More Information
For a one-page summary of a benefits-risk analysis of circumcision, see here Circumcision risk-benefit analysis povided by Prof. Brian Morris.
Circumcision Myths
Here is a list of some of the popular myths about circumcision that can be found on some of the anti-circumcision sites followed by an explanation as to why each is wrong.
Myth 1: The foreskin is the natural protective covering for the glans and protects it from injury.
It is nowadays thought that the foreskin might have
served as some kind of protection from shrubs, rocks etc.
when our ancestors were still walking around naked and
"all fours". In other words: it is a by-product of
evolution [1]. Since
this is no longer the case, the foreskin
has become a liability: instead of offering any "protection",
the warm and moist area under the foreskin acts as an
ideal breeding ground for a host of bacteria, fungi and
germs which are known to be responsible for
a variety of diseases and infections
[1],
[2],
[20].
Myth 2: Circumcision amounts to the "amputation" of a normal, functional body part.
Calling circumcision an "amputation" is a deliberate exaggeration that is used to to frighten prospective parents or instill a feeling of dissatisfaction and loss in those who had been circumcised as infants (see also the discussion below). Circumcision amounts to the removal of between 20% - 50% of the foreskin depending on the method used. It can therefore in no way be described as an "amputation".
The claim is sometimes made that a baby is born with a perfect body, and that the foreskin must therefore serve a purpose like protecting the glans of the penis. That might have been the case if humans were still walking around naked. The question why human males are still born with a foreskin can of course be asked. It should, however, be kept in mind that human beings have only been wearing clothing as we currently know it for the last 10-20 thousand years (although our human ancestors certainly wore e.g. animal skins for covering and protection, especially during winter times). On the evolutionary time-scale this constitutes a very brief period - certainly too short to have given nature time enough to do away with the foreskin.
Another significant - and interesting - fact is that the only human cultures to routinely wear no clothing are all uncircumcised: in many of these cultures, a male with an exposed glans is considered "naked", i.e. the foreskin acts as a kind of natural covering. Circumcision is therefore exclusively associated with clothed males.
Myth 3: Circumcision is a traumatic and painful experience for the newborn infant.
The issue of how much pain infants experience during circumcision is a very controversial and hotly debated subject [1], [2]. Even though it is nowadays generally agreed that newborns experience pain more intensely than was previously thought, there are still those who regard the potential dangers involved in administering anesthesia to newborns to outweigh the benefits [3].
The methods of local anesthesia deemed most effective were the use of either a local anesthetic cream (applied about an hour before the procedure),dorsal penile nerve block or a subcutaneous ring block [18]. Sugar coated pacifiers [4] or even a drop of alcohol (usually wine, which is sometimes used at Jewish circumcisions) have also been advocated for use in conjunction with the anesthetics named above.
Regardless of what kind of pain relief is used, parents can ensure that the circumcision of their newborn is made as comfortable as possible by on the one hand being there to comfort him, and also by choosing a qualified operator to do the operation, which will minimize the time required to do the operation.
Circumcisions performed on newborns normally only take between 5 to 10 minutes. With the use of anesthesia and/or analgesia, the discomfort and pain to the infant can be almost totally eliminated. Under these conditions, the claim that circumcision is a "traumatic" experience is clearly false and misleading.
Parents should also bear in mind that studies have shown that the crying observed in babies during circumcision is often not pain-related (if some kind of pain relief is used), but instead might be caused by the discomfort of being strapped into a circumstraint (the apparatus that is used to restrain the baby during circumcision). However, these days more gentler ways of constraining the baby during the operation are often used instead.
Myth 4: Circumcision is a dangerous surgical procedure.
Circumcision is a surgical procedure - albeit a minor one -
and therefore inherently carries some risks. However,
medical studies done over the past decades have
provided overwhelming evidence that, if performed by an experienced
operator, circumcision is a very safe surgical procedure.
Like all minor
operations, complications
might arise for a number of reasons.
The most common ones
[6],
[1],
[24] include:
(i) excessive bleeding (occurring in one in every 1000 cases)
which can normally easily be stopped by e.g. applying
pressure or using a locally acting agent;
(ii) local infections (which occur in one to ten
out of every thousand circumcisions) which can
easily be treated by antibiotics;
(iii) mortality: according to medical records, three
deaths were recorded in the period 1954-1989 out of
a total of more than 50 million circumcisions.
It should be noted, however, that two of these deaths
occurred during at-home circumcisions by non-physicians
[24].
