Issue Report: Infant male circumcision

Is male circumcision beneficial and/or ethically sound?

Male circumcision is the removal of some or all of the foreskin (prepuce) from the penis. The word “circumcision” comes from Latin circum (meaning “around”) and cædere (meaning “to cut”).
Early depictions of circumcision are found in cave drawings and Ancient Egyptian tombs, though some pictures may be open to interpretation. Male circumcision is considered a commandment from God in Judaism. In Islam, though not discussed in the Qur’an, circumcision is widely practiced and most often considered to be a sunnah. It is also customary in some Christian churches in Africa, including some Oriental Orthodox Churches. According to the World Health Organization (WHO), global estimates suggest that 30% of males are circumcised, of whom 68% are Muslim. The prevalence of circumcision varies mostly with religious affiliation, and sometimes culture. There is controversy surrounding circumcision. Advocates for circumcision state that it provides important health advantages which outweigh the risks, has no substantial effects on sexual function, has a low complication rate when carried out by an experienced physician, and is best performed during the neonatal period. Opponents of circumcision state that it is extremely painful, adversely affects sexual pleasure and performance, may increase the risk of certain infections, and when performed on infants and children violates the individual’s human rights.

Infant health: Is circumcision safe and healthy for infants?

Circumcision better done as infant than later in life

Edgar J. Schoen, MD, Clinical Professor of Pediatrics. “Risk and Complications of Circumcision”. Opposing Views: “Newborns are metabolically best suited for the operation, they heal very quickly, and the surgery is most easily done at this age, with the lowest complication rate. Complications in infants are generally slight with an incidence of about 0.2-0.4 %. At older ages the procedure takes longer, healing is slower and the complication rate, with generally mild problems, is about 10 times higher at 2-4%.”

Michael Benatar. "How Not to Argue About Circumcision". The American Journal of Bioethics. 2003

“it is far from clear that non-circumcision leaves open a future person’s options in every regard.”

Circumcision is sometimes a necessary emergency procedure

Dr David Hawker. "The Benefits of Male Circumcision". March 2004

“When does circumcision become necessary? There are a few situations where it is clearcut. If there is only a small opening in the foreskin so that passing urine is difficult, or when the foreskin is painful to pull back during an erection or won’t return forward again. The latter is an emergency situation needing urgent surgery to avoid really serious consequences.”

Complications from circumcision stem only from faulty surgery

Philip G. Klotz. "In Defence of Circumcision". Canadian Medical Association. 9 Oct. 1966

“I am convinced that most of the current difficulties that follow routine circumcision stem from the improper use of the Gomco clamp and the Plastibell technique[…]Circumcision should not be abandoned because it has been poorly performed in the past as a result of reliance on mechanical gadgets rather than sound surgical principles. It is my belief that adequate surgical circumcision of newborns should be a routine.”

Circumcision has sufficient medical benefits to be routine

"Task force says circumcision has benefit". Science News. 11 Mar. 1989

“Marking a subtle but significant change of view, the American Academy of Pediatrics this week concluded there are “medical benefits and advantages” to circumcision. The nation’s largest pediatric organization stopped short of recommending the procedure, which involves the surgical removal of foreskin from the penis. But the new statement, the first from the academy in five years of heated debate on the topic, represents a departure from past statements declaring circumcision has “no absolute medical indications.” The percentage of boys circumcised as newborns has fallen from about 95 percent in the 1960s to about 60 percent in 1978, in part because of a growing movement among parents and some physicians emphasizing the shortage of documented medical benefits.”

Circumcision is akin to vaccination of infants

Dr. Brian Morris, Professor of Molecular Medical Sciences. “Circumcision Should Be Routine; is Akin to a Safe Surgical ‘Vaccine’”. Opposing Views] – “Circumcision is a simple surgical procedure that removes the foreskin, which is a sleeve of skin covering the tip of the penis. Parents have the legal right to authorize circumcision. In order to make an informed decision, they should carefully consider the benefits and risks.

The foreskin traps bacteria and other infectious agents. It accumulates smegma, which has an unpleasant smell. Therefore removal of the foreskin improves genital hygiene and reduces risk of diseases and other conditions over the lifetime for the boy and his future sexual partners.”

