Wednesday, August 29, 2012

Let's Talk about Circumcision

I recently heard an interview with Cameron Diaz about the film, What to Expect When You're Expecting.  In the interview she stated that in order to maintain a PG13 rating, much of the dialogue in a scene about circumcision had to be edited out.  Frankly, I find it disturbing that a discussion about the details of the procedure would earn the film an R rating, but the practice itself is routinely performed on baby boys (in the US) in their first days of life outside the womb.  

I'd hadn't given much thought to the subject until I was pregnant with Riker and Brian informed me that no son of ours would ever be circumcised.  It was then that I started to research the subject and the more I learned, the more I felt angry and profoundly sad that this is a socially acceptable practice in this country. Circumcision is rarely discussed openly and as a result new parents may not give the subject much thought until a doctor or nurse offers the procedure and suggests that it's beneficial and painless. Nothing could be further from the truth.  So, in an effort to bring a taboo subject to light, let's talk about circumcision.


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Circumcision is NOT recommended by medical organizations:

Infant circumcision is elective cosmetic surgery. No major medical body in the world recommends routine neonatal circumcision including The American Association of Pediatrics.*  The Royal Australasian College of Physicians states:
"Ethical and human rights concerns have been raised regarding elective infant male circumcision because it is recognized that the foreskin has a functional role, the operation is non-therapeutic and the infant is unable to consent. After reviewing the currently available evidence, the RACP believes that the frequency of diseases modifiable by circumcision, the level of protection offered by circumcision and the complication rates of circumcision do not warrant routine infant circumcision in Australia and New Zealand."
The policy statements of  major medical organizations around the world concur; none recommend routine neonatal circumcision.


Intact is the norm:

Almost 90% of men worldwide are intact and the US is one of the only countries to routinely circumcise infant boys for non-religious reasons. Circumcision rates among US newborn boys fell from 63% in 1999 to 56% in 2006 to 33% in 2009
 
One of the most common reasons parents in the US give for circumcising their boys is because they want them to look like their fathers.  I highly doubt that their sons are going to be comparing nor would most men have vivid recollections of their fathers penises anyway.  Most men wouldn't make the choice to style or color their hair to match their fathers let alone surgically alter their bodies to match.  Since when does parent/child bonding require a matching set of genitals?  And since fewer Americans are choosing to circumcise, parents needn't worry that the intact boy will stand out in the locker room as some argue. 


Circumcision is painful:

Circumcision is extremely painful and traumatic for babies. In babies and children, the foreskin is fused to the head of the penis with the same type of tissue that adheres fingernails to the nail beds.  In order to remove it, a baby's arms and legs are strapped down to a board and a blunt probe is inserted between the foreskin and the head of the penis to tear it away before it is clamped, crushed and cut with a surgical knife.

Infants are usually returned to their mothers asleep, not because the procedure is pain free, but because they go into traumatic shock from the overwhelming pain of the surgery. Anesthetics are not always used because they are contraindicated for infants and few have been found to be safe and effective in preventing circumcision pain.  No anesthetic that would be strong enough to properly numb a baby for such an invasive procedure would be safe to give to an infant. Tylenol and a pacifier soaked in sugar water are frequently given as pain relief.  Would you go into surgery with only Tylenol to numb the pain?  And even if an effective anesthetic were always used, surgery and its recovery are always highly unpleasant.  Then consider that the resulting open wound is placed in a diaper where it's constantly abraded and showered with urine and feces.  For details on the procedure and infant pain response see Neonatal Circumcision (a video for healthcare professionals), Plasitbell Infant Circumcision and Infant Responses to Circumcision


The foreskin is useful:

The foreskin is a highly functional piece of skin with both protective and erogenous functions. In an adult man it is about 15 square inches of skin or the size of a 3x5" index card.

The foreskin is a double-layered sheath of skin that covers and protects the glans, or head, of the normal penis. The glans was designed to be an internal organ; the foreskin protects the glans and keeps it moist and clean much the way the eyelid protects the moist and sensitive eyeball.  The foreskin and glans contain an extensive array of over 20,000 highly sensitive nerve endings.  Amputation of the foreskin not only removes this erogenous zone, but also forces the glans to build up many layers of calloused skin to protect itself, causing the loss of even more sensitivity.
 