Only one fatality has been reported since then in Miami.
In this instance, the death was due to the fact that excessive
bleeding went unheeded by the baby-sitter until it was too late.
If the bleeding had been noticed earlier, this death could
have been avoided.
The statistics listed above clearly refute the statement
that circumcision is a dangerous surgical
procedure.
Myth 5: Infants who are circumcised can remember the pain for a long time afterwards.
A medical study has shown that infants who were circumcised without pain relief reacted more intensely to pain during immunization injections at 6 months of age than those infants who were circumcised using pain relief or were uncircumcised [23]. This study was (by the authors´ own admittance) only based on a small statistical sample, so more research into this subject is needed.
There is however no medical or scientific evidence that circumcision has long term effects on how infants (or even adults) react to pain, or that those who were circumcised (without pain relief) can remember the pain. The Myths made by activists like Goldman [21] and repeated on many of the anti-circumcision websites are therefore simply wild and unsubstantiated claims not supported by any credible medical evidence.
Myth 6: Circumcision disrupts mother-child bonding.
If the circumcision was done without effective anesthesia, it may sometimes happen that the infant does not wish to suckle for a brief period afterwards. Most observations of babies have shown that they almost always calm down within 24 hours after the circumcision was performed [5]. There is furthermore no scientific evidence that mother-child bonding is negatively influenced compared with uncircumcised infants. It should also be noted that if effective anesthesia is provided, the infant is usually back to normal soon aterwards.
Myth 7: Circumcision is to blame for many social and psychological problems in adult males.
During the past 20 years or so various "support" groups for of men who were circumcised as infants have been formed. These groups claim that men have harmed by circumcision, that they feel psychologically damaged and mutilated by it and that their sex lives have been ruined by the lack of a foreskin.
It has been the aim of the anti-circumcision lobby to make - and support - these claims in order to further their cause of stopping circumcision. It is, after all, hard to get people to change their views about a subject if they are happy about it.
The easiest - and most susceptible - targets for this propaganda are those men who - for whatever reason - are unhappy with their lives and/or with their bodies, and as a result suffer from low self-esteem. To these people, circumcision becomes an easy target - and a convenient scape goat - for all their problems [25] .
Myth 8: Male circumcision is basically the same as female genital mutilation (FGM).
Male circumcision and female genital mutilation (sometimes also incorrectly called "female circumcision") are two completely different procedures. Circumcision of males, except if done for religious reasons, is considered by most people as a prophylactic (health) procedure. FGM - by its nature - usually results in the mutilation of the female sexual organ, which makes it very hard for the person involved to experience sexual pleasure [7]. The equivalent of FGM in males would be the complete amputation of the penis.
Myth 9: An uncircumcised penis can be kept sufficiently clean by proper washing.
As "cleanliness" is often mentioned in conjunction with circumcision, this subject has been a favorite target of the opponents of circumcision, who proclaim that the implication that men cannot be entrusted with maintaining their own penile hygiene is an insult to them.
If humans only needed to use the bathroom once a day, there might at least be some truth in the statement that proper cleaning of the genital area once a day with soap and water is enough. However, since this is not the case, and most men moreover either don´t have the opportunity, inclination or time to clean themselves every time after urinating - as is needed to ensure proper penile hygiene - the statement is clearly false.
Most parents know how difficult it is to get their children to take a bath or shower every day. Even if they do get them to bathe regularly, parents often fail to instruct their children about proper personal hygiene or see to it that it is also carried out in practice. In uncircumcised boys the foreskin usually cannot be retracted until the age of around six. Cleaning the penis in this instance not only requires extra attention and effort, but becomes absolutely necessary since the non-retractable foreskin can very easily trap dirt, bacteria and other microorganismsgerms. This can lead to a variety of infections, which in infants and young boys can have serious consequences [22], [26].
From the facts
outlined above it is clear that personal hygiene in
uncircumcised boys often leaves a lot to be desired. What is
more, this situation does not improve in adolescent boys:
a study of boys in Germany
[8] has shown that
penile hygiene actually worsens as boys grow older.
The reason for this might lie in cultural attitudes
towards personal hygiene: in many European
societies bathing on a daily basis is not the norm.
A recent article in Time Magazine
[9] for example mentioned
that only 47% of all French men and women bathe
on a daily basis. Taking into account the fact that
most males in Europe are uncircumcised, the scenario
discussed above paints a pretty dire picture of
(especially) male personal hygiene in those societies.
