A Categorized collection of academic articles and resources on foreskin and circumcision.
Page last updated: April 2, 2022
+ Comprehensive reviews of the practice of neonatal penile circumcision
Dekker, R., & Bertone, A. (2019). Evidence and Ethics On: Circumcision. Evidence Based Birth.
Excerpt: “Male circumcision is defined as the partial or total surgical removal of the foreskin (also called prepuce), which is specialized tissue that covers the head (or glans) of the penis…The United States (U.S.) is unusual in that the vast majority of newborn circumcisions performed in the country are done for non-religious reasons (WHO/UNAIDS, 2007). In the U.S., the overall rate of newborn circumcision is on the decline, but circumcision is still the most frequent procedure performed on children during hospital stays—more than 10 times as common as any other pediatric surgical procedure, and the only surgical procedure that is regularly performed without any urgent medical need on healthy infants (Witt et al. 2014). Circumcision is so familiar and routine in U.S. culture that many parents and care providers scarcely even think of it as a surgical procedure, viewing it instead as one of several relatively minor newborn medical procedures performed at the hospital before discharge…In this article, we explore the research evidence as well as the ethical debate around routine circumcisions performed on healthy newborn males.”
Abstract: “In December of 2014, an anonymous working group under the United States’ Centers for Disease Control and Prevention (CDC) issued a draft of the first-ever federal recommendations regarding male circumcision. In accordance with the American Academy of Pediatrics’ circumcision policy from 2012 – but in contrast to the more recent 2015 policy from the Canadian Pediatric Society as well as prior policies (still in force) from medical associations in Europe and Australasia – the CDC suggested that the benefits of the surgery outweigh the risks. In this article, we provide a brief scientific and conceptual analysis of the CDC’s assessment of benefit versus risk, and argue that it deserves a closer look. Although we set aside the burgeoning bioethical debate surrounding the moral permissibility of performing non-therapeutic circumcisions on healthy minors, we argue that, from a scientific and medical perspective, current evidence suggests that such circumcision is not an appropriate public health measure for developed countries such as the United States.”
Abstract: “The American Academy of Pediatrics recently released its new Technical Report and Policy Statement on male circumcision, concluding that current evidence indicates that the health benefits of newborn male circumcision outweigh the risks. The technical report is based on the scrutiny of a large number of complex scientific articles. Therefore, while striving for objectivity, the conclusions drawn by the 8 task force members reflect what these individual physicians perceived as trustworthy evidence. Seen from the outside, cultural bias reflecting the normality of nontherapeutic male circumcision in the United States seems obvious, and the report’s conclusions are different from those reached by physicians in other parts of the Western world, including Europe, Canada, and Australia. In this commentary, a different view is presented by non–US-based physicians and representatives of general medical associations and societies for pediatrics, pediatric surgery, and pediatric urology in Northern Europe. To these authors, only 1 of the arguments put forward by the American Academy of Pediatrics has some theoretical relevance in relation to infant male circumcision; namely, the possible protection against urinary tract infections in infant boys, which can easily be treated with antibiotics without tissue loss. The other claimed health benefits, including protection against HIV/AIDS, genital herpes, genital warts, and penile cancer, are questionable, weak, and likely to have little public health relevance in a Western context, and they do not represent compelling reasons for surgery before boys are old enough to decide for themselves.”
+ Breastfeeding / infant feeding
Excerpt: “Infant circumcision is a non-therapeutic procedure without documented benefit for the infant. Therefore, no harm can come to an infant from foregoing or postponing a circumcision. The Work Group on Breastfeeding of the American Academy of Pediatrics formally recommends that such stressful procedures be avoided. The AAP recognizes breastfeeding as primary in achieving optimal infant and child health, growth, and development. Therefore, successful initiation of breastfeeding should be given absolute priority over neonatal circumcision. Prospective parents should be warned in advance of circumcision’s interference with breastfeeding. While current informed medical opinion does not support the practice, some parents, however, still have their baby circumcised. In this case, the circumcision should be avoided at least until breastfeeding is well established. Such a recommendation should be a part of all printed material regarding breastfeeding that is provided to expectant mothers in advance of delivery and should be volunteered by lactation consultants in every pre-partum counseling session.”
Conclusion: “Neonates in both groups showed significant increases in heart rate, respiratory rate, and crying during circumcision with no clinically significant differences observed between the groups. Postoperative comfort scores showed no significant differences between the groups until the 360-minute postoperative assessment, at which time the acetaminophen group had significantly improved scores. Feeding behavior deteriorated in breast- and bottle-fed neonates in both groups, and acetaminophen did not seem to influence this deterioration...This study confirms that circumcision of the newborn causes severe and persistent pain. Acetaminophen was not found to ameliorate either the intra-operative or the immediate postoperative pain of circumcision, although it seems that it may provide some benefit after the immediate postoperative period.”
Excerpt: “We did find…that immediately following circumcision there were differences in the feeding patterns between the two groups. The experimental group exhibited fewer intervals of uninterrupted feeding than did the control group. Similar patterns, although not at highly significant levels, were demonstrated by the experimental group mothers. Although the volume of formula consumed was not monitored, subjective descriptions support the observations that the infants who were circumcised sucked on the bottles harder, faster and more concertedly.”
+ Circumcision complications and deaths
Excerpt: "This preliminary study investigates what role early trauma might have in alexithymia (difficulty in identifying and expressing feelings) acquisition for adults by controlling for male circumcision. Three hundred self-selected men were administered the Toronto Twenty-Item Alexithymia Scale checklist and a personal history questionnaire. The circumcised men had age-adjusted alexithymia scores 19.9 percent higher than the intact men; were 1.57 times more likely to have high alexithymia scores; were 2.30 times less likely to have low alexithymia scores; had higher prevalence of two of the three alexithymia factors (difficulty identifying feelings and difficulty describing feelings); and were 4.53 times more likely to use an erectile dysfunction drug. Alexithymia in this population of adult men is statistically significant for having experienced circumcision trauma and for erectile dysfunction drug use."
Abstract: "The sensitivity of the foreskin and its importance in erogenous sensitivity is widely debated and controversial. This is part of the actual public debate on circumcision for non-medical reasons. Today some studies on the effect of circumcision on sexual function are available. However they vary widely in outcome. The present study shows in a large cohort of men, based on self-assessment, that the foreskin has erogenous sensitivity. It is shown that the foreskin is more sensitive than the uncircumcised glans mucosa, which means that after circumcision genital sensitivity is lost. In the debate on clitoral surgery the proven loss of sensitivity has been the strongest argument to change medical practice. In the present study there is strong evidence on the erogenous sensitivity of the foreskin. This knowledge hopefully can help doctors and patients in their decision on circumcision for non-medical reasons."
Abstract: “We sought to quantify early deaths following neonatal circumcision (same hospital admission) and to identify factors associated with such mortality. We performed a retrospective analysis of all infants who underwent circumcision in an inpatient hospital setting during the first 30 days of life from 2001 to 2010 using the National Inpatient Sample. Over 10 years, 200 early deaths were recorded among 9,833,110 subjects (1 death per 49,166 circumcisions). Note: this figure should not be interpreted as causal but correlational as it may include both undercounting and overcounting of deaths attributable to circumcision. Compared with survivors, subjects who died following newborn circumcision were more likely to have associated comorbid conditions, such as cardiac disease, coagulopathy, fluid and electrolyte disorders, or pulmonary circulatory disorders. Recognizing these factors could inform clinical and parental decisions, potentially reducing associated risks.”
Excerpt: "While vaginal dryness is considered an indicator for female sexual arousal disorder, male circumcision may exacerbate female vaginal dryness during intercourse. O'Hara and O'Hara reported that women who had experienced coitus with both intact and circumcised men preferred intact partners by a ratio of 8.6 to one. Most women (85.5%) in that survey reported that they were more likely to experience orgasm with a genitally intact partner: They [surveyed women] were also more likely to report that vaginal secretions lessened as coitus progressed with their circumcised partners (16.75, 6.88–40.77)."
