including an immunoprotective enzyme, lysozyme, which is also found in tears, breastmilk, and other body fluids. When the foreskin is removed during circumcision, smegma no longer accumulates between the foreskin and glans, and smegma's immunoprotective properties are lost.14
Circumcised men are becoming more aware of what they have lost through circumcision, and a growing number are attempting to restore their foreskins with devices that help stretch the skin of the penis and restore sensitivity to the glans. One of these devices, the Foreball, was developed by Dr. Wayne Griffiths, cofounder of the National Organization of Restoring Men.
Ironically, the value of the male foreskin is not lost on the cosmetics and medical research industries. Organogenesis is among several companies that use cells from foreskins amputated from male infants to produce artificial skin. Organogenesis received FDA approval for Apligraf, an artificial skin made from a combination of foreskin and bovine collagen. Cosmetics companies such as SkinMedica sell wrinkle creams and moisturizers made from infant foreskins. SkinMedica's TNS (Tissue Nutrient Solution) Recovery Complex, which retails for about $125 per half-ounce, is said to reduce facial lines and wrinkles.15 According to the product's box, it is made from "human fibroblast conditioned media"—in other words, human foreskin. medical myths vs. reality
The medical value of circumcision is very much in dispute. Throughout its history, circumcision has been claimed by the medical community to cure a wide range of ailments, from epilepsy to tuberculosis. More recently, some claim it prevents penile and cervical cancers and other sexually transmitted diseases (STDs). However, all these claims either remain unproved or have been disproved.
According to the American Academy of Family Physicians (AAFP), "The evidence indicates that neonatal circumcision prevents urinary tract infections (UTIs) in the first year of life with an absolute risk reduction of about one percent and prevents the development of penile cancer with an absolute risk reduction of less than 0.2 percent."16 In its position paper on neonatal circumcision, the AAFP goes on to state that "evidence suggests that circumcision reduces the rate of acquiring an STD, but careful sexual practices and hygiene may be as effective."
As far back as 1989, the American Academy of Pediatrics (AAP) stated that "factors other than circumcision are important in the etiology of penile cancer . . . human papillomavirus types 16 and 18 DNA sequences have been found in 31 of 53 cases of penile cancer, suggesting the importance of these viruses in the development of this condition."17 The AAP has continued to amend its position on circumcision and no longer recommends it as a routine newborn procedure.
The Centers for Disease Control and Prevention (CDC) in 1996 found that the incidence of gonorrhea in the US was 26 times greater than the rate in Germany and 50 times the rate in Sweden. The CDC also reported in 1996 that the total rate of syphilis in the US was 13 times higher than that in Germany and 33 times greater than in Sweden.18 But while the US's circumcision rate is still above 50 percent, the circumcision policy statements of both the AAP and the Canadian Pediatric Society acknowledge that circumcision is uncommon in most of Europe, including Germany and Sweden.
A study by Edward Laumann, PhD, published in the Journal of the American Medical Association, showed a US rate of chlamydia infection of 25.1 per 1,000 circumcised men, and zero for intact men.19
Some doctors continue to believe that circumcision can prevent certain cancers, including penile cancer and, in women, cancer of the cervix. But the American Cancer Society (ACS) has stated that "circumcision is not of value in preventing cancer of the penis,"20 though the ACS does not have an official policy on circumcision. According to the ACS, proven risk factors include unprotected sex with multiple partners and cigarette smoking. Penile cancer continues to be one of the rarest forms of cancer, accounting in the US for less than one-half a percent of cancers diagnosed among men and less than one-tenth of a percent of cancer deaths among men.21
As far back as 1996, ACS members discouraged the AAP from promoting routine circumcision as a preventive measure for penile or cervical cancer. According to a letter from Drs. Hugh Shingleton and Clark W. Heath Jr. to the AAP's Committee on Practice and Ambulatory Medicine, "Research suggesting a pattern in the circumcision status of partners of women with cervical cancer is methodologically flawed, outdated and has not been taken seriously in the medical community for decades. Likewise, research claiming a relationship between circumcision and penile cancer is inconclusive."22
Faced with this growing array of medical contradictions, the American Academy of Pediatrics in 1999 amended its position statement on neonatal circumcision to state: "Existing scientific evidence demonstrates potential medical benefits of newborn male circumcision; however, these data are not sufficient to recommend routine neonatal circumcision."23
