Male Circumcision: Medical Basis or Cultural Bias

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About the Author

Sam Carnes RT(T) CMD is an intact man who is a medical professional and an intactivist. After finishing active duty military time in 2006, he went to IUPUI and received a Bachelor of Science in Radiation Therapy, graduating in 2010. He then went on to graduate school for a Graduate Certificate in Medical Dosimetry (radiation treatment planning for cancer patients). While working full time as a Medical Dosimetrist, he is also pursuing a Master of Science in Health Science. He is proud to be intact and happy to answer questions for new parents or anyone else who wants to learn about normal male anatomy and the problems with circumcision. Many find this information strange or intimidating because it is different from what they are used to hearing. However, being intact is the natural state and it is Sam’s goal to help make intact the norm here in the United States just as it is in practically everywhere else in the world. Sam can be reached at [email protected]

 

Male Circumcision: Medical Basis or Cultural Bias

Circumcision is a very ancient procedure which gained popularity in the United States only in the past 150 years. Recently, there has been much controversy surrounding the procedure. Most Americans assume that newborn males must be circumcised or else face many problems throughout life. They are unaware that this opinion is not shared by the majority worldwide. The medical community is also divided on the issue. Physicians in the United States tend to recommend the procedure and cite all of the claimed benefits while ignoring their colleagues abroad who disagree. Physicians from outside the United States tend to question the existence of these benefits or at least to question whether they outweigh both the possible complications from the procedure and the benefits an intact foreskin provides. If any issues arise in the foreskin area these doctors tend to recommend treatments that preserve the foreskin rather than remove it as their American counterparts tend to do. American literature is silent about the benefits and functions of the foreskin and so if an issue arises, physicians in the United States often do not to see any value in retaining what they consider to be superfluous. There is a clear bias in favor of circumcision in this country and people claim the health benefits as a reason to justify this cultural bias. There is no need to circumcise. Intact men and boys are just as healthy as their circumcised counterparts and have the additional benefits gained from having a foreskin.

People have many reasons for circumcising their sons including: the father being circumcised, they believe everyone is, they think it looks better, they do not want their son to look or feel different, they want to prevent teasing in the locker room, and they believe it to be healthier. A study found that males born and raised in the United States were the most in favor of circumcision with one comment being, “All I can say is that everybody should be circumcised” and another, “It is healthier for males to get circumcised” (Jia et al. 94-95). For a small percentage, it is an event of religious significance such as in Judaism or Islam. The most often cited reasons however, are the medical/health benefits of reducing urinary tract infection (UTI), preventing phimosis and balanitis, reducing incidence of penile cancer, reducing incidence of contracting STDs and HIV, and improving penile hygiene.

The American Academy of Pediatrics (AAP) writes that “current evidence indicates that the health benefits of newborn male circumcision outweigh the risks and that the procedure’s benefits justify access to this procedure for families who choose it” (585). Some believe that lower circumcision rates are bad for the public health, claiming that those who are uncircumcised will have a disproportionate level of health problems in the future (Leibowitz, Desmond, and Belin 144). One very common health reason given for circumcision is that it reduces urinary tract infections (UTI) which can occur in up to 4% of boys before they are one year old (The Royal Australasian College of Physicians 10). Schoen claims that it was once only suggested that UTIs were more common in uncircumcised boys but that it is now definitive (258). He claims that there is a “greater than 10-fold increased risk of UTI in uncircumcised boys compared with their circumcised counterparts in the first year of life” and that “uncircumcised preschool boys and men are also at increased risk for UTI” (258).

Phimosis is another frequently mentioned argument in favor of circumcision. This is a condition in which the foreskin is narrowed at the opening, preventing retraction (Ahmed 12). It is claimed that this could be a source of infections, inadequate hygiene, and balanitis (Hunter 37). According to Schoen, this inflammation of the glans and foreskin occurs in about 4% of uncircumcised boys with circumcision being the best method of prevention saying, “Although treatment can be conservative, late circumcision is often necessary for recurrent cases and medical management requires additional physician visits and treatment” (258). Another medical condition is balanitis which is the inflammation of the glans of the penis, the part normally covered by the foreskin in the uncircumcised male, most commonly caused by Candida (Hunter 36). It is a simple yeast infection.