Abstract: “Sudden infant death syndrome (SIDS) is the leading cause of death among USA infants under 1 year of age accounting for ~2,700 deaths per year. Although formally SIDS dates back at least 2,000 years and was even mentioned in the Hebrew Bible (Kings 3:19), its etiology remains unexplained prompting the CDC to initiate a sudden unexpected infant death case registry in 2010. Due to their total dependence, the ability of the infant to allostatically regulate stressors and stress responses shaped by genetic and environmental factors is severely constrained. We propose that SIDS is the result of cumulative painful, stressful, or traumatic exposures that begin in utero and tax neonatal regulatory systems incompatible with allostasis. We also identify several putative biochemical mechanisms involved in SIDS. We argue that the important characteristics of SIDS, namely male predominance (60:40), the significantly different SIDS rate among USA Hispanics (80% lower) compared to whites, 50% of cases occurring between 7.6 and 17.6 weeks after birth with only 10% after 24.7 weeks, and seasonal variation with most cases occurring during winter, are all associated with common environmental stressors, such as neonatal circumcision and seasonal illnesses. We predict that neonatal circumcision is associated with hypersensitivity to pain and decreased heart rate variability, which increase the risk for SIDS. We also predict that neonatal male circumcision will account for the SIDS gender bias and that groups that practice high male circumcision rates, such as USA whites, will have higher SIDS rates compared to groups with lower circumcision rates. SIDS rates will also be higher in USA states where Medicaid covers circumcision and lower among people that do not practice neonatal circumcision and/or cannot afford to pay for circumcision. We last predict that winter-born premature infants who are circumcised will be at higher risk of SIDS compared to infants who experienced fewer nociceptive exposures. All these predictions are testable experimentally using animal models or cohort studies in humans. Our hypothesis provides new insights into novel risk factors for SIDS that can reduce its risk by modifying current infant care practices to reduce nociceptive exposures.”
Conclusion: "Epidemiological analyses are useful to generate hypotheses but cannot provide strong evidence of causality. Biological plausibility is provided by a growing body of experimental and clinical evidence linking aversive preterm and early-life SIDS events. Together with historical and anthropological evidence, our findings emphasize the necessity of cohort studies that consider these phenotypes with the aim of improving the identification of at-risk infants and reducing infant mortality. Relevance for patients: Preterm birth and neonatal circumcision are associated with a greater risk of SIDS, and efforts should be focused on reducing their rates."
Abstract: “Meatal stenosis is markedly more common in circumcised than genitally intact males, affecting 5–20 percent of circumcised boys. However, no population-based study has estimated the relative risk of meatal stenosis and other urethral stricture diseases (USDs) or the population attributable fraction (AFp) associated with non-therapeutic circumcision...Muslim males had higher rates of meatal stenosis than ethnic Danish males, particularly in <10 data-preserve-html-node="true" year-old boys. HRs linking circumcision to meatal stenosis or other USDs were high, and attempts to reduce potential misclassification and confounding further strengthened the association, particularly in <10 data-preserve-html-node="true" year-old boys. Conservative calculations revealed that at least 18, 41, 78, and 81 percent of USD cases in <10 data-preserve-html-node="true" year-old boys from countries with circumcision prevalences as in Denmark, the United Kingdom, the United States and Israel, respectively, may be attributable to non-therapeutic circumcision.”
Abstract: “Amid growing bioethical and human rights concerns over nontherapeutic infant male circumcision, calls have been made to investigate long-term impacts on the men these infants eventually become. The present inquiry attempts to identify factors contributing to concerns of men claiming dissatisfaction with or ascribing harm from neonatal circumcision. This large sample size survey involved an online questionnaire with opportunities to upload photographic evidence. Respondents revealed wideranging unhealthy outcomes attributed to newborn circumcision. Survey results establish the existence of a considerable subset of circumcised men adversely affected by their circumcisions that warrants further controlled study. Empirical investigations alone, however, may be insufficient to definitively identify long-term effects of infant circumcision. As with non-therapeutic genital modifications of non-consenting female and intersex minors, responses are highly individualistic and cannot be predicted at the time they are imposed on children. Findings highlight important health and human rights implications resulting from infringements on the bodily integrity and future autonomy rights of boys, which may aid health care and human rights professionals in understanding this emerging vanguard of men who report suffering from circumcision. We recommend further research avenues, offer solutions to assist affected men, and suggest responses to reduce the future incidence of this problem.”
Abstract: "In the United States, circumcision is a commonly performed procedure. It is a relatively safe procedure with a low overall complication rate. Most complications are minor and can be managed easily. Though uncommon, complications of circumcision do represent a significant percentage of cases seen by pediatric urologists. Often they require surgical correction that results in a significant cost to the health care system. Severe complications are quite rare, but death has been reported as a result in some cases. A thorough and complete preoperative evaluation, focusing on bleeding history and birth history, is imperative. Proper selection of patients based on age and anatomic considerations as well as proper sterile surgical technique are critical to prevent future circumcision-related adverse events."
Excerpt: “In 2013 there were 26,069 male births and 6298 circumcisions were captured...725 (11.5%) complications were identified. The two most common complications were phimosis in 433 (6.9%) and other wound related complications such as acquired torsion, buried penis and edema in 168 (2.7%). The incidence of post-circumcision complications at 2 years is much higher than expected at 11.5%, but does not appear to be influenced by age at circumcision, healthcare setting or a rural vs. urban location. A minority of subjects needed reoperation during the ensuing 2 years.”
Results: “NICU neonates experienced increased bleeding complications versus NNN neonates. No differences were found regarding gestational age at delivery, age at circumcision, and birth weight. Neonates with circumcision performed at ≥5 days of life experienced increased rates of bleeding complications versus those performed at ≤4 days. All neonates with circumcision performed ≥5 days of life were initially admitted to the NICU.”
Excerpt: "Premature ejaculation (PE) is common. However, it has been underreported and undertreated. The aim of the study was to determine the prevalence of PE and to investigate possible associated factors of PE. This cross-sectional study was conducted at a primary care clinic over a 3-month period in 2008. Men aged 18-70 years attending the clinic were recruited, and they completed self-administered questionnaires. A total of 207 men were recruited with a response rate of 93.2%. Their mean age was 46.0 years. The prevalence of PE was 40.6%. No significant association was found between age and PE. Multivariate analysis showed that erectile dysfunction, circumcision, and sexual intercourse =5 times in 4 weeks were predictors of PE. These associations need further confirmation."
Results: “Circumcision in 315 boys aged from 3 weeks to 16 years (median five years) were evaluated. A total of 16 boys (5.1%) had significant complications, including three incomplete circumcisions requiring re-surgery, two requiring re-surgery six months and five years postoperatively due to fibrotic phimosis and two requiring meatotomy due to meatal stenosis two and three year postoperatively. Acute complications included two superficial skin infections one week postoperatively and five cases with prolonged stay or re-admissions for bleeding the first or second postoperative day, whereof two underwent operative treatment. Finally, two had anaesthesiological complications leading to a need for overnight surveillance, but no further treatment.”
+ Ethical considerations
Summary: “The Kenyan and Ugandan studies show a reduction in acquisition of HIV in men circumcised as adults in Kenya and Uganda. They do not translate well to infant circumcision, especially in regions with a low lifetime risk of HIV infection. Urinary tract infections in infants and toddlers have very good diagnostic and treatment options and do not require surgical prophylaxis. The concept brings to mind a comment by a surgical colleague, ‘If there is a medical treatment and a surgical treatment, why would anyone opt for a medical treatment?’ Although there is evidence that circumcision will provide certain health benefits, the evidence continues to show that for little boys born in Canada, where antibiotics are readily available, the physical harm outweighs long-term benefit for both HIV and UTI prevention. The ethical issues in removing healthy tissue from patients who are unable to consent to the procedure forms the basis of another treatise. One can only imagine the outcry if baby girls were submitted to cosmetic surgery in the first few days of life. Do our baby boys deserve less?”
Abstract: Much of the contemporary debate about the propriety of nontherapeutic circumcision of male infants and boys revolves around the question of risks vs. benefits. With its headline conclusion that the benefits outweigh the risks, the current circumcision policy of the American Academy of Pediatrics [AAP] (released 2012) is a typical instance of this line of thought. Since the AAP states that it cannot assess the true incidence of complications, however, critics have pointed out that this conclusion is unwarranted. In this paper it is argued that the AAP’s conclusion is untenable not only for empirical reasons related to lack of data, but also for logical and conceptual reasons: the concept of risk employed—risk of surgical complications—is too narrow to be useful in the circumcision debate. Complications are not the only harms of circumcision: the AAP and other parties debating the pros and cons of circumcision should conceptualize their analysis more broadly as risk of harm vs. prospect of benefit, thereby factoring in the value of the foreskin to the individual and the physical and ethical harms of removing it from a non-consenting child."
Abstract: "Non-therapeutic circumcision refers to the surgical removal of part or all of the foreskin, in healthy males, where there is no medical condition requiring surgery. The arguments for and against this practice in children have been debated for many years, with conflicting and conflicted evidence presented on both sides. Here, we explore the evidence behind the claimed benefits and risks from a medical and health-related perspective. We examine the number of circumcisions which would be required to achieve each purported benefit, and set that against the reported rates of short- and long-term complications. We conclude that non-therapeutic circumcision performed on otherwise healthy infants or children has little or no high-quality medical evidence to support its overall benefit. Moreover, it is associated with rare but avoidable harm and even occasional deaths. From the perspective of the individual boy, there is no medical justification for performing a circumcision prior to an age that he can assess the known risks and potential benefits, and choose to give or withhold informed consent himself. We feel that the evidence presented in this review is essential information for all parents and practitioners considering non-therapeutic circumcisions on otherwise healthy infants and children."
