Circumcision: The Unkindest Cut

If your baby is a boy, you will be asked if you want him circumcised--the flap of skin at the end of the penis removed. The act of asking this question of a parent implies that the procedure is, to a certain extent, desirable. I believe that routine circumcision of the newborn is, as Shakespeare said in another context, the unkindest cut of all. It is not only unkind, but painful, unnecessary, and dangerous.

About eight years ago the American Academy of Pediatrics and the American College of Obstetrics published statements saying that routine neonatal circumcision is unnecessary and that the risks outweigh the benefits, but obstetricians and the general public have largely ignored these statements. Studies have shown that educating parents about the risks of circumcision has little effect on their behavior, and the majority still have their boys circumcised. The reasons for doing so are vague: Everybody does it, It's cleaner, or I thought it was necessary are the usual parental responses. In a study at the University of Utah, pediatrician Dr. Lucy Osborne asked parents why they had their baby boys circumcised, and 14 percent of them had no reason! Obviously, ritual circumcision--for example, the Jewish ceremonial bris--is a different issue. The choice of having it done is religious, and the arguments for and against are largely nonmedical.

Circumcision is the most commonly performed surgical procedure in the United States; while 85 to 90 percent of American males are circumcised, 85 to 90 percent of males in the rest of the world are not. There's an old saying: Fifty million Frenchmen can't be wrong. If we're doing something the rest of the world isn't doing, we must examine whether there's a good reason for us to continue the practice.

In the Victorian era, routine neonatal circumcision was popular because it was thought that circumcising the newborn would prevent hypersexuality later and would keep children from masturbating (then considered an unhealthy practice). In addition, it was believed that circumcision could alleviate or prevent illnesses ranging from rheumatism to indigestion. Of course, this is nonsense.

In that era, the practice of circumcision increased throughout the world and then gradually declined over the next fifty years everywhere except the United States. By the 1980s, the procedure is hardly performed in Europe at all, although it's just as commonplace here as it ever was.

Parents may think that if their son is not circumcised, he will seem an outsider later, particularly in the locker room. While it's true that most boys are circumcised, it is important to understand that the boy who is not circumcised is as normal as the other boys who have been altered. In a similar vein, some people believe that if a father is circumcised, his son should be, too. In his book Circumcision, A Health Fallacy, Edward Wallerstein, an advocate of leaving male anatomy alone, tells of a circumcised father with an uncircumcised son. At around age three, the child asked his father about the difference between them. The father told the son, When I was a baby, they thought it was a good idea to cut off that part of the penis.

The son thought for a minute and then said, That was sure dumb, and that was the end of it.

The myth that circumcision reduces the risk of cancer of the penis in the male and cancer of the cervix in the female is untrue. There is no evidence that uncircumcised men contract penile cancer more frequently than circumcised men. Jewish women whose husbands are circumcised have a lower rate of cervical cancer than non-Jewish women who husbands are not circumcised, so people came to believe that circumcision prevented cancer of the cervix. But in recent years we've discovered that there are genetic predispositions to certain forms of cancer. The fact that Jewish males are circumcised does not account for the low rate of cervical cancer. It's just that Jewish women are less genetically inclined to develop cervical cancer. Conversely, there is a rise in cervical cancer among teenaged girls who are sexually active, and most of their partners are circumcised.

Another fallacy is that the man who has been circumcised has more sexual staying power, can remain erect longer and has greater sexual prowess. Totally false. In fact, premature ejaculation is the most common complaint of men seeking treatment for sexual dysfunction, and most of them are circumcised.

There is also the assumption that a circumcised penis is cleaner. There is a secretion under the foreskin called smegma, which is normal and similar to mucus. It's true that boys without foreskins don't have these secretions, but that doesn't mean that the foreskin is unclean. It was once believed that uncircumcised males were more susceptible to venereal disease, that germs could collect underneath the foreskin. There's no evidence that circumcision lessens that risk of venereal disease.

The only advice necessary for taking care of the foreskin is to wash it with the same attention to hygiene given to any other part of the body. There's nothing scary or complicated about the uncircumcised penis. As Dr. Alex Comfort said, Wash, don't amputate. I've heard of many boys who were circumcised because a poorly informed doctor thought that the foreskin was too tight when it couldn't be pulled back. Foreskins don't retract in babies; that's just the way they're made. Only after three to five years can they be pulled back even halfway.

The foreskin was put there for a purpose. It protects the opening at the end of the penis, the meatus, through which males urinate. Boys who no longer have this protection often develop ulcers around the meatus, which can lead to later narrowing of the opening and problems with urination.

Another argument has it that if your son is not circumcised at birth, he may need the operation later. The rate of neonatal circumcision in Finland is almost zero, and the rate among older men is about 6 in 100,000. In other words, the chances are very small that adult circumcision will be necessary; and even if it is, adults are better able to tolerate complications such as infection and bleeding than are newborns.

Two to four percent of circumcised males develop infections, and while most of these are minor and of little concern, some can be serious. That makes sense, since the fresh wound is immediately enclosed in a diaper into which the infant urinates and defecates, not the best environment for clean wound healing. Normal infants can bleed from the circumcision site, and babies with unsuspected bleeding disorders can develop a serious problem.

Some people think that circumcision doesn't hurt. Anyone who has been present when a clamp was placed on a newborn's foreskin can never again doubt that the procedure hurts. An infant who's just gone through the stress of birth should emerge into a world that's loving and tender. Why should we immediately attack his most precious possession?

One day I attended, with one of my obstetrical colleagues, a natural birth with soft lights, a quiet room, a Leboyer bath, all things kind and gentle. A few minutes later the obstetrician came into the nursery to circumcise another newborn. This baby boy was lying on a table tied to a little board with his penis poking through a sterile drape.

As the doctor was getting ready to apply the clamp, I asked, How can you do this after that lovely, warm delivery?

His reply was Don't ask.

A strange thing about circumcision is this: for any other operation, the surgeon who performs the procedure would follow the patient's progress in the hospital and take care of any later complications. Circumcision is traditionally performed by obstetricians, who almost never see the patient again. Pediatricians see the complications and deal with the problems, and therefore, most obstetricians think that circumcision is a benign uncomplicated procedure and don't inform parents about the negative aspects.

Any surgical procedure should be undertaken only after informed consent, which means that the patient or the patient's guardian is fully aware of the benefits and the risks--and the benefits, of course, should outweigh the risks.

The natural-childbirth movement and the humanization of birth practices arose when public awareness and pressure met with the cooperation of the medical community. Since the medical establishment has been remiss, I hope someday a public action group will effectively discourage circumcision.

Excerpt from: Off To A Great Start: How To Relax and Enjoy Your Baby by Loraine Stern, M.D. and Kathleen Mackay

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