Most people will probably agree that this is hardly an ideal
to strive for. Most heterosexual women also have a preference for
circumcised sexual partners (see
discussion below).
Myth 10: The foreskin plays an integral part in facilitating intercourse and in experiencing sexual pleasure.
The experience of pleasure during sexual intercourse is very individual, and likely based on many factors which are very unique to the person and the situation, but there is no credible scientific evidence that circumcision has much relevance. After circumcision the glans - because it is not covered for the most time by the foreskin - does dry out a bit, that there is no evidence that this has any influence on sensitivity.
The same applies to the often quoted argument that the layer of skin gets "keratinizated", i.e. develops a thin but tough protective layer of skin cells. One study specifically addressed this issue by taking skin samples from the glans of the circumcised and non-circumcised penis, sectioned and stained them for keratin and measured them down a microscope. There was no difference (Szabo & Short, 2000, "How does male circumcision protect against HIV infection?" BMJ, 320, p.1592). The keratinization issue is just a myth, nothing more,
Also, contrary to the claim often repeated by the anti-circumcision lobby the foreskin is not the only erogenous part of the penis! Taking into account the factors mentioned here, as well as the much improved hygienic state of the circumcised penis, it should come as no surprise that a survey of women demonstrated female sexual preference for circumcised men [11].
A study by researchers from the University of Chicago, based on a survey of 1400 men, moreover indicated that circumcised men have more varied sex lives [12]. This finding should not be surprising: oral sex, for example, is more likely to be a cleaner and more enjoyable experience for women if their partner is circumcised. The facts mentioned here hardly support the premise that circumcised men suffer from reduced sexual pleasure. For futher information see the section Circumcision and Sexual Function.
Myth 11: Circumcision can lead to sexual dysfunction in later life.
This claim has been widely publicized by the opponents of circumcision, but it is however not supported by any credible scientific studies. As a mater of fact, just the opposite is the case: the study quoted above [12] showed that circumcised men suffer less sexual dysfunction, especially if they are over the age of 45!
Many of the causes that may lead to sexual problems
are directly eliminated by circumcision. Some of the commonest
of these include phimosis, balanitis, genital infections
(due to the presence of bacteria or fungi under the foreskin)
and premature ejaculation. Any one (or combination) of these
factors can have a negative effect on a person's sex life.
Diabetic men have greater sexual dysfunction if uncircumcised.
Myth 12: Circumcision amounts to the "mutilation" of a sexual organ.
A well-known researcher has made the comment that "comparing circumcision to amputation is akin to comparing a nose-job to decapitation merely because both events occur above the neck!". It should also be clear from the previous discussions that this statement is utter nonsense.
Myth 13: Infant circumcision violates the (human) rights of the child since it is done without his consent.
From the day that a child is born until it is old enough to make its own decisions, it is the responsibility of the parents to look after the welfare of their child. This means making decisions that they believe will be in their child´s best interest. If parents are convinced that circumcision will benefit their child, they have the legal and moral right to make this decision for him. This is, after all, what parenthood is all about [13]. In the light of this, some of the comments made by those opposed to the procedure (e.g. that infant circumcision "is an atrocity and a fraud; that it´s brutal, perverse, outrageous violation ...") can only be described as being bizarre on the one hand and totally misguided on the other. Some even equate circumcision with child abuse. Comments like these are irresponsible, not only because they are totally false, but also because they trivialize real suffering and abuse.
Myth 14: Circumcision is a waste of money and resources that can be better utilized for other purposes.
Circumcision is by its nature a prophylactic procedure. As such it is usually performed just after birth in order to prevent medical problems from occurring later in life (adolescence or adulthood). Performed on infants it is a very cheap procedure, costing only in the region of $150-$200 (and is free for families with Medicaid coverage). Taking into account the number of problems that can arise in later life due to the lack of circumcision and the high costs involved, if e.g. an operation - or extensive long term medical treatment - is necessary (not to mention the personal inconvenience and potential embarrassment involved), it is clear that circumcision is a very economic and cost effective procedure, that not only saves money for the patient in the long term but also for the health insurance companies.
Moreover, considering that the average delivery can cost
anything between $2000 - $6000 (depending on duration of
stay, procedures needed etc.), the cost involved for
performing the circumcision is almost negligible.
Myth 15: If my child is circumcised he will be teased by his peers.
Since the circumcision rate in the US at present is conservatively estimated to be at least 60% (see below) just the opposite will be the case. It is a well-documented fact [10] that young uncircumcised boys get teased quite a lot when they are amongst their peers, most of whom are circumcised.