Conclusion: "The solution to this ethical and human rights dilemma is simple: Do not perform circumcision on infants. By ceasing to perform infant circumcision, nothing is lost. Any adult male may, with fully informed consent, have circumcision whenever he wishes. As the public becomes aware of the accumulating scientific evidence, circumcision is declining, and with the current attention to unnecessary cost, insurance plans are ceasing to pay for circumcision. Most hopefully of all, caring physicians are reviewing this operation in the light of their own ethical standards and are refusing to perform infant circumcision."
Abstract: “The Centers for Disease Control and Prevention (CDC) have announced a set of provisional guidelines concerning male circumcision, in which they suggest that the benefits of the surgery outweigh the risks. I offer a critique of the CDC position. Among other concerns, I suggest that the CDC relies more heavily than is warranted on studies from Sub-Saharan Africa that neither translate well to North American populations nor to circumcisions performed before an age of sexual debut; that it employs an inadequate conception of risk in its benefit vs. risk analysis; that it fails to consider the anatomy and functions of the penile prepuce (i.e., the part of the penis that is removed by circumcision); that it underestimates the adverse consequences associated with circumcision by focusing on short-term surgical complications rather than long-term harms; that it portrays both the risks and benefits of circumcision in a misleading manner, thereby undermining the possibility of obtaining informed consent; that it evinces a superficial and selective analysis of the literature on sexual outcomes associated with circumcision; and that it gives less attention than is desirable to ethical issues surrounding autonomy and bodily integrity. I conclude that circumcision before an age of consent is not an appropriate health-promotion strategy.”
Conclusion: “Future studies on penile sensitivity should explore individual differences in attitudes toward circumcision, along with relevant psychological and contextual mediators. By contrast, the current tendency to draw broad conclusions about the effects of neonatal circumcision on adult sexuality from group ‘averages’, thereby obscuring the responses of individual participants, is problematic. No one engages in sexual activity as an embodied statistical average; instead, each person’s sexual experience is unique. Moreover, it will be important to explore a wider range of sexual outcome variables and to do so with longer-term follow-up into older age. In the meantime, a precautionary approach suggests that non-therapeutic circumcision should generally not be performed until boys can assess the sensitivity of their own foreskins as compared to other parts of the penis – as well as their role in sexual experience more generally – in light of their own considered sexual preferences and values.”
Abstract: "Critics of non-therapeutic male and female childhood genital cutting claim that such cutting is harmful. It is therefore puzzling that ‘circumcised’ women and men do not typically regard themselves as having been harmed by the cutting, notwithstanding the loss of sensitive, prima facie valuable tissue. For female genital cutting (FGC), a commonly proposed solution to this puzzle is that women who had part(s) of their vulvae removed before sexual debut ‘do not know what they are missing’ and may ‘justify’ their genitally-altered state by adopting false beliefs about the benefits of FGC, while simultaneously stigmatising unmodified genitalia as unattractive or unclean. Might a similar phenomenon apply to neonatally circumcised men? In this survey of 999 US American men, greater endorsement of false beliefs concerning circumcision and penile anatomy predicted greater satisfaction with being circumcised, while among genitally intact men, the opposite trend occurred: greater endorsement of false beliefs predicted less satisfaction with being genitally intact. These findings provide tentative support for the hypothesis that the lack-of-harm reported by many circumcised men, like the lack-of-harm reported by their female counterparts in societies that practice FGC, may be related to holding inaccurate beliefs concerning unaltered genitalia and the consequences of childhood genital modification."
Abstract: "Campaigns to circumcise millions of boys and men to reduce HIV transmission are being conducted throughout eastern and southern Africa, recommended by the World Health Organization and implemented by the United States government and Western NGOs. In the United States, proposals to mass‐circumcise African and African American men are longstanding, and have historically relied on racist beliefs and stereotypes. The present campaigns were started in haste, without adequate contextual research, and the manner in which they have been carried out implies troubling assumptions about culture, health, and sexuality in Africa, as well as a failure to properly consider the economic determinants of HIV prevalence. This critical appraisal examines the history and politics of these circumcision campaigns while highlighting the relevance of race and colonialism. It argues that the “circumcision solution” to African HIV epidemics has more to do with cultural imperialism than with sound health policy, and concludes that African communities need a means of robust representation within the regime."
Excerpt: "The debate about the advisability of circumcision in English-speaking countries typically has focused on potential health factors. The position statements of committees from national medical organisations are expected to be evidence-based; however, the contentiousness of the ongoing debate suggests that other factors are involved. Various potential factors related to psychology, sociology, religion, and culture may also underlie policy decisions. These factors could affect the values and attitudes of medical committee members, the process of evaluating the medical literature, and the medical literature itself. Although medical professionals highly value rationality, it can be difficult to conduct a rational and objective evaluation of an emotional and controversial topic such as circumcision. A negotiated compromise between polarized committee factions could introduce additional psychosocial factors. These possibilities are speculative, not conclusive. It is recommended that an open discussion of psychosocial factors take place and that the potential biases of committee members be recognized."
Hutson, J. M. (2004). Circumcision: a surgeon’s perspective. Journal of Medical Ethics, 30(3).
Conclusion: “All surgeons know that circumcision, albeit a simple operation, is still dangerous and carries potential risks to the patient. As surgeons, we need to weigh up these risks carefully against the possible benefits of any surgical intervention. The surgical argument for circumcision of all neonatal males at present is very weak, and with rising public health standards in the developed world, is likely to remain weak. These issues raise numerous ethical questions about surgery used as a social or religious custom, and as a potential preventive measure for possible diseases far into the future.”
Excerpt: "Boys: Goal - Non-medical circumcision of boys can only be performed when the person himself gives his informed consent. Action - A discussion about the age limit begins, i.e. about postponing the circumcision until the boy himself can join and make the decision (t. ex. so-called round table discussions)."
Conclusion: “Newborn circumcision remains an area of controversy. Social, cultural, aesthetic and religious pressures form the most common reasons for non-therapeutic circumcision. Although penile cancer and UTIs are reduced compared with uncircumcised males, the incidence of such illness is so low that circumcision cannot be justified as prophylaxis. The role of the foreskin in HIV transmission in developed countries is unclear, and safe sexual practice remains the cornerstone of prevention. There remains a lack of knowledge regarding what constitutes the normal foreskin both among parents and among primary care providers. This lack of knowledge results in a burden of costs to our health care system in the form of unnecessary urological referrals, expansion of wait times and circumcisions. Routine circumcision of all infants is not justified from a health or cost-benefit perspective.”
Abstract: “We argue that physicians should, in certain cases, be held accountable by patients and their families for harm caused by ‘successful’ genital surgeries performed for social and aesthetic reasons. We explore the question of physicians’ blameworthiness for three types of genital surgeries common in the United States. First, we consider surgeries performed on newborns and toddlers with atypical sex development, or intersex. Second, we discuss routine neonatal male circumcision. Finally, we consider cosmetic vaginal surgery. It is important for physicians not just to know when and why to perform genital surgery, but also to understand how their patients might react to wrongful performance of these procedures. Equally, physicians should know how to respond to their own blameworthiness in socially productive and morally restorative ways.”
Abstract: "Male circumcision is known to be one of the oldest and perhaps one of the most controversial body modification procedures in the history of humanity (Darby 2005; Gollaher 1994, 2000; Grimes 1980). Such scholars and activists, especially those who self-identify as being against the routinized procedure of male neonatal circumcision, discuss circumcision as a human rights violation. However, what is notable about the anti-circumcision movement more broadly is how they implement a Western notion of human rights in which there are contradictions between the rights of children versus the concept of cultural rights, which are both religious and secular in nature. In this article, I provide a very brief literature review of the relevant topics regarding male circumcision from a Western perspective. Second, I demonstrate how newer social movements such as the anti-circumcision/intactivist movements have attempted to reframe the procedure as a human rights violation when they compare circumcision to other body modification procedures such as female genital cutting (FGC) and surgery done on children born intersexed. However, those who feel that circumcision is a religious act believe that to deny any group of people the ability to practice their own religion freely is, in itself, a human rights violation. I conclude with a discussion of the ways in which such Western notions of human rights are not only inherently contradictory but also fail to include other conceptualizations of what human rights as a global term broadly incorporates."
Abstract: “The foreskin is a complex structure that protects and moisturizes the head of the penis, and, being the most densely innervated and sensitive portion of the penis, is essential to providing the complete sexual response. Circumcision—the removal of this structure—is non-therapeutic, painful, irreversible surgery that also risks serious physical injury, psychological sequelae, and death. Men rarely volunteer for it, and increasingly circumcised men are expressing their resentment about it. Circumcision is usually performed for religious, cultural and personal reasons. Early claims about its medical benefits have been proven false. The American Academy of Pediatrics and the Centers for Disease Prevention and Control have made many scientifically untenable claims promoting circumcision that run counter to the consensus of Western medical organizations. Circumcision violates the cardinal principles of medical ethics, to respect autonomy (self-determination), to do good, to do no harm, and to be just. Without a clear medical indication, circumcision must be deferred until the child can provide his own fully informed consent.”
