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Evaluating Newborn Procedures: The Risks and Benefits of Circumcision

amy February 4, 2016

By: Amy Wood, Contributing Writer

When evaluating proposed medical interventions and procedures it can sometimes be difficult to know what questions to ask and what to consider, but a helpful acronym (BRAIN) has been developed to help us walk through this process. We can use this acronym to help us further evaluate circumcision.

Evaluating Newborn Procedures: The Risks and Benefits of Circumcision

B- Benefits- What Are the Benefits to This Procedure?

There are a few commonly claimed benefits to infant circumcision, let’s consider them:

Reduced Risk of Urinary Tract Infections

It is said that removing the foreskin reduces the risk of urinary tract infections during the first year of life. In the 1980’s Thomas Wiswell conducted a study which looked at hospital records of babies born in military hospitals and found a slightly lowered incidence of urinary tract infections in circumcised babies compared to intact babies.

This study has since been shown to have some major problems– it didn’t take into account other aspects which affect UTI risk, such as whether a baby was breastfed or not, whether a baby was premature or full term, and whether intact babies were being cared for properly or if their foreskins were being forcibly retracted. Common, though wrong, advice in the 1980’s instructed parents to pull back the foreskin to “ clean” the glans. In addition to being wrong, this advice is also harmful as it prematurely separates the foreskin from the glans, leaves small tears, and opens the door to infection.

In 1989 the AAP reviewed this information and stated that as a retrospective study it may have been methodologically flawed. In 2012 a group of doctors set out to determine the safety and effectiveness of routine circumcision for prevention of UTI’s during infancy, but they could not find any studies that were properly done and met their criteria.

The previously mentioned response to the AAP’s 2012 technical report confirmed the lack of appropriate studies, stating that “There are no randomized controlled trials (RCTs) linking UTIs to circumcision status.” They go on to say (emphasis mine):

“The evidence for clinically significant protection is weak, and with easy access to health care, deaths or long-term negative medical consequences of UTIs are rare. UTI incidence does not seem to be lower in the United States, with high circumcision rates compared with Europe with low circumcision rates, and the AAP report suggests it will take ∼100 circumcisions to prevent 1 case of UTI. Using reasonable European estimates cited in the AAP report for the frequency of surgical and postoperative complications (∼2%), for every 100 circumcisions, 1 case of UTI may be prevented at the cost of 2 cases of hemorrhage, infection, or, in rare instances, more severe outcomes or even death.

Another analysis of studies found that “net clinical benefit [of circumcision] is likely only in boys at high risk of UTI”, such as those with defects in their urinary system.

Furthermore, this idea demonstrates a lack of understanding as to what the foreskin is and implies that the foreskin itself is insignificant and lacks any meaningful function. The foreskin protects the urinary opening in males- it is fused to the glans at birth and the end of the foreskin functions as a sphincter which allows for the release of urine, yet keeps contaminants out. As a protective organ we would not expect its removal to decrease the risk of infection.

Any male, whether intact or circumcised, has a very low risk of getting a UTI in their first year or throughout their lifetime, especially in comparison to females, and such infections can be treated with antibiotics if they do occur. It is not considered good medical practice to remove a healthy body part in order to try and prevent an infection in that area of the body, especially when such infections can be easily treated. This is not how the rest of our body is treated.

Reduced Risk of Contracting STD’s, Including HIV

More recently it has been claimed that males who are circumcised are less likely to contract sexually transmitted diseases. The studies most commonly referred to regarding this aspect were done on adult males in Africa, and according to several evaluations, were not even done well. If the studies were done appropriately they found an absolute risk reduction of just 1.3%. These studies apply to African men in high risk HIV transmission areas, but whether this applies to males in America remains to be seen. It doesn’t apply to infants at all.

Currently (emphasis mine), “there is no evidence that circumcision, whether in infancy, childhood, or adulthood, is effective in preventing heterosexual transmission in countries where HIV prevalence is much lower and routes of transmission are different, such as Europe and the United States. Sexually transmitted HIV infections in the West occur predominantly among men who have sex with men, and there is no evidence that circumcision offers any protection against HIV acquisition in this group”.

After performing a systematic review of the relevant medical data, a urology journal concluded:
“[T]he prevention of sexually transmitted infection 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”.

Other studies and analyses find that whether one is circumcised or not has no bearing on his risk of contracting STD’s, including HIV.

Countries that do not practice circumcision have lower rates of STD’s than the US, where the vast majority of current adult males are circumcised. The US has one of the highest rates of STD’s among Western nations and we also have the highest rate of circumcised males.

