A detour

Permit me to use my own blog space to express my feelings for a moment here. Anyone who wishes to ignore the opinions of others can look away now.

I hate circumcision. Period. I think it’s wrong, on many levels, and I think it’s abusive to remove (amputate) a part of a perfectly healthy boy who can’t possibly consent to the operation. It is genital mutilation, quite simply – and that’s an industry standard term, not my own. FGM was banned in the United States in 1996, but baby boys have yet to be offered the same protection. There isn’t a single medical institution or group in the world that recommends routine infant circumcision – and in truth, the “medical” circumcision in the United States began as a way to prevent masturbation, and was pioneered by Kellogg (as in the cereal) and Grahm (as in the cracker) as a new way to keep men from going blind from masturbating too much.

The worst – most despicable – reason I’ve heard is simply for the sake of someone’s sense of beauty or attractiveness. A parent thinks that a circumcised penis is more visually appealing, and forces a painful and traumatic procedure on a non-consenting infant.

There are many, many resources available online, but for the sake of brevity we’ll combine several and go with a list. Without further ado, some circumcision myths and facts:

Part 1: Circumcision Surgery Myths

Myth 1: They just cut off a flap of skin.

Reality check: Not true. The foreskin is half of the penis’s skin, not just a flap. In an adult man, the foreskin is 15 square inches of skin. In babies and children, the foreskin is adhered to the head of the penis with the same type of tissue that adheres fingernails to their nail beds. Removing it requires shoving a blunt probe between the foreskin and the head of the penis and then cutting down and around the whole penis. Check out these photos: http://www.drmomma.org/2011/08/intact-or-circumcised-significant.html

Myth 2: It doesn’t hurt the baby.

Reality check: Wrong. In 1997, doctors in Canada did a study to see what type of anesthesia was most effective in relieving the pain of circumcision. As with any study, they needed a control group that received no anesthesia. The doctors quickly realized that the babies who were not anesthetized were in so much pain that it would be unethical to continue with the study. Even the best commonly available method of pain relief studied, the dorsal penile nerve block, did not block all the babies’ pain. Some of the babies in the study were in such pain that they began choking and one even had a seizure (Lander 1997).

Myth 3: My doctor uses anesthesia.

Reality check: Not necessarily. Most newborns do not receive adequate anesthesia. Only 45% of doctors who do circumcisions use any anesthesia at all. Obstetricians perform 70% of circumcisions and are least likely to use anesthesia – only 25% do. The most common reasons why they don’t? They didn’t think the procedure warranted it, and it takes too long (Stang 1998). A circumcision with adequate anesthesia takes a half-hour – if they brought your baby back sooner, he was in severe pain during the surgery.

Myth 4: Even if it is painful, the baby won’t remember it.

Reality check: The body is a historical repository and remembers everything. The pain of circumcision causes a rewiring of the baby’s brain so that he is more sensitive to pain later (Taddio 1997, Anand 2000). Circumcision also can cause post-traumatic stress disorder (PTSD), depression, anger, low self-esteem and problems with intimacy (Boyle 2002, Hammond 1999, Goldman 1999). Even with a lack of explicit memoryand the inability to protest – does that make it right to inflict pain? Law requires anesthesia for animal experimentation – do babies deserve any less?

Myth 5: My baby slept right through it.

Reality check: Not possible without total anesthesia, which is not available. Even the dorsal penile nerve block leaves the underside of the penis receptive to pain. Babies go into shock, which though it looks like a quiet state, is actually the body’s reaction to profound pain and distress. Nurses often tell the parents “He slept right through it” so as not to upset them. Who would want to hear that his or her baby was screaming in agony?

Myth 6: It doesn’t cause the baby long-term harm.

Reality check: Incorrect. Removal of healthy tissue from a non-consenting patient is, in itself, harm (more on this point later). Circumcision has an array of risks and side effects. There is a 1-3% complication rate during the newborn period alone (Schwartz 1990). Here is a short list potential complications.

Meatal Stenosis: Many circumcised boys and men suffer from meatal stenosis. This is a narrowing of the urethra which can interfere with urination and require surgery to fix.

Adhesions. Circumcised babies can suffer from adhesions, where the foreskin remnants try to heal to the head of the penis in an area they are not supposed to grow on. Doctors treat these by ripping them open with no anesthesia.

Buried penis. Circumcision can lead to trapped or buried penis – too much skin is removed, and so the penis is forced inside the body. This can lead to problems in adulthood when the man does not have enough skin to have a comfortable erection. Some men even have their skin split open when they have an erection. There are even more sexual consequences, which we will address in a future post.

Infection. The circumcision wound can become infected. This is especially dangerous now with the prevalence of hospital-acquired multi-drug resistant bacteria.

