April 24, 2003

¶ You're cutting my WHAT?!: Routine infant circumcision. If baby boys could talk, what do you think they'd say?

Note: I am not a doctor. If possible, I'm not even as medically qualified as The Simpsons Dr. Nick Riviera ("Hi, everybody!") None of what follows should be construed as professional advice. It is amateur advice at best, and you deserve better. So stop kidding yourself: If this is a topic of concern to you, research it and reach your own conclusions. I'm happy to tell you what I think, but at the end of the day I'm just some slack-jawed yokel with a web site.

Circumcision is the surgical removal of the skin and mucosal tissue, known medically as prepuce and more commonly as the foreskin, that normally covers the head of the penis. Presumably most of us have never seen this procedure because (1) guys circumcised as infants don't remember it, (2) it's not exactly high-class Friday night entertainment, and (3) if you think men wince when a player gets hit in the nuts by a baseball, you ain't seen nuthin'. So I am not recommending you view the following pictures or movies. They're for neither the squeamish nor those on dial-up. But if you want to see the reality of the procedure and know exactly what I'm talking about, well, here it is.

Religious, Social, and Medical History
The history of circumcision pre-dates the Bible, recorded on tomb walls in ancient Egypt as early as 2400 BC. In the United States, it is the Judeo-Christian background of the procedure that provides the context for most of its use. There are multiple references in the Hebrew Scriptures. In Genesis 17:10-14 God tells Abraham,

This is my covenant, which you shall keep, between me and you and your offspring after you: Every male among you shall be circumcised. You shall circumcise the flesh of your foreskins, and it shall be a sign of the covenant between me and you. Throughout your generations every male among you shall be circumcised when he is eight days old, including the slave born in your house and the one bought with your money from any foreigner who is not of your offspring. Both the slave born in your house and the one bought with your money must be circumcised. So shall my covenant be in your flesh an everlasting covenant. Any uncircumcised male who is not circumcised in the flesh of his foreskin shall be cut off from his people; he has broken my covenant.

Interestingly, Moses must have thought this was crap, because neither he nor his sons were circumcised, and circumcision was not practiced while he led the Jews during the Exodus. After Moses, the Israelites returned to the practice under Joshua (Joshua 5:2-8). For what it's worth, both the Greeks and Romans thought circumcision crazy, the Romans even going so far as to pass laws against it. The Christian apostles and elders debated circumcision (Acts 15:1-11) and concluded the procedure was unnecessary to receive the grace of God:

Then certain individuals came down from Judea and were teaching the brothers, "Unless you are circumcised...you cannot be saved...."

The apostles and the elders met together to consider this matter. After there had been much debate, Peter stood up and said to them, "My brothers, you know that in the early days God made a choice among you, that I should be the one through whom the Gentiles would hear the message of the good news and become believers. And God, who knows the human heart, testified to them by giving them the Holy Spirit, just as he did to us; and in cleansing their hearts by faith he has made no distinction between them and us. Now therefore why are you putting God to the test by placing on the neck of the disciples a yoke that neither our ancestors nor we have been able to bear? On the contrary, we believe that we will be saved through the grace of the Lord Jesus, just as they will."

For the Christian, Paul's letters on the subject are decisive. In Galatians 5:6 Paul says, "For in Christ Jesus neither circumcision nor uncircumcision counts for anything; the only thing that counts is faith working through love." In Colossians 3:10 Paul again describes circumcision is irrelevant: "...there is no longer Greek and Jew, circumcised and uncircumcised, barbarian, Scythian, slave and free; but Christ is all and in all!" Romans 2:29 says that "...real circumcision is a matter of the heart—it is spiritual and not literal." Clearly, there is no Christian imperative for the procedure.

Nonetheless, it was mid-1800 fundamentalist Christians who helped bring circumcision into wide-spread practice in the United States. Interestingly, two of the most ardent and leading proponents of the surgery were Dr. John Harvey Kellogg and Syvester Graham, who might alternately be called Dr. Corn Flakes and Mr. Graham Crackers (as they invented these foods). With Puritan sensibilities and a strict code of moral correctness, they proved influential advocates of circumcision as a means for halting masturbation and other supposed crimes of moral turpitude. As Kellogg wrote in Treatment for Self-Abuse and its Effects in 1888:

A remedy for masturbation which is almost always successful in small boys is circumcision. The operation should be performed by a surgeon without administering an anesthetic, as the brief pain attending the operation will have a salutary effect upon the mind, especially if it be connected with the idea of punishment. In females, the author has found the application of pure carbolic acid to the clitoris an excellent means of allaying the abnormal excitement.

