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1. The American Academy of Pediatrics (the conveyor of circumcision policies to the country) is the most comprehensive resource to learn of the risks and benefits of neonatal circumcision.
FALSE
The authors of the AAP's most recent policy statement on circumcision (2012) claimed that the benefits of the procedure outweigh the risks. In direct contradiction to this statement, the accompanying technical report states that "the true incidence, impact, or added costs of circumcision complications is unknown.” Moreover, there is no mention of the natural functions of the foreskin lost to circumcision at any point in the 18-page report.
In some cases, too little foreskin is removed during the procedure, which can lead to additional circumcision surgeries; in other cases, too much foreskin is removed, which can cause painful erections and curvatures of the penis in adulthood. During the surgery itself, bleeding, pain, and post-operative pain is common. Less common are infections caused by painful adhesions during the recovery process. Hemorrhaging and death are very rare but very possible complications.
a. “Circumcision Policy Statement.” Pediatrics, American Academy of Pediatrics, 1 Sept. 2012, pediatrics.aappublications.org/content/130/3/585.
b. “Male Circumcision Technical Report.” Pediatrics, American Academy of Pediatrics, 1 Sept. 2012, pediatrics.aappublications.org/content/130/3/e756.
c. Earp, Brian, et al. “Factors Associated With Early Deaths Following Neonatal Male Circumcision in the United States, 2001 to 2010.” SAGE Journals, 1 Aug. 2018, journals.sagepub.com/doi/10.1177/0009922818790060.
2. The American Academy of Pediatrics’s current Policy Statement on Circumcision has expired.
TRUE
“All policy statements from the AAP automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that time." The current AAP Policy Statement on Circumcision was issued in 2012 and it expired in 2017.
a. Policy Statements. (n.d.). Retrieved from https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/healthy-foster-care-america/Pages/Policy-Statements.aspx#:~:text=All policy statements from the,at or before that time.&text=Organizational principles to guide and,the health of all children.
3. There is no need to locate the urethral opening in an otherwise healthy pediatric patient, even during the neonatal period.
TRUE
Without evidence of possible infection, there is no need to do so.
“There are times when bladder catheterization may be indicated. Fortunately, forced retraction or complete exposure of the glans are not necessary for catheterizing a boy or for cleaning the area in preparation for the catheter.”
a. Carmack A, Milos MF. Catheterization without foreskin retraction. Can Fam Physician. 2017;63(3):218-220.
4. Parents should not push their intact child’s foreskin back during diaper changes and bath time because the age at which foreskin is retractable varies greatly. Even if a child cannot retract their foreskin in childhood or later, medical intervention is not necessary.
TRUE
Most males are born with the foreskin fused to the underlying glans penis. During this time, the foreskin should NEVER be forcibly retracted. Doing so can cause micro-tearing, bleeding, and pain, and can significantly increase the risk of infection. The foreskin gradually becomes more retractable through childhood into puberty, becoming fully retractile in late puberty for the vast majority of males. The male foreskin, like the female foreskin (clitoral hood), is self-cleaning and does not require special care. During infancy, “only clean what is seen.” This means, WITHOUT retracting the foreskin, gently clean the genitals with warm water. Typically, the foreskin slowly becomes more retractile over several years, and most males can fully retract their foreskin by the end of puberty. If a pubescent child’s foreskin is fully retractable, they can gently retract, clean the area with warm water (no soap), and then gently return over the head of the penis as part of their washing routine.
*Note* The international physicians’ organization, Doctors Opposing Circumcision, hears of at least 100 cases of Premature Forcible Foreskin Retraction (PFFR) per year. In addition, in 2019, the children’s human rights organization, Your Whole Baby, sent over 100 care packets to doctors at parents’ requests.
a. Geisheker, J. (2011, October 23). What Is the Greatest Danger for an Uncircumcised Boy? Retrieved from https://www.psychologytoday.com/us/blog/moral-landscapes/201110/what-is-the-greatest-danger-uncircumcised-boy
b. American Academy of Pediatrics. (2007). Care of the Uncircumcised Penis. Retrieved from https://patiented.solutions.aap.org/handout.aspx?gbosid=156581
c.. Kabaya, Hiroyuki, et al. “Analysis of Shape and Retractability of the Prepuce in 603 Japanese Boys.” The Journal of Urology, Elsevier, 21 Nov. 2005, www.sciencedirect.com/science/article/pii/S0022534701655447?via%3Dihub.
d. “Wrongful Foreskin Retraction.” Doctors Opposing Circumcision, 2019, www.doctorsopposingcircumcision.org/for-parents/help-with-forcible-foreskin-retraction/.
