Tuesday, March 30, 2010

An Essay on Circumcision

Making recent provincial and international headlines, the topic of male infant circumcision (herein referred to as MIC), brought up in any forum, is considered by some one of the most controversial debates of the century, with personal views ranging from dead set against it to why wouldn’t you. Many say it is a personal decision, but people are now asking whose decision is it: the boy’s or his parents’? According to a Men’s Health article, MIC became popular in the late 1800s after Lewis Sayre, MD claimed it could cure many diseases including epilepsy and TB; MIC soon became routine after John Harvey Kellogg, MD stated it was a successful remedy for masturbation, considered a major problem in those days.

There are many arguments for leaving a baby boy intact and here are four of the most common. First, MIC is a surgery, even though it is routinely done without sedation or local anaesthetic, with surgical side effects including bleeding and severe pain and surgical risks such as infection, various types of deformities and dysfunctions of the penis, and of course, death. Second, MIC frequently interferes with mother-child bonding and early breastfeeding. Third, recent studies, including Taddio’s, have shown it has detrimental effects of the developing brain and alters pain perception, decreasing pain thresholds in circumcised males. Finally, in later life, MIC causes significantly reduced sexual pleasure.

The four of the most common arguments for MIC are as follow. First, religious reasons including the covenant between Abraham and his descendants and God as written in Genesis 17:10-14 are often cited. Second, there are generations-old family traditions where boys are circumcised and the decision is not questioned as to why. Third, there is a belief that MIC results in decreased urinary tract infections, sexually transmitted infections including HIV and penile cancer, which has recently been disproved by newer studies. Finally, there is the thought that if done early enough in life the boy will not feel the pain or remember the procedure.

More and more research is coming out, or becoming public, about circumcision. Since 1975, the Canadian Association of Paediatricians has recommended against routine circumcision. Their US counterpart had taken a lighter approach until 1999 when they too, began recommending against routine MIC. According to the Canadian Paediatric Society's statement on circumcision in 1975 (and restated in 1982, 1989 and again in 1996), there is no medical indication for circumcision during the neonatal period.

Most of the commonly known reasons for routine circumcision are misunderstood or blown out of proportion. For example, the rate of UTI (urinary tract infection) for an intact baby boy is about 7/1000 and for a circumcised baby is about 2/1000. BUT, the rate of complication from the circumcision surgery is 20-30/1000 with 2-3/1000 being serious complications. Approximately 10/1000 circumcised babies need to have the surgery repeated in later life and only 10/1000 intact boys need to be circumcised in later life.

There is also a belief that the boy should look like his peers, but according to recent studies, Canada has a 31.9% circumcision rate, meaning 68.9% of new baby boys are intact. Currently, Alberta is the highest province with approximately 44% circumcised and Nova Scotia is the lowest with only 6%.
One cannot forget that foreskin has a purpose. It is designed to protect the glans, keeping it soft, moist and warm; it protects the boy from UTIs; it provides the extra skin needed for an erection; it reduces friction during sex and it maintains sexual sensitivity. Every circumcised male experiences an estimated 15% decrease in sexual sensitivity.

I am so glad that I am cheap and questioned getting my son circumcised because it cost so much (almost $400 is Alberta after doctors fee and tray fee). This led me to start researching why they charge for it, and, in turn, led me to question it in general. I have found that circumcision is one subject that the more I read and learn, the more against it I become. Therefore, yes, I am very pro-intact, anticircumcision. I intentionally did not use the word uncircumcised in any of my writing because that makes it sound like circumcision is the norm, which it is not. I also had a little difficulty getting in the opposing arguments, because some are no longer backed by fact and I do not want somebody to believe that some of the old arguments are valid.

While this debate rages on, more research is being done in hopes of ending the controversy. In the meantime, many are choosing to delay the procedure until the boy can decide for himself.

