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Circumcision: Whose Choice Is It?

To talk about penises and foreskin isn’t done in polite society, but we should.

Key points

  • The risks from circumcision are low, but it is an irreversible, elective procedure which has limited proven benefits.
  • One of the primary reasons Americans adopted routine infant circumcision was to prevent masturbation.
  • Some equate circumcision to female genital mutilation (FGM) but this is inaccurate, as FGM removes all possibility of sexual pleasure.
djedzura/Deposit Photo
A parents decision or the child's?
Source: djedzura/Deposit Photo

Disclaimer: My comments are my opinions and are not medical advice.

The first time I held a scalpel in my hand was in 1966 as a third-year medical student. The screaming newborn was strapped to a “bundle board” by the nurses.

We didn’t use an anesthetic. We placed the cigar-cutter-like instrument in place, clamped down on the foreskin, and cut around the edges.

When I asked if the newborn experienced a lot of pain, the response was, “They’re too young. They won’t remember it.” The social workers told whoever signed the consent form, “It’s the way things are done.”

What young physicians think

I interviewed a group of young physicians. The consensus of these young physicians was that although the risks are low, there is no justification for an irreversible, elective surgery without much higher and proven benefits. Some held stronger opinions. They referred to circumcision as genital mutilation without consent and a violation of human rights.

Many believed that healthcare providers did not give decision-makers enough information about the balance of risks versus benefits to offer informed consent. Nor were they educated adequately about care if they chose to leave the foreskin intact.

These physicians concluded that except in religious or cultural tradition, circumcision should be delayed until the boy with a foreskin can make his own decision.

In newborn circumcision, parents are proxy decision-makers, and they make decisions in consultation with a physician. Parents make decisions with which their healthcare providers may not agree. The adult version of that child may also disagree.

Circumcision as tradition

klanneke/Deposit photo
A controversial decision
Source: klanneke/Deposit photo

In Judaism, the ritual of circumcision is an ancient practice called “the bris,” traditionally held on the eighth day following birth. It has been carried out by Jewish parents for more than 3,000 years. According to the Torah, God commanded Abraham to circumcise himself, all males of his household, descendants, and slaves.

Muslims are the largest religious group to circumcise boys. The Qur’an does not mention circumcision, but circumcision is called a “law for men.” The main reason given is cleanliness. Most Muslims see circumcision as an introduction to the Islamic faith and a sign of belonging.

Christians continue the practice but have primarily abolished it as a ritual. At one time, the Roman Catholic church forbade Christians from being circumcised without a medical reason. Protestants were never circumcised until the late 1800s. Secular thought introduced the practice in the modern United States.

Circumcision and masturbation

The foreskin is an extremely erogenous zone and carries out several functions related to both partners’ pleasure and comfort. Removing the foreskin reduces sensitivity significantly and makes masturbation without lubricant more difficult.

One of the primary reasons Americans adopted the practice of routine infant circumcision was to make masturbation less pleasurable.

In the late 1700s, masturbation became viewed as one of the most significant health hazards because it was thought to deplete energy.

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

—John Harvey Kellogg, the Cornflakes guy

The World Health Organization (WHO) advocates for circumcision in the prevention of HIV. Their recommendations were based on research done in Sub-Saharan Africa on heterosexual men and therefore may not apply to men who have sex with men.

The young physicians in the discussion group said that the effectiveness of circumcision in preventing HIV is uncertain while Pre-Exposure Prophylaxis (PrEP) with condoms is nearly 100% effective.

The American Academy of Pediatrics (AAP) has been deferential to parental choice and tradition. The AAP makes only incidental comments on the human rights of the child.

Some child advocates say that children have too little autonomy over their bodies, and they believe physicians should perform only necessary and medically indicated surgeries on minors.

Medical organizations outside the U.S. have taken official positions against the medical circumcision of newborns. European statements rely on evidence-based medicine, rejection of tradition or parental preference, and a concern for the child’s human rights.

Physicians take an oath to “First do no harm.” The ethical question, then, is, “Will delaying a medical procedure until a child can give consent cause harm to the individual?”

Physicians follow “best practices” and read the literature to aid their decisions. But we often choose to read papers that support our beliefs and not those that don’t.

Genital mutilation

Although some have equated circumcision to female genital mutilation (FGM), this is a false equivalency. FGM removes the clitoris and inner lips of the labia; this eliminates all possibility of experiencing sexual pleasure. FMG would compare more closely to the removal of the head of the penis than to circumcision.

Care of an uncircumcised penis

How to care for an uncircumcised penis and the medical risks of the procedure go beyond this essay’s scope and the expertise of this author. I’ve included some links to respected discussions at the end.

Many believe that 15 seconds in the shower with soap and water with the foreskin retracted is all that is needed. Often even minimal care instruction isn’t given.

Why do we do it?

Americans have long forgotten the reasons the practice became entrenched, but the tradition continues because “it’s just what we do” or “I want him to look like Daddy.”

Others criticize this surgery as simply a moneymaker for physicians. Beauty product companies buy baby foreskins for use in beauty products to grow and cultivate new cells. Foreskin fibroblasts are also used to treat burns and diabetic ulcers.

Physicians need to provide truly informed consent about the risks and benefits of circumcision. And this decision should be made by parents before the birth of their infant. Waiting until they are emotionally exhausted from the delivery is not a good time to ask them to make rational decisions.

Although circumcision is less barbaric now than it was when I was a medical student, the question remains: Is it necessary?

References

American Circumcision (Documentary)

Beyond the Bris

Care of the Uncircumcised Penis

Doctors Opposing Circumcision

Protecting Children’s Rights

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