Circumcision

For many decades of the twentieth century, American physicians both recommended and presumed consent for routine infant circumcision. However, the American Academy of Pediatrics sharply revised its policy position in 1999 to hold that circumcision was strictly a cultural and/or religious consideration with no medical bias for or against. A decade later, the AAP again revised its policy position in 2012 citing two medical benefits—reduced risk of UTIs for the first year of life and reduced risk of STIs later in adulthood. (There may also be an indirect reduction in risk of penile cancer due to a reduced risk of HPV, but there is now a male HPV vaccine). However, the data only showed that the statistical benefit was greater than the statistical risk of the procedure. Therefore, infant circumcision was categorized as an acceptable medical procedure, but the data were not strong enough to medically recommend the procedure.

I would also add that circumcision does greatly reduce (but not completely eliminate) the risk of balanitis caused by yeast overgrowth, though yeast infections are easily avoided by daily cleansing of the foreskin and glans when bathing. Circumcision also eliminates the risk of phimosis and paraphimosis but both of these conditions can also be treated by preputioplasty which is a small incision made into the foreskin to make the opening larger. On the other hand, circumcision carries its own risks. Too much skin might be removed causing a buried penis, and circumcision scars can rarely require surgical revision later in life to remediate problems achieving a full erection. Very rarely, a physician performing the circumcision catastrophically damages the infant’s penis by negligence or defective instrument (clamp, plastibel, etc).

Proponents of circumcision often advocate the practice as a hygienic aid and a means of improving an adult man’s coital stamina, but both of these arguments are tenuous and strained. The same hygiene logic could (but never would) be applied to females so it is unclear why it is so necessary for males. As for UTI/STI prophylaxis, this argument is an equally difficult justification as the prevention is disproportionate to the risk. By way of example, every person carries a risk of developing bothersome tonsillitis and life-threatening appendicitis, but no one would perform prophylactic tonsillectomies and appendectomies just to avoid that statistically low risk later in life. And, of course, STI/STD rates have much more to do with risky behaviors than with circumcision.

The American obsession with circumcision probably has a great deal to do with the legacy of puritanical prudishness. Starting in the mid- to late-1800s and lasting about a century, male circumcision was accepted and prescribed by physicians as a treatment for excessive masturbation. This, of course, belies the dark side of circumcision as reducing the quality of a man’s sexual experience.

The penile foreskin consists of two parts, epidermis and mucosa, which is the same at one’s oral labia (lips). The point at which the skin color and texture changes from epidermis to mucosa is the mucocutaneous juncture and is also found on the eyelids, vaginal labia, and anus. The glans (or penis head) is covered by mucosa, not epidermis. Removing the foreskin exposes this mucosa to chaffing and drying which keratinizes the glans mucosa making it tougher and less sensitive. Opponents of circumcision argue that this reduces nerve sensitivity (which explains how circumcision is said to increase coital stamina). The circumcised penis also looses its skin sheath and thus makes masturbation less functional (in other words, the uncircumcised penis is free to move about in its skin sheath and does not require lubricant for masturbation).

Infant circumcision is very different form adult circumcision. Just as females are born with hymens, the foreskin of the male infant is adhered to the glans by a membrane. The penile membrane will naturally dissolve on its own by puberty, but for infant circumcision it must be forcibly broken. Until the AAP’s 1999 policy statement calling for the use of anesthetic, most practitioners performed circumcisions without anesthesia and many still do not inject anesthesia to this day. As is narrated and demonstrated in the video links below, infant circumcision begins by strapping the infant’s arms and legs into a special cradle. A local anesthesia might or might not be injected into the penis. Scissors then forcibly stretch the hole to enable a probe to be inserted which then destroys the membrane. An incision is made into the foreskin and a clamp is applied to crush the skin. The crushing action fuses the skin together and usually prevents bleeding. The foreskin is then trimmed with a scalpel and the clamp is removed. Post-procedure care calls for massive application of petroleum jelly for several weeks to protect the penis from feces and urine as it heals.

Since the size of the adolescent/adult penis cannot be foreknown, how much foreskin to remove during Infant circumcision is something of a guess. If too much skin is removed, the adolescent/adult male will develop a “buried penis” meaning that his erections cannot achieve full extension because the remaining shaft skin is too short. This is not a concern if too little skin is removed, but the adolescent/adult male may be displeased with the appearance and might choose to have it surgically revised. Infant circumcision also does not generally remove the ventral frenulum which is a narrow band of tissue that attaches just below the urethral meatus (pee hole). Since the frenulum is not removed, both the circumcised and uncircumcised male may turn out to have frenulum breve (“short frenulum”) which causes the penis head to curve downward. This is easily corrected by an in-office frenulotomy which involves placing a few dissolvable sutures that will cause the frenulum to detach within two to three weeks.

Circumcision opponents focus on the anatomical structures of the penis. They point out that the preputial skin is different than other skin and is very densely populated with specialized nerve endings. The prepuce also contains lightly contractile Dartos fascia which is what naturally causes the foreskin to return to its forward position to protect the glans mucosa from friction and irritation. The glans mucosa will thus retain its natural color, texture, and sensitivity throughout the male’s life. Also, since the penis is free to move longitudinally within its skin sheath, lubrication is unnecessary to enjoy masturbation. Furthermore, the longitudinal movement within the sheath aids in retaining vaginal lubrication within the vaginal canal during intercourse.