Penile cancer is a very rare disease, affecting approximately 1 in 100,000 men per year (Frisch et al. 797). Some risk factors given are: being uncircumcised, phimosis, and poor genital hygiene (Ahmed 14). Schoen states “evidence that circumcision protects against penile cancer is overwhelming” and that “Newborn circumcision virtually eliminates this devastating threat” (258). This seems to be quite a forceful statement for a disease that is so rare. He also claims that the incidence is vastly more common in uncircumcised men (258).

One of the most often stated arguments today is that circumcision prevents, or at least dramatically reduces one’s chances of contracting STDs and HIV. It is claimed that “men with an intact foreskin are at increased risk for sexually transmitted diseases (STDs)” and that uncircumcised men have a 3 times greater risk of getting an STD with circumcision reducing this risk by 48.2% (Ahmed and Ellsworth 14-15). It is argued that “circumcision can significantly lower the risk of adult males acquiring HIV through heterosexual intercourse” (14). According to the World Health Organization (WHO) “Three separate randomized controlled trials in South Africa demonstrated that circumcised men have a 48-60% reduced risk of becoming infected with HIV (22). The researchers even stopped the trials early because they considered it unethical to allow the control group to continue in life without being offered circumcision (Ahmed and Ellsworth 15). There is also an article which while criticizing the methodology used in drawing conclusions from this series of trials, does not call into question the findings of the studies (Lie and Miller). Instead, they state that “we do have substantial data from observational research that complement and strengthen the results from the RCTs, [Randomized Controlled Trials] giving us sufficient confidence to recommend circumcisions as a public health intervention to prevent HIV infection” (5).

Another argument in favor of circumcision is that it improves penile hygiene. According to Wilson et al., “Conditions such as urinary tract infections, cancer of the penis, acquired phimosis, paraphimosis, and candida infection (thrush) can result from poor hygiene” (107). Schoen says that “US anticircumcision groups claim that genital hygiene can easily be maintained as the foreskin naturally separates, but, in reality, genital hygiene in uncircumcised boys has been shown to be poor” (258). A vast majority of people in the United States believe that unless one retracts and cleans underneath the foreskin daily then it remains dirty and is a haven for bacteria to grow. Since people believe this necessary even in children, they think that is less hygienic for the glans to remain covered by foreskin. Since the foreskin often does not retract until later it makes this cleaning process more involved for those that follow this policy.

There is also the issue of informed consent. Proponents argue that parents can give consent for their children to undergo the procedure. After all, vaccinations are given to infants and young children, who obviously cannot give consent, but whose parents consent for them (Benatar and Benatar 37). Delaying vaccinations until later in life would leave children exposed to risk of infection and so it “seems entirely reasonable that parents or other guardians of a child’s best interests be morally entitled to decide for the child” (37). It is the same with the case of circumcision. Parents are trying to prevent diseases in their children and so for this reason give consent to the procedure in an effort to do what is best for their child.

Now it is necessary to look at the arguments against circumcision. When circumcision started becoming common in this country the fact that many fathers were intact did not prevent widespread circumcision, causing fathers and sons not to match. Children are more likely to notice the difference in size than they will notice presence or lack of foreskin. If they do notice, then one merely needs to explain, age appropriately, so that they can understand the difference. Many fathers and sons are different in areas other than circumcision status. The father might have a tattoo, different colored hair or eyes, or have a beard. In all of these cases society does not seem to have a problem with this lack of matching so why is it that the penis must match? There is no need to circumcise to match the father. Neither is it a sufficient reason to circumcise to prevent possible teasing. Boys will tease each other over many different things and if not about circumcision status then it will be about something else. Boys should be taught to have confidence in themselves and to be proud of who they are. It is not necessary to cut off a body part just so that they will look like everyone else.