He must have been a delightful fellow. Porn Flakes is a relatively detailed history of these sad gentlemen and their misguided moral crusade. However wacked their ideas, their wide-spread social influence both in terms of circumcision and food stuffs continues to be felt over 125 years later.

This attack on the "immorality" aside, circumcision gained mid- to late-1800s popularity with the medical establishment as well. At various times it was seen as a cure for, among other ailments, hip-joint paralysis, bad digestion, hernias, bladder inflammation, epilepsy, curvature of the spine, and lunacy. It would be comforting to think that such a curative was trotted out by quacks and charlatans; however, the procedure's foremost proponent was one Dr. Lewis A. Sayre, the esteemed president of the American Medical Association. A medical history of the procedure in the United States makes for enlightening and occasionally laughable reading: Journal of Social History, Vol. 28, No. 1, p. 5-36, Fall 1994.

Circumcision Arguments in Modern Medicine
Against this backdrop, it is worth noting that today no other industrialized western democracy routinely performs infant circumcision without medical justification. Routine infant circumcision has become virtually an America-only phenomenon, and it is contra-indicated by many foreign specialty societies and medical organizations. Increasingly, US medical societies and organizations are questioning the wisdom of the practice as well.

Nowadays, we understand that circumcision will not cure most of what the American medical establishment once claimed. We understand that the current medical practitioners and associations take a more scientific approach to medicine. We understand that the body knowledge is larger from which to draw conclusions and recommendations. Given a profession that has gone from quackery 150 years ago to rightful respectability today, it behooves us to examine what positions are being taken and what medical arguments are being advanced surrounding routine infant circumcision.

The American Academy of Pediatrics' (AAP) most recent policy statement on circumcision was issued on March 1, 1999. It says in part, "Circumcision is not essential to a child’s well-being at birth, even though it does have some potential [emphasis mine] medical benefits. These benefits are not compelling enough to warrant the AAP to recommend routine newborn circumcision." (Personal note: An amazing number of recent US birth and childcare books intentionally misstate or distort the AAP's position to make it sound pro-circumcision. I find such intellectual dishonesty to be a credibility-destroying move.)

This is a partial reversal of earlier AAP policy positions (1971, 1975, 1985) which said that "...there was no absolute medical indication for routine circumcision." The 1999 policy is an extension of AAP's 1989 policy which says that there may be links between circumcision and a reduction in urinary tract infections and sexually transmitted diseases including AIDS. Additionally, the 1999 AAP position notes that uncircumcised men face a three-fold increase in the risk of penile cancer. The AAP also says that circumcision with analgesia has proved safe and effective in reducing infant pain during the procedure and that the procedure itself is generally safe. We'll examine all these claims.

There seems to be little question that circumcision lowers the risk of urinary tract infection in the first year of life and of penile cancer later in life. Some doctors recommend circumcision on this basis, though they are in the minority. Indeed, as the American Medical Association's Council on Scientific Affairs reported, "...the low incidence of these minimizes the potential medical benefits compared to the risks of circumcision." Nationwide, the incidence of urinary tract infection, or UTI, is less than 1 percent. Again, the AMA's policy paper on neonatal circumcision:

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.

Further, none of the studies on UTI have taken into account what the APA calls "potential confounders"—other methods of stopping UTI—as part of their work. (See this article from the Canadian Medical Association Journal.) Breast feeding, for example, has been shown in at least one study to offer significant protection to infants against UTI. This makes a certain amount of sense from a biological point of view, as both intact male genitalia and breast feeding would be norms for the species. There is also some evidence that the trauma of circumcision increases the difficulty of breast feeding for the infant. Finally, while urinary tract infections can have complications, they are usually easily treatable with antibiotics.

