The male circumcision debate: what, why, and why not.

I am not a huge fan of starting conflict.  Although I have in the past, on occasion, I seriously regretted it afterwards.  However, this topic, although much debated, is one that is often argued about for the wrong

reasons.  In 2007, I did a paper and a team debate on the topic, and what I learned from my piles of information and searching was horrific.  I want to present both the facts and the theories, so that you may make up your own mind.  I must warn now, however, that I am against ROUTINE circumcision and the information may be biased that way.  Also another warning- this is probably going to get really long due to all the information, most from research articles and proven evidence, but I want to include ALL the important points.  At the risk of plagerism, I have chosen not to include all of my sources (my reference list was 5 pages long), for fear of going way over the word limit and boring people, but if anyone wants to know a specific source then I can give it.

What is circumcision and how is it done

Circumcision involves the removal of the foreskin, exposing the glans of the penis.  It involves tearing away the membrane that attaches the foreskin to the glans to enable the foreskin to be extended and then clamped.  A surgical cut is made into the foreskin, and then it is folded back, exposing raw and bleeding glans.  In the case of the plastibell method, the plastibell ring is then placed over the glans and the foreskin is then laid over it.  A ligature is tied, crushing the penis, and then the foreskin is sliced off.  It takes 5-10 days for the plastibell and the necrotic (dead) skin to separate from the penis.  On average, 1/3 of the penile skin system is removed.  Other methods include the Gomco clamp or Mogen clamp techniques.  Shockingly, this is often done without anaesthetic, but may also (and should) be done under a general anaesthetic.

Why is it done

History- There is evidence that circumcision was practiced from around 4000BC and was strongly tied to religious practices.  A resurgence in routine circumcision began in the Victorian era in attempts to cure masturbation at a time when it was considered shameful.

Society- Sociological reasons to support circumcision include “locker room ridicule” and “like father like son” debates.  Some people came to realise that locker room ridicule is based on intolerance, hence promoting un-acceptance and a perception that the altered body is superior to the natural body.

Pathology- Circumcision is a treatment for conditions such as phimosis, paraphimosis, balanitis xerotica obliterans, balanoposthitis and vesicoureteral reflux.  Even these medical conditions can be treated with options other than surgery, or less severe surgery.

Prevention-circumcision has been found to decrease the incidence of HIV in Africa, but some may argue that education and awareness may be just as effective and circumcising to prevent HIV may result in complacency with safe sex.  Circumcised babies have a lower risk of urinary tract infections (UTI’s)- 7-14 out of every 1000 uncircumcised male infants will develop a UTI compared with 1-2 out of every 1000 circumcised male infants.  Countires with higher rates of circumcision have lower rates of penile cancer.  Although the risk of developing this cancer is very rare (only 1 man per million in the US will get penile cancer, and it accounts for only 0.2% of all cancers in men in North America and Europe), some feel that circumcision is necessary to prevent this cancer.  Compare that with the risk of breast cancer, a woman has a 1 in 8 (12%) chance of developing breast cancer in her life, and although much more common, we don't routinely remove our daughters breasts just in case.

Ethics and Legal debates

Entire books have been written about ethics in medicine.  This is because what may be deemed ethical to one person may not be to another- due to the variances in individual morals, cultural differences and the grey line between right and wrong.  There are 2 main ethical issues surrounding circumcision in infants- firstly, children are minors and are too young to speak for themselves, and secondly, circumcision is more prevalent in certain cultural situations and therefore one must be sensitive to trans-cultural ethics.

A judge during a 1996 trial defined some considerations when making medical decisions based on the child’s best interests, including:

~ Is the condition of the child likely to be improved by the treatment?

~will the child’s condition deteriorate without the treatment?

~Are the anticipated benefits from the treatment outweighed by the risks of harm to the child?

~Is the treatment the least restrictive and least intrusive that meets the first three criteria?

Some argue that male circumcision and female genital mutilation are very similar, in that both procedures involve the removal of erogenous tissues.  Most countries have laws against female genital mutilation, but not male circumcision, which creates an ethical argument that perhaps males should be protected by the same laws.

According to the ethical considerations, circumcision can only be justified when performed to correct a pathological condition after other non-surgical treatments have been exhausted.  The health benefits of any surgical procedure must outweigh the risks involved.  Children do not always develop the same values, beliefs or religion as their parents.  Infants will eventually become adults, and then have the choice to be circumcised later in life- at this point, at least it is their own decision, and not one that has been imposed irreversibly upon them.  If a medical procedure cannot be justified, then parents should not be allowed to make that decision for their child based solely on aesthetics, religion or parental preference.  Children need to feel good about themselves and be encouraged to accept themselves for who they were born as- if a child’s first lesson in life is that you must be altered to be accepted, this may have dire effects on their identity.