Many people are not well informed about circumcision. Most of the world is not circumcised but many Americans are surprised to learn this. In a study, participants were asked how they felt about circumcision “including the fact that 70% of the males worldwide are not circumcised” (Jia et al. 94). The knowledge level displayed was quite embarrassing with circumcised participants born and raised in the United States shocked to discover that they were in the minority. They also made comments in reference to the number of those uncircumcised worldwide such as “That is a lot of males and a lot of germs” (94). Immigrants were more aware that it is not a world-wide norm and did not feel disadvantaged. Their comments were “I am one of these 70%” and “I am not circumcised and never got any diseases in my life” (94-95). Fortunately, the rates are starting to drop in the United States and the societal norm is slowly changing as people become more aware that there is no real reason to circumcise. Rather than follow the majority, it is important that people be educated so that they will see that there is no reason for this societal norm. It is merely a cultural bias. The Royal Dutch Medical Association calls circumcision “a procedure in need of a justification” (7).

Those who circumcise for religious reason, such as Jews and Moslems, are a very small percentage of the population. For these cases an argument could be made for returning to the original form of circumcision where only a small portion of the foreskin was removed. During the second century the religious leaders of the Jewish people became concerned because so many men were trying to hide the fact that they were circumcised. The leaders revised the circumcision rite from being a small snip to removing the entire foreskin, thus eliminating the ability to appear uncircumcised (Gollaher 16-17). So even early on, religious circumcisions preserved a large portion of the foreskin.

Physicians from many European countries came together and issued a document refuting four health-related reported benefits of circumcision claimed by the AAP (Frisch et al.). The only possibly relevant argument was that of circumcision preventing urinary tract infections (UTIs) but even this argument “fails to meet the criteria to serve as a preventive measure for UTI” they said (797). They pointed out that “1% of boys will develop a UTI within the first years of life” (797). They also mention that there have been no trials linking a lack of circumcision to UTIs (797). UTIs are rarely serious, and evidence for any protective effect is weak (797).They also show that the risk of complications from circumcision is higher than the chance of getting a UTI. It is extremely telling that the rate of UTIs is similar between the United States and Europe even though the circumcision rate is vastly different (797).

Dr. Rowena Hitchcock of the Royal College of Surgeons of England says that the paper by Dr. Schoen “reflects the influence of culture and habit on the interpretation of medical practice” (260). She goes on to say that there are alternatives to circumcision that are just as effective for both balanitis and phimosis, yet preserve the foreskin. She indicates that American physicians are much more aggressive and tend to cut off, rather than treat the problem. She believes that this preference for circumcision is a cultural bias rather than sound medical practice (260). She concludes:

In countries where neonatal circumcision is rarely practiced, and appropriate non-aggressive management of the normal foreskin, with non-forcible retraction and regular cleaning after spontaneous relaxation of the physiological phimosis, there is no population demand for neonatal circumcision. This supports the conclusion that neonatal circumcision is a social ritual with a grain of medical origin (260).

She also brings up a very interesting point by noting that the incidence of penile cancer is comparable for the United States and Finland even though the rate of circumcision in Finland is less than 1% (260). Another author notes that the incidence of penile cancer is actually slightly higher in the United States where most men are circumcised than in Denmark were most are not (Benetar and Benetar 38). This calls into question the idea that being circumcised reduces one’s risk of this disease. As for the STDs and HIV argument, it has been noted that while the United States widely practices circumcision, they also have a high incidence of both STDs and HIV.

That the relationship between circumcision and transmission of HIV is at the very least unclear is illustrated by the fact that the US [United States] combines a high prevalence of STDs and HIV infections with a high percentage of routine circumcisions. The Dutch situation is precisely the reverse: a low prevalence of HIV/AIDS combined with a relatively low number of circumcisions. As such, behavioural factors appear to play a far more important role than whether or not one has a foreskin (Royal Dutch Medical Association 7-8).

If circumcision is really supposed to greatly reduce these diseases, then the United States with its high circumcision rates should have much lower rates of STDs and HIV than the rest of the world. This has not proven true, however. Is it not much more likely that promiscuity is the culprit? If having a foreskin was really the problem it seems that those countries where circumcision is much less common would have a corresponding increase in incidence of these diseases. The fact that this is not the case is a serious flaw in this argument.