Paul M. Fleiss, MD. "The Case Against Circumcision". Mothering. Winter 1997

“Circumcision is always risky: Circumcision always carries the risk of serious, even tragic, consequences. Its surgical complication rate is one in 500.48 These complications include uncontrollable bleeding and fatal infections.49 There are many published case reports of gangrene following circumcision.50 Pathogenic bacteria such as staphylococcus, Proteus, Pseudomonas, other coliforms, and even tuberculosis can cause infections leading to death.51, 52 These organisms enter the wound because it provides easy entry, not because the child is predisposed to infection.”

Faulty circumcision can result in loss of penis

There are instances in which botched circumcisions have resulted in the complete loss of the penis.

Other methods than circumcision can reduce risk of foreskin infection.

Infant circumcision has only one possible benefit before the onset of sexual activity: circumcised boys appear to have lower rates of urinary tract infections. I agree with the Swedish doctors who argued 20 years ago that this is not a reason to remove the foreskin, but rather to colonize newborns with good bacteria, to make it harder for bad bacteria to get a toehold.

Swelling of infant foreskin is natural

Rosemary Romberg. "Circumcision - The Painful Dilemma. Chapter Eleven: Complications of Circumcision (Condensed)". Bergin & Garvey Publishers, Massachusetts. 1985

“The foreskin of the intact infant can occasionally become reddened and swollen. Some doctors believe that this is an indication for immediate circumcision. … In actuality the swollen, red foreskin is performing its function of protecting the sensitive glans from more painful and troublesome irritation.”

Circumcision creates risk of infections in infants

Any laceration on an infant poses a serious risk of infection. Circumcision creates a significant laceration on the infant, opening the door to serious infections and subsequent risk of illness and even death.

Circumcisions often remove too much foreskin

This can result in a shortened and deformed penis, as well as pain during sex.

Circumcision can result in a "concealed penis"

This is a situation in which, following the circumcision, the penis retracts back into the body, out of view. This can be a permanent issue if not resolved immediately by additional surgery.

Circumcision can result in urethral fistula

Rosemary Romberg. "Circumcision - The Painful Dilemma. Chapter Eleven: Complications of Circumcision (Condensed)". 1985

“A fistula is an abnormal opening in any part of the body. A urethral fistula is a hole going from the side of the male urethra to the outside of the penis. Usually the fistula occurs on the underside. This can develop as a result of circumcision. It results either from accidental crushing of the urethra by the circumcision clamp, an abnormality in the urethra, or from a stitch placed in the underside of the penis to control excessive bleeding at the site of the frenulum.”

Circumcision can cause hemorrhaging and death

Hemorrhaging is defined as excessive bleeding. Because circumcision involves the cutting of tissue as well as significant veins and even arteries, it can result in severe bleeding, hemorrhaging and even death.

Circumcision can cause sleep apnea in infants

Circumcision entails risk of pulmonary embolism

Circumcision does not have sufficient medical justifications

General statements of opposition to circumcision

Adult health: Is a circumcised penis healthy through adulthood?

Non-circumcision can result in many complications

Philip G. Klotz. "In Defence of Circumcision". Canadian Medical Association. 9 Oct. 1966

“I am impressed by the complications of non-circumcision, particularly acute paraphimosis, chronic phimosis, penile carcinoma and papillomata about the prepuce.”

The uncircumcised often suffer from penis infections

The foreskin can trap bacteria and give rise to infections of the penis.

Circumcision helps prevent balantis in the penis

"Sexual Health: Circumcision". WebMD. 1 Feb. 2006

“Prevention of balanitis (inflammation of the glans) and balanoposthitis (inflammation of the glans and foreskin).”

Circumcision helps prevent phimosis

"Sexual Health: Circumcision". Web MD. 1 Feb. 2006

“Prevention of phimosis (the inability to retract the foreskin) and paraphimosis (the inability to return the foreskin to its original location).”

Circumcision helps protect against cancer of the penis

Dr David Hawker. "The Benefits of Male Circumcision". March 2004

“Some older men develop cancer of the penis – about 1 in 1000 – fairly rare, but tragic if you or your son are in that small statistic. Infant circumcision gives almost 100% protection, and young adult circumcision also gives a large degree of protection.”

