Index:

• Official Recommendations of Medical Organizations
• A History of the Medicalization of a Ritual
• Urinary Tract Infection
• Cancer of the Penis
• AIDS
• Hygiene
• Care of intact and circumcised boys

Official Recommendations of Medical Organizations

No national medical orginization in the world has ever promoted routine infant male circumcision for medical reasons. Here are some links to statements of various medical organizations:

–Canadian Paediatric Society, 1996: “Circumcision of newborns should not be routinely performed.”

–American Academy of Pediatrics, 1999: “...the benefits are not significant enough for the AAP to recommend circumcision as a routine procedure.” The AAP statement is significantly flawed due to selective suppression and misinterpretation of studies on risks of circumcision, as well as failure to consider ethical issues and AAP's own guidelines on consent. Comments on the statement.

For more official position statements, including the AMA, AAFP, and others, please click here (off site).

A History of the Medicalization of a Ritual

The belief that there are medical benefits of circumcision is widely held, but close examination reveals it to have little substance. Although circumcision has been performed for thousands of years, historically it has only been in the last century and a half that it was associated with the idea of medical benefits. Rather, it was done in the past for reasons of religion, social control, or punishment. Non-religious “medical” circumcision was begun in Victorian times to prevent masturbation or to cure or prevent a long list of maladies including paralysis, lunacy, epilepsy, curvature of the spine, fever, whooping cough, tubercular meningitis, weight loss, and syphilis. By the time it became clear that circumcision did not prevent masturbation nor did it cure any of the many illnesses claimed, the procedure was firmly established in English-speaking countries. A variety of medical “benefits” have been claimed over the years as justification for a procedure, and these claims change over time. The procedure as a means of diminishing male sexual response has been an important underlying theme throughout its history. Circumcision is known, today, to alter male sexual behaviour though little research has been done on the consequences of circumcision on male sexual response.

—Gollaher DL. From ritual to science: the medical transformation of circumcision in America. Journal of Social History 1994;28(1):5-36 [Full Text]
—Laumann, EO, Masi CM, Zuckerman EW. Circumcision in the United States. JAMA 1997; 277(13):1052-1057 [Full text]

The first hint that there is something unusual about circumcision as a medical procedure is the very fact that there are so many different “benefits” claimed. All other amputations are done for a specific medical indication, not for reasons that change as one reason after another is debunked. The very fact that discussions of this procedure quickly become heated debates also is a hint that this is not an ordinary medical procedure. When routine tonsillectomies were shown to have minimal benefit, there was no passionate defense of them, no attempt to promote new, formerly unknown “benefits” of the procedure, no discussion of parental rights to demand this medical intervention whether indicated or not, or to have it done to match peers or parents.

The American Academy of Pediatrics, in its March 1999 statement on circumcision, appeared to make every effort to find some rationale for the promotion of medical benefits for circumcision. In doing so, the AAP selectively ignored information on the risks of circumcision, citing a complication rate that is not supported by the medical literature, being understated by roughly an order of magnitude. They also conveniently neglected to mention one well-known, though rare complication: death. Thus, their claim of an “evidence-based” examination of the medical literature is dishonest.

The AAP also selectively ignored data that several sexually transmitted infections (STDs) are known to be more prevalent in circumcised males, including chlamydia, one of the most common STDs in the U.S.

Despite this, the AAP was still unable to come up with evidence for a meaningful “benefit” of circumcision. They were forced to conclude:

...the benefits are not significant enough for the AAP to recommend circumcision as a routine procedure.

This conclusion should come as no surprise to anyone, since no major medical organization anywhere in the world (including the AAP) has ever, at any time, recommended routine male circumcision.

What is known about the evidence supporting claims of medical benefits of various sorts?