Abstract: “Nontherapeutic circumcision (NTC) of male infants and boys is a common but misunderstood form of iatrogenic injury that causes harm by removing functional tissue that has known erogenous, protective, and immunological properties, regardless of whether the surgery generates complications. I argue that the loss of the foreskin itself should be counted, clinically and morally, as a harm in evaluating NTC; that a comparison of benefits and risks is not ethically sufficient in an analysis of a nontherapeutic procedure performed on patients unable to provide informed consent; and that circumcision violates clinicians’ imperatives to respect patients’ autonomy, to do good, to do no harm, and to be just. When due consideration is given to these values, the balance of factors suggests that NTC should be deferred until the affected person can perform his own cost-benefit analysis, applying his mature, informed preferences and values.”
Introduction: "Neonatal circumcision is the surgery most commonly performed on children, yet reliable information regarding the surgery is not usually made available to parents when they are asked to consent to the procedure for their newborn sons. Often, parents are simply presented with a paper to sign permitting the physician to perform the surgery, without any discussion of the health risks or alternatives. Many medical professionals, medical ethicists and legal scholars now dispute the advisability, and even permissibility, of circumcising newborn boys. Margaret Somerville, a prominent Canadian medical ethicist, recently went so far as to assert that neonatal circumcision constitutes assault under the Canadian criminal code. Numerous legal scholars have concluded that routine neonatal circumcision falls within the legal definition of child abuse and violates children's civil and human rights under national and internationallaw. Consent to a procedure that is per se illegal is, of course, invalid regardless of the motives of the consenting party. But even if it were legally and ethically permissible for parents to authorize circumcision of their sons, empirical studies have shown that the manner in which doctors typically obtain "informed consent" for neonatal circumcision from parents falls far below the standard of care required of the medical profession."
Abstract: “Despite the millenniums-old tradition in Abrahamic circles of removing the foreskin of a penis at birth, the involuntary and aggressive practice of circumcision must not be made an exception to the natural, negative right to self-ownership—a birthright which should prevent a parent from physically harming a child from the moment of birth going forward. This paper will present a natural rights argument against the practice of male child circumcision, while also looking into some of the potential physical and psychological consequences of the practice. It will compare the practice with that of female circumcision, which is banned in developed nations but still practiced in the third world, as well as other forms of aggressive action, some once-prevalent, while disputing arguments made for parental ownership of the child, religious expression, cultural tradition, cleanliness, cosmetics, and conformity.”
+ Financial considerations
Abstract: "Since 1965, tens of millions of boys have been circumcised under the Medicaid program, most at birth, at a cost to the United States Federal Government, the States and taxpayers of billions of dollars. Although 18 States have ended coverage since 1982, the United States Government and 32 States continue to pay for non-therapeutic circumcision, even though no medical association in the world recommends it. Many cite American medical association policy that the procedure has potential medical benefits as well as disadvantages, and that the circumcision decision should be left to parents. This article shows that Medicaid coverage of circumcision is not a policy issue because it is prohibited by federal and State law. As American medical associations concede, non-therapeutic circumcision is unnecessary, elective, cosmetic surgery on healthy boys, usually performed for cultural, personal or religious reasons. The fundamental principle of Medicaid law is that Medicaid only covers necessary medical treatments after the diagnosis of a current medical condition. Physicians and hospitals face severe penalties for charging Medicaid for circumcisions. Medicaid officials and the Federal and State Governments are also required to end coverage. It is unlawful to circumcise and to allow the circumcision of healthy boys at the expense of the government and taxpayers."
Abstract: “A cost-utility analysis, based on published data from multiple observational studies, comparing boys circumcised at birth and those not circumcised was undertaken using the Quality of Well-being Scale, a Markov analysis, the standard reference case, and a societal perspective. Neonatal circumcision increased incremental costs by $828.42 per patient and resulted in an incremental 15.30 well-years lost per 1000 males. If neonatal circumcision was cost-free, pain-free, and had no immediate complications, it was still more costly than not circumcising. Using sensitivity analysis, it was impossible to arrange a scenario that made neonatal circumcision cost-effective. Neonatal circumcision is not good health policy, and support for it as a medical procedure cannot be justified financially or medically.”
+ Foreskin anatomy and functions
Abstract: “Over the past century, numerous boys born in Canada and the United States have been circumcised. However, this trend is changing, with neonatal circumcision being performed less commonly than in years past. Because of these historical practices, many physicians and nurses have limited experience treating patients with intact foreskins and engage in ill-advised procedures such as premature foreskin retraction for purposes of ‘hygiene’ or catheterization. Premature retraction of the foreskin can lead to tearing of healthy tissue, which is painful and increases the risk of preputial scarring and infection. We describe a method for catheterization in which premature retraction of the foreskin is not necessary.”
Excerpts: “[The prepuce] protects and lubricates the glans and inner lamella of the prepuce, facilitating erection, preputial eversion, and penetration during sexual intercourse…The inner prepuce contains…lysozyme…which is also found in tears, human milk, and other body fluids, destroys bacterial cell walls…The natural composition of preputial bacterial flora is age dependent and similar to that of the eyes, mouth, skin, and female genitals…[The prepuce] contains a rich, complex network of nerves and an abundance of mucocutaneous end organs sensitive to motion, touch, temperature, and erogenous stimulation…Amputation of the prepuce neither inhibits risky sexual behaviour nor confers immunity after exposure to pathogens. This is demonstrated by the fact that the United States has both the highest number of sexually active circumcised males and the highest rates of genital cancers, STDs, and AIDS of any first world nation.”
Conclusion: "Circumcision was associated with frequent orgasm difficulties in Danish men and with a range of frequent sexual difficulties in women, notably orgasm difficulties, dyspareunia and a sense of incomplete sexual needs fulfilment. Thorough examination of these matters in areas where male circumcision is more common is warranted."
Excerpt: "Symptomatic phimosis is a common childhood urology complaint. Circumcision was traditionally the treatment of choice, but its popularity in cases of non-scarred phimosis has been superseded by more conservative methods like preputioplasty. We sought to examine outcomes of preputioplasty for the treatment of non-scarred pathological phimosis in two UK paediatric surgery tertiary centres...Foreskin conserving methods like preputioplasty are a valid option in the treatment of non-scarred pathological phimosis."
Conclusion: “There are significant variations of appearance in circumcised boys; clinical findings are much more common in these boys than previously reported in retrospective studies. The circumcised penis requires more care than the intact penis during the first 3 years of life. Parents should be instructed to retract and clean any skin covering the glans in circumcised boys, to prevent adhesions forming and debris from accumulating. Penile inflammation (balanitis) may be more common in circumcised boys; preputial stenosis (phimosis) affects circumcised and intact boys with equal frequency. The revision of circumcision for purely cosmetic reasons should be discouraged on both medical and ethical grounds.”
Conclusion: “The absolute indications for male circumcision in childhood are rare and include [pathological] phimosis secondary to balanitis xerotica obliterans and recurrent balanoposthitis, both of which affect about 2% of children. Preputial adhesions and pearls, ballooning on micturition, and a non-retractile foreskin are all physiological, and parents can be reassured without the need for specialist referral. Relative indications include urinary infection in association with an abnormality of the urinary tract, an abnormally formed foreskin, and the possible benefits of a reduced risk of sexually transmitted infection and penile cancer. Specialist referral for these relative indications is justified, for worried parents, to discuss the risk:benefit ratios.”
Excerpt: "The ultimate goal of hypospadias surgery is to achieve a good functioning and cosmetic penis with the lowest complication rate. There is an ongoing debate [1] in regard of the fate of the foreskin at the time of the hypospadias repair with evidence available that the complication rate in the short period is comparable when considering single-stage hypospadias repair associated with foreskin reconstruction (FR) and classic repair with circumcision (C) [2, 3]. Our aim was to investigate whether foreskin repair is safe evaluating the incidence of complications after single-stage hypospadias repair in our institution in the long term...FR (foreskin restoration) does not increase the complication rate or the need for a reoperation after single-stage HR. Parents should be offered the option between the two procedures according to their personal preference."
Excerpt: “Free nerve endings, Meissner's corpuscles and Pacinian corpuscles are present in the human male foreskin and exhibit characteristic staining patterns…FNEs are receptive to touch, temperature, and pain…Meissner's corpuscles are receptors located in the dermal papillary layer just beneath the epidermal basal lamina of hairless skin (the finger tips, palms of the hands, soles of the feet, nipples, and female and male external genitalia). They are believed to respond to low frequency vibration and light touch.”
