Circumcision? Cutting out the routine cut

As happens from time to time, medical journal on both sides of the Atlantic are reviving the arguments against circumcision. But parents still lack any real knowledge when deciding whether their baby should be circumcised.

There have always seemed to be as many medical reasons for circumcision as against it, and none of them has been especially strong or convincing. Those in favour may have been loosely influenced by a feeling that wise forefathers in the Judeo-Christian tradition had some important reason for this ritual, a reason presumably based on some notion of pioneering hygiene or sanitary measures. And possibly this illogical, atavistic belief has tilted the scale so that, certainly in my own practice and, I suspect, in most practices these days, an overwhelming majority of parents demand circumcision for their newborn boys.

Barbaric custom

While this procedure was a religious practice known in Egypt before being introduced to the Hebrews by Abraham, and is best known as prevailing among those of Jewish and Muslim faith, it has been practiced by peoples from every continent. As well, the rather brutal and barbaric custom of circumcision and clitoridectomy of baby girls is known in Islam and is extensively performed in certain African tribes and nations.

When, according to the Old Testament, Jehovah promised to make Abraham’s descendants His chosen people and to place them under His protection in the promised land of Canaan, there was a stipulation that His chosen people must be circumcised on the eighth day after birth or upon conversion to the faith, “even the homeborn slave and the one bought from an outsider who is not of yourseed”.

Then, in about 1200 BC, the God of Abraham commanded an exiled Egyptian prince, Moses, to return to Egypt and to lead the Jews to freedom. He gave the Israelites the Ten Commandments and the other Mosaic laws, imposing the same covenant with Moses that He had made with Abraham, including the same rite of circumcision.

In the first century AD, the Roman philosopher Seneca was alarmed by the prevalence of Jewish customs and feared a loss of the Roman way of life. The actual conversions were numerous and would have been even greater but for the necessity of circumcision and the strict dietary laws.

Then a Jew named Saul was cured of blindness by the laying on of hands of another Jew of the Ananias sect and was converted to Christianity. Later he changed his name to the Roman Paul and broke from the Apostolic church of Jerusalem, because of arguments regarding the procedure of converting pagans.

Saint Paul felt that pagans should become Christians directly, without first converting to Judaism. He also stated that man should know God only through Christ — not, as the Jews believed, only through the word of God as revealed in the Torah (Old Tesament). He abandoned Jewish dietary laws and the rite of circumcision to make conversion easier.

Circumcision for religious purposes remains a rite — and a right — but otherwise the question of desirability of routine circumcision has to be answered on biologic and pathophysiologic grounds. And, if this is not decisive, then strictly on the basis of medical economics and priorities, since medicare at present covers routine circumcision.

The only definite indication for circumcision (or simpler dorsal slit) is phimosis — congenital or acquired narrowing and constriction of the distal portion of the foreskin. With newborn, you can never be sure if circumcision is essential, since the future growth of the penis and prepuce usually provides adequate circumference of foreskin for easy retractability, and only a small handful of boys develop phimosis and have to be circumcised.

Simple hygiene with soap and water should prevent accumulation of foreskin secretions (smegma) from which infection and ulceration can occur, and which can be factors in penile carcinoma, a rare disease.

Should we routinely remove all appendices and tonsils because of the respective dangers of appendicitis or hypertrophy? I don’t think so. Yet every GP or pediatrician will gladly perform circumcision.

Is it worth it?

I consider the advantages and disadvantages of routine circumcision rather marginal and the risks either of removal or preservation of the foreskin to be minimal. But many recent reports in medical journals stress that possible complications of this procedure (mutilation, hemorrhage, septicemia and neonatal sepsis) outweigh by far its possible advantages as a preventive procedure.

While I don’t remember having seen any of these complications in my 27 years of family practice, I probably did not associate some neonatal sepsis or severe, infected diaper rash with bacterial entry at the point of circumcision.

The history of these few millimeters of skin is utterly epochal and fascinating. Yet since this procedure in Canada rests mostly in the hands of family practitioners, we should try to restrict this practice by advising parents, rather than letting them decide in arbitrary fashion. To do that, we need a full awareness of the seriousness of complications as pointed out by cases our pediatricians describe.

Note:

There have been some changes since this paper was published in 1980, when medically-unnecessary non-therapeutic circumcision of infant boys still was a common practice in Canada and was covered by the various health insurance plans. Since that time, this operation has lost popularity, no longer is covered by any health insurance plan, and today, very few infant boys are circumcised in Canada. Dr. Prucha recommends circumcision to treat phimosis but this has been replaced by treatment with topical steriod ointment. Although Dr. Prucha considered circumcision to be a "right" in 1980, the Canadian Charter of Rights and Freedoms (1982) and recent decisions of the Supreme Court of Canada pursuant to that Charter put that alleged "right" in jeopardy. Please see An examination of legal and ethical issues surrounding male circumcision: the Canadian context for more information about the legal status of male neonatal non-therapeutic circumcision in Canada

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