• Urinary Tract Infection: Although there appears to be a small difference in the rate of urinary tract infection (UTI) in the first year of life between boys who are circumcised and those who are intact, complications of the procedure occur at a rate far greater than the overall rate of UTIs. This is before considering the permanent loss of function entailed by the amputation of normal male genital tissue. In addition, there are effective preventive strategies for UTIs, as well as effective treatments for UTIs that leave no permanent sequelae. Therefore, there is no meaningful benefit of circumcision in the case of UTIs. (More complete evaluation of the UTI evidence and references here) (Top)
• Cancer of the Penis: This extremely rare cancer (even less common than male breast cancer) seems to be related to smoking and infection with Human Papilloma Virus (HPV, or genital warts). There is no evidence that circumcision has any causal relation to penile cancer. This cancer occurs more frequently in the U.S. (where the circumcision rate is around 80% in older males) than in Denmark (where circumcision is virtually unheard of). Two former officials of the American Cancer Society have ridiculed the American Academy of Pediatrics for trying to promote the idea of a link between circumcision and penile cancer. They note that the rate of death from penile cancer is roughly equivalent to circumcision-related deaths. Although the American Cancer Society states that they do not take a position on the issue, they confirm the validity of the facts stated in the letter by the two former officials, and elsewhere state “...circumcision is not of value in preventing cancer of the penis.” (Top)
• AIDS: Circumcision has been promoted as a means of reducing the risk for infection with the HIV virus. Some early studies showing a correlation between HIV infection and the presence of a prepuce relied on outdated African anthropological data, and did not actually verify the circumcision status of any men in the study. Because of the structure of many of these studies, they can show only correlations but not causation. As anyone who has studied basic research methods or epidemiology knows “correlation does not imply causation.” An example of a correlation would be that SAT test scores correlate with race. This does not necessarily imply that race determines test scores. There may be other factors at work (such as socioeconomic status or educational experience) which correlate with and help to determine both of the other factors.
  
  While some studies found a positive correlation between lack of circumcision and HIV status, several other studies found the exact opposite — a higher HIV risk in circumcised men. It seems that the ethnic and socioeconomic circumstances of different groups are related to both the likelihood of circumcision, as well as the likelihood of HIV infection. A recent meta-analysis published in the medical journal International Journal of STD and AIDS concludes:

  When the raw data are combined, a man with a circumcised penis is at greater risk of acquiring and transmitting HIV than a man with a non-circumcised penis (odds ratio (OR)=1.06, 95% confidence interval (CI)=1.01-1.12). Based on the studies published to date, recommending routine circumcision as a prophylactic measure to prevent HIV infection in Africa, or elsewhere, is scientifically unfounded. (Van Howe RS. Circumcision and HIV infection: review of the literature and meta-analysis. Int J STD AIDS 1999;10:8-16)

  
  The U.S. HIV incidence rate is 3.5 times higher than that of the closest advanced industrialized nation according to World Heath Organization data from 1995. The U.S. also has the highest circumcision rate of any of these countries. Clearly, if HIV transmission is related to lack of circumcision, this finding would not be expected. Could circumcision be a risk factor for HIV infection? A letter published in The American Family Physician states:

  If linear regression analysis is applied to the relationship between circumcision rates and the prevalence of acquired immunodeficency syndrome in industrialized countries (using 1994 World Health Organization data) and weighted for population, a strongly positive correlation between circumcision and the prevalence of AIDS is found. While this does not prove that circumcision is a risk factor for AIDS, it is clear that the circumcision experiment in the United States did not prevent the spread of the infection. (Storms MR. AAFP Fact Sheet on neonatal circumcision: a need for updating. Am Fam Physician 1996;54(4):1216-17).

  
  Recently, there has been evidence that the foreskin may have an immunological function in the prevention of infection, by virtue of the presence of Langerhans cells (specialized cells of the immune system) as well as by the production of lysozyme (an enzyme which destroys bacterial cell walls and which is found in various secretions including tears and milk) and cathepsin B, neutrophil elastase, cytokine (a non-antibody protein that generates an immune response on contact with specific antigens). (Fleiss P, Hodges F, Van Howe RS. Immunological functions of the human prepuce. Sex Trans Inf 1998;74:364-367)
  
  For more on the controversy on a link between circumcision and HIV infection, see this page. (Top)
• Hygiene: The American Academy of Pediatrics (AAP) states: “The uncircumcised penis is easy to keep clean. No special care is required. No attempt should be made to forcefully retract the foreskin [of a child whose foreskin is as yet unretractable].” Hygiene for intact adult males is somewhat more complicated than for boys, since the foreskin is retracted to gently wash and rinse, but still takes very little time, certainly less time than shaving or brushing the teeth.(Top)
  
  