Excerpt: "There has been a move away from routine circumcision in our population in the last few decades [1]. This trend has also increased the popularity of foreskin reconstruction in distal hypospadias. Traditional distal hypospadias repair included a circumcision, often with use of the inner prepuce as an extra layer over the neourethra. With foreskin reconstruction, this inner layer is not mobilised, but rather defined and then reconstructed in the midline as one of the preputial layers according to normal anatomy. Anecdotal evidence at our institute pointed towards a lower complication rate in foreskin reconstructed distal hypospadias repairs compared to those that were circumcised. The purpose of the study was to determine if there were differences in the complication rates between foreskin reconstruction (FR) and circumcision (CIRC) in distal hypospadias repairs...Foreskin Reconstruction conferred a significantly lower rate of complications, particularly the UF rate, dehiscence rate, and number of patients that required reoperation. Our rate of complications in the CIRC group is much higher than other published data."
Shahid S. K. (2012). Phimosis in children. ISRN urology, 2012, 707329. doi:10.5402/2012/707329
Abstract: "Phimosis is nonretraction of prepuce. It is normally seen in younger children due to adhesions between prepuce and glans penis. It is termed pathologic when nonretractability is associated with local or urinary complaints attributed to the phimotic prepuce. Physicians still have the trouble to distinguish between these two types of phimosis. This ignorance leads to undue parental anxiety and wrong referrals to urologists. Circumcision was the mainstay of treatment for pathologic phimosis. With advent of newer effective and safe medical and conservative surgical techniques, circumcision is gradually getting outmoded. Parents and doctors should be made aware of the noninvasive options for pathologic phimosis for better outcomes with minimal or no side-effects. Also differentiating features between physiologic and pathologic phimosis should be part of medical curriculum to minimise erroneous referrals for surgery."
Conclusion: "The glans of the circumcised penis is less sensitive to fine touch than the glans of the uncircumcised penis. The transitional region from the external to the internal prepuce is the most sensitive region of the uncircumcised penis and more sensitive than the most sensitive region of the circumcised penis. Circumcision ablates the most sensitive parts of the penis."
Abstract: "Although there continues to be considerable debate over the merits of circumcision, it is clear that preservation of the pediatric foreskin, even in the presence of phimosis, is a viable option. Steroid topical cream is a painless, less-complicated, and more economical alternative to circumcision for treating phimosis. Success rates are quite high, especially when patient selection is appropriate and parents are adequately instructed on application. In those children in whom topical steroid therapy has failed, there remains a variety of foreskin-preserving surgical options for treating phimosis. Compared to circumcision, these less-invasive techniques are associated with lower morbidities and cost. Furthermore, depending on the tissue-preserving technique used, satisfactory cosmesis is also achieved. Thus, those males who were not circumcised at birth now have medical and surgical options, which will decrease the likelihood of requiring circumcision at an older age. As health care providers in the United States see more and more uncircumcised male children, it is important for these children and their parents to understand the natural history of physiologic phimosis. Additionally, it is the responsibility of health care providers to present the management options available for the treatment of the persistent nonretractile foreskin and/or pathologic phimosis. These options are particularly important for those individuals whose religious, cultural, or personal preference is to retain the foreskin."
Taves, D., “The Intromission Function of the Foreskin,” Med Hypotheses 59 (2002): 180.
Excerpt: "Masters and Johnson observed that the foreskin unrolled with intercourse. However, they overlooked a prior observation that intromission (i.e., penetration) was thereby made easier. To evaluate this observation an artificial introitus was mounted on scales. Repeated measurements showed a 10-fold reduction of force on entry with an initially unretracted foreskin as compared to entry with a retracted foreskin. For the foreskin to reduce the force required it must cover most of the glans when the penis is erect."
Conclusion: “The glans of the circumcised penis is less sensitive to fine touch than the glans of the uncircumcised penis. The transitional region from the external to the internal prepuce is the most sensitive region of the uncircumcised penis and more sensitive than the most sensitive region of the circumcised penis. Circumcision ablates the most sensitive parts of the penis.”
+ History of circumcision
Excerpt: “The medical history of circumcision in the United States properly begins in New York on 9 February 1870. That morning Dr. Lewis A. Sayre was summoned by a colleague, the eminent New York gynecologist James Marion Sims, to consult on a perplexing case…After he examined the patient though, Sayre concluded that ‘the deformity was due to paralysis and not contraction, and it was therefore necessary to restore vitality to the partially paralyzed extensor muscles, rather than to cut the apparently contracted flexors.’ But the cause of this paralysis was a mystery….Pondering this information, Sayre suddenly imagined that he knew the source of the boy's problem. ‘As excessive venery is a fruitful source of physical prostration and nervous exhaustion, sometimes producing paralysis,’ he explained afterward, ‘I was disposed to look upon this case in the same light, and recommended circumcision as a means of relieving the irritated and imprisoned penis.’…
In the months that followed, Sayre hypothesized that irritation of the genitals was the source of many varieties of paralysis and hip-joint disease which stubbornly defied conventional treatments.”
+ Human Immunodeficiency Virus (HIV) / AIDS
Excerpt: "For more than a decade, the most powerful organizations in global health have pushed an American-style, universal War on the Human Foreskin, citing the scourge of HIV across the African continent as the target of its furor. Utilizing the notoriously controversial strategy of prophylactic, non-therapeutic circumcision, this effort has left its mark on millions of boys and men. Public initiatives, as they relate to combatting the HIV epidemic, have included policy directives and massive investments in the proliferation of male circumcision campaigns. These operations have promoted the circumcision of adult men in a voluntary capacity, semi-voluntarily for teenagers, and involuntarily for infants and children. Their influence has spread throughout Sub-Saharan Africa, the United States, and more recently, beyond. But how did this all begin?"
Abstract: “In 2007, WHO/UNAIDS recommended male circumcision as an HIV-preventive measure based on three sub-Saharan African randomised clinical trials (RCTs) into female-to-male sexual transmission. A related RCT investigated male-to-female transmission. However, the trials were compromised by inadequate equipoise; selection bias; inadequate blinding; problematic randomisation; trials stopped early with exaggerated treatment effects; and not investigating non-sexual transmission. Several questions remain unanswered. Why were the trials carried out in countries where more intact men were HIV-positive than in those where more circumcised men were HIV-positive? Why were men sampled from specific ethnic subgroups? Why were so many participants lost to follow-up? Why did men in the male circumcision groups receive additional counselling on safe sex practices? While the absolute reduction in HIV transmission associated with male circumcision across the three female-to-male trials was only about 1.3%, relative reduction was reported as 60%, but, after correction for lead-time bias, averaged 49%. In the Kenyan trial, male circumcision appears to have been associated with four new incident infections. In the Ugandan male-to-female trial, there appears to have been a 61% relative increase in HIV infection among female partners of HIV-positive circumcised men. Since male circumcision diverts resources from known preventive measures and increases risk-taking behaviours, any long-term benefit in reducing HIV transmission remains uncertain.”
Excerpt: "Further research is required to assess the feasibility, desirability and cost-effectiveness of circumcision to reduce the acquisition of HIV. This paper endorses the need for such research and suggests that, in its absence, it is premature to promote circumcision as a reliable strategy for combating HIV. Since articles in leading medical journals as well as the popular press continue to do so, scientific researchers should think carefully about how their conclusions may be translated both to policy makers and to a more general audience. The importance of addressing ethico-legal concerns that such trials may raise is highlighted. The understandable haste to find a solution to the HIV pandemic means that the promise offered by preliminary and specific research studies may be overstated. This may mean that ethical concerns are marginalized. Such haste may also obscure the need to be attentive to local cultural sensitivities, which vary from one African region to another, in formulating policy concerning circumcision."
Abstract: "Whether male circumcision in infancy or childhood provides protection against the acquisition of human immunodeficiency virus (HIV) or other sexually transmitted infections (STIs) in adulthood remains to be established. In the first national cohort study to address this issue, we identified 810,719 non-Muslim males born in Denmark between 1977 and 2003 and followed them over the age span 0-36 years between 1977 and 2013. We obtained information about cohort members' non-therapeutic circumcisions, HIV diagnoses and other STI outcomes from national health registers and used Cox proportional hazards regression analyses to calculate hazard ratios (HRs) with 95% confidence intervals (CIs) associated with foreskin status (i.e., circumcised v. genitally intact). During a mean of 22 years of follow-up, amounting to a total observation period of 17.7 million person-years, 3375 cohort members (0.42%) underwent non-therapeutic circumcision, and 8531 (1.05%) received hospital care for HIV or other STIs. Compared with genitally intact males, rates among circumcised males were not statistically significantly reduced for any specific STI. Indeed, circumcised males had a 53% higher rate of STIs overall (HR = 1.53, 95% CI: 1.24-1.89), and rates were statistically significantly increased for anogenital warts (74 cases in circumcised males v. 7151 cases in intact males, HR = 1.51; 95% CI: 1.20-1.90) and syphilis (four cases in circumcised males v. 197 cases in intact males, HR = 3.32; 95% CI: 1.23-8.95). In this national cohort study spanning more than three decades of observation, non-therapeutic circumcision in infancy or childhood did not appear to provide protection against HIV or other STIs in males up to the age of 36 years. Rather, non-therapeutic circumcision was associated with higher STI rates overall, particularly for anogenital warts and syphilis."
