What is male circumcision?

Indications and Procedures

Routine circumcision of the newborn male—in which the foreskin of the penis is stretched, clamped, and cut—is becoming an increasingly controversial procedure. Famed pediatrician Benjamin Spock once contended that circumcision is a good idea, especially if most of the boys in the neighborhood are circumcised; then a boy feels “regular.” Yet, many wonder if that is justification for circumcision. Allowing routine circumcision of newborns as a religious and cultural rite still leaves the debate over medical necessity. The United States is the only country in the world that circumcises a majority of newborn males without a religious reason. In fact, circumcision has been termed a “cultural surgery.”

True medical indications for the surgery are seldom present at birth. Such conditions as infections of the head and/or shaft of the penis may be indications for circumcision; an inability to retract the foreskin in the newborn (phimosis) is not an indication. Some argue that circumcision should be delayed until the foreskin has become retractable, making an imprecise surgical procedure presumably less traumatic. In 96 percent of infant boys, however, the foreskin is not fully retractable; it is normally so tight and adherent that it cannot be pulled back and the penis cleaned. By age three, that percentage decreases to 10 percent.

There are other definite contraindications to newborn circumcision. Circumcising infants with abnormalities of the penal head or shaft makes treatment more difficult because the foreskin may later be needed for use in reconstruction. Prematurity, instability, or a bleeding problem also preclude early circumcision. The foreskin is a natural protective membrane, representing 50 to 80 percent of the skin system of the penis, having 240 feet of nerve fibers, more than one thousand nerve endings, and three feet of veins, arteries, and capillaries. It keeps the sensitive head protected, facilitating intercourse, and prevents the surface of the glans from thickening and becoming desensitized. Also, within the inner surface of the foreskin are a series of tiny ridged bands that contribute significantly to stimulating the glans.

The two most persistent arguments for the operation, however, are the risks of infection and cancer in the uncircumcised. Without circumcision, smegma accumulates beneath the base of the covered head of the penis. This cheeselike material of dead skin cells and secretions of the sweat glands is thought to be a cause of cancer of the penis and prostate gland in uncircumcised men and cancer of the cervix in their female partners. Doctors who argue against circumcision, however, say that the presence of smegma in the uncircumcised is simply a sign of poor hygiene and that poor sexual hygiene, inadequate hygienic facilities, and sexually transmitted diseases cause an increased incidence of cancer in ethnic groups or populations that do not practice circumcision. Doctors who argue against circumcision also point out that complete circumcision is found as often in male partners of women without cancer of the cervix as in male partners of women who have cervical cancer. In Sweden, moreover—where
newborn circumcision is not routinely practiced but where good hygiene is practiced—the rates of these cancers are essentially the same as those found in Israel, where ritualistic circumcision is practiced.

The increased incidence of urinary tract infections and sexually transmitted diseases (STDs) in uncircumcised males sufficiently argues for circumcision, say its proponents. They warn that the intact foreskin invites bacterial colonization, which leads to urethral infection ascending to the bladder that ultimately may spread upward to the kidneys and sometimes cause permanent kidney damage. On the other hand, no proof exists that uncircumcised male infants who sustain urinary tract infections will have future urologic problems. Furthermore, the operation is not a simple procedure and is not without peril. Penile amputation, life-threatening infections, and even death have been well documented.

Slightly increased rates of infection with sexually transmitted diseases in the uncircumcised argue the case for some proponents, but it is Acquired immunodeficiency syndrome (AIDS)
that they most fear. In Africa, where male circumcision is seldom practiced, the acquisition of AIDS by heterosexual men from infected women during vaginal intercourse is the most common mode of transmission.

Proponents say that infection with Human immunodeficiency virus (HIV)
, the virus that leads to AIDS, depends on a break or an abrasion of the skin to gain entry. The intact foreskin provides a site for the transfer of infected cervical secretions. In Africa, doctors at the University of Nairobi noted a relationship of HIV infection to genital ulcers and lack of circumcision. Uncircumcised men had a history of genital ulcers more often than did the circumcised, and they were more often HIV-positive. They were also more frequently HIV-positive even if they did not have a history of genital ulcer disease.

Every evaluation of circumcision, pro or con, should reflect the confounding genetic and environmental variables, as well as the actual increased risks and benefits. All the pros and cons should be explained to parents before informed consent is obtained.

Uses and Complications

In 1989, the American Academy of Pediatrics’ Task Force on Circumcision concluded that “newborn circumcision has potential medical benefits and advantages as well as disadvantages and risks. When circumcision is being considered, the benefits and risks should be explained to the parents and informed consent obtained.” This neutral statement does not lessen the anxiety of parents who are trying to weigh the pros and cons of routine newborn circumcision, but examination of the evidence does allow parents to weigh the individual benefits and risks and see if the scale tips in either direction.

Worldwide studies of predominantly uncircumcised populations have shown a higher incidence of urinary tract infection in boys during the first few months of life, which is the reverse of what is found in older infants and children, where girls predominate. In 1986, Brooke Army Medical Center in Fort Sam Houston, Texas, took a closer look. The doctors found the incidence of urinary tract infection in circumcised infant males to be 0.11 percent but 1.12 percent in the uncircumcised. Even without proof that the uncircumcised male infants who get urinary tract infections will have future urologic problems, the proponents for the surgical procedure claim about a 1 percent advantage.