Death. Babies can even die of circumcision. Over 100 newborns die each year in the USA, mostly from loss of blood and infection (Van Howe 1997 & 2004, Bollinger 2010).

References for Part 1

Anand et al., “Can Adverse Neonatal Experiences Alter Brain Development and Subsequent Behavior? Biol Neonate 77 (2000): 69-82.

Bollinger, D. “Lost Boys: An Estimate of U.S. Circumcision-Related Infant Deaths,” Thymos: Journal of Boyhood Studies Volume 4, Number 1 (2010).

Boyle, G.,et al., “Male Circumcision: Pain, Trauma, and Psychosexual Sequelae,” Journal of Health Psychology 7 (2002): 329-343.

Hammond, T., “A Preliminary Poll of Men Circumcised in Infancy or Childhood,” BJU 83 (1999): suppl. 1: 85-92.

Goldman, R., “The Psychological Impact of Circumcision,” BJU 83 (1999): suppl. 1: 93-102.

Lander, J. et al., “Comparison of Ring Block, Dorsal Penile Nerve Block, and Topical Anesthesia for Neonatal Circumcision,” JAMA 278 (1997): 2157-2162.

Schwartz, William M., MD et al., PEDIATRIC PRIMARY CARE: A Problem-solving Approach, 2nd Edition, Year Book Medical Publishers, Inc., 1990, pp. 861-862.

Stang, H. et al., “Circumcision Practice Patterns in the United States,” Pediatrics Vol. 101 No. 6 (1998): e5.

Taddio A, et al., “Effect of neonatal circumcision on pain response during subsequent routine vaccination.” Lancet 1997;349(9052):599-603.

Van Howe, R., “Variability in Penile Appearance and Penile Findings: A Prospective Study,” BJU 80 (1997): 776-782.

Van Howe, R., “A Cost-Utility Analysis of Neonatal Circumcision,” Med Decis Making, December 1, 2004; 24(6): 584 – 601.

Part 2: STD/Hygiene Myths

Myth: You have to get the baby circumcised because it is really hard to keep a baby’s penis clean.

Reality check: In babies, the foreskin is completely fused to the head of the penis. You cannot and should not retract it to clean it, as this would cause the child pain, and is akin to trying to clean the inside of a baby girl’s vagina. The infant foreskin is perfectly designed to protect the head of the penis and keep feces out. All you have to do is wipe the outside of the penis like a finger. It is harder to keep circumcised baby’s penis clean because you have to carefully clean around the wound, make sure no feces got into the wound, and apply ointment.

Myth: Little boys won’t clean under their foreskins and will get infections.

Reality check: The foreskin separates and retracts on its own sometime between age 3 and puberty. Before it retracts on its own, you wipe the outside off like a finger. After it retracts on its own, it will get clean during the boy’s shower or bath. Once a boy discovers this cool, new feature of his penis, he will often retract the foreskin himself during his bath or shower, and you can encourage him to rinse it off. But he should not use soap as this upsets the natural balance and is very irritating. There is nothing special that the parents need to do. Most little boys have absolutely no problem playing with their penises in the shower or anywhere else! It was harder to teach my boys to wash their hair than it was to care for their penises. (Camille 2002)

Myth: Uncircumcised penises get smelly smegma.

Reality check: Actually, smegma is produced by the genitals of both women and men during the reproductive years. Smegma is made of sebum and skin cells and lubricates the foreskin and glans in men, and the clitoral hood and inner labia in women. It is rinsed off during normal bathing and does not cause cancer or any other health problems.

Myth: “My uncle wasn’t circumcised and he kept getting infections and had to be circumcised as an adult.”

Reality check: Medical advice may have promoted infection in uncircumcised males. A shocking number of doctors are uneducated about the normal development of the foreskin, and they (incorrectly) tell parents that they have to retract the baby’s foreskin and wash inside it at every diaper change. Doing this tears the foreskin and the tissue (called synechia) that connects it to the head of the penis, leading to scarring and infection.

Misinformation was especially prevalent during the 1950s and 60s, when most babies were circumcised and we didn’t know as much about the care of the intact penis, which is why the story is always about someone’s uncle. Doing this to a baby boy would be like trying to clean the inside of a baby girl’s vagina with Q-tips at every diaper change. Rather than preventing problems, such practices would cause problems by introducing harmful bacteria. Remember that humans evolved from animals, so no body part that required special care would survive evolutionary pressures. The human genitals are wonderfully self-cleaning and require no special care.

Myth: My son was diagnosed with phimosis and so had to be circumcised.

Reality check: Phimosis means that the foreskin will not retract. Since children’s foreskins are naturally not retractable, it is impossible to diagnose phimosis in a child. Any such diagnoses in infants are based on misinformation, and are often made in order to secure insurance coverage of circumcision in states in which routine infant circumcision is no longer covered.