By stating this, the AAP joined the rest of the world's medical associations in no longer recommending routine infant circumcision. The Canadian Pediatric Society does not recommend circumcision for newborn baby boys.24 The more strongly worded position statement of the College of Physicians and Surgeons of British Columbia reads: "male circumcision is an unnecessary and irreversible procedure."25 And in the UK, the British Medical Association's position on circumcision is: "The medical benefits previously claimed, however, have not been convincingly proven, and it is now widely accepted, including by the BMA, that this surgical procedure has medical and psychological risks."26
Ethical and legal
US-based doctors, nurses, and childbirth services providers are increasingly counseling their patients and clients against circumcision and joining organizations such as Doctors Opposing Circumcision (Seattle, Washington) and Nurses for the Rights of the Child (Santa Fe, New Mexico). "As a nurse in the area of childbirth and newborn care, I refuse to participate in circumcisions and will not assist in getting the paperwork or consent signed," says Tora Spigner, RN, MSN, of Berkeley, California. "I am an advocate for the family, and that includes the newborn. I have not even seen a circumcision since 1995 and care never to see one again."27
Broadly based ethical concerns have also arisen about a new mother's ability to give informed consent to circumcise so shortly after birth, as well as the human rights and legal issues surrounding the infant's own inability to consent to the permanent removal of healthy tissue (see article by Gussie Fauntleroy). People such as Matthew Hess, president of MGMbill.org, believe that the Federal Prohibition of Female Genital Mutilation (FGM) Act, which criminalizes circumcision of females under the age of 18 in the US, is unconstitutional because of its lack of equal protection for males. Hess's group submitted a bill proposal to the US Congress to amend the law accordingly, and is looking for a sponsor to take up the bill. The Ashley Montagu Resolution to End the Genital Mutilation of Children Worldwide, named for Professor Ashley Montagu, a globally recognized scientist, scholar, humanist, and author, was drawn up in 1996. Its signatories include Dr. Jonas Salk and Nobel Prize recipient Dr. Francis Crick. Its goal is for governments worldwide to outlaw any kind of genital mutilation, including the circumcision of male and female infants and children.
The cost in dollars
Routine infant circumcision, acknowledged to be a medically unnecessary surgery, is proving to be a tremendous strain on the finances of medical insurance companies and government-sponsored services such as Medicaid.
According to a 2004 cost-utility analysis by Dr. Robert S. Van Howe, neonatal circumcision increased incremental medical costs by $828.42 per patient and resulted in an incremental 15.30 well-years lost per 1,000 males.28 Dr. Van Howe's study also found that "if neonatal circumcision was cost-free, pain-free and had no immediate complications, it was still more costly than not circumcising."
A report published this year by the International Coalition for Genital Integrity found that US taxpayers pay for 28 percent of circumcisions, each state paying an average of $754,478 for the surgery in 2003.29 Faced with looming budget gaps, more state legislatures are looking to cut RIC funding through such programs as Medicaid. In fact, 14 states, including California, Florida, Oregon, Arizona, and Utah, have eliminated state funding for RIC. Other states are considering doing the same thing. (editor's note: this number is 18 rather than 14 in 2012)30 Circumcision is a highly personal decision. The most qualified person to make that decision is the one who will live with the lifelong consequences of body modification. The best thing you can do is to educate yourself about the medical, ethical, religious, or even monetary factors involved in circumcision before your son is born.
1. Daniel H. Bollinger III, "Of Waste and Want: A Nationwide Survey of Medicaid Funding for Medically Unnecessary Non-Therapeutic Circumcisions," International Coalition for Genital Integrity, West Lafayette, IN (3 January 2005): 3. 2. Randi Hutter Epstein, "Circumcision Controversy: Doctors Debate the Benefits and the Risks of this Common Procedure But for Most Parents the Decision is Personal," Washington Post (7 October 1997): 214.
3. Daniel H. Bollinger III, "Nearly Half of American Boys Escape the Knife," International Coalition for Genital Integrity, West Lafayette, IN (11 March 2005): 1.
4. Marilyn Milos, "Answers to Your Questions About Infant Circumcision," National Organization of Circumcision Information Resource Centers pamphlet, San Anselmo, CA (January 2004).
5. Maria Fitzgerald and Suellen Walker, "The Role of Activity in Developing Pain Pathways," in J. O. Dostrovsky et al. (eds.), Proceedings of the 10th World Congress on Pain. Progress in Pain Research and Management 24 (Seattle: IASP Press, 2003): 185-196.
6. Suzanne Fournier, "Lack of Post-Surgery Info Angers Grieving Parents," The Province, Vancouver, BC, Canada (13 February 2004): www.cirp.org/news/theprovince02-13-04/
7. "Infant Dies After Home Circumcision," Munster Express, Munster, Ireland (22 August 2003): www.cirp.org/news/munsterexpress08-23-03
8. "Circumcision that Didn't Heal Kills Boy," NewsNet5, Cleveland, OH (20 October 1998): www.noharmm.org/evansdeath.htm
9. See photographic series: J. A. Erickson, "Three Zones of Penile Skin." In M. M. Lander, "The Human Prepuce," in G. C. Denniston and M. P Milos, eds., Sexual Mutilations: A Human Tragedy (New York: Plenum Press, 1997): 79-81.