The claim is often made that a circumcised penis is cleaner and easier to care for but this is incorrect given the fact that the foreskin's role is to regulate pH, temperature, lubrication, antibodies, movement and functioning of the penis.  The tip of the foreskin is a sphincter which acts to prevent contaminants from entering the body thus preventing infection. 

For more information see:


Cleanliness and Urinary Tract Infections:

As mentioned above, one of the most important functions of the foreskin is to protect the penis and keep it clean and healthy. Some studies suggest that UTIs are slightly more common in intact males. There is a simple explanation for this. Doctors in the US are on the whole incredibly misinformed when it comes to care of the intact penis and frequently advise parents to retract the foreskin for cleaning. The foreskin, however, should never be retracted before it naturally separates from the glans and the boy is able to do it himself, usually somewhere between five and twelve years of age.  The studies showing more UTIs in intact males likely included boys who were forcefully retracted at an early age, thus predisposing them to infection.  Therefore the increased rate of UTIs in these studies is more likely attributed to misinformation and malpractice than to any inherent deficiency in the male anatomy.

The American Medical Association states, "Despite the increased relative risk in uncircumcised infants, the absolute incidence of UTI is small in this population (0.4%-1%). Depending on the model employed, approximately 100 to 200 circumcisions would need to be performed to prevent 1 UTI. In this case, a large relative risk reduction translates into a small absolute risk reduction because the baseline prevalence is low. One model of decision analysis concluded that the incidence of UTI would have to be substantially higher in uncircumcised males to justify circumcision as a preventive measure against this condition."

Intact boys and men contract UTIs to a much lesser degree than girls and women. The inner labia and clitoral hood of the female have more folds than the foreskin. What if someone said that it would be easier to keep the vulva clean if the clitoral hood were removed?  If it is not acceptable for female genitals, it should not be acceptable for male genitals. Equality notwithstanding, all UTIs are treated quickly and easily with a round of antibiotics making the preemptive removal of a functioning body part unnecessary and unethical. 

Some label the presence of smegma under the foreskin as unclean and therefore, a reason for circumcision.  Smegma is a creamy substance made of skin cells and oils and it is present in both males and females.  It keeps the glans moist and acts a lubricant during intercourse. It is not dirty or unhygienic and requires no special cleaning.  The truth is that both male and female genitals are largely self cleaning. An intact penis is very simply cleaned with water (and should never ever be retracted for cleaning before it naturally separates). Read more in this concise guide to foreskin care.


HIV:

Studies conducted in African populations have suggested that circumcision could reduce HIV transmission.  HIV transmission, however, is the result of behavior.  Suggesting that HIV transmission can be reduced by altering male anatomy through circumcision implies that condoms (which are actually effective in halting the spread of sexually transmitted diseases) are unnecessary.  The American Medical Association states that "behavioral factors are far more important risk factors for acquisition of HIV and other sexually transmissible diseases than circumcision status, and circumcision cannot be responsibly viewed as "protecting" against such infections."

Promoting an unnecessary surgery when much less invasive, less costly, and more effective methods are available is a dangerous distraction in the fight against HIV/AIDS. Read more about Circumcision and HIV and HIV, AIDS and Circumcision.


Penile cancer:

Penile cancer is a rare disease in the United States (0.9 to 1 per 100,000). Among intact men the incidence is estimated to be 2.2/100,000.  Identified risk factors for penile cancer include genital warts, infection with human papilloma virus, a large number of sexual partners and cigarette smoking. The American Medical Association states "because this disease is rare and occurs later in life, the use of circumcision as a preventive practice is not justified." 

The AAP cites a study stating that 322,000 newborn male circumcisions would be required to prevent one case of penile cancer and that 644 circumcision complications could be expected for every case of penile cancer avoided.  