Jenkins, Mark. Separated at Birth. Men’s Health, July/August 1998, pages 130-135,163
Taddio, A. et al. Effect of neonatal circumcision on pain responses during vaccination in boys. The Lancet Volume 345, Number 8945: Pages 291-292, 4 February 1995.
Taddio, A. et al. Effect of neonatal circumcision on pain response during subsequent routine vaccination The Lancet, Volume 349, Number 9052: Pages 599-603, March 1, 1997.
Canadian Paediatric Society’s webpage: www.cps.ca
American Paediatric Society’s webpage: www.aap.org
Peaceful Parenting’s webpage: www.drmomma.org,
Circumcision Information and Research Pages: www.cirp.org

By Alicia Farvolden

17 comments:

  1. There isn't a day that goes by that I don't feel grateful that I was made aware of the inequity, trauma, and non-necessity of MIC (it was actually in a class on feminism in a unit about FGM that the teacher first led me to question the practice). And I am also hugely grateful that my husband, who was raised Jewish, backed the decision to keep our sons intact, despite great pressure from his parents. I pray that some day boys in the US will have equal protection to girls when it comes to keeping their genitals intact.

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  2. I would love to see circumcision become illegal in the US within my lifetime. Baby boys have the same inherent right to genital integrity as baby girls -- it horrifies me that undereducation, misinformation, and culturally accepted mutilation in the name of religion perpetuates such a terrible practice (and will admit that I fell into the undereducated and misinformed camp at one point -- had my daughter been born a boy, I probably would have allowed her to be mutilated as my thought was to leave the decision to my then husband).

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  3. You might also want to check out the following:

    Canadian Paediatric Society
    "Recommendation: Circumcision of newborns should not be routinely performed."

    http://www.caringforkids.cps.ca/pregnancy&babies/circumcision.htm
    "Circumcision is a 'non-therapeutic' procedure, which means it is not medically necessary."
    "After reviewing the scientific evidence for and against circumcision, the CPS does not recommend routine circumcision for newborn boys. Many paediatricians no longer perform circumcisions.


    RACP Policy Statement on Circumcision
    "After extensive review of the literature, the Paediatrics & Child Health Division of the Royal Australasian College of Physicians has concluded that there is no medical reason for routine newborn male circumcision."
    (almost all the men responsible for this statement will be circumcised themselves, as the male circumcision rate in Australia in 1950 was about 90%. "Routine" circumcision is now *banned* in public hospitals in Australia in all states except one.)

    British Medical Association: The law and ethics of male circumcision - guidance for doctors
    "to circumcise for therapeutic reasons where medical research has shown other techniques to be at least as effective and less invasive would be unethical and inappropriate."

    Drops in male circumcision:
    USA: from 90% to 57%
    Canada: from 48% to 32%
    UK: from 35% to about 5% (about 1% among non-Muslims)
    Australia: 90% to 12.6% ("routine" circumcision has recently been *banned* in public hospitals in all states except one, so the rate will now be a lot lower)
    New Zealand: 95% to below 3% (mostly Samoans and Tongans)
    South America and Europe: never above 5%

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  4. Let me start by saying that I fall solidly in the "pro-intact" camp. My son is intact, although my husband is not.

    I am wondering though about the claim that circumcision is protective against the spread of HIV. Last I "heard" (from my family practice doctor I believe) studies in Africa were stopped before completion because the evidence that circumcision was protective was so overwhelming that continuing the study without offering the control group circumcision was deemed unethical. Do you know where these studies stand now?

    I also wanted to comment that next to "looking like daddy" the hands down most common argument I've heard for MIC is cleanliness. This seems to be separate from the UTI/STD issue. I have heard more times than I can count that the intact penis is "dirty" or "disgusting" or "gross" - often, and I find very interestingly, in relation to what women will think when the intact boy becomes sexually active in adulthood. Also, little boys are apparently considered less capable than little girls of keeping their genitals clean. The power of these purely cultural mores can not be underestimated when confronting this issue.

    Thanks Alicia for your post!

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  5. In Europe, almost no-one circumcises unless they're Muslim or Jewish, and they have significantly lower rates of almost all STI's including HIV.