Circumcision reduces the risk of prostate cancer

Dr. Brian Morris, Professor of Molecular Medical Sciences. “Here are the Main Benefits of Circumcision”. Opposing Views – “Reduces by 30–50% risk of prostate cancer, which affects 1 in 6 men.”

Circumcision helps protect against human papilloma virus

Edgar J. Schoen, MD, Clinical Professor of Pediatrics. “Protection Against A Number of Sexually Transmitted Infections”. Opposing Views – “2. Human Papilloma Virus (HPV). This is the most prevalent STI in the United States (US) – 6 million new cases/year. An international study involving 5 nations has shown that HPV is 3 times more commonly found on uncircumcised penises as compared to those circumcised. HPV is the cause of penile, cervical and anogenital cancers.”

Circumcision helps protect against chlamydia

Edgar J. Schoen, MD, Clinical Professor of Pediatrics. “Protection Against A Number of Sexually Transmitted Infections”. Opposing Views – “3. Chlamydia is second in prevalence to HPV as an STI in the US. Women sexual partners of uncircumcised men are 5 times more likely to have high antibody titers to Chlamydia as the partners of circumcised men. Chlamydia is a leading cause of female infertility.”

Circumcision helps protect against syphilis

Edgar J. Schoen, MD, Clinical Professor of Pediatrics. “Protection Against A Number of Sexually Transmitted Infections”. Opposing Views: “4. Syphilis has long been known to be more common in uncircumcised men. Easy tearing of the delicate inner foreskin lining during intercourse offers entry to the spirochete.”

Circumcision helps prevent chancroids

Edgar J. Schoen, MD, Clinical Professor of Pediatrics. “Protection Against A Number of Sexually Transmitted Infections”. Opposing Views “5. Chancroid. Less lethal than syphilis but prevalent in under developed countries. During the Korean War, 90% of chancroid cases in US soldiers occurred in the 30% who weren’t circumcised.”

[[Argument: Circumcision helps prevent herpes| Circumcision helps prevent herpes

Edgar J. Schoen, MD, Clinical Professor of Pediatrics. “Protection Against A Number of Sexually Transmitted Infections”. Opposing Views: “6. Herpes simplex. A recent study showed that circumcision reduces the acquisition of genital herpes by 25%.”

Circumcision helps protect against kidney infections

Uncircumcised Europeans do not experience significant health problems.

The vast majority of continental European men who are not Moslems are intact. If being intact leads to worse health outcomes, comparing data from Europe and America would reveal that. I know of no such comparison, except one: the circumcised USA has the highest frequency of HIV positive individuals in the OECD.

Most male sexual health problems stem from irresponsible sex, not circumcision.

It is absolutely essential to always use a condom during casual sexual encounters and extramarital affairs. Having no foreskin is “healthy” in the trivial sense that nothing can go wrong with an absent organ. Parents should not assume that their sons will be sexually irresponsible in a way that will defy their authority, but instead should teach their sons to respect the opposite sex and themselves. And failing that, to use a condom!

The foreskin is a brilliant product of human evolution

Paul M. Fleiss, MD. "The Case Against Circumcision". Mothering. Winter 1997

“Millions of years of evolution have fashioned the human body into a model of refinement, elegance, and efficiency, with every part having a function and purpose. Evolution has determined that mammals’ genitals should be sheathed in a protective, responsive, multipurpose foreskin. Every normal human being is born with a foreskin. In females, it protects the glans of the clitoris; in males, it protects the glans of the penis. Thus, the foreskin is an essential part of human sexual anatomy.”

Circumcision eliminates foreskin's many protective functions

Paul M. Fleiss, MD. "The Case Against Circumcision". Mothering. Winter 1997

“Protection: Just as the eyelids protect the eyes, the foreskin protects the glans and keeps its surface soft, moist, and sensitive. It also maintains optimal warmth, pH balance, and cleanliness. The glans itself contains no sebaceous glands-glands that produce the sebum, or oil, that moisturizes our skin.11 The foreskin produces the sebum that maintains proper health of the surface of the glans.”