Risk and complications:

Complications from circumcision surgery are not uncommon and include skin problems such as adhesions, scarring and skin bridges, desensitization, hemorrhage, infection, surgical injury and death. Millions of dollars have been paid out in circumcision related lawsuits where botched surgeries resulted in death, severed penises, scarring and other traumas. 

Each year approximately 117 neonatal (first 28 days after birth) circumcision-related deaths occur in the United States or one out of every 77 male neonatal deaths.  This number is likely higher than reported because cause of death can be listed as 'hemorrhage' or other related complication, instead of the circumcision itself.  To put this in perspective, about 44 neonatal boys die each year from suffocation, and 8 from auto accidents. About 115 boys die annually from SIDS, nearly the same as from circumcision during the same neonatal period.  One hundred percent of circumcision deaths are preventable.

Circumcision can also have damaging psychological effects. Psychologists have suggested for decades that we are significantly impacted by what happens to us in the first five years of our lives, especially traumas, whether we remember them or not.

Various studies have found that short-term effects of circumcision include changes in sleep patterns, activity levels and mother-infant interactions along with more irritability and disruptions in feeding and bonding. Long-term effects have not been studied.  

The AAP, in discussing risks involved with the common Plastibell method of circumcision, states that bleeding ranged from 0.8% to 3% of cases; infection occurred in 2.1% of cases. Urinary retention and problems with the Plastibell ring have been reported in 3.6% of cases. Studies of the Plastibell device found, overall, that complications range from 2.4% to 5%.  Ask yourself, what level of risk is acceptable for a child who has no disease and gives no consent?
 

Sexual pleasure:

The absence of the foreskin significantly affects sexual function for a man and his partner. The foreskin provides a gliding function that reduces friction while having sex, making it more comfortable for both partners.  With tens of thousands of nerve endings, the foreskin has the majority of fine touch nerve receptors in the penis.  The foreskin also houses the Ridged Band, one of the most sensitive areas on the male body. This band has a function in stimulating the female sexual partner and is the reason why ribbed condoms were invented.

A 2011 Danish research article found that circumcised men are three times as likely to experience frequent inability to reach orgasm and their partners are at a three-fold risk of frequent difficulties in achieving orgasm and an eight-fold risk of feeling pain during intercourse.


Genital integrity and human rights:

I've heard women say that they prefer circumcised men and cite this as a reason for circumcising their sons. But what if the situation were reversed and men expressed a preference in women's genitals?  Would we then tolerate that preference being imposed on their baby daughters?

When the homologous organ on a female body (the clitoral hood) is altered or removed, it's commonly referred to as female genital mutilation.  This practice was made illegal in the United States in 1997.  Doctors who perform routine circumcision on infant males or females are not acting in accordance with their ethical duties to the patient. Do no harm ring a bell?  Baby boys should be afforded the same rights to genital integrity as baby girls.  Would you circumcise your daughter?


Consent:

When making a choice about circumcision it is important to remember that the foreskin under discussion belongs to a person and he cannot (and would not) give his consent to have it removed. Removal of healthy tissue from a minor should not be subject to parental discretion. As parents we make lots and lots of choices on our children's behalf but circumcision is an irreversible and irreparable cosmetic surgery - it is a decision that should be made by the person who owns the penis. His body, his choice.  


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This list is not exhaustive.  These are the things that stand out to me as the most poignant arguments against circumcision and the most relevant rebuttals to the reasons frequently cited in favor of circumcision.  

I'm not entirely sure why circumcision is such a taboo subject and why people seem to be afraid to question it.  Science has certainly not shown it to be medically necessary and the tradition has robbed millions of men of one of the most sensitive parts of their bodies without their consent.  But this is exactly why we must start talking about circumcision.

For the record, I want to make it clear that this post is not intended to make readers feel guilty about decisions made in the past. Rather, this information is provided for the benefit of baby boys yet to grace us with their presence in the hope that new parents will be fully informed when faced with this decision.  Because when it comes to circumcision, the decision should be clear - bring home the whole baby. Like girls, baby boys arrive perfect just they way they are. No disassembly required.  