Research findings- complications and long term effects

Surgical complications

The most common surgical complications are local infection and bleeding.  Other complications include meatal stenosis- occurs exclusively in circumcised males and is a deformity resulting in deflection of the urine stream, painful or difficult urination and blood in the urine.  Also skin bridges can occur resulting in pain and penile curvature with erection.  Ulcers can occur as a result of constant exposure of the wound to burning and irritating urine in the nappy.  Other complications include- buried penis, penile amputation, severe infection and sepsis, injury to other important parts of the penis, penile necrosis and urethral fistula.  Any surgical complication may result in increased and prolonged pain, need for further surgery, psychological, emotional and sexual adverse effects and even death.

Neonatal Pain

Some may think that when a baby has pain, once the pain goes away…that’s the end of it.  But neonatal pain has been found to have both short term and long term effects.

Pain in infants undergoing circumcision without anaesthesia can result in life threatening breathing difficulties including choking and apnoea (baby stops breathing).  The vigorous crying can cause heart injuries, lung injuries like pneumothorax and gastric rupture.

For up to 2 weeks the baby will have pain that intensifies every time he wees, poos, has a nappy change or is held to tightly.

Research shows that infants who have experienced pain in the neonatal period respond differently to subsequent painful events.  There is no way of knowing if a baby can remember actual events of pain, but there is evidence that memory for pain may be recorded at a biological level.  Studies have shown that circumcised boys have a greater pain response during routine immunisations than those who have not been circumcised, suggesting that circumcised infants have long term changes in behaviour and coping with pain.

Psychological and behavioural effects

A weaker argument, although also studied, involves some evidence that peri-natal trauma, including circumcision close to birth, can contribute to later aggressive, violent or suicidal behaviours and post traumatic stress symptoms.  One may suffer grief over the loss of a body part, resulting in psychological issues later in life.

Impact on sleep

Studies have shown that circumcised boys have disturbed sleep and irritability in the hours and days following the surgery.  It is thought that a combination of pain and psychological and physical trauma are the causes.

Impact on breastfeeding

The benefits of breastfeeding are widely known.  Breastfeeding failure occurs at a higher rate among circumcised babies and breastfeeding problems among circumcised babies have been verified by lactation consultants.  This may be attributed to the baby being in pain and in an exhausted, weakened and debilitated condition.  Although, normal breastfeeding may resume after the initial healing period, its takes effort in rebuilding milk supply and teaching the baby to feed.

Infant-maternal bonding

When sleep and breastfeeding is interfered with, it also impacts on the infant-maternal bonding experience.

 Sexual function

Some links have also been made between circumcision and sexual function, self esteem, relationship issues and divorce rates, particularly when the procedure has caused more deformities and dysfunction than originally intended.  By cutting off 1/3 of the penile skin, this decreases the amount of nerve endings available for sexual pleasure.  Circumcision was performed historically because of the known decrease in sexual response, which was deemed to be beneficial to religious conservative society.

Medical board stance

From the findings and analysis of the research and ethical considerations, major medical bodies now recommend against routine male circumcision.  These national bodies include, but are not limited to The British Medical Association, The Canadian Paediatric Society, The American Medical Association, The American Academy of Paediatrics, The Royal Australasian College of Paediatrics and The Australasian Association of Paediatric Surgeons.  The hospital where I work also opposes routine male circumcision.

In conclusion

All the evidence and ethical arguments that I found in my studies have a strong case against routine male circumcision.  If circumcision is to be performed on a minor, it should be to treat a medical condition known to benefit from the procedure, once other alternatives have been exhausted, and be done under general anaesthetic with adequate post procedural pain relief.

http://www.veoh.com/videos/e176471PJGJ6FGQ

-this is a video of a hospital circumcision without anaesthesia.  Watch with the sound up.  I must say, the scream of that poor baby was too much for me to handle, and I make kids cry for a living (not on purpose, I avoid it if I can).  There is no way I would put my son through that, and I am sure that most mothers instincts would be to protect their child from pain like that.

http://au.youtube.com/watch?v=WJGKvXU8Aog –this is a gentler version of the argument.

Thanks for reading.