Even some adult men have foreskins that do not retract, but as long as it doesn’t interfere with sexual intercourse, it is no problem at all, as urination itself cleans the inside of the foreskin (note that urine is sterile when leaving the body.)

Phimosis can also be treated conservatively with a steroid cream and gentle stretching done by the man himself, should he so desire it, or, at worst, a slit on the foreskin, rather than total circumcision. (Ashfield 2003) These treatment decisions can and should be made by the adult man.

Myth: Uncircumcised boys get more urinary tract infections (UTIs.)

Reality check: This claim is based on one study that looked at charts of babies born in one hospital (Wiswell 1985). The study had many problems, including that it didn’t accurately count whether or not the babies were circumcised, whether they were premature and thus more susceptible to infection in general, whether they were breastfed (breastfeeding protects against UTI), and if their foreskins had been forcibly retracted (which can introduce harmful bacteria and cause UTI) (Pisacane 1990). There have been many studies since which show either no decrease in UTI with circumcision, or else an increase in UTI from circumcision. Thus circumcision is not recommended to prevent UTI (Thompson 1990). Girls have higher rates of UTI than boys, and yet when a girl gets a UTI, she is simply prescribed antibiotics. The same treatment works for boys.

Myth: Circumcision prevents HIV/AIDS.

Reality check: Three studies in Africa several years ago that claimed that circumcision prevented AIDS and that circumcision was as effective as a 60% effective vaccine (Auvert 2005, 2006). These studies had many flaws, including that they were stopped before all the results came in. There have also been several studies that show that circumcision does not prevent HIV (Connolly 2008). There are many issues at play in the spread of STDs which make it very hard to generalize results from one population to another.

In Africa, where the recent studies have been done, most HIV transmission is through male-female sex, but in the USA, it is mainly transmitted through blood exposure (like needle sharing) and male-male sex. Male circumcision does not protect women from acquiring HIV, nor does it protect men who have sex with men (Wawer 2009, Jameson 2009).

What’s worse, because of the publicity surrounding the African studies, men in Africa are now starting to believe that if they are circumcised, they do not need to wear condoms, which will increase the spread of HIV (Westercamp 2010). Even in the study with the most favorable effects of circumcision, the protective effect was only 60% – men would still have to wear condoms to protect themselves and their partners from HIV.

In the USA, during the AIDS epidemic of the 1980s and 90s, about 85% of adult men were circumcised (much higher rates of circumcision than in Africa), and yet HIV still spread.

It is important to understand, too, that the men in the African studies were adults and they volunteered for circumcision. Babies undergoing circumcision were not given the choice to decide for themselves.

Myth: Circumcision is worth it because it can save lives.

Reality check: Consider breast cancer: There is a 12% chance that a woman will get breast cancer in her lifetime. Removal of the breast buds at birth would prevent this, and yet no one would advocate doing this to a baby. It is still considered somewhat shocking when an adult woman chooses to have a prophylactic mastectomy because she has the breast cancer gene, yet this was a personal choice done based upon a higher risk of cancer. The lifetime risk of acquiring HIV is less than 2% for men, and can be lowered to near 0% through condom-wearing (Hall 2008). How, then, can we advocate prophylactic circumcision for baby boys?

Science and data do not support the practice of infant circumcision. Circumcision does not preclude the use of the condom. The adult male should have the right to make the decision for himself and not have his body permanently damaged as a baby.

References for Part 2

Ashfield, J., et al., Treatment of phimosis with topical steroids in 194 children, JOURNAL OF UROLOGY, Volume 169, Number 3: Pages 1106-1108, March 2003.

Auvert, B. et al., Randomized, controlled intervention trial of male circumcision for reduction of HIV infection risk: the ANRS 1265 Trial, PLoS Med. 2005 Nov;2(11):e298. Epub 2005 Oct 25.

Camille CJ, Kuo RL, Wiener JS. Caring for the uncircumcised penis: What parents (and you) need to know. Contemp Pediatr 2002;11:61.

Connolly, C. et al., Male circumcision and its relationship to HIV infection in South Africa: Results of a national survey in 2002, South African Medical Journal, October 2008, Vol. 98, No. 10.

Hall, H. et al., Estimating the lifetime risk of a diagnosis of the HIV infection in 33 states, 2005-2005; J Acquir Immune Defic Syndr. 2008;49(3):294-297.

Jameson, D. et al., The Association Between Lack of Circumcision and HIV, HSV-2, and Other Sexually Transmitted Infections Among Men Who Have Sex With Men, Sex Transm Dis. 2009 Nov 6.

Pisacane A, et al. Breastfeeding and urinary tract infection. The Lancet, July 7, 1990, p50.

Thompson RS: Does circumcision prevent urinary tract infection? An opposing view. J Fam Pract 1990; 31: 189-96.