 * The 1999 American Academy of Pediatrics position statement found both potential benefits and risks in infant circumcision, but concluded that there was insufficient data to recommend routine neonatal circumcision.  On Monday, the AAP issued a new 2012 statement saying "Although health benefits are not great enough to recommend routine circumcision for all male newborns, the benefits of circumcision are sufficient to justify access to this procedure for families choosing it and to warrant third-party payment for circumcision of male newborns." 

Having read the lengthy new statement, I found it rife with problems.  For example, it relies on a limited number of studies within a five year period (the 1999 statement studied forty years of research), it inflates the benefits of circumcision for UTIs, penile cancer and HIV and it cites controversial studies.  Furthermore, it glosses over sexual impacts, consent issues and concerns regarding pain and then fails to mention at all the function and anatomy of the foreskin, ethical issues involving amputation, a child's right to bodily integrity and it barely mentions the issue of risk and complications. The report states that “the health benefits of newborn male circumcision outweigh the risks,” and yet elsewhere in the paper the AAP admits that “the true incidence of complications after newborn circumcision is unknown.”  If the risk of complications is unknown, then it cannot be stated that the benefits outweigh the risks. The AAP lacks the evidence it needs to make this claim. 

The addition of a recommendation regarding funding for the procedure highlights the fact that the AAP is not an advocacy group for pediatric patients - rather they are a professional trade organization that exists for the benefit of its members - pediatric doctors and hospitals - and the new recommendations ensure that insurance companies keep the dollars flowing to a billion dollar per year industry.  This revised statement is an awkward attempt at saving face with other medical societies around the world while at the same time insuring that their members can still profit from the practice.  A medical position statement and the organization issuing it lose credibility when the paper includes a section on financing newborn circumcision by third-party payers.

The new statement includes several quotes that would appear in favor of leaving baby boys intact. For example, "Newborn males who are not circumcised at birth are much less likely to elect circumcision in adolescence or early adulthood." This suggests that men appreciate their foreskins and actually possess the ability to keep them clean and healthy!

Finally, it's worth mentioning again that The Canadian Paediatric Society, the British Medical Association, the Royal Dutch Medical Association, and the Royal Australasian College of Physicians have issued statements that oppose this new position of the AAP. 

Read more:

12 comments:

  1. Anonymous7:37 AM

    Hi Jenn (and Brian),

    As requested I started to read the blog post but have an exam today so cannot read it in full. Suffice to say that my skim reading was informative and good on you for going there. I have not been cut and could not imagine it otherwise.

    As I was reading your post I remembered wathcing a doco from the US about men who had been cut and felt so bad about it that they put a weight on their tiny flap to stretch it out and become foreskin. Poor dudes.

    Good luck with the learning by doing marathon that is parenthood and challenges like the said topic!

    Back to study for me...
    Bindu

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    1. Foreskin restoration is, from what I understand, gaining popularity and is another example confirming that men would prefer to be left intact. If they were meant to have foreskins, they'd be born with them!

      Lots of challenges and decisions with parenthood as you say, but at least this one was easy!

      Thanks for reading and best of luck with exams.

      Jenn

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  2. Anonymous1:40 AM

    In the following quote, you describe very nicely a huge problem with the AAP's new report:

    " The report states that “the health benefits of newborn male circumcision outweigh the risks,” and yet elsewhere in the paper the AAP admits that “the true incidence of complications after newborn circumcision is unknown.” If the risk of complications is unknown, then it cannot be stated that the benefits outweigh the risks. The AAP lacks the evidence it needs to make this claim. "

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    1. Yes, it's rather dangerous when the logic used to declare that the benefits outweigh the risks is totally flawed.

      Here's another worrying quote from the technical document:

      "The majority of severe or even catastrophic injuries are so infrequent as to be reported as case reports (and were therefore excluded from the this literature review). These rare complications include glans or penile amputation, transmission of herpes simplex after mouth-to-penis contact by a mohel (Jewish ritual circumcisers) after circumcision, methicillin-resistant Staphylococcus aureaus infection, urethral cutaneous fistula, glans ischemia and death."