5. Ballooning of the foreskin during urination and infections/irritation of the penile area generally require invasive interventions.
FALSE
“Ballooning of the foreskin with voiding may occur in some boys when separation has progressed to some degree underneath the foreskin, but the outlet is still tight. It is not pathologic and requires no treatment. It is a sign that development is proceeding but is not yet complete, and disappears as the foreskin opening becomes looser. If treatment of non-retractile foreskin is deemed necessary, there are three less invasive alternatives to circumcision: topical application of steroids, manual stretching, and minimally-invasive preputioplasty. If inflammation of the glans penis and foreskin occurs, conservative measures include using saline baths and avoiding soap.”
a. 21. McGregor TB, Pike JG, Leonard MP. Pathologic and physiologic phimosis: approach to the phimotic foreskin. Can Fam Physician. 2007;53(3):445-8.
b. 24. Rickwood AMK. The prepuce. In: Thomas DFM, Rickwood AMK, Duffy PG, editors. Essentials of paediatric urology. London: Martin Dunitz, Ltd.; 2002. p. 181-8.
c. Babu R, Harrison SK, Hutton KA.. Ballooning of the foreskin and physiological phimosis: is there any objective evidence of obstructed voiding? BJU Int. 2004;94(3):384-7.
d. Conservative Treatment. (2020, January 08). Retrieved from https://www.doctorsopposingcircumcision.org/for-professionals/conservative-treatment/
6. There is consensus in scientific literature that circumcision protects against penile cancer.
FALSE
In the mid-1900s, American medical experts argued that smegma was a carcinogen that caused penile cancer. Apart from the fact no study has been able to prove this association — and that smegma production is completely normal in males and females and important in mammalian genital health — more recent studies from Denmark have found that tobacco use and hygiene practices play far more significant roles in influencing the likelihood of penile cancer in an adult male. Most importantly, penile cancer, in both the United States (with a high circumcision rate) and Europe (with a low circumcision rate), is an extremely rare cancer, with an adult male having a 1 in 100,000 risk of being diagnosed with this cancer in his lifetime.
a. Frisch, Morten, et al. “Falling Incidence of Penis Cancer in an Uncircumcised Population (Denmark 1943-90).” British Medical Journal (London), 2 Dec. 1995, www.cirp.org/library/disease/cancer/frisch/.
b. Van Howe, R. S., and F. M. Hodges. “The Carcinogenicity of Smegma: Debunking a Myth.” JOURNAL OF THE EUROPEAN ACADEMY OF DERMATOLOGY AND VENEREOLOGY, Oct. 2006, www.cirp.org/library/disease/cancer/vanhowe2006/.
7. There is consensus in the scientific literature that circumcision protects against UTIs.
FALSE
In the late 1900s, American medical experts argued that circumcision may decrease the likelihood of a UTI in infant males under the age of 6 months. However, the commonly cited 1986 Wiswell study potentially caused UTIs by encouraging the all-too-common forcible retraction of the foreskin and did not take into account the many confounding variables, (including lack of breastfeeding) in influencing the likelihood of UTI in an infant male. More recently, a Cochrane review of current UTI literature found no robust scientific evidence supporting infant male circumcision as an effective prophylactic treatment for UTIs. Most importantly, the risk of a UTI is extremely rare in boys overall (less than a 1% likelihood) so more than 100 circumcisions would have to be performed to prevent a single case. Finally, UTIs are as easily treatable in infant males as in infant females.
a. Geisheker, John. “What Is the Greatest Danger for an Uncircumcised Boy?” Psychology Today, Sussex Publishers, 11 Oct. 2011, www.psychologytoday.com/us/blog/moral-landscapes/201110/what-is-the-greatest-danger-uncircumcised-boy.
b. Jagannath, Vanitha A, et al. “Routine Neonatal Circumcision for the Prevention of Urinary Tract Infections in Infancy.” Cochrane Database of Systematic Reviews, 2012, doi:10.1002/14651858.cd009129.pub2.
c. Van Howe, R. S. “Effect of Confounding in the Association between Circumcision Status and Urinary Tract Infection.” Journal of Infections, Elsevier, 1 Oct. 2004, www.sciencedirect.com/science/article/pii/S0163445304001562?via%3Dihub.