Furthermore, we know of other safer, more effective, less invasive ways to protect against STD’s- such as abstaining from sex, being in a monogamous relationship with a person who does not have an STD, and using condoms. In fact, condoms provide a nearly 100% risk reduction for contracting STD’s and men need to use condoms to protect against such things regardless of whether they are circumcised or not.

Reduced Risk of Penile Cancer

It used to be thought that circumcision reduced the risk of developing penile cancer, but in 1996 The American Cancer Society released this statement:

“As representatives of the American Cancer Society, we would like to
discourage the American Academy of Pediatrics from promoting routine
circumcision as preventative measure for penile or cervical cancer.
The American Cancer Society does not consider routine circumcision
to be a valid or effective measure to prevent such cancers.

Research suggesting a pattern in the circumcision status of partners
of women with cervical cancer is methodologically flawed, outdated and
has not been taken seriously in the medical community for decades.

Likewise, research claiming a relationship between circumcision and
penile cancer is inconclusive. Penile cancer is an extremely rare
condition, effecting one in 200,000 men in the United States. Penile
cancer rates in countries which do not practice circumcision are lower
than those found in the United States. Fatalities caused by
circumcision accidents may approximate the mortality rate from penile
cancer.

Portraying routine circumcision as an effective means of prevention
distracts the public from the task of avoiding the behaviors proven to
contribute to penile and cervical cancer: especially cigarette smoking
and unprotected sexual relations with multiple partners. Perpetuating
the mistaken belief that circumcision prevents cancer is inappropriate.”

However, there is a connection between the foreskin and penile cancer as penile cancer is more common in men with phimosis, a rare condition affecting perhaps up to 2% of adult males, where the foreskin is very tight and can’t be retracted. Phimosis can be treated and corrected in many non-invasive ways, including applying topical steroid cream.

When phimosis is diagnosed and treated properly any benefit that circumcision is found to provide regarding the risk of penile cancer is reversed. The AAP states:
“[I]n men with an intact prepuce and no phimosis, there is a decreased risk of invasive penile cancer (OR: 0.5). When excluding phimosis, the risk disappears, which suggests that the benefit of circumcision is conferred by reducing the risk of phimosis and that the phimosis is responsible for the increased risk.” They also note that the rate of penile cancer has been declining both in the US and in countries that don’t practice infant circumcision and that this decline cannot be attributed to circumcision.

It is not likely that circumcision itself protects against penile cancer, but rather that phimosis- more common in men who are intact, but easily treated and corrected through non invasive measures- is what increases one’s risk of developing penile cancer.

Ease of Cleaning

It is said that it is easier to clean a circumcised penis than to clean one that has not been circumcised, but this again demonstrates a lack of understanding of penile anatomy.

A penis in its normal state requires no special care. When the foreskin is fused to the glans the penis is self-cleaning, similar to a girl’s vagina (we don’t have to scrub up inside the vagina). The only thing a parent needs to do for a baby is wipe the outside of his penis as needed during diaper changes and give him warm baths as usual. Basically you just leave the foreskin alone. A circumcised penis requires more care in the first several years of life than an intact penis.

When a boy gets older and his foreskin retracts- meaning he is able to pull it back to expose his glans- then all he needs to do is retract and rinse while showering. This takes a few seconds, but is in no way difficult.

Are There Any Contraindications to This Procedure?

There are many contraindications to circumcision, including family history of blood disorders, hypospadias and other penile abnormalities, ambiguous genitalia, and prematurity. A more extensive list of contraindications can be found here.

Levi Bathtime 3

 

R- Risks- Are There Any Risks Involved With This Procedure?

It is difficult to determine the true rate of complications from circumcision because often such complications are not reported in medical literature. Some studies only take into account immediate surgical risks and ignore longer term complications or issues that only arise later in life. Studies have found a large range of complication rates, ranging from under 1% to 3% to 20%.

It is commonly believed that circumcision is a safe procedure and that complications are rare, yet one pediatric urologist states that,
“In my practice, as a pediatric urologist, I manage the complications of neonatal circumcision. For example, in a two year period, I was referred over 275 newborns and toddlers with complications of neonatal circumcision. None of these were ‘revisions’ because of appearance, which I do not do. 45% required corrective surgery (minor as well as major, especially for amputative injury), whereupon some could be treated locally without surgery.

Complications of this unnecessary procedure are often not reported, but of 300 pediatric urologists in this country who have practices similar to mine… well, one can do the math to understand the scope of this problem…”

There are several different types of complications associated with circumcision- immediate surgical risks, short and long term complications, and negative effects due to lack of foreskin. Several of these complications can require further surgery to correct.

Surgical Risks

The AAP reports that significant, acute complications occur in about 1 of every 500 infant circumcisions. Over 1 million infants are circumcised each year in the US, which translates to about 200 significant surgical complications each year. Since the true rate of complications isn’t known, it is likely this number is higher than estimated.