Penile cancer odds are substantially reduced for circumcised males, from 2.2 cases per 100,000 to 1 case per 100,000, but there are a number of other risk factors for penile cancer including sleeping around, smoking, HPV infection, and genital warts. The AMA's position: "...because this disease is rare and occurs later in life, the use of circumcision as a preventive practice is not justified." Penile cancer is not a disease of infancy or childhood but of elderly men, so the full benefit of reduced incidence may be enjoyed, so to speak, through adult circumcision. It is also worth noting that other types of cancer could be reduced via the surgical removal of the offending organ; nonetheless, we don't routinely perform mastectomies on little girls in hopes of some day preventing breast cancer (which has a far greater incidence, as evidenced by some 36,000 breast cancer-related deaths in the US in 2001).

On the issue of HIV infection and sexually transmitted diseases (STDs), the AMA found that there is a relatively higher risk of incidence with intact males. Again, however, because "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." In other words, circumcision may or may not make a slight difference in terms of infection—I would guess that it does—but a guy who's sleeping around is probably screwed (haha) whether he's intact or not.

Medically speaking, circumcision is not a high risk procedure. Odds of complication are between .2 percent and .6 percent, and even then most complications are minor. Although major postoperative complications are possible and can be incredibly severe, they are highly unlikely. Death from the procedure or its complications is extraordinarily rare in western medicine, but it is not unheard of. Use of anesthetic increases the risk of problems, but is now almost universally recommended in reducing infant pain.

In that regard, one cannot stress enough that circumcision is not a pain free event. On the contrary, one imagines that it hurts like hell. Infants feel pain, and some research indicates that they feel it perhaps even more acutely than adults. Medical associations throughout the world including the APA and AMA say that analgesics should be used for the procedure if it is done at all. Nonetheless, there is little mention, at least in the policy papers, that after the anesthetic wears off the infant faces somewhere between 3 to 10 days of post-operative pain.

Unbelievably, until very recently circumcision was usually performed without anesthetic. A 1994 study published in OBG management found only 14 percent of obstetricians used in anesthesia for the surgery. By 1998, this number had risen to 25 percent. The numbers were higher for family practitioners and pediatricians at 56 and 71 percent respectively. That still leaves a staggeringly high number of circumcisions performed without pain medication. It is mind boggling that anyone could believe infant circumcision to be even relatively painless when the infant must be either strapped or held down for the surgery to take place. Nonetheless, there it is....

Besides pain, there are substantial disadvantages to performing infant circumcision. The foremost among these is that circumcision does exactly what Dr. Kellogg and Mr. Graham intended: It decreases sexual pleasure for males. The foreskin is a highly sensitive tissue, and plays an important role in male sexuality:

The crucial point here is that removal of the foreskin is not removal of something without use. This isn't an appendectomy we're talking about. Circumcision alters normal human sexual function. The consequence of a reduction in male sexual stimulation effects his partner as well:

The thickened, drier tissue covering the glans of the circumcised penis may necessitate the use of synthetic lubricants to facilitate nontraumatic sexual intercourse. Often, it is erroneously considered the woman's lack of lubrication that makes intercourse painful rather than the lack of natural male lubrication, which is more likely the cause (ibid).

Unsurprisingly, many intact men with sexual experience who have later had a circumcision report a dramatic comparative decline in sexual pleasure.

Why Americans Circumcise
What is it in the American psyche that leads us to circumcise infant males as a routine practice? Religion can play a role, particularly for Islamic and Jewish parents, though Jews account for only 4 percent of all circumcisions performed in the US. Christians, as I've noted, have no spiritual imperative for the procedure, though many parents of circumcised infants certainly regard themselves as Christian. Others may believe the minor or dubious medical advantages are worth the risk and price, though no other surgery is so routinely performed for so little medical benefit—a benefit so small that both the APA and AMA won't endorse it on that basis.

More likely what we're seeing is the result of several other factors. First, cultural inertia, the "we've always done it this way" syndrome. This is, to my mind, a terrible reason to do most anything, but societal expectation is slow to change and difficult to overcome. On the whole Americans are very compliant toward authority, and when the medical establishment says, "This is good" most readily accept it without research, comment, or complaint. As I indicated in my preamble, I find this a horrible idea.