Circumcision is not a good solution to phimosis of foreskin

Phimosis is a situation in which the foreskin has difficulty retracting or returning over the head of the penis due to abnormally tight foreskin. This, however, can be solved by other means than circumcision. In addition, doctors often mistaken the natural state of the infants foreskin (which does not retract until later years) as phimosis, and subsequently mistakenly opt to circumcise the infant.

Circumcision can cause "skin bridge" on penis

Rosemary Romberg. "Circumcision - The Painful Dilemma. Chapter Eleven: Complications of Circumcision (Condensed)". Bergin & Garvey Publishers, Massachusetts. 1985

“‘Skin bridge’ can result from circumcision. It is a complication in healing of the wound, by which a piece of skin from the shaft of the penis has become attached to the glans, or another point along the shaft, forming a ‘bridge’ that must be surgically corrected.”

Circumcision industry drives false medical justifications

Paul M. Fleiss, MD. "The Case Against Circumcision". Mothering. Winter 1997

“Most parents are pressured to hand their baby sons over to a stranger, who, behind closed doors, straps babies down and cuts their foreskins off. The billion-dollar-a-year circumcision industry has bombarded Americans with confusing rhetoric and calculated scare tactics.”

Ideologies drive false medical justifications for circumcision

Circumcision has been driven by a religious and other ideologies that have, for example, considered masturbation a sin and circumcision a solution to this sin. Medical studies and conclusions are often driven by a desire to justify these ideological positions.

HIV: Can circumcision help reduce the risk of HIV transmission?

Circumcision reduces the risk of HIV infection

Sabin Russell, Chronicle Medical Writer. "Male circumcision shows promise as defense against HIV transmission". San Francisco Chronicle. 14 Dec. 2006

“separate studies in Kenya and Uganda [in 2006] were financed by the National Institutes of Health and compared HIV infection rates between groups of circumcised and uncircumcised men and teenage boys.[…] an NIH safety panel examined interim results and found that the uncircumcised men in both studies were becoming infected at twice the rate of the men who had the procedure. The panel concluded it would be unethical to allow the experiments to continue until mid-2007 as planned without offering the surgery to the uncircumcised group.”

Edgar J. Schoen, MD, Clinical Professor of Pediatrics. Opposing Views

“Protection against a number of sexually transmitted infections- the moist inner surface of the foreskin is both a magnet and a refuge for infectious agents.

1. HIV/AIDs. In the past 20 years since the outbreak of the HIV/AIDS epidemic more than 20 million people have died, and 40 million people now carry HIV with 2.5 million new cases each year. More than 30 separate studies, including the gold standard, 3 randomized clinical trials in the past 3 years, have proven that circumcision is 50-60% effective in preventing the acquisition of HIV on exposure. This evidence is accepted by the UN, the World Health Organization (WHO) and the U.S. NIH among others, and 5 African countries are starting mass adult circumcision programs. At the same time multiple attempts at developing an HIV vaccine have failed.”

Circumcision is a rare practice in the world

Paul M. Fleiss, MD. "The Case Against Circumcision". Mothering. Winter 1997

“How Common Is Circumcision? Circumcision is almost unheard of in Europe, South America, and non-Muslim Asia. In fact, only 10 to 15 percent of men throughout the world are circumcised, the vast majority of whom are Muslim.29 The neonatal circumcision rate in the western US has now fallen to 34.2 percent.30 This relatively diminished rate may surprise American men born during the era when nearly 90 percent of baby boys were circumcised automatically, with or without their parents’ consent.”

Condoms/education are better than circumcision against HIV

“Circumcision Falsehoods: Don’t Be Conned by the Pros”. National Organization of Circumcision Information. Opposing Views: “AIDS has been curbed successfully in Thailand, Senegal, and Eastern Uganda by governments taking a strong leadership role, targeting commercial sex workers and the populace with an aggressive educational campaign, and distributing free condoms. Condoms are 95 times more cost-effective than circumcision. Promoting expensive circumcisions in a continent lacking adequate food, safe water, good hygiene, and modern medical facilities, is a deadly approach, likely to exacerbate the pandemic.”