Wawer, M. et al., Circumcision in HIV-infected men and its effect on HIV transmission to female partners in Rakai, Uganda: a randomised controlled trial, The Lancet, Volume 374, Issue 9685, Pages 229 – 237, 18 July 2009.

Westercamp, W., et al., Male Circumcision in the General Population of Kisumu, Kenya: Beliefs about Protection, Risk Behaviors, HIV, and STIs, PLoS ONE 5(12): e15552. doi:10.1371/journal.pone.0015552

Wiswell TE, Smith FR, Bass JW. Decreased incidence of urinary tract infections in circumcised male infants. Pediatrics 1985, 75: 901-903.

Part 3: Social and Sexual Myths

Myth: You have to circumcise the baby so that he will match his dad.

Reality check: The major difference that boys notice is that dad’s penis has hair, and is larger. When a boy notices the difference between his foreskin and his father’s lack of one, just tell him, “When your father was born, they thought that you had to cut off the foreskin, but now we know better.” Since when does parent/child bonding require a matching set of genitals? If it did, could mothers and sons bond, or fathers and daughters? The real issue at play here is protecting the father: if it is okay for his son to not be circumcised, then he did not have to be circumcised, and so he is missing something from his penis. It is not right to harm the child’s body to spare the father’s emotions.

Myth: My first son is circumcised, so I have to circumcise my second son.

Reality check: You can explain this to your children the same way as with the circumcised father. There are plenty of families who changed their minds after one or more sons were circumcised, and didn’t circumcise any more. See here. As with the “matching dad” myth, what is really at issue here are the parents’ feelings: if they don’t circumcise the second son, then that means that they didn’t have to circumcise the first child, and so they harmed their first child. This can be unbearably painful, but it is not right to continue to harm future children to avoid dealing with pain and regret. As they say, two wrongs do not make a right.

Myth: My husband is the one with the penis, so it is his choice.

Reality check: If your husband is circumcised, he has no idea what having a foreskin is like, and he is likely operating from a psychological position of needing to believe that what was done to him was beneficial and important. (See here for an extended discussion of pre and post circumcised adult men and much more by Marilyn Milos, director of NOCIRC.) The baby is the one who is going to have to live with the decision for the rest of his life, not your husband. The baby will be the one who has to use the penis for urination and sex — it should be his decision.

Myth: Everyone is circumcised.

Reality check: Actually, world-wide, only 30% of men are circumcised, and most of these men are Muslim (WHO 2007). Most modern, Westernized countries have rates well below 20%. In the United States about 25 years ago, around 85% of babies were circumcised. The rates have dropped substantially to 32% in 2009, according to a report by the Centers for Disease Control (El Becheraoui 2010).

Myth: Circumcision is an important tradition that has been going on forever.

Reality check: In the United States, circumcision wasn’t popularized until Victorian times, when a few doctors began to recommend it to prevent children from masturbating. Dr. Kellogg (of Corn Flakes fame) advocated circumcision for pubescent boys and girls to stop masturbation: “A remedy which is almost always successful in small boys is circumcision, especially when there is any degree of phimosis. The operation should be performed by a surgeon without administering an anæsthetic, as the brief pain attending the operation will have a salutary effect upon the mind, especially if it be connected with the idea of punishment… In females, the author has found the application of pure carbolic acid to the clitoris an excellent means of allaying the abnormal excitement” (Kellogg 1877). Circumcision caught on among the sex-negative Victorians, but only wealthy parents could afford it. In 1932, only 31% of men were circumcised; this peaked around 85% in 1980, and has been dropping ever since (Laumann 1997, Wallerstein 1980). Far from an ancient tradition, it was only popular in post-war America; think of it as “your parent’s body mod.”

Myth: The other boys will make fun of him.

Reality check: What other cosmetic surgeries will we perform on our children to prevent them from being teased? Should a “flat” girl get implants? What about the boy with a small penis? What surgery would be recommended for him? Circumcised babies are the minority now, and so intact will not be mocked. Plus, as our husbands say, “You just don’t look at or comment on another man’s penis in the locker room.”

Myth: Circumcision makes sex better for the woman.

Reality check: The function of the foreskin for women in intercourse is to seal the natural lubrication inside the vagina and provide a gentle internal massaging action. The intact penis moves in and out of its foreskin, which provides a frictionless, rolling, gliding sensation. Intact men tend to make shorter strokes that keep their bodies in contact with the clitoris more, thus aiding female orgasm (O’Hara 1999). On the other hand, the circumcised penis functions like a piston during intercourse – the head of the penis actually scrapes the lubrication out of the vagina with each stroke. As the man thrusts, his skin rubs against the vaginal entrance, causing discomfort, and sometimes pain (O’Hara 1999, Bensley 2001). Far from making sex better for women, circumcision decreases female satisfaction.