Hygiene of the intact penis is not difficult. Those who were circumcised at birth seem to labor under the delusion that adequate cleaning of an intact penis is a very labor-intensive procedure. This is totally false. In an article on the proper care of intact boys, Bollinger shows that many physicians and medical websites give either no information on proper intact care or varying degrees of erroneous information (208-211). For an intact infant or young boy all that should be done is to clean the outside of the penis like one would clean a finger. The foreskin is not to be retracted for any reason whatsoever. Bollinger notes that “Premature forced foreskin retraction (PFFR) is essentially being skinned alive” (214). At some point in the life of an intact boy the foreskin, which is initially fused to the glans, will begin to separate and become retractable. When it is ready to retract the boy himself is the only one who should ever retract it. Even if retractable at a younger age, it is not necessary to retract and clean until after the onset of puberty. Once an intact male begins washing under his foreskin it is a very quick and easy process. The foreskin is retracted and the area is cleaned. Some men prefer soap while others rinse with water only. Either is fine and depends solely on the preference of the individual. If using soap, the area is rinsed off before returning the foreskin to its original position. The entire process takes no more than ten seconds. Unfortunately, many upon learning that one is intact or that one’s child is intact immediately say “Make sure you keep it clean!” This is highly insulting to all those who are intact and implies that the person speaking believes that the foreskin must be retracted for cleaning which, as previously stated, must never be done to a child or infant. To say this to an adult conveys the impression that the speaker believes that he is naturally less hygienic. Washing under the foreskin is such a habit for an intact man to do in the normal course of his shower that making comments like this is like telling him not to forget to wash his left leg or to keep his right arm clean.

Another powerful argument against the circumcision of infants and children is that they cannot give consent for the procedure. In a circumcision, a helpless young boy is strapped down and a very sensitive part of his penis is chopped off. It is gone forever and he can never get it back. An important part of his body was taken from him without his permission. In an article the author correctly notes that those opposed to the procedure “regard circumcision of children to be a form of assault—which is what surgery amounts to when appropriate consent or exceptional circumstances (such as necessity) are absent” (Benatar and Benatar 36-37). These authors make a critical mistake however, by saying, “Nor can it be argued that nothing is lost by delaying a choice about circumcision of one’s child until he can make it himself” (37). On the contrary, The Royal Australasian College of Physicians indicates that the supposed health benefits being sought through circumcision “could largely be obtained by deferring circumcision to a much later age (14). Deferring circumcision until one can give informed consent to the procedure is the only ethical choice. It is the one undergoing the procedure who is having an important body part, the foreskin, permanently removed and not his parents. It would be necessary to defer the procedure until the boy reaches his majority to ensure that he is not signing the consent form under coercion from his parents or from a sense of obedience to them. How can parents take away this choice from their sons? Or even worse, when they are too young to resist, remove their foreskin from them? This is an irrevocable decision. If left intact, they can choose to undergo the procedure as an adult if they wish, but if circumcised, they have no choice, regardless of their wishes in the matter.

Much of the American literature ignores the benefits the foreskin, instead seeing it as a troublesome extra flap of skin. They remain ignorant of what the foreskin provides. The Royal Australasian College of Physicians states that “The foreskin has two main functions. Firstly it exists to protect the glans penis. Secondly the foreskin is a primary sensory part of the penis, containing some of the most sensitive areas of the penis” (7). The foreskin is not a useless flap of skin. There are many nerves: “The male prepuce has somatosensory innervation by the dorsal nerve of the penis and branches of the perineal nerve” (Cold and Taylor 17). “Nerve supply accounts for approximately 36% of the total penile allotment of nerve endings” (Hunter 36).

I can attest to these arguments personally since I am intact. As a young boy and teenager I did not go the doctor very often. Perhaps this is a good thing since I was unretractable until I was fifteen and many physicians in the United States would have diagnosed me with phimosis and recommended circumcision even though I never had any issues or problems with my foreskin. They would not have recognized this as a regular physiologic process but would rather have considered it a pathologic condition. Such is the extent of the bias against the foreskin in this country. I cannot imagine having been deprived of my foreskin at birth and I would never choose to be amputated in that way nor would I choose it for anyone else. Intact men and boys are healthy. They have no more issues with their penises than their circumcised counterparts, despite the hype. The foreskin does not cause more problems than any other part of the body. If there is an issue, it needs to be treated rather than cut off. The foreskin is not a breeding ground for disease; rather it is an important part of the male anatomy that is vastly underappreciated in this country. In the practice of medicine the instinct should always be to treat and to heal rather than to remove. Remember the ancient medical axiom “first, do no harm.” The foreskin is causing no problems and is supposed to be there. Therefore it is harmful to remove it for no cause. In the future it will become increasingly clear to Americans that this need for circumcision is a cultural bias. They will eventually come to see that the rest of the world is correct in saying that there is no need to circumcise.

