Circumcision: What Does Science Say?

Some people think circumcision is mutilation; others want one even if they don’t know what it is. When I was working in an Air Force hospital emergency room one night, a young airman came in requesting a circumcision. I asked him why he wanted one. He said a couple of his friends had had it done, and he’d heard it was a good idea, and he was going to be getting out of the Air Force pretty soon and wanted to have it done while Uncle Sam would still foot the bill. I examined him: he had a neatly circumcised penis without so much as a hint of any foreskin remnant. I’ve always wondered what he thought we were going to cut off.

The subject of circumcision evokes strong emotions. Some people think of neonatal circumcision as a religious duty or a valuable preventive health measure; others think it is the epitome of child abuse. I have no strong feelings either way. I’m not sure what I would have decided if I’d had sons; fortunately my children were both daughters so I didn’t have to decide. I’m going to try to stand back and look at the scientific evidence objectively. What are the medical benefits and risks of circumcision?

There is a website that is admittedly biased in favor of circumcision but that has collected an impressive amount of information in one place, with 660 references. I learned way too much from that website. For instance that the circumcised penis averages 0.8 cm shorter than the uncircumcised penis (possibly due to improper technique occasionally removing too much tissue and “tethering” the organ slightly). And that an intact foreskin is an absolute requirement for a mutual masturbation practice amongst homosexual men known as “docking,” in which the penis is placed under the foreskin of the male partner. I didn’t need to know that. You probably didn’t want to know that either, but now it’s too late.

In addition to pro-circumcision groups like Circinfo.net, there are numerous anti-circumcision activist groups. There are even groups that encourage re-creation of the lost foreskin by stretching the penile skin with specially-designed weights. Penn and Teller featured this on an episode of their cable TV series Bullshit! An elderly man exposed his genitals – weights and all – on national television to promote his cause. It was pretty amazing. A somewhat blurred version can be seen on U-Tube.

Arguments against circumcision

• “Nature makes no mistakes.”
• It’s genital mutilation and a violation of human rights.
• Doctors just do it to earn more money.
• It’s cruel; babies suffer terrible pain.
• Babies remember the pain.
• There are permanent physiologic consequences: boys who were circumcised at birth are more sensitive to pain later in life.
• The uncovered glans becomes less sensitive.
• Circumcised men don’t get as much pleasure from sex.
• Circumcised men are psychologically damaged.
• Some men mourn their lost foreskin; some miss it so much that they try to reconstruct it.
• The foreskin is required for the homosexual practice of “docking.”
• An intact foreskin provides more scope for body art like piercings and tattoos.
• There are complications from the surgery including hemorrhage, infection and even death (in one famous case a boy’s penis was accidently burned off by an electrocautery device and they elected to raise him as a girl).
• Other complications include poor cosmetic results and meatal stenosis.
• If reconstructive surgery is needed later in life, an intact foreskin can provide tissue.
• It’s elective surgery and the patient doesn’t get a choice in the matter.

Some of these arguments are medical; some are not. Some are questionable. The “doctors want to make money” argument doesn’t seem to hold water, since plenty of circumcisions are done in settings where doctors are on a fixed salary and circumcisions just mean more work.

There’s no good evidence that circumcised men get less pleasure from sex. Studies have shown little or no difference in sensitivity or sexual satisfaction with circumcision. If there were lowered sensitivity it might theoretically enhance pleasure by allowing more prolonged intercourse; and one man commented, “most [circumcised] men will tell you that if their genitalia were any more sensitive, it would cry during Meryl Streep movies.”

If some men are psychologically damaged by circumcision and mourn their lost foreskin, their mental health must be pathologically fragile. Get over it, guys!

I don’t think there is any evidence that babies are capable of remembering the pain of circumcision or for that matter the birth experience. There have been studies suggesting that infant circumcision alters pain response later in life, but they are contradictory and unconvincing.

The risks are minimal if the procedure is done under sterile conditions by an experienced operator. Many of the serious complications documented in the literature were easily preventable. “Overall complications should approach zero for an experienced operator” especially if the safer techniques are used and contraindications like hemophilia and penile abnormalities are heeded.

A colleague told me he challenges his students to find any difference in babies who just had the procedure, and they can’t. Babies seem to get just as upset from lesser procedures like having blood drawn, and sometimes an irritable baby goes into a hissy fit just from being dressed or from being hungry. They cry uncontrollably for even trivial reasons, but they get over it promptly.

I used to do assembly-line circumcisions where we’d strap several babies to molded plastic restraining boards; they didn’t like being restrained, but by the time the last baby was restrained, the first one would usually have stopped crying and would often remain calm throughout the actual procedure, especially if he’d been given a sugar pacifier. Sometimes he’d even go to sleep. I used a Plastibell device: the actual cutting part of the procedure is painless even without anesthesia, because the tissue is already “dead” – the blood supply has been cut off by tying a string over the groove in the plastic ring. Studies have documented physiologic changes during the procedure, but it’s not clear that those changes mean anything that really matters to the child’s mental state or physical welfare. It’s current practice to inject an anesthetic, but that carries its own small risk and also causes pain: it’s not 100% clear whether we’re using it for the infant’s benefit or the adults’. Some doctors still wonder if it might be kinder to skip the anesthesia and just get the procedure over with and the baby back in Mom’s arms as quickly as possible.