Myth: Women don’t want to have sex with uncircumcised men.

Reality check: In a landmark study of US women, 85% who had experienced both circumcised and intact men preferred sex with intact men. Sex with a circumcised man was associated with pain, dryness and difficulty reaching orgasm (O’Hara 1999). In another study, women were twice as likely to reach orgasm with an intact man (Bensley 2003). Even when a woman said she preferred a circumcised partner, she had less dryness and discomfort with intact men (O’Hara 1999).

Myth: “Being circumcised doesn’t affect my sex life.”

Reality check: Men who are circumcised are 60% more likely to have difficulty identifying and expressing their feelings, which can cause marital difficulties (Bollinger 2010). Circumcised men are 4.5 times more likely to be diagnosed with erectile dysfunction, use drugs like Viagra, and to suffer from premature ejaculation (Bollinger 2010, Tang 2011). Men who were circumcised as adults experienced decreased sensation and decreased quality of erection, and both they and their partners experienced generally less satisfaction with sex (Kim 2007, Solinis 2007).

Myth:If I were any more sensitive, it would be a problem.”

Reality check: The foreskin contains several special structures that increase sexual pleasure, including the frenulum and ridged band (the end of the foreskin where it becomes internal), both of which are removed in circumcision. The LEAST sensitive parts of the foreskin are more sensitive than the MOST sensitive parts of the circumcised penis (Sorrells 2007). In other words, if you wanted to decrease a penis’ sensitivity the most, circumcision would be the ideal surgery. The foreskin has nerves called fine-touch receptors which are clustered in the ridged band (Cold 1999). This type of nerve is also found in the lips and fingertips. To get an idea of the sensation these nerves provide, try this experiment: first lightly stroke your fingertip over the back of the other hand. Now stroke your fingertip over the palm of your hand. Feel the difference? That is the kind of sensation the foreskin provides, and the circumcised man is missing.

It may feel like the penis is overly sensitive to a circumcised man because there is little sensation left to indicate excitement, leading to unexpected premature ejaculation (a common problem with circumcised young men). However, as circumcised penises age they become calloused and much less sensitive. (See this interview for more details.)

References for Part 3

Male circumcision: Global trends and determinants of prevalence, safety and acceptability. (PDF). World Health Organization. 2007. http://whqlibdoc.who.int/publications/2007/9789241596169_eng.pdf. Retrieved Sept. 14, 2011.

Bensley GA, Boyle GJ. Physical, sexual, and psychological effects of male infant circumcision: an exploratory survey. In: Denniston GC, Hodges FM, Milos MF, editors. Understanding circumcision: a multi-disciplinary approach to a multi-dimensional problem. New York: Kluwer Academic/Plenum Publishers; 2001. p. 207-39.

Bensley, G. et al., Effects of male circumcision on female arousal and orgasm, NEW ZEALAND MEDICAL JOURNAL, Volume 116, Number 1181: Pages 595-596,
12 September 2003.

Bollinger, D., Van Howe, R. S. (2010). Alexithymia and Circumcision Trauma: A Preliminary Investigation (in press).

Cold CJ, Taylor JR. The prepuce. BJU International 1999; 83, Suppl. 1: 34-44.

El Becheraoui C, Greenspan J, Kretsinger K, Chen R. Rates of selected neonatal male circumcision-associated severe adverse events in the United States, 2007-2009 (CDC). Proceedings, AIDS 2010, Vienna, Austria. 5 Aug 2010.

Kellogg, J. Plain facts for old and young: embracing the natural history and hygiene of organic life, 1877.

Kim D, Pang M. The effect of male circumcision on sexuality. BJU Int 2007;99(3):619-22.

Laumann, EO, Masi CM, Zuckerman EW. Circumcision in the United States. JAMA 1997;277(13):1052-7.

O’Hara K, O’Hara J. The effect of male circumcision on the sexual enjoyment of the female partner. BJU Int 1999;83 Suppl 1:79-84.

Solinis I, Yiannaki A. Does circumcision improve couple’s sex life? J Mens Health Gend 2007;4(3):361.

Sorrells ML, Snyder JL, Reiss MD, et al. Fine-touch pressure thresholds in the adult penis. BJU Int 2007;99:864-9.

Tang WS, Khoo EM. Prevalence and correlates of premature ejaculation in a primary care setting: A preliminary cross-sectional study. J Sex Med, 14 Apr 2011, Available online at: http://onlinelibrary.wiley.com/doi/10.1111/j.1743-6109.2011.02280.x/abstract

Wallerstein E. Circumcision: An American health fallacy. New York: Springer Publishing Company; 1980:217.

Part 4: The Ethics and Economics of Circumcision

Infant circumcision is an ethical issue that has lifelong effects on the child and societal costs.

No medical association in the world recommends routine infant circumcision. None.

