Unnecessary Circumcision

COMMENTARY:  UNNECESSARY CIRCUMCISION

In many hospitals, circumcision has become a routine part of the
care provided for male infants.  This author contends that it is
time for the medical establishment to rethink both the reasons for
and the consequences of this procedure.


In recent years, the debate on circumcision has been conducted on
a relatively low plane, with proponents arguing that circumcision
may prevent some unusual or rare conditions.  Opponents of
circumcision argue that it has no medical benefits.  This article
seeks to simplify the subject and raise it to a higher plane-
focusing on the positive value of the intact foreskin.

Physiology:

Before birth, the glans penis is covered with skin.  This skin is
not loosely attached; indeed, it is as tightly attached to the
glans as is the skin on the hand, for example.1
     
At approximately 17 weeks' gestation, cells in the area of
separation between the future foreskin and the glans initiate the
process of creating the preputial space (ie, the space between the
glans penis and the intact foreskin).  They begin to form
microscopic balls comprising multiple layers of cells.  As these
whorls of cells enlarge, cells at the center are cut off from
nutrients; they die and create a space.  These minute spaces
coalesce, eventually becoming the preputial space.1  This process
is completed by age 3 in 90% of boys, but it may take as long as
17 years for some boys to have a fully retractable foreskin.
     
At birth, the separation of the foreskin from the glans has just
begun.  The newborn's penis is, of course, not yet fully
developed.  Not only does circumcision interfere with its
development, but it re quires that the surgeon tear the skin from
the sensitive glans to permit removal.  Perhaps as a way to avoid
confronting this reality, physicians refer to this as "breaking
adhesions."

Function:

If physicians would simply leave the newborn's penis intact, as Dr
Spock came to recommend,2 the foreskin would be left to fulfil its
several functions. In infancy, the foreskin protects the glans
from irritation and from fecal material.  The function of the
foreskin in adulthood may at first seem more obscure.  The shaft
and usually the glans of an uncircumcised man's penis are covered
by skin.  Retracting the foreskin reveals the glans and makes the
skin on the shaft somewhat loose.  Of what use is this redundant
skin? During erection, the penile shaft elongates, becoming about
50% longer.  The foreskin covers this lengthened shaft and is thus
specifically designed to accommodate an organ that is capable of a
marked increase in diameter and length.
     
In addition, the foreskin is one of the most sensitive parts of
the penis and can enhance the quality of sexual intercourse. 
Anatomical studies demonstrate that the foreskin has a greater
concentration of complex nerve endings than the glans.3  If there
is any possibility that the foreskin can contribute significantly
to sexual enjoyment, is that not a cogent reason for rethinking
our motives for this ritual procedure?

The Case Against Circumcision:

History shows that the arguments in favor of circumcision are
questionable.  At the beginning of this century, one of the
reasons given for circumcision was to decrease masturbation, which
was thought to lead to insanity and other "morbid" conditions.  We
now know that circumcision does not prevent masturbation, nor does
masturbation lead to insanity.
     
More recently, circumcision was promoted as a means of preventing
cervical cancer in the man's .sexual partners; this notion has
been proved incorrect.4
               
The current excuses are that failure to remove the foreskin may
contribute to urinary tract infections and penile cancer, but
neither of these contentions has been proved.  Performing 100
mutilative surgeries to possibly prevent one treatable urinary
tract infection is not valid preventive medicine-it is just
another excuse.  Penile cancer occurs in older men at a rate of
approximately I per I 00,000.  The idea of performing 100,000
mutilating procedures on newborns to possibly prevent cancer in
one elderly man is absurd.  Applying this type of reasoning to
women would seem to lead to the conclusion that breast cancer
should be prevented by removing the breasts at puberty.

                                     
                 ---------------------------------------
                       "Not only does circumcision
                          interfere will penile
                       development, but it requires
                      that the surgeon tear the skin
                       from the sensitive glans to
                             permit removal."
                 ---------------------------------------
                                     
                                     
One thousand years ago, the Jewish sage Maimonides said that the
effect of circumcision was "to limit sexual intercourse, and to
weaken the organ of generation as far as possible, and thus cause
man to be moderate...for there is no doubt that circumcision
weakens the power of sexual excitement, and sometimes lessens the
natural enjoyment; the organ necessarily becomes weak when ...
deprived of its covering from the beginning.  Our sages say
distinctly: it is hard for a woman, with whom an uncircumcised
[man] had sexual intercourse, to separate from him.5
     
Infants are routinely circumcised without anesthesia.  In the past
few years, scientific papers have demonstrated that infants'
responses to pain are similar to those of adults, indicating that
babies do indeed experience pain.6  This is supported by the fact
that the quality of an infant's cry is appallingly different at
circumcision.
                                     
                                     
                 ----------------------------------------
                      "To me, the idea of performing
                      100,000 mutilative procedures
                         on newborns to possibly
                      prevent cancer in one elderly
                             man is absurd."
                -----------------------------------------
                                     
                                     
                                     
Who has the right to order or perform such surgery on a newborn
infant? I contend that no one does, not even a physician or the
parent, especially as there is no proven medical reason to do so,
and the procedure may even be harmful.  It can always be performed
in adulthood for men who desire it, with fully informed consent.
     
I believe that physicians who continue to perform routine
circumcision are not only harming infants but are also harming the
integrity of the medical profession.  It is hard to accept that
these physicians, most of whom have been circumcised themselves
are using their medical licenses to mutilate others.  This is
tragedy perpetuating itself.                          TFP


REFERENCES:

1.   Hunter RH.  Notes on the development of the prepuce.  J Anat.
     1935; 70:  68-75

2.   Spock B, Rothenberg MB.  Dr. Spock's Baby and Child Care. 
     6th ed.  New York, NY:  Simon and Schuster; 1992:  227

3.   Taylor J.  The prepuce:  what exactly is removed by
     circumcision?  Presented at Second International Symposium on
     Circumcision; May 1991; San Francisco, Calif.

4.   Terris M, Wilson F, Nelson JH.  Relation of circumcision to
     cancer of the cervix.  Am J Obstet Gynecol.  1973; 117: 
     1056-1066.

5.   Maimonides.  Guide for the Perplexed.  Part III, chapter XLIX

6.   Anand KJS, Hickey PR.  Pain and its effects in the human
     neonate and fetus.  N Engl J Med.  1987; 317:  1321-1326

----------------------------------------------------------
----------------------------------------------------------
By:
George C. Denniston, M.D., MPH
President, Population Dynamics
Seattle, Washington

Printed in:
The Female Patient/Vol.17/July 1992

    


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