8. There is consensus in the scientific literature that circumcision protects against STIs.
FALSE
Evidence indicates that circumcision does not protect against urethritis-related diseases of gonorrhea and chlamydia, the two most common STIs in the United States. It may protect against genital ulcer disease; however, no studies have unequivocally proven this linkage. Most importantly, in developed countries, STIs and HIV can be prevented far more effectively through the use of condoms, which are easily accessible and have an over 90% protective effect.
a. “CDC Newsroom.” Centers for Disease Control and Prevention, 26 Sept. 2017, www.cdc.gov/media/releases/2017/p0926-std-prevention.html.
b. Van Howe, R. S. “Does Circumcision Influence Sexually Transmitted Diseases? (STDs).” BJU INTERNATIONAL, Jan. 1999, www.cirp.org/library/disease/STD/vanhowe6/.
9. There is consensus in the scientific literature that circumcision protects against HIV.
FALSE
In the early 2000s, results of three randomized controlled trials (RCTs) conducted in Kenya, Uganda, and South Africa suggested that adult circumcision provided an overall 60% relative risk reduction in female-to-male HIV transmission in high-prevalence HIV regions. These results are contested in the literature due to their notable methodological flaws and biases (see ref.), but U.S.-funded mass circumcision programs in several sub-Saharan nations continue. The RCTs gloss over the more pertinent absolute HIV risk reduction from circumcision, which is clinically insignificant at 1.3%. Additionally, the questionable protective effect found in this research is only applicable to adult circumcision, only during penis-in-vagina sex, only for female-to-male transmission, only in sub-Saharan Africa where HIV rates are far higher than in most high-income countries, including the U.S. By contrast, there is no conclusive evidence that infant circumcision in the U.S. — which has the one of the highest HIV rates among high-income countries and the highest non-religious circumcision rate — has any public health benefit.
a. Boyle, Gregory J., and George Hill. “Sub-Saharan African Randomised Clinical Trials into Male Circumcision and HIV Transmission: Methodological, Ethical, and Legal Concerns.” Thomson Reuters, 2011, www.salem-news.com/fms/pdf/2011-12_JLM-Boyle-Hill.pdf.
b. Green, Lawrence W., et al. “Male Circumcision and HIV Prevention: Insufficient Evidence and Neglected External Validity.” American Journal of Preventative Medicine, 2010, www.thewholenetwork.org/uploads/4/2/0/2/4202929/ajpmgreenetal2010_pub.pdf.
10. Meatal stenosis, an abnormal narrowing of the urethral opening (meatus) is a common complication after circumcision, occurs almost exclusively in circumcised males, and circumcised males are far more likely than their intact counterparts to develop this problem.
TRUE
Meatal stenosis, an abnormal narrowing of the urethral opening (meatus) is a common complication after circumcision occurring in 9%-10% of males. This disorder is characterized by an upward deflected, difficult-to-aim urinary stream, dysuria, urgency, frequent, and prolonged urination. If left untreated, this can lead to urinary tract infections and kidney problems. Surgical meatotomy/meatoplasty is curative. Meatal stenosis is almost always seen in males who have been circumcised. It is rare for uncircumcised males to have meatal stenosis. This may mean that circumcision has caused the meatus to become narrower. The risk of developing [meatal stenosis] is 16-26 times higher in circumcised than intact boys under the age of ten. These are the conclusions of a new study based on data from the National Patient Register, the Central Population Register, and the National Health Service Register in Denmark between 1977 and 2013.