The American Academy of Pediatrics Policy Statement on Circumcision says:

“Existing scientific evidence demonstrates potential medical benefits of newborn male circumcision; however, these data are not sufficient to recommend routine neonatal circumcision.” (AAP 1999)

The British Medical Association says:

“[P]arental preference alone is not sufficient justification for performing a surgical procedure on a child.” (BMA 2006)

The Royal Australasian College of Physicians says:

“After reviewing the currently available evidence, the RACP believes that the frequency of diseases modifiable by circumcision, the level of protection offered by circumcision and the complication rates of circumcision do not warrant routine infant circumcision in Australia and New Zealand.” (RACP 2010)

The Canadian Paediatric Society says:

“Circumcision of newborns should not be routinely performed.” (CPS 1996)

The Royal Dutch Medical Association (KNMG – Netherlands) policy statement is wonderfully clear:

“There is no convincing evidence that circumcision is useful or necessary in terms of prevention or hygiene… circumcision entails the risk of medical and psychological complications… Non-therapeutic circumcision of male minors conflicts with the child’s right to autonomy and physical integrity.” (KNMG 2010)

Circumcision wastes money.

Medicaid spends $198 million each year on routine infant circumcision in the 33 states that still pay for it, a procedure its own guidelines consider to be medically unnecessary. Private insurance programs are reimbursing an additional $677 million, raising prices for us all (Craig 2006.) In addition to the cost of circumcision itself, correcting its complications are said to double the cost, bringing the total bill to $1.75 billion each year. Is this what we should be spending money on during a recession and at a time when healthcare costs are skyrocketing?

Circumcision violates the Hippocratic Oath to “First, do no harm.”

Doctors have an ethical duty to treat the patient by the most conservative means possible, but removing healthy tissue in the absence of any medical need absolutely harms the patient. In the case of routine infant circumcision, nothing was diseased, and thus nothing justifies its removal. Medical personnel who support infant circumcision in any way should reexamine their ethical duties to the child.

Everyone has a right to bodily autonomy and self-determination.

This is a fundamental tenet of international human rights law (UNESCO 2005). As babies cannot speak for themselves, they need special protection. Balancing the potential benefits of circumcision with the definite risks can be difficult decision, but the only person qualified to make this decision is the owner of the penis, as he is the one who is going to have to live with the results, not his parents.

Parents’ aesthetic preferences are not valid reasons for circumcision.

If a mother thinks her daughter’s nose is too big, should she force her to get a nose job? If a father prefers large breasts, can he force his daughter to get breast implants? If a woman prefers circumcised men, can she force her son to be circumcised?

Even if you are fine with being circumcised, your son may not be.

If you have never had a foreskin, you cannot possibly know what having one would feel like. You only know what it feels like to not have a foreskin. You cannot know now how your son will feel in 20 or 30 years. If you have your son circumcised, he may grow up to regret the decision you made for him, but circumcision is irreversible. (Yes, men can partially restore their foreskins, but it is difficult and the sensitive nerve endings are gone forever.) Leave the decision to your son. It is his penis. He deserves to decide for himself.

Parents have a duty to educate themselves on circumcision rather than do it just because it was done to them.

As parents, we are entrusted by God or the universe or by nature with the care of our babies. They truly are a gift, but one that we do not get to keep. We have a responsibility to care for them as best as we can, because they cannot speak nor care for themselves. Though they are babies now, and we have to make decisions for them, they will be adults, with minds and feelings of their own. We need to make decisions for them that we will be proud to stand behind now and in the future. If your son asks you why you had him circumcised, how will you answer? “Because I am circumcised and I needed your penis to match mine?” “Because I didn’t trust you to be able to make your own decisions?” When making this decision for your son, be brutally honest with yourself. What does your decision serve: the child’s rights, or your ego?

For clear, easy and plain-language help making the circumcision decision, try the Circumcision Decision Maker at http://circumcisiondecisionmaker.com/.

Just because it has been a “tradition” does not make it right.

Slavery and child labor were traditions sanctioned by religions and other authorities. But we abandoned those practices because they were unjust and harmful. Infant circumcision, similarly supported by authorities, should be abandoned by the people who care for children because it is unjust and harmful.

It’s time to face our discomfort and admit that circumcision was a mistake.

Routine infant circumcision is a 90-year aberration in the more than 150,000 years that Homo sapiens has existed on this planet. It’s a remnant of times when people thought it was okay to beat your wife and children, that babies couldn’t feel pain and so could be operated on without any anesthesia, and that it was bad to enjoy your sexuality. We’ve discarded all these other ideas, and now we’re discarding circumcision, too.

It is time to face reality.