The evidence for an increase in sexually transmitted diseases (such as genital herpes, gonorrhea, and syphilis) among the uncircumcised is conflicting. Furthermore, apparent correlations between circumcision status and these diseases do not reflect confounding genetic and environmental variables. It is also difficult to factor in the risk from HIV infections. The studies from Africa do not look at any variables in the transmission of HIV except circumcision status and previous history of genital ulcers. The nutritional and economic status of the men was not examined, even though it is known that malnourishment suppresses the immune systems. Moreover, if everyone practiced safer sex, the argument for circumcision would be moot.

Almost all the surgical complications of circumcision can be avoided if doctors performing the procedure adhere to strict asepsis, are properly trained and experienced in the procedure, remove the appropriate and correct amount of tissue, and provide adequate hemostasis. The variety of circumstances, populations, and physicians affects the incidence of complications. In the larger, teaching hospitals, often the newest physicians with the least experience or supervision perform the operation. As a result, complications may arise. Excessive bleeding is the most frequent complication. The incidence of bleeding after circumcision ranges from 0.1 percent to as high as 35 percent in some reports. Most of the episodes are minor and can be controlled by simple measures, such as compression and suturing, but some of these efforts can lead to diminished blood supply to the head and shaft of the penis with necrosis of the affected part. Chordee can result if improper technique or bad luck intervenes, and such penile deformity begets the risk of emotional distress. The urethral opening on the end of the penis can become infected or ulcerated when the glans is no longer protected by foreskin; such infection rarely occurs in the uncircumcised. Finally, any surgical
procedure runs the risk of infection. These localized infections rarely spread to the blood, but death from sepsis and its sequelae has been documented.

Overall, the surgical complication rate after circumcision runs around 0.19 percent, which could be lowered with strict protocols, meticulous technique, strict asepsis, and well-trained, experienced physicians. Strict protocols, it is hoped, would ensure that absolute contraindications to the procedure—such as anomalies of the penis, prematurity, instability, or a bleeding disorder—were honored.

Another human factor must be considered. Many insurance companies do not provide payment for newborn care, since it is considered preventive medicine. In 1997, a physician’s fee for performing a circumcision ranged to approximately $400, with a nationwide average of $137. Interestingly, a growing number of circumcised men are undergoing expensive foreskin restoration procedures.

In part because of an additional cost that arises with anesthesia, the vast majority of infant circumcisions are performed without pain control. The surgery is painful, yet some physicians claim that the minute that the operation ends, the circumcised baby no longer cries and frequently falls asleep. Continuing pain, therefore, is probably not present.

Another perspective to examine is the experience of adult males, who are circumcised by their own choice. Many complain of at least a week’s discomfort after the operation. The most compelling argument against adult circumcision, however, comes from their answer to “Would you do it again?” In one study of several hundred men who were circumcised as adults, they were asked five years later if they would do it again. All said no.

Perspective and Prospects

Routine newborn circumcision originated in the United States in the 1860s, ostensibly as prophylaxis against disease. Some medical historians, however, believe that nonreligious circumcision was a deliberate surgical procedure to desensitize and debilitate the penis to prevent masturbation. During this era, and for nearly one hundred years afterward, most American physicians viewed masturbation as an inevitable cause of blindness, weak character, insanity, nervousness, tuberculosis, sexually transmitted disease, and even death. One physician maintained that a painful circumcision would have a salutary effect upon the newborn’s mind, so that pain would be associated with masturbation. As late as 1928, the American Medical Journal published an editorial that justified male circumcision as an effective means of preventing the dire effects of masturbation. During World Wars I and II, soldiers were forcibly circumcised under threat of court martial, being told that the surgery was for reasons of hygiene and the prevention of epilepsy and other diseases.

Eventually, a general change in attitude occurred, notably in Great Britain and New Zealand, which virtually have abandoned routine circumcision. Rates of circumcision have also fallen dramatically in Canada, Australia, and even the United States. As recently as the mid-1970s, approximately 90 percent of US male babies were circumcised. Not until 1971 did the American Academy of Pediatrics determine that circumcision is not medically essential. In 1999, an estimated 65 percent of US male babies were circumcised; by 2010, the incidence of newborn circumcision had declined to 55 percent.

In 1971, the American Academy of Pediatrics’ Committee on the Fetus and Newborn issued an advisory that said, “There are no valid medical indications for routine circumcision in the neonatal period.” In 1978, when the American College of Obstetricians and Gynecologists affirmed this statement, the circumcision rate had already declined to an estimated 70 percent of newborn males, compared to previous rates of between 80 and 90 percent.

Undoubtedly, the future will bring improved surgical techniques. More emphasis will be placed on avoiding surgical complications by more rigid monitoring of the operation and who performs the procedure. It is unlikely that circumcision will disappear completely.

Organizations such as Doctors Opposing Circumcision and the National Organization to Halt the Abuse and Routine Mutilation of Males, however, are actively proposing an end to routine neonatal circumcision. Some nursing groups and concerned mothers have formed local groups to oppose circumcision in male neonates. They argue that subjecting a baby to this procedure may impair mother-infant bonding. Another question posed by some physicians and parents is the ethics involved in the unnecessary removal of a functioning body organ, particularly without the patient’s consent. Others claim that the baby’s rights are being violated, noting that it is the child who must live with the outcome of the decision to perform a circumcision. As a result of these efforts, the rates of circumcision will probably continue to fall.

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