Time for U.S. Parents to Reconsider the Acceptability of Infant Male Circumcision

What many Americans are not aware of, however, is the fact that the United States is not just unusual, but actually unique among developed nations in finding such widespread medical support for infant male circumcision.
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Do the benefits of male circumcision outweigh the risks? The U.S. Centers for Disease Control -- echoing the 2012 policy statement of the American Academy of Pediatrics -- have recently suggested that they do. What many Americans are not aware of, however, is the fact that the United States is not just unusual, but actually unique among developed nations in finding such widespread medical support for infant male circumcision. This support originated in the late 1800s, when doctors promoted the operation as a "cure" for masturbation; today it comes primarily from doctors' trade associations -- such as the AAP -- that protect financial and other interests of physicians who continue to perform such surgeries. Doctors in peer nations, by contrast, along with the medical associations that represent them, tend to see the U.S. circumcision ritual as more of a cultural habit, not something rooted in sound medical science.

Circumcision removes a substantial part of the penis, which is not just "a piece of skin." The foreskin is a specialized, retractable sleeve of erogenous tissue that protects the head of the penis, can be manipulated during sex and masturbation, and amounts to about 50 square centimeters in the adult male. In recent years, more and more circumcised men have begun speaking out in favor of leaving baby boys' penises intact. According to one recent poll, fully 10 percent of circumcised U.S. men wish they had not been circumcised. Many argue that future generations of boys and men should have the chance to decide for themselves whether something as significant and personal as an irreversible surgery on their sexual organ is what they really want, when they reach an age of understanding.

But doesn't circumcision promote health and hygiene, as the AAP and CDC suggest? The short answer is no. In fact, only one health claim is even potentially relevant to young boys in western countries: the claim that circumcised newborns may have an approximately 1 percent lower absolute risk of getting a urinary tract infection in the first 1-2 years of life. One possible explanation might be the distinctly American habit of trying to retract young boys' foreskins in order to wash their penises -- a practice that should never be done, because retraction is unnecessary for proper hygiene in infants and can cause small tears, which may increase the risk of infection. But even if this "circumcision protects against UTIs" claim is accepted, approximately 100 circumcisions would have to be performed to prevent just one urinary tract infection. Compare this to girls, who get urinary tract infections far more frequently than boys do: no one proposes that we remove their labia or their clitoral hood in infancy. We just prescribe antibiotics, when necessary.

All of the other claimed health benefits apply to adolescents and men after their sexual debut. Consider penile cancer. A reduced risk of this disease is a favorite argument used in support of circumcision. But penile cancer only develops in older men, and is so rare in Western countries that it would take between 900 and more than 300,000 circumcisions according to some estimates - with all the associated risks of surgery - to prevent just one case.

Other claimed benefits of circumcision, including a lowered risk of HIV and sexually transmitted infections, are based on studies of adult men -- not infants -- undergoing circumcisions in poor, African countries. Making health policies for newborn boys in the United States based on studies of adult males in Africa is scientifically unjustified. The situation in Europe, where most men are not circumcised, provides an important insight: all of the diseases that circumcision is claimed to prevent are about equally or even less common there than in the United States. For example, the prevalence of HIV/AIDS in the United States, where most men are circumcised, is 2-6 times higher than in non-circumcising countries of Northern Europe. While there are many cultural and other variables that play into these differences, the point is that the percentage of excised foreskins in a given population is far from the most relevant factor.

Some people claim that circumcision does not affect sexual function or satisfaction. But this, too, is based on studies of African men circumcised in adulthood, not infancy. Because of the limited follow-up in the African studies, we still don't know what these men will say about their sexual experiences as they get older, potentially finding that their penises are less and less responsive to touch over time, due to the removal of erogenous tissue and the gradual desensitization of the now-unprotected glans. Indeed, studies from western countries do suggest that circumcision is associated with an increased risk of adverse sexual experiences, which even the CDC has recently acknowledged. Curiously, however, the CDC failed to mention this important finding in their newly proposed federal recommendations, made public in December of 2014.

What about complications? It is often said that these are "low" for circumcision, but there are at least two problems with this. First, research into complications is surprisingly superficial: there is no systematic mechanism in place to collect data on complications, and some problems (like the removal of too much tissue to allow for a normal erection) may take years to develop or recognize -- so they will never be recorded in an official database. Second, our tolerance for risk should be extremely low - in fact, close to zero - when we are talking about an unnecessary surgery performed on a healthy individual before he can provide his consent. Each year, thousands of U.S. boys undergo reparative penile surgery for complications. Clinical studies show that somewhere between 7 and 20 percent of newborn boys undergoing circumcision will develop a potentially serious complication called meatal stenosis, a narrowing of the urethral opening on the tip of the penis that usually requires surgery. Ignoring this fact, both the CDC and the AAP rely on poor quality register data to conclude that there is less than a half-a-percent risk of complications in newborn boys. Judged from the frequency of meatal stenosis alone, this estimate is likely to be at least 14 times too low.

Although it may be uncomfortable to think about, most parents don't know that the foreskin is fused to the head of the penis at birth as part of its function to keep out contaminants. So before the doctor can cut it off, he or she has to forcefully separate the foreskin by inserting a probe between it and the glans and then scrape it all the way around. This is why the penile head has such a bloody appearance in newly circumcised infants. Studies have shown that this early step is particularly painful -- only to be followed by the clamping and cutting parts of the circumcision procedure. Even when a local anesthetic is used, it cannot fully eliminate the procedural pain. Parents in one recent U.S. study reported varying levels of pain up to six weeks after the circumcision in more than two-thirds of newborn boys.

Based on both medical and ethical considerations, routine circumcision is not a sensible procedure in countries where individual rights (like the right to bodily integrity) are more than a political buzzword. Boys need cosmetic genital surgery no more than girls do. And keeping one's intact genitals healthy and clean is simple regardless of one's gender: mild soap and running water are all that is needed. Cutting off a functional, protective and sensitive body part is a far-reaching decision that the vast majority of Europeans believe should be left to its owner when he becomes old enough to understand the consequences. Despite the recent, backward-looking statements by U.S. medical organizations, more and more Americans are beginning to agree.

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