If you are a circumcised man, or a parent who circumcised his child because you thought it was good for him, you have a painful task in front of you. It’s time to face reality:

You were circumcised because your dad was circumcised because everyone else was circumcised because 140 years ago, some perverted doctors wanted to stop boys from masturbating. Being circumcised isn’t better, and it isn’t popular anymore. The 70% of the world’s men who have foreskins almost never choose to have them cut off and consider them to be the best part of the penis. You don’t have this part of your penis, and that’s really terrible, but it would be even more terrible to make the same mistake with your own child.

The future

Circumcision is ending with the generation being born now – only 32% of babies born in 2009 in the USA were circumcised. Boys born today who keep their foreskins are not going to be mocked, because they’re in the majority, and because people now are more informed. Uncircumcised boys are not going to be scarred because their penises do not match their fathers’. The myths are dying – more and more people are realizing that leaving children’s penises intact is better.

References for Part 4

American Academy of Pediatrics. Circumcision Policy Statement (1999) Pediatrics 1999;103(3):686-93.

Circumcision of Male Infants. Sydney: Royal Australasian College of Physicians, 2010.

Craig A, Bollinger D. Of waste and want: A nationwide survey of Medicaid funding for medically unnecessary, non-therapeutic circumcision. In: Denniston GC, Gallo PG, Hodges FM, Milos MF, eds. Bodily Integrity and the Politics of Circumcision: Culture, Controversy, and Change. New York: Springer; 2006:233-46.

Fetus and Newborn Committee, Canadian Paediatric Society. Neonatal circumcision revisited. (CPS) Canadian Medical Association Journal 1996;154(6):769-80.

Intergovernmental Bioethics Committee. Universal Declaration on Bioethics and Human Rights. Adopted by the General Conference of the United Nations Educational, Scientific and Cultural Organization on 19 October 2005.

Medical Ethics Committee. The law & ethics of male circumcision – guidance for doctors. London: British Medical Association, 2003, 2006.

Non-therapeutic circumcision of male minors. Utrecht, Royal Dutch Medical Association (KNMG), 2010.

Part 5: The Greatest Danger for Uncircumcised Boys

*Written by John Geisheker, J.D., LL.M.


Aside from circumcision? … a well-baby visit. Our physicians’ international non-profit intervenes in over 100 cases each year of intact boys who were injured by a primary care provider. The injury is called ‘PFFR,’ or Premature Forcible Foreskin Retraction. We conservatively estimate the annual incidence in the U.S. at more than 100,000 cases. Ironically, many occur when a parent takes the child to a well-baby visit, at 6, 12, or 24 months; but this injury might occur at any age. The children we have helped range in age from one week to 12 years.

Here is a typical email we receive:

Dear Doctors:

At a well-baby visit yesterday for my uncircumcised son Jonah, 18-months, the doctor pushed his foreskin back so hard I could see my boy’s entire glans, which was oozing blood. The Dr. told me I must do this at every bath or my child “will need to be circumcised for sure.” Jonah now screams when we change him, is restless, and seems to be in pain. Is this really necessary? It does not seem reasonable to hurt a boy in order to clean him. Please help us.


At birth the penis is under-developed. The foreskin is fused to the glans (head) by a normal connective membrane, the balano-preputial lamina, (translation: glans-foreskin layer). The two are functionally an undifferentiated single structure. It takes many years for this membrane to naturally dissipate, a few cells at a time. The average age for full foreskin retraction without trauma is ten years, with half of all boys at age ten fully retractable, and half not yet so. At age 6, for instance, only 20% of boys are fully retractable (Øster et al., 1968-2005).

Typically this injury occurs when a poorly-trained physician or nurse tells the parent that the child has ‘adhesions’ (an unnatural tissue connection) which must be separated “for hygiene.” He or she will then tear the foreskin from the glans by forcing it towards the abdomen, exposing the entire glans and destroying the boy’s protective membrane. Some doctors insert a blunt metal probe or closed hemostat to “lyse the adhesions.” Either way, this is intensely painful and traumatic for the child, as well as exposing him to infection, scarring, and even adult sexual problems.


The trauma of tearing the glans and foreskin apart before they separate naturally will cause intense pain, bleeding, swelling, and expose what was formerly a sterile, internal site to infection. The trauma and subsequent infection may create scarring all the way around the foreskin that will make the it inelastic and thus difficult to retract in later life, when adult hygiene will actually be needed. This condition is called phimosis. In older children and adolescents, true phimosis is almost invariably due to forced retraction in childhood with its resultant infection and scarring. (False diagnoses of phimosis are, sadly, commonplace, the clinician mistaking the natural membrane for claimed ‘adhesions.’)