Surgical complications can be minor or significant and include, but are not limited to:
Bleeding
Infection- including meningitis, staph, gangrene, and sepsis
Anesthetic intoxication
Inclusion cysts, which may become large or infected
Abnormal healing
Excessive skin removal– including accidental removal of all penile skin
Injuries related to the circumcision device being used
Urinary retention
Chordee- curvature of the penis thought to be due to uneven foreskin removal
Urethrocutaneous fistula- caused by injury to the urethra
Buried penis
Necrosis of the penis
Amputation of the glans or other penile injury, which can lead to the inability to urinate properly, have sex, or father children
Shock
Death

Short and Long Term Complications

Breastfeeding difficulties and other changes in an infant’s sleeping, eating, and behavior
Post-Traumatic Stress Disorder
Meatitis– a red and inflamed urethral opening
Meatal Stenosis– a narrowing of the urethral opening due to friction and chafing against diapers and clothing. This occurs in up to 10% of circumcised males and often needs corrective surgery.
Adhesions and skin bridges- when the cut skin tries to heal by attaching back on to the head of the penis.
Increased penile inflammation
Painful erections because there is not enough skin to allow for a normal erection

Negative Effects

Negative effects are especially critical to understand when considering removing a body part. Since all parts of our body have a role to play in how our body functions and may have many different purposes we need to evaluate what occurs when this part is gone and the body changes because of it.

Removal of the foreskin significantly changes the form, function, and development of the penis. Dr. John Warren explains:
“Male circumcision results in permanent changes in the appearance and functions of the penis. These include artificial exposure of the glans, resulting in its keratinization and altered appearance. Additionally, circumcision results in loss of 30–50% of the penile skin, loss of at least 10,000–20,000 specialized erotogenic nerve endings, loss of reciprocal stimulation of foreskin and glans, and loss of the natural coital gliding mechanism, etc. From the point of view of sensation and function, the most important effect is caused by the tissue loss itself. The most sensitive part of the penis is removed, and the normal mechanisms of intercourse and erogenous stimulation are disturbed.”

He goes on to list the negative physical effects of circumcision as follows:

Cosmetic Effects
Circumcision causes scarring- all men who are circumcised have a scar encircling their glans. It also reduces penis size and leads to abnormal coloring and thickening of the glans due to its exposure. If there is not enough skin left on the penis after circumcision then scrotal skin can be pulled up, leaving pubic hair on the shaft during erections.

Glans Externalization and Keratinization
Circumcision changes the glans from an internal organ to an external organ and the glans then must protect itself, which it does by building up skin layers, which is referred to as keratinization. This is what causes the glans to change color from a pinkish/red/purple, or even brown in darker skinned males, to the same color as the rest of the skin on the penis. This also leads to a progressive desensitization of the glans.

Tissue Loss From Circumcision
All of the specialized structures and tissue which are part of the foreskin are clearly lost when it is removed.  This also includes the loss of the immunological properties that the foreskin provides.  The foreskin is the most sensitive part of the penis, plays a primary role in sexual sensitivity, and allows for ample shaft coverage as it unfolds during an erection.

This study “confirms the importance of the foreskin for penile sensitivity, overall sexual satisfaction, and penile functioning. Furthermore, this study shows that a higher percentage of circumcised men experience discomfort or pain and unusual sensations as compared with the uncircumcised population.”

Many sexual issues can arise from the lack of this structure such as:
Erectile problems– including erectile dysfunction due to loss of a significant amount of blood vessels
Orgasm difficulties and painful sex
Negative effects on the sexual enjoyment of female partners– including pain, soreness, and bleeding, as the gliding mechanism and natural lubrication that the foreskin provides are gone, increasing friction and contributing to vaginal dryness, and orgasm difficulties.
Decrease in sexual pleasure

Loss of Sensory Nerve Endings
Removing the foreskin causes the loss of all nerve endings contained within the foreskin and also changes the way sexual sensations are felt. The foreskin and glans have different nerve receptors which is what causes this difference. The glans is the least sensitive area of the penis and only contains simple nerve endings which sense deep pressure and pain. The foreskin is rich with fine-touch pressure receptors.

Loss of Reciprocal Stimulation of Foreskin and Glans
The foreskin and glans are meant to work together and also stimulate each other during sexual experiences. When the foreskin is removed this can no longer occur and there is a change in the way sex works and in a man’s sexual response:
“Physiologically, a man’s brain expects stimulation from both the foreskin and the glans to achieve a healthy sexual response. Circumcised men lack the nerve inputs from the foreskin, and additionally, the stimulation from the glans is unnatural, because the glans of the circumcised penis is exposed and therefore stimulated directly (the glans of an intact man is stimulated indirectly). These physical and sensory changes caused by circumcision often result in problems with the male sexual response. Studies show that circumcised men have a much higher likelihood of experiencing problems such as premature ejaculation and delayed ejaculation.”