a. Wang M. H. (2010). Surgical management of meatal stenosis with meatoplasty. Journal of visualized experiments : JoVE, (45), 2213. https://doi.org/10.3791/2213. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3159600/#:~:text=Meatal%20stenosis%2C%20an%20abnormal%20narrowing,%2C%20frequent%2C%20and%20prolonged%20urination.
b. Meatal Stenosis: Symptoms, Causes, Tests and Treatment. (n.d.). Retrieved from https://my.clevelandclinic.org/health/diseases/16295-meatal-stenosis
c. a. Hoffmann, T. (2016, December 30). Male circumcision greatly increases risk of urinary tract problems. Retrieved from https://sciencenordic.com/childrens-health-circumcision-denmark/male-circumcision-greatly-increases-risk-of-urinary-tract-problems/1441376
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11. Possible complications of circumcision include amputation of the penis and death.
TRUE
“[Amputation] is a rare but devastating complication of circumcision which has been reported with inappropriate placement of the Mogen clamp. The clamp is designed to allow the device to open only enough to allow the foreskin, and nothing else, into the area of compression, but if placed incorrectly with all or part of the glans admitted into this area, amputation will occur...Death is an extremely unlikely complication of neonatal circumcision, but it has been reported.”
a. Newborn Nursery. (n.d.). Complications. Retrieved from https://med.stanford.edu/newborns/professional-education/circumcision/complications.html
b. Earp, B. D., Allareddy, V., Allareddy, V., & Rotta, A. T. (2018). Factors Associated With Early Deaths Following Neonatal Male Circumcision in the United States, 2001 to 2010. Clinical Pediatrics, 57(13), 1532–1540. doi: 10.1177/0009922818790060
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12. The foreskin has value and serves a function in the human body.
TRUE
In infancy, the foreskin serves a protective function. It is a flexible, double layered sheath of specialized skin that shields the glans and the foreskin itself from foreign substances like fecal matter; keeping both healthy, clean, warm, soft, and moist. As the male grows older, the foreskin takes on an erogenous function. The foreskin and its 'frenulum delta' have thousands of nerve endings, including free nerve endings (FNEs), Meissner corpuscles, and Pacinian corpuscles. While FNEs are neuroreceptors of deep pressure and pain, Meissner and Pacinian corpuscles are fine touch neuroreceptors similar to the ones found in fingers, palms, and lips. These fine-touch receptors create a sensitive sexual experience impossible to recreate without the foreskin because the glans has virtually no fine-touch receptors and can barely distinguish hot from cold. Interestingly, the most fine-touch sensitive regions on the circumcised penis are the circumcision scar and/or the remnant portion of the truncated frenulum. In fact, circumcised men sometimes notice that their erogenous sensation ends abruptly at their scar, with the rest of the organ no more sensitive than their lower abdomen. Finally, the foreskin helps to retain the natural lubrication coming from the bulbourethral glands, which assists in creating a smooth, gliding, motile motion during sexual intercourse, avoiding excess friction and the use of additional lubrication.
a. Fleiss, Paul M. “What Your Doctor May Not Tell You About(TM): Circumcision.” Google Books, 2002
b. Fleiss, P M, et al. “Immunological Functions of the Human Prepuce.” Sexually Transmitted Infections, vol. 74, no. 5, 1998, pp. 364–367., doi:10.1136/sti.74.5.364.
c. Harryman, Gary L. “An Analysis of the Accuracy of the Presentation of the Human Penis in Anatomical Source Materials.” Flesh and Blood, 2004, pp. 17–26., doi:10.1007/978-1-4757-4011-0_2.
d. Martín-Alguacil, Nieves, et al. “Terminal Innervation of the Male Genitalia, Cutaneous Sensory Receptors of the Male Foreskin.” Clinical Anatomy, vol. 28, no. 3, 2015, pp. 385–391., doi:10.1002/ca.22501.
e. Taylor, John R. “Fine-Touch Pressure Thresholds In The Adult Penis.” BJU International, vol. 100, no. 1, 2007, pp. 218–218., doi:10.1111/j.1464-410x.2007.07026_4.x.
f. Cold, C., & Taylor, J. (2002). The prepuce. BJU International, 83(S1), 34-44. doi:10.1046/j.1464-410x.1999.0830s1034.x