    Even in Africa, there are six countries where men are *more* likely to be HIV+ if they've been circumcised: Cameroon, Ghana, Lesotho, Malawi, Rwanda, and Swaziland. Eg in Malawi, the HIV rate is 13.2% among circumcised men, but only 9.5% among intact men. In Rwanda, the HIV rate is 3.5% among circumcised men, but only 2.1% among intact men. If circumcision really worked against AIDS, this just wouldn't happen. We now have people calling circumcision a "vaccine" or "invisible condom", and viewing circumcision as an alternative to condoms. . The South African National Communication Survey on HIV/AIDS, 2009 found that 15% of adults across age groups "believe that circumcised men do not need to use condoms".

    The one study into male-to-female transmission showed a 54% higher rate in the group where the men had been circumcised btw.

    ABC (Abstinence, Being faithful, Condoms) is the way forward. Promoting genital surgery will cost lives, not save them.

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  6. @Minnesota Mom: You are quite right to question the HIV claims.

    A study has just come out (Bassler et al., JAMA. 2010;303(12):1180-1187) showing that stopping a trial early makes it more likely to seem to show a benefit, even if there is none. All three of the African trials on which the claims for circumcision are based were stopped early. This is especially so where events are few (less than 500). The total number of events (men becoming HIV+) in the three trials was 201 (65, 69 and 67).

    The trials also suffer from "attrition bias" - men dropping out differentially according to their HIV status and circumcision status. Only 64 circumcised men from the three trials are known to have become HIV+, but 327 circumcised men dropped out, their HIV status unknown.

    For "A boy should look like his father" see this cartoon.

    @Alicia: great post, and on UTIs, even before the "BUT" (even if there were no complications), your figures of 7/1000 intact vs 2/1000 circumcised mean that 995 in every 1000 circumcisons are wasted, 2 on boys who will still get UTI, and 993 on boys who will never get them. Meanwhile about 40/1000 girls get UTI, and these are of course treated without surgery.

    You touch on the human rights aspect with "delay the procedure until the boy can decide for himself" but this still implies that it is virtually inevitable, and opens the way for circumcision advocates to roll out the bogus claims that doing it neonatally has fewer complications, hurts less, that he won't remember, etc. In fact, very, very few men ever choose to have themselves circumcised, or need to.

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  7. I am so, so sorry that we chose to circumcise my son, for no other reason than a cultural one, and not my culture (I am Greek, and Greek men and boys are generally not circumcised--but my husband is American, and he is circumcised).

    I remember being in the hospital, and them taking my son away to do the deed. He came back, and when I opened his diaper and saw the bloody gauze on his little body, I thought, "I sent my perfect baby away and they've butchered him." My gut was screaming, no, no, NO! But I didn't listen. Just writing it here brings me waves of sadness.

    Before we decided to have another baby, after I had gone over to the crunchy side, I asked my husband what he wanted to do about circumcision were we to have another boy. I sent him all the circ info and research I had done which had cemented my belief that I did not want to cut another son of mine. But I left it up to my husband. He looked at what I had found, did some research on his own, and said he did not ever want to circ another baby boy of ours.

    We had a girl. :)

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  8. http://www.facebook.com/#!/pages/Childrens-Community-Clinic/192741812401?v=info

    http://www.coalitionclinics.org/childrens.html

    These links are for Children's Community Clinic in Portland, Oregon. Their mission statement is: "Our mission is to provide high quality and compassionate health care for children, birth to 21 years old, of families being undeserved (uninsured/under-insured), regardless of ethnicity, geographic location or ability to pay."

    I ran across this clinic in the process of doing a search on the Olympic Circumstraint - a device used to restrain baby boys being circumcised. The clinic happens to have this item on their wish list http://www.ccc4kids.org/edonate-you-can-help/our-wish-list/ .

    So what is up with this? Are they offering this service because medicaid is no longer covering circumcisions in many states? (Medicaid will not cover cosmetic/cultural/religious MIC in Minnesota, where I am from.) I was really shocked that they would advertise this service at a community health clinic, and divert resources to provide the service. Then I thought perhaps it is a revenue generator. They do charge $210 at the time services are rendered. They have special clinic times devoted to the procedure and apparently there is demand - so maybe this is a money maker.

    Or perhaps this is about a clinic director or doctor or benefactor who has strong pro MIC feelings?

    Any readers from Portland/Oregon have the scoop?

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  10. http://aids.about.com/od/hivprevention/a/circumcision.htm

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