Another possible factor is personal psychological baggage. Some parents fear that if their child is intact he'll be seen as different and ridiculed by other boys in the middle school or high school locker room. If my own experience is any guide, such a scenario is highly unlikely. Middle school and high school boys are disinclined to make remarks about others privates. They don't want to be caught looking at them, let alone making comments. Further, being able to say, "I'm normal, you're the one missing things" strikes me as a potent answer. (Actually, that's understating it. Forgive the crudeness, but the real high school locker room comeback would be "Dude, I'm normal. They cut off part of your dick!") Kids will inherit whatever fears parents give them. If parents raise their son to understand being intact as normal (which it is), none of this will be an issue. If the parenting is poor, this will be the least of the child's worries.

The most common and most irrational reason for circumcision, I believe, is that fathers fear looking unlike their sons. Usually when communicated this fear is turned around to be something like "sons are supposed to look like their fathers" so that it appears as if the father is thinking of the kid first and foremost. Oh if men were that generous. The male ego is a strange, strange thing. And as if an infant or toddler cares one way or another (unless parents urge him to do so). A much more accurate test of manhood ought to be doing what's best for the child regardless of the consequence to the father's ego, but I concede that here I'm arguing against emotion not logic. Telling someone not to be fearful and presenting valid arguments why one shouldn't be afraid does very little to counteract fear itself. So here's my emotion-laden appeal: Fathers, your son will love you whether he's circumcised like you or not. If you show him respect, care, and concern, he will love you. One way you could do those things is to leave the choice of circumcision up to him. It's his body, after all, and having the operation done is permanent decision. Why not wait until he's older, and he can make the decision for himself?

Conclusion
The good news, such as it is with a topic like this, is that the cultural inertia of "we've always done it this way" is slowly being overcome. Circumcision rates in the US are declining, and throughout the mid- to late-1990s run at roughly 60 percent circumcised versus 40 percent intact. That number varies greatly depending on region, however, with the circumcision rates of the Midwest (aka the Bible Belt) continue to hover around 80 percent. Interestingly, the western US runs against the national average with about 37 percent being circumcised and 63 percent intact. Nonetheless, all these trends represent a huge drop from the 1960s, 1970s, and 1980s when the national circumcision rate was as high as 85 percent. (See Normal versus Circumcised: U.S. Neonatal Male Genital Ratio.)

This is important because society is slow to change expectations and traditions. At one time we thought smoking tobacco was harmless, that bottle feeding infants was superior to breast feeding, that drinking "medicinal" mercury healed rather than poisoned, and so on. Changes in these opinions did not come overnight, but they did come. We look back now and wonder how we ever believed it could be so. I am convinced it will be the same with routine infant circumcision.

To be clear, other than thinking it a little weird I have no issue with adult males who wish to be circumcised. I also have no problem with infant circumcision when medically indicated, and there are rare circumstances when such is the case. I have strong objections to the infant circumcision as a routine procedure. If one steps back and considers the biological norms for human beings, it seems very strange to violate the primacy of the individual in this fashion.

What's most persuasive to me is not that as a parent I have an obligation to protect my son from unnecessary trauma (though there is a strong argument to be made). It is that I have no right to subject any other human being, whether it be my child or not, any permanent injury to their bodily integrity without overwhelming medical benefit. Some day the boy becomes a man, and if he chooses to have the procedure and gain the questionable benefit it entails, he is free to do so. That 99.3 percent of all US circumcisions are done on infants—and that intact men in the US are not lined up outside the clinics to have the procedure performed—should tell us all we need to know about the choices men would make.

I am not a medical ethicist, but a number who are claim that circumcision violates the medicine's standard of care guidelines. A most engaging summary of these arguments is The Bioethics of the Circumcision of Male Children. Although the article does not directly apply to those outside the health care field, I found it both compelling and persuasive reading. It is perhaps also telling that the Oregon Health Plan does not cover routine infant circumcision because it is an elective and not medically necessary procedure.

Parents who have had their sons circumcised are not bad parents. Perhaps they are caught in the cultural tide of history and unthinkingly commit to an act that from a different vantage point they might reject. Or maybe they are trusting medical authorities who wrongly believe that circumcision offers sufficient benefit to make the procedure worthwhile. Even taking the male ego into account, obviously parents do not subject their sons to this operation because they believe it is worse for their child. To the extent ignorance is an excuse, we are talking about very little moral culpability given that the parental intent is benign. Their guilt, if any, lies in trusting medical authorities who, on some level, must be trusted. (See also Circumcision: A Medical or a Human Rights Issue?.)

That doesn't mean that routine infant circumcision shouldn't be stopped immediately. It should.