Some falsely believe circumcision makes condom-use unnecessary

“Circumcision Falsehoods: Don’t Be Conned by the Pros”. National Organization of Circumcision Information. Opposing Views – “Africans are lining up to be circumcised, believing they will not need condoms. Others are being blamed for the pandemic and forcibly circumcised. Coerced or forced circumcision is unethical.”

Lower sensitivity of circumcised penis reduces condom-use

HIV-prevention is poor justification for neonatal circumcision

Studies cannot prove effectiveness of infant circumcision.

You can not conclude causation from studies on circumcision. These studies prevent a double-blind study (you can’t have placebo circumcision). How do we know the circumsized men did not have less sex during the course of the study because of the initial period of recovery from the procedure? What about the psychological effects of being in the “circumsized” group of men and how that would impact a person’s behavior?

Urinary infections: Does male circumcision help or cause urinary infections?

Circumcision reduces risk of urinary tract infections

Dr David Hawker. "The Benefits of Male Circumcision". March 2004

“Urinary tract infections sometimes occur in babies and can be quite serious. Circumcision in infancy makes it 10 times less likely.”

Dr. Brian Morris, Professor of Molecular Medical Sciences. "Here are the Main Benefits of Circumcision". Opposing Views

Means an over 10-fold decrease in risk of urinary tract infection (UTI). Whereas risk of UTI is only 1 in 500 for a circumcised boy; approx. 1 in 50 uncircumcised male infants will get a UTI. This very painful condition is particularly dangerous in infancy, and in 40% of cases can lead to kidney inflammation and disease. Sepsis and meningitis can also result. A lengthy stay in hospital is possible.

Circumcision can cause "urine burns" in infant

Rosemary Romberg. "Circumcision - The Painful Dilemma. Chapter Eleven: Complications of Circumcision (Condensed)". 1985

“Many infants and toddlers in diapers develop “urine burns” from contact with ammonia in urine-soaked diapers. … The destruction of the foreskin creates an abnormal state in which the glans is exposed and in constant contact with outer clothing, and for the infant, with urine soaked diapers. Ammonia burns on the glans, especially around the urinary opening, which is known as the meatus, can be a particularly troublesome problem for the circumcised male infant.”

Circumcision can cause urinary retention in infants

This is where, in the hours and days following a circumcision, an infant is unable to urinate. This can have damaging consequences.

Pain: Is it acceptable that circumcision is painful for infants?

There is good pain relief for infant circumcision

Deborah Stead. "Circumcision's Pain and Benefits Re-Examined". New York Times. 2 Mar. 1999

“The American Academy of Pediatrics, which issued a new circumcision policy yesterday…says that if parents do circumcise a son, for cultural, religious or medical reasons, relieving pain is essential. “Recent studies show that numbing creams and injections are safe and effective, the report says.”

Edgar J. Schoen, MD, Clinical Professor of Pediatrics. “Risk and Complications of Circumcision”. Opposing Views – “When properly performed by a trained operator using local anesthesia (including newborn infants) circumcision is quick, safe and virtually painless.”

Pain of neonatal circumcision helps avoid future suffering.

It is acceptable to inflict some pain on an individual as a means to avoid future pain. A good example is vaccination, in which the pain of the needle is justified by the future avoidance of suffering. Another good example is a surgery to remove molars or to remove a failing appendix.

Circumcision wrongly inflicts severe pain on infants

Anesthetics cannot be administered to infants due to the risks. This means that infants are subjected to a level of pain beyond what adults are allowed to tolerated; adults undergoing circumcisions are given anesthetics. It is wrong to inflict infants to this level of pain.

Pain of circumcision is traumatizing for infants

Paul M. Fleiss, MD. "The Case Against Circumcision". Mothering. Winter 1997

“Circumcision harms the developing brain: Recent studies published in leading medical journals have reported that circumcision has long-lasting detrimental effects on the developing brain,36 adversely altering the brain’s perception centers. Circumcised boys have a lower pain threshold than girls or intact boys.37 Developmental neuropsychologist Dr. James Prescott suggests that circumcision can cause deeper and more disturbing levels of neurological damage, as well.”

Circumcision violates the trust between parent and child

Crying of circumcised babies can cause complications

Pain relief for neonatal circumcision does not make it OK

Individual rights: Does circumcision violate patient rights?