Abstract: “The study analysed the HIV/AIDS situation in Zambia six years after the onset of mass campaigns of Voluntary Medical Male Circumcision (VMMC). The analysis was based on data from Demographic and Health Surveys (DHS) conducted in 2001, 2007 and 2013. Results show that HIV prevalence among men aged 15–29 (the target group for VMMC) did not decrease over the period, despite a decline in HIV prevalence among women of the same age group (most of their partners). Correlations between male circumcision and HIV prevalence were positive for a variety of socioeconomic groups (urban residence, province of residence, level of education, ethnicity). In a multivariate analysis, based on the 2013 DHS survey, circumcised men were found to have the same level of infection as uncircumcised men, after controlling for age, sexual behaviour and socioeconomic status. Lastly, circumcised men tended to have somewhat riskier sexual behaviour than uncircumcised men. This study, based on large representative samples of the Zambian population, questions the current strategy of mass circumcision campaigns in southern and eastern Africa.”
Excerpt: "An article endorsed by thirty-two professionals questions the results of three highly publicized African circumcision studies. The studies claim that circumcision reduces HIV transmission, and they are being used to promote circumcisions. Substantial evidence in this article refutes the claim of the studies. Examples in the article include the following: 1 . Circumcision is associated with increased transmission of HIV to women. 2 . Conditions for the studies were unlike conditions found in real-world settings. 3 . Other studies show that male circumcision is not associated with reduced HIV transmission. 4 . The U.S. has a high rate of HIV infection and a high rate of circumcision. Other countries have low rates of circumcision and low rates of HIV infection. 5 . Condoms are 95 times more cost effective in preventing HIV transmission. Circumcision removes healthy, functioning, unique tissue, raising ethical considerations."
Excerpt: "The push to institute mass circumcision in Africa, following the three randomized clinical trials (RCTs) conducted in Africa, is based on an incomplete evaluation of real-world preventive effects over the long-term – effects that may be quite different outside the research setting and circumstances, with their access to resources, sanitary standards and intensive counseling. Moreover, proposals for mass circumcision lack a thorough and objective consideration of costs in relation to hoped-for benefits. No field-test has been performed to evaluate the effectiveness, complications, personnel requirements, costs and practicality of proposed approaches in real-life conditions. These are the classic distinctions between efficacy and effectiveness trials, and between internal validity and external validity.
Campaigns to promote safe-sex behaviors have been shown to accomplish a high rate of infection reduction, without the surgical risks and complications of circumcision, and at a much lower cost. For the health community to rush to recommend a program based on incomplete evidence is both premature and ill-advised. It misleads the public by promoting false hope from uncertain conclusions and might ultimately aggravate the problem by altering people’s behavioral patterns and exposing them and their partners to new or expanded risks. Given these problems, circumcision of adults, and especially of children, by coercion or by false hope, raises human rights concerns."
Conclusion: "The findings suggest that behavior change programs are more efficient and cost effective than circumcision. Providing free condoms is estimated to be significantly less costly, more effective in comparison to circumcising, and at least 95 times more cost effective at stopping the spread of HIV in Sub-Saharan Africa. In addition, condom usage provides protection for women as well as men. This is significant in an area where almost 61% of adults living with AIDS are women."
Conclusion: “Circumcision prevalence was higher among black MSM than among Latino MSM. Circumcised MSM in both racial/ethnic groups were more likely than uncircumcised MSM to be born in the United States or to have a US-born parent. Circumcision status was not associated with prevalent HIV infection among Latino MSM, black MSM, black bisexual men, or black or Latino men who reported being HIV-negative based on their last HIV test. Further, circumcision was not associated with a reduced likelihood of HIV infection among men who had engaged in unprotected insertive and not unprotected receptive anal sex...In these cross-sectional data, there was no evidence that being circumcised was protective against HIV infection among black MSM or Latino MSM.”
Summary: "In heterosexual men, the penis is the primary site of Human Immunodeficiency Virus (HIV) acquisition. Levels of inflammatory cytokines in the coronal sulcus are associated with an increased HIV risk, and we hypothesized that these may be altered after insertive penile sex. Therefore, we designed the Sex, Couples and Science Study (SECS study) to define the impact of penile-vaginal sex on the penile immune correlates of HIV susceptibility. We found that multiple coronal sulcus cytokines increased dramatically and rapidly after sex, regardless of condom use, with a return to baseline levels by 72 hours. The changes observed after condomless sex were strongly predicted by cytokine concentrations in the vaginal secretions of the female partner, and were similar in circumcised and uncircumcised men. We believe that these findings have important implications for understanding the immunopathogenesis of penile HIV acquisition; in addition, they have important implications for the design of clinical studies of penile HIV acquisition and prevention."
Excerpt: “Randomized trials from Africa demonstrate that circumcision reduces the risk of acquiring HIV among males. However, few studies have examined this association in Western populations. We sought to evaluate the association between circumcision and the risk of acquiring HIV among males from Ontario, Canada. We found that circumcision was not independently associated with the risk of acquiring HIV among males from Ontario, Canada. Our results are consistent with clinical guidelines that emphasize safe-sex practices and counselling over circumcision as an intervention to reduce the risk of HIV.”
+ Legal issues surrounding circumcision
Introduction: "An important, divisive, and unanswered question of American law – and indeed of international law – is whether it is legal to circumcise healthy boys. American medical associations and experts assert that circumcision is a common, safe, and relatively painless procedure with many medical benefits that exceed the risks. They argue that insurance should pay for it. Some religious organizations argue that circumcision is a sacred religious ritual. In any event, proponents claim that parents have a general and religious right to make the circumcision decision. They can point to the fact that no physician has ever been held liable by an American court for a properly performed circumcision. Legal scholars, foreign medical associations, intactivist organizations, and increasing numbers of men claim the opposite, namely that circumcision is painful, risky, harmful, irreversible surgery that benefits few men, if any. These opponents of circumcision argue that, in any event, boys have a right to be left genitally intact, like girls under federal law, and to make the circumcision decision for themselves as adults. These opponents of circumcision can point to a June 2012 decision by a court in Cologne, Germany, which held that non therapeutic circumcision for religious reasons is criminal assault. The German court reasoned that circumcision causes grievous bodily harm, and that boys have a fundamental right to genital integrity that supersedes their parents’ religious rights. Thus, a battle is unfolding in courts and legislatures as to the legality of circumcision. Amidst all of the divisiveness and hyperbole, we need to ask, what are the relevant facts, legal issues, and what is the applicable law?"
Excerpt: "This Article suggests that non-therapeutic male circumcision or male genital cutting (MGC), the irreversible removal of the foreskin from the penises of healthy boys, is not only unlawful in the United States but also fraudulent. As a German court held in 2012 before its ruling was effectively overturned by a special statute under political pressure, circumcision for religious or non-medical reasons is harmful, violates the child’s rights to bodily integrity and self-determination (which supersedes competing parental rights), and constitutes criminal assault. MGC also violates the child’s rights under U.S. law, and it constitutes a battery, a tort and a crime, and statutory child abuse. Building upon a 2016 case in the United Kingdom, we make the novel suggestion that when performed by a physician, MGC is a breach of trust or fiduciary duty, and hence constructive fraud, where courts impute fraud even if intent to defraud is absent. We reprise and build upon the argument that it is unlawful and Medicaid fraud for physicians and hospitals to bill Medicaid for unnecessary genital surgery. Finally, we suggest that MGC constitutes intentional fraud by the American Academy of Pediatrics (AAP) and most physicians who perform circumcisions in the United States. They have long portrayed MGC as medicine when it is violence, and as a parental right when males have the right to keep their penile foreskin, and physicians are not allowed to take orders from parents to perform unnecessary genital surgery on children. Various aspects of potential litigation would be favorable to the plaintiffs. Hence, we conclude that MGC exposes physicians, hospitals, and the AAP to large and possibly uninsured liability."
Abstract: “We are witnessing a disturbing tend to ‘enshrine’ male circumcision into law, shielding the practice from health and safety regulation of any kind. This trend precedes any honest attempt to assess ‘morbidity,’ the unavoidable complications of any surgery, especially poignant for this unregulated and pre-germ-theory practice. Without a thorough assessment of morbidity, all bioethical discussions are logically, premature. The author details a ‘permissive and incautious’ milieu, including a lack of qualifications for circumcisers, rudimentary training, septic non-clinical settings, withheld anesthesia and analgesia, sub-optimal surgical protocols, a lack of back-up resources, minimal post-operative observation, minimal legal remedies, and other shortcomings. It is argued that serious inquiry must ethically precede blanket legal protections accommodating atavistic adult urges.”
