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Circumcision – Is it Still a Decision to Make?

If I ever want to liven up an antenatal class I always introduce the topic of circumcision (of boys, I hasten to add!). At this point the men usually wake up and enthusiastically express their opinions, without reservation. Sometimes there are quite heated disagreements between partners but it is usually the father-to-be, who is the most dogmatic, whilst the women are often unusually passive during the debate. Generally there is division of opinion between Americans (who support it) and the rest of the world, (who don’t) excluding, of course, those who practise circumcision for religious reasons, such as Jews and Muslims and a handful of non American men who were also circumcised when it was fashionable in the UK, Canada, Australia or wherever.

These fathers offer the argument that they have been circumcised and want their sons to be like them; but the most common reason given by those opting for circumcision is that they don’t want their son to be teased in the locker room. Well I’ve never been in a locker room (a men’s locker room, anyway) so I could be missing the point here, but it does seem a very strange reason to subject a small baby to a painful surgical procedure. In fact, thinking about it, the whole concept of cutting a little skin off the end of a penis seems unnatural, and this has led me to ask a number of questions.

What is Circumcision? Circumcision is a procedure, in which the skin, covering the end of the penis, is removed. This skin is called the foreskin and it protects and moistens the delicate glans (or tip) of the penis, when it is not erect. When the penis is erect the foreskin retracts. The foreskin is attached to the glans in newborns and, if left alone, in 80-90% of uncircumcised boys will gradually separate from the glans by 3 years of age. Once a penis has been circumcised the glans remains exposed, so that the red, round, tip of the penis is visible.

Where did Circumcision Originate? The first record of circumcision is in the Old Testament. God tells Abraham, “every male among you shall be circumcised. You shall circumcise the flesh of your foreskins and it shall be a sign of the covenant between me and you. Throughout your generations every male among you shall be circumcised when he is eight days old, including the slave born in your house…” (Gen 17 verses10-12). Note here that circumcision is a sign of a covenant with God and not, as many people have suggested about Old Testament circumcision, commanded as a reason to protect the penis from infection, whilst travelling. According to Edward Wallerstein (“Circumcision: An American Health Fallacy”) the circumcision decision is a cultural one. Historically people from Europe, The Soviet Union, Southeast Asia, China, Japan and Latin America do not routinely practise circumcision. Until about 100 years ago it was not customary in the English-speaking world but was introduced during the Victorian period as a way of curbing “hypersexuality, masturbation, rheumatism, asthma, epilepsy, cholera, feeble-mindedness, gout, alcoholism and lunacy”. In this English-speaking world circumcision rates increased rapidly until the 1940’s, and then, with the exception of USA, began to decline. Present rates are less than 1% for non-religious circumcision in the UK and New Zealand. Canadians are circumcising less than 20% of all infants born and Australians around10%. In the 1970’s more than 90% of babies were circumcised in the USA, today it is thought that numbers are around 64% and declining. The reason the circumcision rates remained high in the States was because the medical establishment believed that it provided health benefits. However within the last few years the American Academy of Pediatrcis has issued a policy statement declaring that routine neonatal circumcision is unwarranted by scientific evidence. The task force found that “existing scientific evidence demonstrates potential medical benefits of newborn circumcision; however, these data are not sufficient to recommend routine neonatal circumcision”. The task force also stressed that any benefits of the surgery are minor (Task Force on Circumcision. Circumcision policy statement. Pediatrics 1999; 103(3): 686-93). Many American insurance companies no longer cover routine neonatal circumcision in their health care packages.

The Operation Circumcision is one of the few operations that can be conducted by a variety of practitioners. In Hong Kong, for example, paediatricians, obstetricians, urologists and rabbis all carry out the operation. The baby is usually restrained on special apparatus, the penis cleaned and then sometimes a local anaesthetic is applied, to the base of the penis, to numb the area. The way the foreskin is cut varies between practitioners. Some doctors use a clamp to cut the foreskin or another method is to separate the foreskin from the glans with a probe. Then a plastic dome is applied to prevent blood circulating to the foreskin, which, after a few days, dies and falls off, along with the dome.

Is it Painful? As the operation is usually performed on newborn babies, it is impossible to conduct a consumer survey. However, The Task Force on Circumcision, mentioned above, cited evidence indicating that infants undergoing circumcision experience pain. Consequently the statement recommended the use of pain killing medication during the procedure. Most doctors in Hong Kong also prescribe post-operative medication for pain relief.

What Happens after the Operation? Whoever has performed the circumcision will give advice on how to care for the penis. This usually involves changing dressings and applying cream to the wound, to prevent the penis sticking to the nappy. The penis generally looks red and swollen for a few days following surgery and there may be a little bleeding for a few days. Wearing of double nappies whilst the penis is sore gives a little extra padding for protection. The baby is often unsettled and cries after urinating for the first 24 hours following surgery but the area is often fully healed and apparently pain free within a week.

Why Do Parents Choose to Circumcise their Baby Sons? These are some of the reasons why parents chose to have it done.

• Religious reasons. Jews and Muslims are the most well known faiths to practise it.

• Social Reasons. Parents want their son to look the same as everyone else and worry he will be teased if he looks different.

• Cultural Reasons. Following the tradition that other men in the family are circumcised.

• It’s more hygienic. As Dr Christopher Green says in “Babies” (Christopher Green.1989), “This was certainly true 2000 years ago. Now that we have showers, baths and running water, however, this just doesn’t wash (unless the family don’t believe in washing either).”

• Medical Reasons. As already described above, in 1999 The American Academy of Pediatrics overturned a 1989 statement which concluded that circumcision has both risks and benefits. The new task force stressed that any benefits of surgery are minor. Some of the possible benefits are reduced risks of: getting urinary tract infections; cancer of the penis (this is very rare even amongst non circumcised men); getting sexually transmitted diseases; and getting foreskin infections. Some studies indicate that circumcised men appear to be more resistant to HIV.

Circumcision is a non-reversible, permanent surgical procedure and parents should think carefully before conducting this on a baby, who cannot make a decision for himself. Parents who circumcise their baby for religious reasons are obviously doing so because of their faith but arguments for performing the operation for health benefits should be carefully considered. The British Medical Association has recently made its position on such things clear:

“The medical benefits previously claimed, however, have not been convincingly proven, and it is now widely accepted, including by the BMA, that this surgical procedure has medical and psychological risks. It is essential that Dr’s perform male circumcision only where this is demonstrably in the best interests of the child” (The law and ethics of male circumcision-Guidance for Doctors. BMA, March 2003).

Written by Yvonne Heavyside from The Family Zone.

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