Pediatrics, a reference text for doctors by Rudolph and Hoffman, warns:

“The prepuce, foreskin, is normally not retractile at birth. The ventral surface of the foreskin is naturally fused to the glans of the penis. At age 6 years, 80 percent of boys still do not have a fully retractile foreskin. By age 17 years, however, 97 to 99 percent of uncircumcised males have a fully retractile foreskin… in particular, there is no indication ever for forceful retraction of the foreskin from the glans. Especially in the newborn and infant, this produces small lacerations in addition to a severe abrasion of the glans. The result is scarring and a resultant secondary phimosis. Thus it is incorrect to teach mothers to retract the foreskin.” (Emphasis ours)


The complete answer is a book-length story of medical ignorance, ‘hygiene hysteria,’ prudery, even outright cruelty—but a short synopsis is possible.

In the mid-19th-century, before doctors discovered germs, they devised a disease theory called ‘reflex neurosis.’ This theory held that stimulation, (then called ‘irritation’ or ‘neurosis’) of sensitive tissue, would cause disease to appear in a distant part of the body (the reflex). As the genitals are intensely sensitive tissue, doctors blamed disease even on innocent touching ‘down there.’ A refinement of this theory claimed that children touched themselves because smegma, the natural substance that both sexes produce, would sour, become itchy, and draw the child’s attention to his (or her) genitalia.

Thus if a boy in 1870 contracted tuberculosis, he was accused of ‘irritating’ his penis. The solution? Aggressive, regular, internal cleaning -or circumcision. This medical theory was a perfect fit with the sexual mores of the Victorian era. Thus began a hundred-year tradition in English-language medicine of vilifying the genitals, both male and female, as the source not only of disease, but also a potential temptation to offend ‘moral hygiene.’ Doctors reasoned that rigorous cleaning, drying-up, desensitizing (with acid), or even amputation of genital mucosal tissue (i.e., circumcision) was both a medical and a moral imperative.

Reflex neurosis survived in English language medicine until well after germs were discovered in 1879. Even in the 1930s some doctors were still advising parents to tie scratchy muslin bags on children’s fists to discourage even inadvertent genital contact during sleep. An entire industry of ‘anti-masturbation’ devices for children developed. (Hoag Levins, 1996).

In an influential article in 1949, a British pediatrician conceded the BPL membrane was normal anatomy, but suggested, erroneously, it should disappear by age three years (Gairdner, 1949). This abbreviated and inflexible timetable -to be fair, an incremental improvement on a theory that this membrane was a ‘birth-defect’- thrives today, even though modern, evidence-based medicine has shown otherwise, numerous times since 1968: (Øster, 1968; Kayaba, 1996; Cold & Taylor, 1999; Concepción-Morales, 2002; Ishikawa, 2004; Agawal, 2005; Thorvaldsen and Meyhoff, 2005, Agawal, Mohta, and Anand, 2005.) To reiterate: we have known for over 40 years that it is normal for the foreskin to not retract in children.

It was once standard English-language medical practice (1870-1980) to forcibly separate the glans from the foreskin, either by the doctor or by the parents on doctor’s orders, “a little at each bath.” Mothers reported disliking this chore as they knew it was painful. (cite available) This pernicious practice is not yet dead, and many grandmothers (and doctors) still cling to it. The American Academy of Pediatrics’ has issued a stern (if tardy) prohibition in recent years:

“Until separation occurs, do NOT try to pull the foreskin back – especially an infant’s. Forcing the foreskin to retract before it is ready may severely harm the penis and cause pain, bleeding, and tears in the skin. ”

…but this warning is widely flouted by many practicing clinicians.

Reflex neurosis lives on today in locker room jokes about blindness, insanity, and unusual hair growth caused by touching the genitals. But it also lingers as PFFR, premature, forcible, foreskin retraction.

John V. Geisheker, J.D., LL.M.

George C. Denniston, M.D., M.P.H.

Mark D. Reiss, M.D.

Morris R. Sorrels, M.D.

of Doctors Opposing Circumcision, Seattle

Pediatric consultant: Robert S. Van Howe, M.D., M.S.

3 thoughts on “A detour

  1. Jenn says:

    Sing it to me sister!!!
    100% AGREED!

  2. […] because I was slacking off! No, I was busy writing over on my regular blog, The Good Life, about circumcision. Take a look if you’re interested, but I’ll warn you it’s not the […]

  3. Bart Hall says:

    Well done, Lauren. Neither of your cousins, nearing 40, were ever cut, for most of the reasons you describe. The reasons are NOT new, and the odd thing is that there’s still a big discussion over them.

    That said, I can say as one who WAS cut, that the effects on my “masculinity” were quite trivial, and if for reasons of faith Jews and Muslims wish to continue that practice I support them in that freedom. To argue the same for females, however, as some Muslims do, is utterly preposterous because the results are profound. To claim some sort of religious basis for destroying a female’s source of sexual pleasure is as vicious as it is preposterous.

    The equivalent for a male would be to remove the entire penis. Please keep that in perspective.

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