Care of intact and circumcised boys

Health care providers can often influence parents wavering on their decision on whether or not to circumcise by telling them that a child's intact penis requires special care and cleaning. This is false, but can provoke anxiety, particularly among parents without experience with intact males. In fact, the intact penis of the child requires no special care other than rinsing with water during regular bathing. In particular, parents should avoid trying to retract the foreskin to wash underneath, since the penis is not fully developed in most boys, and the foreskin often remains literally fused to the glans. This condition is normal and can persist well into puberty. Forcing the foreskin back prematurely results in tearing of delicate tissue, pain, and frequently scarring and a predisposition to subsequent infections. Trying to clean underneath a child's foreskin makes no more sense than scrubbing underneath eyelids or washing out the vagina of small girls. Parents who are aware of the fact that the foreskin should not be forced back need to be particularly vigilant when their child is examined by a doctor or nurse or bathed by daycare workers or relatives. Many health care providers are ignorant of the simple fact that the foreskin of young boys should not be retracted and will attempt to do this during physical exams. The ignorance of health care providers regarding the normal development of the penis and proper hygiene is one of the most frequent reasons for calls to the Info-Circumcision phone line.

In contrast to the intact penis, the circumcised penis is more prone to problems during childhood (Van Howe RS. Variability in penile appearance and penile findings: a prospective study. Brit J Urol 1997;80:776-782). It does require special care, particularly in the period immediately following circumcision, when everything forward of the circumcision incision to the end of the penis is a raw wound. In order to prevent the formation of skin bridges between the remaining shaft skin and the glans, parents need to check that these two areas are not healing together during diaper changes, tearing apart any adhesions that appear to be forming, and applying petroleum jelly (vaseline) to prevent areas of the wound from sticking to itself.

This very concise summary of care of the intact penis comes from an article in Minnesota Parent:

Caring for Your Son's Intact Penis

If you choose not to circumcise, your son's intact penis will require no special care (unlike the cut penis, which will need to be treated as a painful and infection-prone wound for several weeks after the procedure). Your baby's whole, healthy penis will also be less inclined to develop diaper rashes and irritation. But one very important thing to know about a baby's intact (uncircumcised) penis is that the foreskin should never be forcibly retracted. According to pediatrician Paul Fleiss, M.D., M.P.H., “Forcibly retracting a baby's foreskin destroys the beneficial bacterial flora that protect the penis from harmful germs and can lead to irritation and infection.” Sometime in the first one to five years of your son's life, his foreskin will loosen and begin to retract naturally on its own. If your pediatrician is not familiar with uncircumcised babies, she may try to convince you to force the foreskin back or even retract it herself. This can tear your baby's delicate tissues and cause permanent scarring.

Once your son’s foreskin begins to retract on its own, you can teach him to gently wash himself, just as you would teach your daughter of the same age to clean the folds and crevices of her own external genitalia. A child's foreskin, like his eyelids, is self-cleansing. Just as you would never lift the eyelid to “wash” the eyeball, it isn't necessary to pull back the foreskin to wash the glans, which is essentially an internal organ. Rinsing in warm water is all that is needed to keep the intact penis clean. Applying soap to the inner lining of the foreskin or the head of the penis isn’t recommended, because it can cause irritation.

The white emollient under the child’s foreskin is called smegma. Dr. Fleiss notes that “Smegma is probably the most misunderstood, most unjustifiably maligned substance in nature. Smegma is clean, not dirty, and is beneficial and necessary. It moisturizes the glans and keeps it smooth, soft, and supple. Its antibacterial and antiviral properties keep the penis clean and healthy.” The best way to care for a child’s intact penis is to leave it alone.

Readers who understand French will enjoy the acerbic commentary of pediatrician Dr. Aldo Naouri in his article “Leave baby’s foreskin alone.” The following is a translation of the first paragraph:

[The necessity of retracting the foreskin of infants and young boys during bathing or medical exams is a widespread notion among childbirth practitioners, generalists and even pediatricians. Yet few prescriptions are as questionable and few ideas are as refractory to critical evaluation as this useless and harmful practice.]

More complete information is contained in two brochures produced by the National Organization of Circumcision Information and Resource Centers:

• Answers To Your Questions About Your Young Son's Intact Penis.
• Answers To Your Questions About Your Young Son's Circumcised Penis.

The American Academy of Pediatricians has prepared a similar brochure:

• Care of the Uncircumcised Penis

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