+ Pain
(See also “Psychological Implications”)
Summary: “Circumcision is a painful procedure frequently performed on newborn baby boys without using pain relief. Available treatments include dorsal penile nerve block (DPNB), which involves injecting anesthetic at the base of the penis. Ring block is another form of penile block. Locally applied anesthetic creams include EMLA, a water‐based cream including lidocaine and prilocaine. Based on 35 clinical trials involving 1,997 newborns, it can be concluded that DPNB and EMLA do not eliminate circumcision pain, but are both more effective than placebo or no treatment in diminishing it. Compared head to head, DPNB is substantially more effective than EMLA cream. Ring block and lidocaine creams other than EMLA also reduced pain but did not eliminate it. Trials of oral acetaminophen, sugar solutions, pacifiers, music, and other environmental modifications to reduce circumcision pain did not prove them effective.”
Abstract: "The prevention of pain in neonates should be the goal of all pediatricians and health care professionals who work with neonates, not only because it is ethical but also because repeated painful exposures have the potential for deleterious consequences. Neonates at greatest risk of neurodevelopmental impairment as a result of preterm birth (ie, the smallest and sickest) are also those most likely to be exposed to the greatest number of painful stimuli in the NICU. Although there are major gaps in knowledge regarding the most effective way to prevent and relieve pain in neonates, proven and safe therapies are currently underused for routine minor, yet painful procedures. Therefore, every health care facility caring for neonates should implement (1) a pain-prevention program that includes strategies for minimizing the number of painful procedures performed and (2) a pain assessment and management plan that includes routine assessment of pain, pharmacologic and nonpharmacologic therapies for the prevention of pain associated with routine minor procedures, and measures for minimizing pain associated with surgery and other major procedures."
Abstract: "Limited understanding of infant pain has led to its lack of recognition in clinical practice. While the network of brain regions that encode the affective and sensory aspects of adult pain are well described, the brain structures involved in infant nociceptive processing are less well known, meaning little can be inferred about the nature of the infant pain experience. Using fMRI we identified the network of brain regions that are active following acute noxious stimulation in newborn infants, and compared the activity to that observed in adults. Significant infant brain activity was observed in 18 of the 20 active adult brain regions but not in the infant amygdala or orbitofrontal cortex. Brain regions that encode sensory and affective components of pain are active in infants, suggesting that the infant pain experience closely resembles that seen in adults. This highlights the importance of developing effective pain management strategies in this vulnerable population."
Conclusion: “Neonates in both groups showed significant increases in heart rate, respiratory rate, and crying during circumcision with no clinically significant differences observed between the groups. Postoperative comfort scores showed no significant differences between the groups until the 360-minute postoperative assessment, at which time the acetaminophen group had significantly improved scores. Feeding behavior deteriorated in breast- and bottle-fed neonates in both groups, and acetaminophen did not seem to influence this deterioration...This study confirms that circumcision of the newborn causes severe and persistent pain. Acetaminophen was not found to ameliorate either the intra-operative or the immediate postoperative pain of circumcision, although it seems that it may provide some benefit after the immediate postoperative period.”
Excerpts: “Circumcision patients showed the lowest efficacy of EMLA cream as the majority (~80%) required some form of further anesthesia until the completion of the procedure...The topical anesthetic EMLA cream is a useful, efficient and safe tool for minor surgical procedures of the penis at the office setting, with the exception of circumcision, where an additional type of anesthesia is likely to be necessary.”
Excerpt: "Newborns in the untreated placebo group exhibited homogeneous responses that consisted of sustained elevation of heart rate and high-pitched cry throughout the circumcision and following. Two newborns in the placebo group became ill following circumcision (choking and apnea). The 3 treatment groups all had significantly less crying and lower heart rates during and following circumcision compared with the untreated group. The ring block was equally effective through all stages of the circumcision, whereas the dorsal penile nerve block and EMLA were not effective during foreskin separation and incision. Methemoglobin levels were highest in the EMLA group…"
Abstract: "Eleven male newborns were circumcised with a local dorsal penile nerve block, and 13 controls were circumcised without anesthetic. Matched pairs of pre- and postcircumcision cortisol levels in the two groups were compared. The adrenal cortisol response to surgery was not significantly reduced by the administration of lidocaine. Blood sampling and anesthetic injection of venipuncture alone did not evoke the adrenal response in uncircumcised control infants. Cortical input or secondary epinephrine elevation may be producing the cortisol elevation in infants despite regional blockage of the afferent nerve pathways."
+ Parental decision making
Abstract: “It is important that expectant parents receive accurate information about the benefits and risks of circumcision as well as the benefits and risks of having an intact foreskin when making a decision about routine infant circumcision (RIC). A pilot study was conducted using the shared decision making (SDM) conceptual model to guide expectant parents through a 3-phase decision-making program about RIC as part of their childbirth education class. The participants showed a high level of preparedness following each of the 3 phases. Preparedness score were highest for those who decided to keep their expected sons’ penises natural. This SDM program was an effective way of guiding expectant parents through the decision-making process for RIC.”
Excerpt: “Elective circumcision in newborns has always been a controversial issue. The purpose of this study was to determine whether personal factors play a role when physicians provide advice to parents regarding elective circumcisions in infants…Although most respondents stated that they based their decisions on medical evidence, the circumcision status of, especially, the male respondents played a huge role in whether they were in support of circumcisions or not. Another factor that had an influence was the circumcision status of the respondents’ sons.”
Conclusion: “Despite new medical information and updated stances from various medical associations, newborn male circumcision rates continue to be heavily influenced by the circumcision status of the child's father.”
Excerpt: “Nurses were most likely to be the first HCPs to ask parents about circumcision. Parental personal and cultural beliefs played an equal or more important role in influencing decision making than medical information received. However, some parents noted that there was a lack of access to accurate information regarding risks and benefits of male circumcision.”
+ Penile cancer
(see also “Sexually Transmitted Infections”)
“Circumcised participants in a study presented at the annual meeting of the American Urological Association were twice as likely as their uncircumcised counterparts to have either of two HPV strains associated with penile cancer, researchers said. Their findings are not consistent with previous research. ‘Classically, circumcision has been shown to be protective against HPV infection and ... we’re not completely sure why, but there was a higher rate of these higher-risk HPV infections in men who are circumcised,’ study researcher Mickey Daugherty, MD, a urology resident at the State University of New York Upstate Medical University, told Infectious Disease News.”
Excerpt: “Using data from the Danish Cancer Registry we investigated the long term trends in the incidence of penis cancer in a virtually uncircumcised population…It seems plausible that better penile hygiene resulting from this improvement in sanitary installations might have contributed to the observed trend [of a decrease in penile cancer].”
+ Prevalence of circumcision
Excerpt: "Across the 32-year period from 1979 through 2010, the national rate of newborn circumcision declined 10% overall, from 64.5% to 58.3% (Table and Figure 1). During this time, the overall percentage of newborns circumcised during their birth hospitalization was highest in 1981 at 64.9%, and lowest in 2007 at 55.4%. However, rates fluctuated during this period, generally declining during the 1980s, rising in the 1990s, and declining again in the early years of the 21st century. These changes occurred during a period of changing guidance on routine newborn circumcision. For example, American Academy of Pediatrics’ (AAP) task force reports during the 1970s (1,2) stated there was no medical indication for routine circumcision of the newborn; AAP revised its position in 1989 (3), stating there were potential medical benefits to newborn circumcision; and then in 1999 (4), an AAP policy statement said that, despite potential medical benefits of newborn male circumcision, there was insufficient evidence to recommend routine circumcision of newborns."
(Note from Your Whole Baby: Global and regional statistics regarding male genital cutting rates are imprecise and in short supply for many reasons. We've included this resource because few others exist, even though the numbers are from the early 2000s and the document itself does not stress the harms and risks of circumcision.)
+ Psychological implications
(See also “Pain”)
Excerpt: "While vaginal dryness is considered an indicator for female sexual arousal disorder, male circumcision may exacerbate female vaginal dryness during intercourse. O'Hara and O'Hara reported that women who had experienced coitus with both intact and circumcised men preferred intact partners by a ratio of 8.6 to one. Most women (85.5%) in that survey reported that they were more likely to experience orgasm with a genitally intact partner: They [surveyed women] were also more likely to report that vaginal secretions lessened as coitus progressed with their circumcised partners (16.75, 6.88–40.77)."
