The Decision to Circumcise: Medically Necessary or Potentially Harmful?

Prepared  for:  Carle Hospital Expectant Parents Club

Prepared by:  Joe Student

May 4, 1999

Abstract

For years, circumcision of male infants has been performed so routinely that many first-time parents do not even consider the alternative. New parents often have little information about the risks and benefits of the procedure, and some base their decision on whether or not the father is circumcised. Although some evidence documents the medical benefits of newborn circumcision, these benefits are slight, and do not outweigh the potential harm that results from the procedure. The preponderance of evidence suggests that new parents should forego the procedure because of the medical risks and possible adverse psychological effects on their son.

Keywords: circumcision, circumcise, foreskin, pediatrics, neonatal medicine, penile cancer, urinary tract infection, UTI

Table of Contents

    Introduction ................................................................ 1
    Research Methods ...................................................... [page no.]
    Discussion .................................................................
         Overview of the major issues .................................
         History of the practice of circumcision  ...............
         Medical benefits of circumcision ...........................
         Medical risks of circumcision ...............................
         Other adverse effects ............................................
         Informed consent and ethical issues .....................
    Recommendations ....................................................
    Conclusion ...............................................................
    Works Cited  ............................................................
    Appendices ..............................................................

Introduction

Expectant parents are faced with many decisions regarding the health and well being of their child, such as choosing the type of birth experience they want and contemplating breast versus bottle feeding. One such decision that more and more expectant parents are struggling with is whether or not to circumcise their newborn sons. For years, the prevailing wisdom held that circumcision functioned as a preventive measure against a variety of problems from excessive masturbation to AIDS. These claims were rarely backed by evidence, however, and recent findings suggest that the medical benefits of circumcision are very small. In addition, mounting evidence suggests that circumcision is a painful experience for infants, with unknown psychological consequences. Thus, many parents are now choosing against this medically unnecessary and possibly traumatic procedure.

Research Goals & Methods

To investigate the  medical and psychological effects of circumcision and determine the best course for parents to follow, I consulted a wide range of publications and web sites. These included articles published in the electronic database Firstsearch (http://firstsearch.org), plus some helpful articles in popular magazines. Some of the most valuable research was found in the Journal of the American Medical Association, which published a series of articles on this issue in 1997-1998.

I also conducted a personal interview with Ms. Deborah Brown, a Registered Nurse at Michael Reese Hospital in Chicago. Ms. Brown has fourteen years' experience as an obstetrics and delivery nurse and offered insights into the medical aspects of circumcision and the trends she has observed regarding new parents' concerns about this issue. (See Appendix A for a full transcript of the Brown interview.)

Discussion

Overview of the major issues

Parents struggling with the decision to circumcise their child are faced with many conflicting arguments. Proponents of circumcision have long argued that the procedure has many medical benefits. Specifically, circumcision has been reported to lower rates of urinary tract infection in infant boys, lower rates of AIDS and other STDs in adult men, and lower the risk of penile cancer. Others in the medical establishment have questioned these claims and believe that the evidence is inconclusive, or that the benefits of circumcision are so slight that they do not outweigh the risks of the procedure.

In addition, many doctors are now questioning the use of pain relief during circumcision. Traditionally, it was believed that infants do not feel the same amount of pain as adults, and that pain management was not needed during the procedure. This belief has also come into question, and new evidence suggests that circumcision not only causes serious pain, but may change infants’ future pain reactions.

Finally, several activist groups have questioned routine newborn circumcision on ethical grounds. These groups believe that it violates an infant’s right to make an informed decision for himself.

History of the practice of circumcision

Circumcision is the surgical removal of the foreskin from the penis. It is the oldest surgical procedure known to humankind  and is the most common form of surgery performed on males today. For more than 3800 years, Jews have circumcised their newborn sons as a sign of their covenant with God. Egyptian hieroglyphics and sculptures show the Pharaoh with a circumcised penis (Shuman 1). More recently, non-religious circumcision was introduced into our culture in the Victorian era (early 19th century), primarily as a means to prevent masturbation (Lowen 66).