Arguments for circumcision

Some of the arguments for circumcision are unavoidably intertwined with a separate issue: hygiene. The warm, moist space under the foreskin is a prime breeding ground for bacteria, it can harbor sexually transmitted disease organisms, and it produces a cheese-like, foul-smelling substance called smegma. It is plausible that this could contribute to infections in the man and his partner, and even to cancer. Many studies support that idea, others don’t. There doesn’t seem to be any good evidence comparing circumcised men to uncircumcised men who practice meticulous hygiene. It’s difficult to sort out whether it is the circumcision itself or just improved hygiene that makes the difference. Circumcision undoubtedly facilitates hygiene, but is that a reason to operate?

• Circumcision reduces the transmission of AIDS. Maybe. A 2008 meta-analysis of studies in Africa indicated that one case of heterosexually transmitted AIDS would be prevented by 72 circumcisions. It seems to be less effective at preventing male-to-male homosexual transmission. This gets confusing, because knowing they have had a risk-reducing procedure might increase promiscuity, and improved hygiene alone might reduce risk. Anyway, circumcision doesn’t remove the risk entirely, and safe sex is still necessary. Since there are other more effective ways to prevent AIDS transmission, few would argue for circumcision just for the purpose of AIDS prevention.
• Circumcision prevents penile cancer. The incidence of penile cancer is about 1 in 100,000 in the US. By one estimate, the lifetime risk for an uncircumcised man in the US is 1 in 600. The 5 year survival rate is about 65%. Penile cancer is almost never seen in circumcised men; such a case is unusual enough to be written up as a case report in a medical journal. In third world countries where hygiene is poorer and circumcision is less common, penile cancer causes up to 10% or 20% of cancers in men. Disgusting photos can be seen at http://www.circinfo.net/cancer_of_the_penis.html
  The American Cancer Society thinks the studies showing reduced penile cancer rates were flawed because they failed to consider other factors that are now known to affect risk, such as smoking, personal hygiene, HPV infection, and multiple sexual partners. It concluded:

  The current consensus of most experts is that circumcision should not be recommended as a prevention strategy for penile cancer.

• Reduced risk of urinary tract infection. Several studies have shown that circumcised baby boys have fewer UTIs but the reduction is small and this study suggests confounding factors might be responsible.
• Reduced risk of balanitis (inflammation of the glans penis). Most studies show balanitis is more common in uncircumcised males, but at least one study indicated that it was more common in circumcised males, especially in early childhood.
• Reduction of the incidence of various sexually transmitted diseases in men and in their female partners. Reduction of cervical cancer and maybe even breast cancer in women. Again, these are likely more related to hygiene than to surgery.
• Circumcision prevents phimosis (the inability to retract the foreskin) and paraphimosis (a painful inability to pull the retracted foreskin back down). Paraphimosis can obstruct urine and blood flow and is a medical emergency.
• About 10% of uncircumcised infants will require circumcision later in life for medical reasons. Adult circumcision is more expensive, more difficult, riskier, requires stitches, and causes more suffering than neonatal circumcision. The conditions that lead to the medical necessity for circumcision also cause suffering that would have been avoided by neonatal circumcision.
• Hygiene. It’s easier to keep a circumcised penis clean. Certainly it’s a convenience, but that doesn’t constitute a medical indication.
• Aesthetics. Women allegedly prefer the appearance of a circumcised penis. Even if true, not a medical indication.
• Zipper injuries to the foreskin can’t occur if you don’t have a foreskin. True, but trivial.
• Other boys will laugh at you in the locker room if you’re uncircumcised. (I don’t think this one even deserves a comment.)

Not medically indicated or contraindicated

What all this really boils down to is that there are no compelling scientific arguments for or against neonatal circumcision.

There are small risks and there are small benefits. The decision is not a medical one. Medical organizations are not “pro” circumcision, but they’re not “con” either. The American Academy of Pediatrics’ official policy states:

Existing scientific evidence demonstrates potential medical benefits of newborn male circumcision; however, these data are not sufficient to recommend routine neonatal circumcision. In circumstances in which there are potential benefits and risks, yet the procedure is not essential to the child’s current well-being, parents should determine what is in the best interest of the child.

Aside from religious reasons, the main reason parents give for circumcision seems to be simply to make junior match Dad. Even if you believe potential medical benefits outweigh the risks, does that justify doing an elective procedure to remove a piece of the child’s skin without his consent? That’s a value judgment and an ethical dilemma that will continue to evoke strong emotions, like abortion.

I used to live in Spain, where you could tell girl babies from boy babies just by looking at their ears: all the baby girls had their ears pierced in the delivery room. That was a “mutilating” procedure with no conceivable medical benefit and a small risk of infection, deformity, or ingestion of earring parts. It was nowhere near as controversial as circumcision. I wonder why.