Excerpt: "Infant male circumcision continues despite growing questions about its medical justification. As usually performed without analgesia or anaesthetic, circumcision is observably painful. It is likely that genital cutting has physical, sexual and psychological consequences, too. Some studies link involuntary male circumcision with a range of negative emotions and even post-traumatic stress disorder (PTSD). Some circumcised men have described their current feelings in the language of violation, torture, mutilation and sexual assault. In view of the acute as well as long-term risks from circumcision and the legal liabilities that might arise, it is timely for health professionals and scientists to re-examine the evidence on this issue and participate in the debate about the advisability of this surgical procedure on unconsenting minors."
Excerpt: "Male circumcision – the surgical removal of the foreskin of the penis – has long been a contested practice in Anglo‐American countries. Competing beliefs about pain as potentially redemptive and as essentially malign have fueled the controversy, with medical professionals and lay people alike debating whether circumcision causes or ameliorates physical or emotional pain, as well as how to respond to that pain. Because circumcision is a surgical intervention performed on bodies that are physiologically male, arguments about circumcision and pain have been indelibly shaped by changing cultural beliefs about boys, men and masculinity – beliefs which have informed approaches to circumcision and pain in turn."
Excerpt: "A poll of circumcised men published in the British Journal of Urology describes adverse outcomes on men’s health and well-being. Findings showed wide-ranging physical, sexual, and psychological consequences. Some respondents reported prominent scarring and excessive skin loss. Sexual consequences included progressive loss of sensitivity and sexual dysfunction. Emotional distress followed the realization that they were missing a functioning part of their penis. Low-self esteem, resentment, avoidance of intimacy, and depression were also noted."
Excerpt: "A questionnaire was used to study the sexuality of men circumcised as adults compared to uncircumcised men, and to compare their sex lives before and after circumcision. The study included 373 sexually active men, of whom 255 were circumcised and 118 were not. Of the 255 circumcised men, 138 had been sexually active before circumcision, and all were circumcised at >20 years of age. Masturbatory pleasure decreased after circumcision in 48% of the respondents, while 8% reported increased pleasure. Masturbatory difficulty increased after circumcision in 63% of the respondents but was easier in 37%. About 6% answered that their sex lives improved, while 20% reported a worse sex life after circumcision. There was a decrease in masturbatory pleasure and sexual enjoyment after circumcision, indicating that adult circumcision adversely affects sexual function in many men, possibly because of complications of the surgery and a loss of nerve endings."
Conclusion: "Our findings resonate with the existing literature suggesting links between altered emotional processing in circumcised men and neonatal stress. Consistent with longitudinal studies on infant attachment, early circumcision might have an impact on adult socio-affective traits or behavior."
Excerpt: "A survey of women who have had sexual experience with circumcised and anatomically complete partners showed that the anatomically complete penis was preferred over the circumcised penis. Without the foreskin to provide a movable sleeve of skin, intercourse with a circumcised penis resulted in female discomfort from increased friction, abrasion, and loss of natural secretions. Respondents overwhelmingly concurred that the mechanics of coitus were different for the two groups of men. Unaltered men tended to thrust more gently with shorter strokes."
Excerpt: "Using four case examples that are typical among his clients, a practicing psychiatrist presents clinical findings regarding the serious and sometimes disabling long-term somatic, emotional, and psychological consequences of infant circumcision in adult men. These consequences resemble complex post-traumatic stress disorder and emerge during psychotherapy focused on the resolution of perinatal and developmental trauma. Adult symptoms associated with circumcision trauma include shyness, anger, fear, powerlessness, distrust, low self-esteem, relationship difficulties, and sexual shame. Long-term psychotherapy dealing with early trauma resolution appears to be effective in healing these consequences."
Summary: “Preliminary studies suggested that pain experienced by infants in the neonatal period may have long-lasting effects on future infant behaviour. The objectives of this study were to find out whether neonatal circumcision altered pain response at 4-month or 6-month vaccination compared with the response in uncircumcised infants… [The study demonstrated that] circumcised infants showed a stronger pain response to subsequent routine vaccination than uncircumcised infants.”
+ Sexually transmitted infections (STIs)
(See also “Penile Cancer” and “HIV” sections)
Discussion: “While the number of confounding factors and the inability to perform a random, double-blind, prospective trial make assessing the role of circumcision in STD acquisition difficult, there is no clear evidence that circumcision prevents STDs. The only consistent trend is that uncircumcised males may be more susceptible to GUD, while circumcised men are more prone to urethritis. Currently, in the developed nations, urethritis is more common than GUD. In summary, the medical literature does not support the theory that circumcision prevents STDs.”
Abstract: “The claim that circumcision reduces the risk of sexually transmitted infections has been repeated so frequently that many believe it is true. A systematic review and meta-analyses were performed on studies of genital discharge syndrome versus genital ulcerative disease, genital discharge syndrome, nonspecific urethritis, gonorrhea, chlamydia, genital ulcerative disease, chancroid, syphilis, herpes simplex virus, human papillomavirus, and contracting a sexually transmitted infection of any type. Chlamydia, gonorrhea, genital herpes, and human papillomavirus are not significantly impacted by circumcision. Syphilis showed mixed results with studies of prevalence suggesting intact men were at great risk and studies of incidence suggesting the opposite. Intact men appear to be of greater risk for genital ulcerative disease while at lower risk for genital discharge syndrome, nonspecific urethritis, genital warts, and the overall risk of any sexually transmitted infection. In studies of general populations, there is no clear or consistent positive impact of circumcision on the risk of individual sexually transmitted infections. Consequently, the prevention of sexually transmitted infections cannot rationally be interpreted as a benefit of circumcision, and any policy of circumcision for the general population to prevent sexually transmitted infections is not supported by the evidence in the medical literature.”
+ Urinary tract infections (UTIs)
Conclusion: “Previously reported differences in the rate of urinary tract infection by circumcision status could be entirely due to sampling and selection bias. Until clinical studies adequately control for sources of bias, circumcision should not be recommended as a preventive for urinary tract infection.”
From summary: “Although limited data from previous studies have shown that this intervention might be beneficial, questions regarding the safety and effectiveness of routine neonatal circumcision for the prevention of UTIs in infancy remain unanswered…The evidence from this review does not at present allow confident decision‐making about the use of routine neonatal circumcision for prevention of UTI in infancy, since there were no included studies in the review.”
Conclusion: “Given a risk in normal boys of about 1%, the number needed-to-treat to prevent one UTI is 111. In boys with recurrent UTI or high grade vesicoureteral reflux, the risk of UTI recurrence is 10% and 30% and the numbers-needed-to-treat are 11 and 4, respectively. Hemorrhage and infection are the commonest complications of circumcision, occurring at rate of about 2%.”
+ Vulvar/vaginal cutting — overlapping issues
Abstract: "In this chapter, we contrast legal and ethical perspectives on two forms of nontherapeutic female genital cutting: those commonly known as “female genital mutilation” and those commonly known as “female genital cosmetic surgeries.” We begin by questioning the usefulness of these categories—and the presumed distinctions upon which they rest— stressing the shared features of the two sets of practices. Taking UK legislation as a case study, we show that there are troubling inconsistencies in the way in which female genital cutting is understood in Western contexts. Specifically: (a) all nontherapeutic genital alterations to female minors are criminalised, typically with harsh penalties for transgressing the law, while even more invasive nontherapeutic genital alterations to male and intersex minors are permitted and almost entirely unregulated; and (b) genital alterations of adult women regarded as “cosmetic” in nature are treated as legal, while in some jurisdictions, anatomically identical procedures classified as “mutilation” are illegal. This chapter highlights these and other inconsistencies, speculates as to why they arise in Western contexts, and explores the scope for more consistent and constructive attitudes and legislation."
Abstract: "In recent years, the dominant Western discourse on “female genital mutilation” (FGM) has increasingly been challenged by scholars. Numerous researchers contest both the terminology used and the empirical claims made in what has come to be called “the standard tale” of FGM (also termed “female genital cutting” [FGC]). The World Health Organization (WHO), a major player in setting the global agenda on this issue, maintains that all medically unnecessary cutting of the external female genitalia, no matter how slight, should be banned as torture and a violation of the human right to bodily integrity. However, the WHO targets only non-Western forms of female-only genital cutting, raising concerns about gender bias and cultural imperialism. Here, we summarize ongoing critiques of the WHO’s terminology, ethicolegal assumptions, and empirical claims, including the claim that non-Western FGC as such constitutes an extreme form of discrimination against women. To this end, we highlight recent comparative studies of medically unnecessary genital cutting of all types, including those affecting adult women and teenagers in Western societies, individuals with differences of sex development (DSD), transgender persons, and males. In so doing, we attempt to clarify the grounds for a growing critical consensus that current anti-FGM laws and policies may be ethically incoherent, empirically unsupportable, and legally unsustainable."
Have you read or conducted a study not listed here about the harms of penile circumcision or the functions of foreskin? Write us: prerna@yourwholebaby.org