      As mentioned in the post, deaths from circumcision are frequently not attributed to the circumcision itself, but rather it's complications, frequently hemorrhage or septic shock. Obviously the benefits exceed the risks when you eliminate death and severe injuries from the review! Not okay AAP.

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  3. The AAP's conclusion was "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."

    I have a friend who has worked as nurse in a retirement home for years. She said the staff has to manually clean the dongs of the uncircumcised men who are unable or unwilling to clean themselves. If they don't, they get crusty and infected.

    When my own son was circumcised, they gave him a local anesthetic. He didn't cry during or after the procedure. Maybe not all doctors do this and maybe they should.

    As far as consent issues, as parents we make thousands of decisions for our children as they grow up. This is just one more.

    For the social aspect, girls like to dress and accessorize like their moms. Boys like to be like their dads. We can rationally and scientifically say it doesn't need to be so, but that ignores the emotional side of it.

    Women don't medically need to shave their armpits, but many men and women prefer it and there's little risk for the social and emotional gains.

    Considering the risks and benefits, I'd say circumcision is a toss up. Parents should go with their instincts.

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    1. I don't quite understand your point about men in nursing homes. Genitals require cleaning yes, and if a person is incapacitated then they will require assistance in this matter. Mouths need to be cleaned after eating, wax needs to be cleaned out of ear canals and bums need to be wiped after defecating. All of these areas would become "crusty" if not cleaned by their owner or caregiver. It is unjustifiable to amputate the foreskin in infancy so that a nurses aide has a slightly easier job when that baby is ninety.

      I agree with you that girls like to dress and accessorize like their moms and that boys like to be like their dads. Girls however are afforded the luxury of CHOOSING to wear jewelry and carry purses to be like their moms. Similarly, adult women choose to shave their armpits, or not, and it's not up to anyone else to decide for them. Boys can carry a wallet, wear a fireman's hat or pretend to shave their faces and that will allow them to meet their emotional need to be like their dads. And importantly, there is no risk associated with the aforementioned activities. I would suggest that fathers give careful consideration to why THEY feel the need to have their sons genitals surgically altered to look like theirs.

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    2. The point about men in nursing homes was that there is a medical advantage to circumcision. It's a popular myth that there is none and that it is just a barbaric desecration of some sort.

      And the point about choosing circumcision for social or emotional reason is that who's going to do that when they're old enough? By the time they know there's even an option, the social and/or emotional damage, if any, will have been done.

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    3. Reducing the time it takes for nursing home staff to clean and bathe a male resident does not constitute medical advantage.

      "Who's going to do that when they're old enough?" Precisely. Very few men choose circumcision as adults which suggests that they are happy with intact genitals. It stands to reason that emotional damage is more likely to result from non-consensual removal of healthy tissue in infancy than from allowing a boy to keep all the bits he was born with. Once a circumcised man knows that there was an option to have a foreskin, the emotional (and physical) damage will have been done.

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  4. The long term eliminated maintenance is a medical advantage.

    I'm just saying that there's a long term gain to be had and the only risk is the same that any medical procedure incurs. The risk sound like those from getting an ear pierced or a tattoo.

    And either way your prefer, there's no MAJOR advantage or disadvantage. That's why a social reason or any other can tip the scales either way.

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    1. I have to brush my teeth every day or plaque would build up which would eventually lead to gum disease, however I avoid this outcome with basic daily maintenance. I don't opt to have my teeth removed so as to eliminate maintenance and if I did, it would not be considered medically advantageous.

      Even the AAP admits that “the true incidence of complications after newborn circumcision is unknown.” Hemorrhage, infection, surgical injury and death have occurred and are pretty serious risks in my book.

      We may have to agree to disagree on the existence of long term gain. Tell the millions of men who are pissed off about having part of their bodies removed in infancy that there is no major disadvantage to the procedure.

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    2. You're correct - we'll agree to disagree. Seems like making a mountain out of a mole hill to me, but that may not be the case for everyone. I thought it might be helpful to provide an opposing view as it really wasn't represented.

      Catch ya on the flip side.

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    3. I certainly don't mind readers expressing dissenting opinions and I welcome open discussion. Thanks for sharing your point of view.

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