Male circumcision is not unique to Western civilization. Several Amerindian cultures, for example, were documented by the Spanish explorers to engage in various forms of foreskin modification ranging from piercing to gauging. Western Judeo-Christian culture largely cites Abraham’s circumcision of himself, his son, and his servants in Genesis 17:9-14. However, another instructive passage can be found in Joshua 5:2-12 where a population-wide adult circumcision occurred. What is interesting about the Joshua passage is that it speaks of “roll[ing] away” their shame. Modern adult circumcision is performed quite differently from infant circumcision. Adults can be circumcised at the foreskin or a the base of the penis (the latter pulls the foreskin back along the penile shaft but leaves it and all of its nerve endings intact). For adults, however, either way requires considerable and careful suturing because unlike infants, adult males get raging nocturnal erections that can tear sutures and rip the wound open. Simply bandaging the adult penis without sutures would not heal well and would produce massive scarring. For these reasons, I don’t believe that the Old Testament passages referred to circumcision as we know it today. Instead, I believe that the “roll[ing] away” describes cutting the ventral frenulum which would allow the foreskin and the sheath to actually roll behind the coronal sulcus (the ridge) and remain there. Medically, this would treat any genetic predispositions for frenulum breve and hygienically, it would avoid balanitis as the Israelites roamed the wilderness without regular bathing. But even then, in the Jewish tradition Mohels generally do not remove nearly as much skin during a brit milah as is removed in a modern medical circumcision.

The Catholic church has long advocated circumcision—particularly in the Americas—as a means of bringing sanctity to the “sinful” member. This doctrine draws a parallel between the Jewish covenant of circumcision and the Christian rite of baptism as if circumcision is a rite that brings special redemption to the penis. The Apostle Paul, however, wrote in 1 Corinthians 7:17-20 that circumcision was irrelevant to salvation: ‘Circumcision is nothing and uncircumcision is nothing. Keeping God’s commands is what counts. Each person should remain in the situation they were in when God called them.’ (However, Paul did previously advise Timothy to be circumcised in Acts 16:3 due to the hostility of area Jews who might otherwise reject Timothy’s preaching). Today, however, some of the Catholic clergy is coming around and speaking against modern circumcision!

Superstition is probably the biggest driver of infant circumcision in the USA, but economics would be a close second. Physicians get paid for performing the procedure, insurers pay for the procedure, a surprising amount of foreskin tissue is collected in hospitals and is sold for medical research and/or use in cosmetics. But outside of the USA, some jurisdictions have even passed legislation banning hospital circumcision to get away from the economic pressures as this Australian 60-Minutes story (below) points out.

Circumcision is a one-way street and as more than 99% of all circumcisions are performed in infancy, circumcised adults have no frame of reference to qualify their sexual satisfaction with the procedure. There are, however, various internet accounts of men who underwent elective circumcision in adolescence or adulthood as in this vice.com piece reporting the stories of four men who underwent adult circumcision.

As one who is not circumcised I can say that I am extremely happy to have 100% of my anatomy. I twice considered circumcision, once when I was eight or nine years old and again at eighteen or nineteen. The first time I declined the procedure because of pain; the second time I decided against it because I found a certain pride in remaining in my natural state…the way God created me, if you will. Much later I came to fully understand the deeper sexual enjoyment of not being circumcised and not only am I thankful that I did not choose circumcision, but I also would not have it any other way. As an adult, I once asked my mother why I had not been circumcised and I was very surprised by the answer. She said that she wanted to circumcise so that I would be like the other boys but my father turned it into a huge fight/battle/war (and I’m thankful that he did). I knew my father was not circumcised but I also asked my paternal grandfather about it and found out that not only was he not circumcised, but neither his father nor his grandfather. That meant that I could trace the non-circumcision at least five generations and I was all the more proud to continue the tradition. When I see the opportunity, I advocate against infant circumcision by explaining my happiness and pride in being fully intact. For those mothers who want their boys to be like other boys in appearance, I suggest explaining to their sons that they should be proud to have 100% of their anatomy and that the other boys should be embarrassed to have had theirs surgically altered. And for the fathers who want their sons to be like other boys I would point out that not being circumcised has actually led to sexual encounters on various occasions simply because my partner had never been with an intact man before.

As I mused in another post, it would be interesting to know what percentage of “pro-choice” individuals apply that same freedom of choice when it comes to infant circumcision. The problem as I see it is that parents are ignorant of the facts of circumcision. These videos will help educate the willing reader on the topic of circumcision.

One Mother’s Deliberation on Circumcising Her Son

Canadian Ladies of TwentySomething TV Discussing Uncircumcised Partners

60-Minutes (Australia)

The Doctors (TV Show) Discussing Circumcision

Samuel Kunin (M.D. & Mohel) Performing Infant Circumcision (with anesthesia)

Unknown Practitioner Performing Infant Circumcision (without anesthesia)

Ryan McAllister, Ph.D. – Child Circumcision: An Elephant In the Hospital

Anatomy & Physiology of the Foreskin

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