Works Cited

Ahmed, Asma, and Pamela Ellsworth. “To Circ or Not: A Reappraisal.” Urologic Nursing 32.1 (2012): 10-19. CINAHL Plus with Full Text. Web. 12 Jan. 2014.

American Academy of Pediatrics Task Force on Circumcision. “Circumcision Policy Statement.” Pediatrics 130.3 (2012): 585-586. Web. 23 Jan. 2014.

Benatar, Michael, and David Benatar. “Between Prophylaxis and Child Abuse: The Ethics of Neonatal Male Circumcision.” American Journal of Bioethics 3.2 (2003): 35-48. CINAHL Plus with Full Text. Web. 7 Jan. 2014.

Bollinger, Dan. “The Penis-Care Information Gap: Preventing Improper Care of Intact Boys.” Thymos: Journal of Boyhood Studies 1.2 (2007): 205-219. SocINDEX with Full Text. Web. 10 Feb. 2014.

Cold, C. J., and J. R. Taylor. “The Prepuce.” BJU International 83 Suppl 1 (1999): 34-44. Academic Search Complete. Web. 7 Feb. 2014.

Frisch, Morten et al. “Cultural Bias in the AAP’s 2012 Technical Report and Policy Statement on Male Circumcision.” Pediatrics 131.4 (2013): 796-800. Web. 24 Jan. 2014.

Gollaher, David. Circumcision: A History of the World’s Most Controversial Surgery. New York: Basic Books, 2000. Web. 12 Jan. 2014.

Hitchcock, Rowena. “Commentary.” Archives of Diseases in Childhood 77 (1997): 260. Web. 23 Jan. 2014.

Hunter, David. “Conditions Affecting the Foreskin.” Nursing Standard 26.37 (2012): 35-39. Academic Search Complete. Web. 12 Jan. 2014.

Jia, Li, et al. “Immigrants Vs. Non-Immigrants: Attitudes Toward and Practices of Non-Therapeutic Male Circumcision in the United States of America.” Journal of Cultural Diversity 16.3 (2009): 92-98. CINAHL Plus with Full Text. Web. 7 Jan. 2014.

Leibowitz, Arleen A., Katherine Desmond, and Thomas Belin. “Determinants and Policy Implications of Male Circumcision in the United States.” American Journal of Public Health 99.1 (2009): 138-145. CINAHL Plus with Full Text. Web. 12 Jan. 2014.

Lie, Reidar K., and Franklin G. Miller. “What Counts as Reliable Evidence for Public Health Policy: The Case of Circumcision for Preventing HIV Infection.” BMC Medical Research Methodology 11.1 (2011): 34-40. Academic Search Complete. Web. 7 Jan. 2014.

The Royal Australasian College of Physicians. Paediatrics & Child Health Division. “Circumcision of Infant Males.” Sept. 2010. Web. 13 Jan. 2014.

The Royal Dutch Medical Association KNMG. Non-Therapeutic Circumcision of Male Minors. Utrecht: KNMG, 2010. Web. 9 Jan. 2014.

Schoen, Edgar J. “Benefits of Newborn Circumcision: Is Europe Ignoring Medical Evidence?” Archives of Diseases in Childhood 77 (1997): 258-260. Web. 23 Jan. 2014.

Wilson, N.J., et al. “Penile Hygiene: Puberty, Paraphimosis and Personal Care for Men and Boys with an Intellectual Disability.” Journal of Intellectual Disability Research 53. Part 2 (2009): 106-114. CINAHL Plus with Full Text. Web. 11 Feb. 2014.

World Health Organization. “Male Circumcision: Global Trends and Determinants of Prevalence, Safety, and Acceptability.” Geneva: WHO, 2007. Web. 10 Feb. 2014.