Circumcision rates continued to rise into the early 20th century, and by the post-World War II era, it had become a routine part of newborn care (Lowen 66). Although rates in the U.S. have been dropping -- from 90% in 1980 to around 60% in 1996 (Shuman 1) -- non-religious circumcision remains primarily a North American custom. In fact, worldwide, 80 percent of males are not circumcised (Laliberte 67).

The roots of the American custom of routine circumcision were planted in the Victorian Era, when it was claimed to be a remedy for excessive masturbation. Other claims followed, and masturbation was often cited as a cure for many types of ailments, including epilepsy, paralysis, elephantiasis, tuberculosis, eczema, bed-wetting, headaches, nervousness, idiocy, mental retardation and insanity. As recently as the 1970s, popular medical textbooks advocated routine circumcision as a way to prevent masturbation (Fleiss 36).

Medical benefits of circumcision

Circumcision is no longer considered as a prevention method for masturbation, tuberculosis or idiocy.  It is, however, still thought by some to offer other medical benefits. Specifically, the debate now focuses around the utility of circumcision as a preventive measure against urinary tract infections, penile cancer, AIDS and other sexually transmitted diseases (Fleiss 37).

Several recent studies have also addressed the association between urinary tract infections (UTIs) and circumcision. Because the majority of UTIs in males occur during the first year of life, almost all of the studies on this topic focus on this period. For example, one study compared hospital admissions for UTI among a group of 29,217 uncircumcised boys and a similar number of circumcised boys (To et al. 1813). The results showed that the one-year probabilities of hospital admission were 1.88 per 1000 for circumcised boys, compared to 7.02 per 1000 for uncircumcised boys. In fact, a review done by the American Academy of Pediatrics found that all studies on this subject have shown an increased risk of UTI in uncircumcised males. Using numbers from several studies, it is estimated that 7 to 14 of 1000 uncircumcised boys will develop a UTI in the first year of life, compared with 1 to 2 of 1000 circumcised boys. However, it is important to note that the overall risk of an uncircumcised infant developing a UTI is extremely low -- less than one percent -- and that such UTIs can typically be treated with prescription antibiotics (688).

Additional studies have looked at the relationship between penile cancer and circumcision. Results show that uncircumcised men are three times more likely than circumcised men to develop penile cancer (AAP 690). However, the annual rate of penile cancer is about 10 cases per year per one million men, which accounts for less than one percent of all cancers in American men (Laliberte 67). Thus, the risk of penile cancer in uncircumcised men, although increased compared to circumcised men, is extremely low.

Unlike the relationship to UTI and penile cancer, the relationship between circumcision and STDs, including AIDS, in unclear. Some authors report that there is a slightly higher risk of STDs in uncircumcised men (Laliberte 67), while others have found that uncircumcised men actually have lower rates of STDs than circumcised men (Laumann, Masi, and Zuckerman 1054). In its circumcision policy statement, the American Academy of Pediatrics (AAP) states that "evidence regarding the relationship of circumcision to STD is complex and conflicting…behavioral factors appear to be far more important risk factors in the acquisition of HIV infection than circumcision status" (691).

Medical risks of circumcision

Any discussion of the medical benefits of a procedure must include a discussion of its side effects or possible complications. Because circumcision is a surgical procedure, it may lead to a variety of complications ranging from minor bleeding and infection to amputation of the glans (the tip of the penis), acute renal failure, and life-threatening sepsis (infection) (CPS 774). The rates of post-circumcision complications vary widely from study to study, ranging from a low of .2% to a high of 55%. Most likely, the rates fall somewhere between 2 and 10 percent (774).

Taken as a whole, the medical research does not present a strong argument for the necessity of newborn circumcision. Based on a thorough review of this research, both the American Academy of Pediatrics and the Canadian Paediatric Society issued recent recommendations stating that the benefits of circumcision are not significant enough to recommend it as a routine procedure. Specifically, the AAP states that: "Circumcision is not essential to a child’s well-being at birth, even though it does have some potential medical benefits. These benefits are not compelling enough …to recommend routine newborn circumcision" (693).