10. M. Davenport, "Problems with the Penis and Prepuce: Natural History of the Foreskin" (photograph 1), British Medical Journal 312 (3 February 1996): 299-301.
11. John R. Taylor, MB, MRCPEd, FRCPC, "The Ridged Band: Specialized Sexual Tissue: Function of the Foreskin," http://research.cirp.org/func1.html
12. John R. Taylor, MB, MRCPEd, FRCPC, "The Prepuce: Specialized Mucosa of the Penis and Its Loss to Circumcision," British Journal of Urology 77 (February 1996): 291-295; http://research.cirp.org/func1.html
13. Dr. Paul M. Fleiss, "The Case Against Circumcision," Mothering no. 85 (Winter 1997): 36-45.
15. Bruce Newman, "For Smooth Skin, the Cutting Edge is Foreskin," San Jose Mercury News (24 October 2004): 1ST.
16. American Association of Family Physicians, "Position Paper on Neonatal Circumcision"; www.aafp.org/x1462.xml
17. American Academy of Pediatrics Task Force on Circumcision, "Report of the Task Force on Circumcision," Pediatrics 84, no. 2 (August 1989): 388-391.
18. U.S. Centers for Disease Control, "HIV Prevention through Early Detection and Treatment of Other Sexually Transmitted Diseases," in United States Recommendations of the Advisory Committee for HIV and STD Prevention (Atlanta, GA: 31 July 1998): 1-24; www.cdc.gov
19. Edward O. Laumann et al., "Circumcision in the United States: Prevalence, Prophylactic Effects, and Sexual Practice," Journal of the American Medical Association 277, no. 13 (2 April 1997): 1052-1057.
20. American Cancer Society, "Misleading Information: Dispelling Miscommunications," ACS NewsCenter (5 November 1998).
22. Drs. Hugh Shingleton and Clark W. Heath Jr., letter to Dr. Peter Rappo, Committee on Practice & Ambulatory Medicine, American Academy of Pediatrics (Atlanta, GA: 16 February 1996); www.cirp.org/library/statements/letters/1996-02_ACS
23. American Academy of Pediatrics, "Circumcision Policy Statement," Pediatrics 103, no. 3 (1 March 1999): 686-693.
24. Canadian Pediatric Society, "Circumcision: Information for Parents;"
25. College of Physicians and Surgeons of British Columbia, "Circumcision (Infant Male)" in Physician Resource Manual (Vancouver, BC: College of Physicians and Surgeons of British Columbia, 2004).
26. British Medical Association Medical Ethics Committee, "The Law & Ethics of Male Circumcision: Guidance for Doctors" (London: March 2003):
27. Personal communication, 22 February 2005.
28. Robert S. Van Howe, MD, MS, FAAP, "A Cost-Utility Analysis of Neonatal Circumcision," Medical Decision Making 24, no. 6 (2004): 584-601.
29. See Note 1.
30. International Coalition of Genital Integrity (ICGI), "Medicaid Defunding of Non-Therapeutic Infant Circumcision," ICGI; www.icgi.org
FOR MORE INFORMATION
Fleiss, Paul M., MD, and Frederick M. Hodges, DPhil. What Your Doctor May Not Tell You About Circumcision: Untold Facts on America's Most Widely Performed—and Most Unnecessary—Surgery. Warner Books, 2002.
Glick, Leonard B., MD. Marked in Your Flesh: Circumcision from Ancient Judea to Modern America. Oxford University Press, 2005.
Goldman, Ronald, PhD. Questioning Circumcision: A Jewish Perspective. Vanguard Publications, 1997.
Lightfoot-Klein, Hanny. Secret Wounds. Authorhouse, 2003.
Ritter, Thomas J., MD, and George C. Denniston, MD. Doctors Re-Examine Circumcision. Third Millennium Publications, 2001.
Organizations and Websites
Catholics Against Circumcision
Circumcision Information and Resource Pages
Circumcision Resource Center
Doctors Opposing Circumcision (DOC)
International Coalition for Genital Integrity
Jews Against Circumcision
National Organization of Circumcision Information Resource Centers
Stop Infant Circumcision Society
Students for Genital Integrity
To order books above, go to www.mothering.com and click on Powell's Books. Articles and discussion boards on circumcision are also on the website.
Editor's note: The topic of HIV and circumcision, while very important, is beyond the scope of this article. However, you may go to www.CIRP.org for a substantial reservoir of research on the issue.
Karen Burka is director of the Hudson Valley/New York Chapter of the National Organization of Circumcision Information Resource Centers. She has a three-year-old intact son, Daniel.