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Historically circumcision has been a topic of emotive and often irrational debate.
At least part of the reason is that a sex organ is involved. (Compare, for example, ear piercing.)
In the USA circumcision has always been common amongst the majority Anglo-Celtic Whites and also amongst Afro-American Blacks.
Australia similarly once conducted routine circumcision of all newborn boys.
In both countries a down-turn took place after the mid-1970s, but is now rising again in each as the medical and health benefits are becoming better known.
The misinformation that produced the downtrend years ago is still embedded in the consciousness of some medical practitioners who hail from the 70s, and their protégés.
In fact there have even been reports of harassment by medical professionals (such as less well-informed midwives, nurses and doctors) of new mothers, especially those that can be more readily identified because they belong to religious groups that practice circumcision, in an attempt to stop them having this procedure carried out.
There has been a trend by pediatric bodies to skirt the truth in favor of what could be viewed as "New-Age political correctness", spurious "human rights" rhetoric, or perhaps fear of litigation stemming from the rare surgical mishap.
The policy statements of professional pediatric bodies have been misused by others as part of an "appeal to authority" fallacy [132] which is often used as a substitute for supplying an actual argument. The bodies themselves also see a trend and copy it so that the statements of one of them can be seen to then trigger a "bandwagon" response.
Those who write the policy statements are often physicians with little or no academic expertise. Not surprisingly they have been criticized by academic experts, as discussed below.
Through the 1990s and into the new millenium a reversal of the downtrend began. In the light of an increasing volume of medical scientific evidence pointing to the benefits of neonatal circumcision, the pediatric professional bodies of various countries have been forced to review the evidence and formulate more up-to-date policy statements.
These documents MUST be read in their entirety to be fully comprehended. (Isolated quotes have been taken from these by anti-circ groups to fuel their propaganda.)
What is stated in the details of the various Statements is much like what is presented in the present review of the medical literature.
However, it is important to note that vital facts have been distorted, watered down or omitted from the various Statements of pediatric bodies, whereas the present review is very much more comprehensive and balanced.
Moreover, no medical body has advocated prohibition of circumcision and arguments by opponents are weak and specious [366].
The latest Statements of the American Association of Pediatrics in 1999 [205], the Canadian Paediatric Society in 1996 [107] and the Royal Australasian College of Physicians, Division of Paediatrics and Child Health in 2004 [39] provide information on the benefits and possibility of rare or minor risks.
These suffer, however, from falling short of drawing the obvious conclusion from the evidence they present, i.e., that circumcision is the best choice for lifetime health and sexual well-being.
The hesitancy is undoubtedly a consequence of the sensitivity of this issue, as well as medico-legal caution and the recognition of the hysteria that this subject can provoke because of the diversity of opinion in the community, where anti-circ groups tend to bombard such professional bodies in an attempt to "win" their political cause.
More on this can be found in the section "Anti-circumcision lobby groups".
The British Medical Association has not even attempted to review the medical literature, producing instead a pompous paternalistic and legalistic statement in 2003 [46, 47].
By and large, the statements of most of these professional bodies tend to recommend that medical practitioners fully inform parents of the benefits and minor, rare risks of having their male children circumcised.
Thus publicly most give the impression that the benefits and harms are very evenly balanced [107].
Indeed, professional bodies have carefully avoided taking sides in the polarized debate, by making noncommittal guidelines and leaving it to the medical practitioner to discuss the matter with the parents [113].
While such bland tolerance has accommodated a broad range of strong and conflicting opinions, the medical profession is now faced with a growing knowledge-base that indicates a wide range of health benefits of circumcision, meaning that the time is fast approaching when affirmative statements cannot be avoided [113].
Indeed, Prof Roger Short states "If we believe in evidence based medicine, then there can be no debate about male circumcision; it has become a desirable option for the whole world" [327].
Of course, well-informed medical practitioners only have to read the present Statements of pediatric bodies in full to be able to draw their own conclusion.
In a deplorable ploy, the Royal Australasian College of Physicians" (RACP) 2002 and 2004 Policy Statement sidestepped making a conclusion by instead substituting the words there "is no medical indication for routine infant male circumcision", i.e., that the foreskin as it presents at birth lacks any medical condition that would mandate its removal.
This tactic is to be condemned as inexcusably irresponsible, especially in the current era of preventative medicine and medical knowledge of the benefits of circumcision.
Recognized authoritative figures in the USA in particular strongly advocate circumcision of all newborn boys.
More details of what they have said in the medical literature appear later.
As a prelude to this, one needs to first understand the anatomy.
The foreskin is composed of an outer layer that is keratinized (as is skin generally), and an inner lining that is a mucosal surface. The inner lining thus resembles other mucosal epithelia such as constitute the cervix, nasal passages and rectum.
It had been suggested that the foreskin protected the glans from drying out and becoming keratinized. However, histological examination has shown the same amount of keratin in the skin of the head of the penis irrespective of circumcision status [345]. The inner layer lines a "preputial sac", which becomes a repository for shed cells, secretions, and urinary residue that accumulates [71, 265]. It is also a hospitable environment for the growth of bacteria and other microorganisms.
During an erection the head and shaft of the penis extend so that the inner layer becomes exteriorized along the distal half of the shaft. This exposes it to infectious agents during sexual intercourse.
It has been speculated that the prepuce is a source of secretions, pheromones, etc, but given the dubious authorship of these reports and the absence of any research support, such suggestions should be regarded as fanciful.
It has been suggested [55] that the increased risk of infection in the uncircumcised may be a consequence of the following:
Some of the health benefits are:
Wiswell looked at the complication rates of having or not having circumcision performed in a study of 136,000 boys born in US army hospitals between 1980 and 1985. 100,000 were circumcised and 193 (0.19%) had complications, mostly minor, with no deaths, but of the 36,000 who were not circumcised the problems were more than ten-times higher and there were 2 deaths [397]. A study by others found that of the 11,000 circumcisions performed at New York's Sloane Hospital in 1989, only 6 led to complications, none of which were fatal [301]. An early survey saw only one death amongst 566,483 baby boys circumcised in New York between 1939 and 1951 [240]. (There are no deaths today from medical circumcisions in developed countries.) Problems involving the penis are encountered relatively frequently in pediatric practice [204]. A retrospective study of boys aged 4 months to 12 years found uncircumcised boys exhibited significantly greater frequency of penile problems (14% vs 6%; P < 0.001) and medical visits for penile problems (10% vs 5%; P < 0.05) compared with those who were circumcised. In infants born in Washington State from 1987-96, 0.2% had a complication arising from their circumcision, i.e., 1 in every 476 circumcisions [65]. It was concluded that 6 urinary tract infections could be prevented for every circumcision complication, and 2 complications can be expected for every penile cancer prevented [65]. The reasons for circumcision, at least in a survey carried out as part of a study at Sydney Hospital, were: 3% for religious reasons, 1-2% for medical, with the remainder suggested by the researchers as "to be like dad" or a preference of one or both parents for whatever reason [92]. The main reason may in fact have more to do with hygiene and appearance, as will be discussed later in the section on socio-sexual aspects. |