Parents have a right to circumcise their children

Viens AM (2004). "Value judgment, harm, and religious liberty". J Med Ethics 30: 241–7. 2003

Summary: “Parents’ freedom to choose infant male circumcision is the correct policy. Individuals and groups lobbying to have infant male circumcision prohibited or restricted often argue that the practice of routinely circumcising infants is unjustified. For instance, in this issue of the journal, John Hutson argues that it is virtually impossible to justify a policy in which the medical establishment should be able to embark on a “mass circumcision” campaign of 100% of the infant male population (with the exception, of course, where it would be contraindicated by the presence of an anatomical or physiological abnormality) [see page 238].1

Indeed, I would be hard pressed to find anyone who could rationally disagree with this contention. However, this is because no one is currently arguing for the enactment of a policy that stipulates that all healthy male infants should be routinely circumcised (independent of parental choice). Arguments seeking to support a prohibition of “routine infant circumcision”, such as the .”

Circumcision is akin to legal vaccination of infants

Circumcision is a form of vaccination in many ways against infections and other complications that result from an uncircumcised penis. And, just as parents have a right to choose to vaccinate their children, parents have a right to choose to circumcise their children.

Neonatal circumcision violates the right to bodily integrity

The Declaration of the First International Symposium on Circumcision, adopted March 3, 1989, by the General Assembly of the First International Symposium on Circumcision, states: “We recognize the inherent right of all human beings to an intact body. Without religious or racial prejudice, we affirm this basic human right.”[1]

Infant circumcision violates the patient's right to informed consent

Paul M. Fleiss, MD. "The Case Against Circumcision". Mothering. Winter 1997

“Circumcision violates patients’ and human rights: No one has the right to cut off any part of someone else’s genitals without that person’s competent, fully informed consent. Since it is the infant who must bear the consequences, circumcision violates his legal rights both to refuse treatment and to seek alternative treatment.”

Neonatal circumcision violates right to avoid inflicted pain

Individuals have a right to avoid pain. Neonatal circumcision violates this right.

Parents lack right to choose non-therapeutic circumcision

Parents do not have the right to inflict circumcisions on their children when the surgery is non-therapeutic and unnecessary (as it usually is).

Hippocratic oath obligates doctors to avoid circumcision

Townsend Letter for Doctors and Patients. Doctors Opposing Circumcision. (D.O.C.). April 1996. – “The physician today has a duty to discourage circumcision and to refuse to perform it.” An organization called Doctors Opposing Circumcision”

Care: Does a circumcised penis require less or more care?

Circumcision ends need to retract foreskin to urinate

Dr David Hawker. "The Benefits of Male Circumcision". March 2004

“Remind [your children] to pull back their foreskins whenever they pee as it helps to keep the foreskin clean. It also makes it easier to aim and assists them to avoid spraying the toilet – just as circumcision does.”

Separation of foreskin during puberty can be problematic.

During infancy, the foreskin is attached to the head of the penis and does not yet pull back. During puberty, uncircumcised boys find that their foreskin begins to separate from the head of the penis. This process can be disturbing for children, as they come to believe something is going wrong. This can be particularly problematic and damaging to the penis if the child decides to forcefully separate the foreskin from the head before it is naturally ready. This process, therefore, introduces both psychological and physical risks.

The natural penis is clean and requires no special care

Paul M. Fleiss, MD. "The Case Against Circumcision". Mothering. Winter 1997

“The natural penis requires no special care. A child’s foreskin, like his eyelids, is self-cleansing. For the same reason it is inadvisable to lift the eyelids and wash the eyeballs, it is inadvisable to retract a child’s foreskin and wash the glans. Immersion in plain water during the bath is all that is needed to keep the intact penis clean.”

Circumcised babies can require more motherly care

Because circumcised babies often lose sleep and sometimes exhibit eradicate behavior, the mother must care for them more.

Myth: circumcision is necessary later if not done at birth

Mary Ray. "Myth: Circumcision Inevitable Later". 1997

“The overwhelming majority of uncircumcised boys never develop medical problems.” [Pantell] The fear that circumcision will be required later is unwarranted. Rates in all countries other than the U.S. are miniscule. They range from 1 in 200 in some, to as low as 1 in 600 in others.”

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