Other adverse effects 

New evidence suggests that in addition to being medically unnecessary, circumcision is a painful experience that can affect an infant’s behavior for a long period of time. Traditionally, the circumcision procedure was performed with no painkillers of any kind, based on the belief that the pain experienced by infants was short-lived and therefore not worth the risks associated with pain medications. The AAP reports that there is now considerable evidence that newborns who are circumcised without analgesia may experience pain and physiologic stress, including changes in heart rate, blood pressure, oxygen saturation and cortisol levels (687). Other studies have found that the pain of circumcision causes a period of non-REM (i.e., unrestful) sleep, and may disrupt newborns’ nursing/feeding patterns for several days (Laliberte 67).

Parents themselves can find the circumsion to be a traumatic experience. Deborah Brown, a Registered Nurse who has assisted with hundreds of circumcisions at Michael Reese Hospital, says that some parents become visibly upset as they watch the procedure. Brown says that many parents are surprised at how loudly their newborn cries when the incision is made.  "Some tell me that they were told the procedure would be 'virtually painless' for the infant, but their son's screams convince them that they were misled," said Brown. "Some leave here saying, 'did we really need to do this?' "

Contrary to the belief that circumcision pain is short-lived and inconsequential, new evidence suggests that circumcision may alter infants’ later reactions to pain. A recent study compared three groups of healthy baby boys ages 4 to 6 months old who were having routine vaccinations against diphtheria-pertussis-tetanus (DPT), Hemophilus influenza type B (HIB) and polio. The three groups consisted of uncircumcised infants, infants who had been circumcised after application of a topical (applied to the skin) anesthetic cream, and infants who had been circumcised after application of a placebo cream (no that had no pain-killing effect). Videotaped recordings measured the infants’ pain reaction to the vaccines as defined by the amount of time they cried and showed certain pain-related facial changes. The researchers found that uncircumcised infants showed the least pain reaction to the vaccines, and the group circumcised with the placebo cream had the greatest reaction (Taddio et al. 602). In light of these findings, the AAP now recommends that if parents choose to circumcise their infant, analgesia be provided (687).

Circumcision may also have long-term effects on sexual functioning and pleasure. Critics of circumcision argue that the foreskin, which is removed during the procedure, is a specialized part of the penis that serves many functions. In addition to providing a protective cover for the glans, the foreskin contains 240 feet of nerves and more than 20,000 nerve endings (Fleiss 41). Thus, some argue that the circumcised penis is less sensitive during sex, although little research has looked at this issue. In studies using rodents, removal of the foreskin resulted in changes in sexual practice and in the hormonal response of the female (Van Howe and Cold 203), and a recent survey of men found that circumcised men engage in a more elaborate set of sexual practices (Laumann, Masi, and Zuckerman 1052). Some evidence shows that a circumcised penis results in less pleasure for the female partner (Van Howe and Cold 203).

Informed consent and ethical issues

Regardless of the medical benefits and risks of circumcision, some have argued that parents do not have the right to give consent for this procedure to be performed on their sons. The process of informed consent requires that a physician explain the benefits, risks and potential alternatives to a patient before a medical decision is made. Infants lack the ability to make informed decisions for themselves, so their parents usually have to make medical decisions for them. The AAP has taken the view that "in cases such as the decision to perform a circumcision in the neonatal period when there are potential benefits and risks and the procedure is not essential to the child’s well being, it should be the parents who determine what is in the best interest of the child" (693). Brown says that this view is shared by most of the physicians she works with at Michael Reese Hospital, but that many still counsel parents to consider the issue of consent before they decide to circumcise.

Others feel, however, that newborn circumcision subjects male infants to an operation that they might reject if they were old enough to consider its advantages and disadvantages. Since circumcision is a non-essential, invasive procedure that can be delayed with little risk, many physicians and medical ethicists now believe that the decision should be postponed until a man can choose for himself (Harrison 202). Others have gone even further, calling circumcision a violation of an infant’s medical rights, and comparing it to physical abuse and female genital mutilation (Shuman 4). While these views may be extreme, they show the depth of feeling that exists about this topic.