Loss of the Gliding Mechanism
The gliding mechanism the foreskin provides is meant to make sex more enjoyable and comfortable for both partners. The loss of this penile function increases friction and can contribute to vaginal dryness due to the way lubrication is drawn out when the foreskin is not there. This also affects several of the aforementioned sexual issues and can particularly affect female partners.

Circumcision has immediate surgical risks, short and long term complications, and a variety of negative effects. Infant circumcision is unnecessary, therefore any risk should not be accepted and even small risks carry more weight.

A- Alternatives- Are There Any Alternatives to This Procedure?

Yes, the alternative to circumcision is to simply leave your son’s penis as it is when he is born. This is commonly referred to as “intact”- the penis is all intact and has not been altered through circumcision.

I- Intuition- What is My Gut Feeling? Does This make Sense?

Removing a healthy body part, such as the foreskin, doesn’t make logical sense. Our gut feelings usually tell us to protect our children from any pain or possible harm and to value their precious bodies.

N- Nothing- What Will Happen If I Do Nothing (or Wait)?

If you do nothing and do not circumcise, then your son will have the penis that he was born with and every part of it will be in place and functioning as it is meant to. You would care for it properly and as with any other properly cared for body part you would not expect to have any issues with it. There are no inherent risks in leaving a baby’s penis exactly how it is.

Circumcision is a surgery and as such I have focused on the medical aspects of the procedure in this evaluation. Circumcision is also a religious tradition among a few major religious groups- this is beyond the scope of this evaluation, but further resources from these religious perspectives can be found here:

For Jewish families:
http://www.jewishcircumcision.org/
http://www.jewsagainstcircumcision.org/brisshalom.htm
http://www.beyondthebris.com/

For Muslim families:
http://www.quranicpath.com/misconceptions/circumcision.html
https://www.facebook.com/IntactIslam

{Wondering why I didn’t include Christianity when considering circumcision from a religious perspective? It’s because circumcision isn’t a Christian tradition, is irrelevant to the Christian faith, and the modern form of circumcision, which differs from the biblical practice, is not consistent with a biblical view of the body. Circumcision isn’t a religious consideration for Christians.}

In America, circumcision is also performed for social reasons. This is ethically concerningIt is inappropriate to remove body parts from an infant unless there is a medical indication to do so. It is inappropriate to alter an infant’s body so that it will look more like other family members or peers, or because a parent or anyone else prefers the altered look.

Conclusion

Although widely practiced in America, male circumcision is not recommended by any major medical group. The foreskin is not disease-causing or more prone to infection than any other body part, it is a normal, healthy, necessary part of the body and there are no risks inherent in having such a normal body part. Removing the foreskin through circumcision carries many risks, both short and long term, and leaves the penis in an unnatural state, with what is meant to be an internal organ permanently exposed and this lack of foreskin and exposure of the glans comes with a range of negative effects. Any benefits claimed to come from circumcision have either been shown to be false, overstated, misleading, or come from a perspective where the foreskin is not rightly valued for its place in the body. The reasons we give for circumcision in America, many of which are not medically related, would not be accepted as justification for the removal of any other body part. It is not good medical practice to remove healthy body parts and it is inappropriate for such a procedure to be offered by doctors.

Were You Told That Circumcision Had Health Benefits For Your Son? Did You Know That the Lack of Foreskin Could Lead to So Many Negative Effects?

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amy
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4 Comments

  1. I disagree about suggesting circumcision for baby boys. There is ample evidence that circumcision does NOT offer the benefits you list. You may want to check out www.http://nocirc.org/
    When we take the time to learn the history of something that has become a routine medical procedure, we sometimes find that the original assumptions were erroneous.

    Reply

    • Thanks for your feedback, I’m wondering if you happened to have read the post before commenting? Nowhere in the post do I suggest that babies should be circumcised, nor do I suggest that circumcision actually offers the benefits that are listed- I listed the perceived benefits of circumcision and also what I found out regarding each claim as I researched it. Please read the post and let me know what you think!

      Amy

      Reply

  2. Excellent information!!!

    Reply

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I’m Kate, mama to 5 and wife to Ben.  I love meeting new people and hearing their stories.  I’m also a big fan of “fancy” drinks (anything but plain water counts as ‘fancy’ in my world!) and I can’t stop myself from DIY-ing everything.  I sure hope you’ll stick around so I can get to know you better!

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