Although the fear of being teased or made fun of should not be an overriding reason for parents to circumcise their boy, they should certainly keep this fact in mind since it can cause psychological problems for their son when he grows up. There has even been a reported case where a boy circumcised himself (and had to be rushed to hospital) because he could no longer stand the ribbing and teasing inflicted on him by his peers [6].
Parents should also take note of an internet
survey of teenage boys which showed that uncircumcised boys
are far less satisfied with their status
than their circumcised peers
[14].
Myth 16: The circumcision rate in the USA is continuing to fall.
According to the National Center for Health Statistics (NCHS) - the body responsible for collecting national statistics - the circumcision rate in the USA reached its peak in the early 70s and then started to fall. This decrease is often ascribed to the statements from the Task Force of the AAP at the time (see below). Current statistics compiled and issued by the NCHS show that for the USA as a whole, the hospital based circumcision rate is around 60%. This number has remained stable throughout the nineties.
In order to save money, health care providers normally
require mothers to leave the hospital
within 24 hours after having given birth
(unless there were complications or the health
of the mother or baby is in question).
As a result, a large number of circumcisions are performed
in out-patient clinics (e.g. doctors´ offices).
These circumcisions are not included in
the NCHS statistics, since this body only
compiles the statistics obtained from hospitals.
Furthermore, adding those circumcisions that
become medically necessary in adolescence due to
problems like phimosis etc.
[15] as
well as those which are done for personal reasons,
the actual circumcision rate in the USA is very
likely much higher than value quoted above.
A more careful reading of the statistics furthermore shows that
in most regions of the US, the rates are far higher than
60%, with the lowest rates reported in California.
This low rate is most likely due to the fact that a sizable
portion of population are of Hispanic origin,
where circumcision is relatively unknown.
Myth 17: Most men outside of North America are not circumcised.
The circumcision rates around the world vary greatly according to geographical region, culture and religion. While it is true that most men in Europe and South America are not circumcised, this is certainly not the case in the Middle East, large parts of Asia and most parts of Africa [16].
For example, in Africa circumcision
is performed either as a religious rite -
mostly in the predominantly Muslim regions in Northern
and Western Africa - or as
as a cultural rite (an initiation into manhood) in most
countries in sub-Saharan Africa. The circumcision rate
around the world has been estimated to lie between 30-40%
[16],
which can hardly be considered a
negligible percentage.
Myth 18: The fact that the majority of men around the world are uncircumcised means that the operation must be unnecessary.
Those opposed to circumcision often state that e.g. in Scandinavia, where the circumcision rate is around 5%, men seem to cope very well without being circumcised. However, in reality the situation is quite different. Adolescent males - and even adults - often have to put up with years of discomfort and suffering due to the effects of phimosis, balanitis and a host of other complications, because the societies they live in are unaware of these problems and therefore unable to deal with them. This ignorance is often reinforced by cultural and/or religious taboos about discussing any subject involving a sexual organ.
To make matters even worse, these physical problems
often causes sexual dysfunction (which, for example,
often happens in the case of phimosis),
which in turn can give rise to
psychological problems.
The incidence of phimosis, especially in adolescent
boys, is so common in uncircumcised males that there is
even a website [17]
which deals with the problems associated with it.
Those who are lucky get help (usually
by being circumcised as adolescents or adults), but many
are destined to suffer unnecessarily their whole lives
without ever realizing that the problems they are
experiencing are not normal and can easily be treated by
circumcision.
Myth 19: Europeans don't circumcise their infant children because they are better informed.
The reason why infant circumcision is rarely performed in most European countries is not because people there made a well-informed decision based on scientific facts and medical evidence. Instead just the opposite is the case - the majority of Europeans have little or no knowledge about the procedure except what they might have gleaned from religious instruction, namely that it is done exclusively for religious reasons by Jews and Muslims.
This ignorance about circumcision is, moreover, not
restricted to the general public: circumcision
as a surgical procedure is hardly ever taught
at medical schools, which means that most medical
personal (doctors and nurses) are also
unaware of circumcision as a standard surgical procedure.
Myth 20: Europeans consider Americans to be "barbaric" for circumcising their infants sons.
Since most Europeans are ignorant about the topic of circumcision (see above), it is hard to imagine that they will have any views or opinions on the subject either way.
Myth 21: Pediatric Societies around the world are against infant circumcision.