Recommendations

Faced with these extreme views and contradictory evidence, how should expectant parents come to a decision about whether to circumcise their newborn boy? A careful reading of the evidence suggests that circumcision is medically unnecessary, and that the very slight benefits that are associated with it do not outweigh the potential risks and complications. In addition, what little evidence is available suggests that the pain of the procedure affects newborns for several months, possibly longer. In fact, there seems to be very little reason to circumcise an infant, except to conform to a social norm that is rapidly changing as more and more parents get information.

As new and expectant parents, you should weigh this evidence carefully and make an informed decision. Except in cases where circumcision is required by your religious faith, the evidence suggests you should reject the procedure. If you have concerns about losing the possible medical benefits of circumcision, talk to your obstetrician or pediatrician. If you are concerned about the social aspects -- the fear that your son might feel "different" because his friends are circumcised -- you can always have your son circumcised later, when and if he expresses a desire for it. Although circumcision is a more complex procedure for adolescents than for infants, it is still a safe, outpatient procedure with a relatively quick recovery time.

Conclusion

Once considered a routine treatment for male newborns, the practice of circumcision is becoming more controversial with every passing year. As research continues on the issue, a growing number of physicians, child psychologists and parents are now questioning the benefits. More and more parents are accepting the idea that a father’s wish to have his son’s penis look like his own does not seem reason enough to permanently alter the infant without his consent. This seems to be the thought that respected pediatrician Dr. Benjamin Spock has come to, stating: "My own preference, if I had the good fortune to have another son, would be to leave his little penis alone" (qtd. in Laliberte 68).

Works Cited

American Academy of Pediatrics (AAP). "Circumcision Policy Statement." Pediatrics November 1999: 686-693.

Canadian Paediatric Society (CPS). "Neonatal circumcision revisited."  Canadian Medical Association Journal 
      May 1996: 769-780. (April 5, 1999)  http://firstsearch.org

Fleiss, Paul. "The Case Against Circumcision." Mothering: The Magazine of Natural Family Living
       February 1997: 36-45.

Harrison, D. "Advantages and Disadvantages of Neonatal Circumcision – Letter." JAMA – the Journal of the
        American Medical Association   September 1997: 202.  http://firstsearch.org

Laliberte, Richard. "The Circumcision Decision." Parents April, 1996: 67-8. (March 31, 1999)  http://firstsearch.org

Laumann, Edward, Christopher M. Masi, and Ezra W Zuckerman. "Circumcision in the United States: Prevalence,
          Prophylactic Effects, and Sexual Practice." JAMA: The Journal of the American Medical Association
          July 1997: 1052-1057.

Lowen, Sara. "Rethinking a Custom." U.S. News and World Report April 12, 1998: 66. http://www.usnews.com

Shuman, Jill. "Circumcision: Cutting Edge Controversy in the 90’s." (March 25, 1999).
           http://bewell.com/healthy/sexuality/1997/circum/circum.shtm

Taddio, A., et al. "Effect of Neonatal Circumcision on Pain Response During Subsequent Routine Vaccination."
        The Lancet June, 1997: 599-603. (March 30, 1999)  http://firstsearch.org

To, Teresa, et al. "Cohort Study on Circumcision of Newborn Boys and Subsequent Risk of Urinary-tract
         Infection."   The Lancet July, 1998: 1813-1816. (March 30, 1999)  http://firstsearch.org

Van Howe, Robert, and Christopher Cold. "Advantages and Disadvantages of Neonatal Circumcision – Letter."
       JAMA – the Journal of the American Medical Association December 1997: 203.

Appendix A

Transcript of an interview with Deborah Brown, a Registered Nurse in the Obstetrics and Delivery Department at Michael Reese Hospital in Chicago, Illinois. April 13, 1999.

Question:  The once-routine practice of circumcision is now being questioned by many health-care professionals and parents. What trends have you observed in the frequency of this procedure at your hospital?

Brown: [answer]

    [transcript continues]