During the 1970s the circumcision rate in the US started to fall after the Task Force of the American Academy of Pediatrics (AAP) Committee for the Newborn reported that "there are no valid medical indications for circumcision" (1971). However, in the light of increasing medical and scientific evidence of the benefits of infant routine circumcision - due also in no small measure to the problems that were starting to develop because of the drop in the number of circumcisions (and were absent before) - subsequent statements were modified substantially to "new evidence has suggested possible medical benefits ..." (1989).
The statement issued by the AAP Task Force on Circumcision in March 1999 stated that circumcision has some health benefits, but that it should not be a routine surgery. Many people - including most of the news media - misinterpreted this statement to mean that the AAP no longer recommends infant circumcision. This was, however, not the case. The statement went on to say that the procedure should not be routinely done, but that parents should consult with their doctor, i.e. they should base their decision on an informed choice [18]. In other words, the decision should not be an automatic one, but should instead be based on the available information about the benefits and risks involved. The latest policy statement by the AAP found that benefits exceed risks and that parents must be provided with accurate unbiased information early in a pregnancy to allow time for them to make a decision to have their baby circumcised if it is a boy. The AAP also recommended provider training and insurance coverage for the procedure (for more infos, see the home page of this site).
In the 1996 report of the Canadian Pediatric Society no recommendation was made either way. Their statement says that the benefits and harms are evenly balanced, but that parents should be advised of the present state of medical knowledge about the procedure, and that cultural and personal preferences should be taken into account [18].
However, more recently the Canadian Paediatric Society has indicated that
it will release a new policy that is in line with the affirmative AAP policy.
In other parts of the world, the working group of the Australian College
of Pediatrics has issued a statement in 1995 urging medical practitioners
to inform parents about the benefits of circumcision.with thee xception of the
Circumcision Academy of Australia's policy statement, circumcision policies
are not evidence-based and should be disregarded.
Myth 22: Circumcision pain causes autism
A claim which has surfaced recently is that circumcision pain causes autism. However this claim has now been debunked:
"Speculative claims by Frisch and Simonsen that ‘circumcision pain’ increases risk of autism spectrum disorder (ASD) are flawed.
They dredged Danish medical records of 342,877 boys aged 0–10 years looking for an adverse effect of circumcision. Marginal significance
was apparent for ASD at age 0–4 for 28 Muslim boys circumcised before age 2. Since HR was 1.54 (95% CI, 1.03–2.31) the circumcision effect
involved approximately 10 boys. In 0–4 year-old circumcised non-Muslim boys they noted 6 ASD and 3 hyperkinetic disorder diagnoses.
Of 337 Muslim boys aged 0–10 with ASD, only 10.9% were ‘circumcised’, 89.1% being ‘intact’, which is improbable and undermines their findings.
The authors cite a survey that found pain was high in 4% of infants during 6 weeks post-circumcision. Since the Danish study was about
pain why didn’t Frisch and Simonsen examine other painful conditions? Urinary tract infections are associated with excruciating pain, are common
and very much higher in uncircumcised infant and older males.
If the authors’ pain hypothesis were correct then ASD should be associated with UTI
and therefore being uncircumcised. Anaesthetics are neurotoxic to the developing brain. Systemic use in children under 3 is associated with later cognitive impairment.3
Could unnecessary general anaesthesia, not pain, have contributed to ASD? They cite a study correlating ASD and circumcision prevalence post-1995,
but fail to state that this was actually a study of
paracetamol usage, circumcisions being merely a proxy.4 That ‘hypothesis generating exploratory analysis’ was prompted by the difference in paracetamol
metabolism in immature brains that might produce neuronal damage in susceptible infants.
Most likely, both ASD diagnosis and early circumcision reflect parental conscientiousness."
For further information, see here. The link to online abstract can be found
here.
References
1. See B.J. Morris,
The Medical Benefits of Circumcision
(http://www.circinfo.net)
2. G.N. Weiss and A.W. Harter, "Circumcision: Frankly Speaking" (Wiser Publications, 1998).
3. H.J. Stang and L.W. Snellman, Circumcision Patterns in the United States Pediatrics 1998; 101(6):e5 See also the discussion and links in the Section Preventing Circumcision Pain.
6. T.E. Wiswell, Neonatal Circumcision: A Current Appraisal, Focus Opin Pediatr 1995; 1:93-9.
7. See the Discussion and Links in the Section Female Genital Mutilation.
8. See: "Analysis of German
Study Shows Penile Hygiene Worsens as Child Matures" on CIRCLIST
(http://www.circlist.com/critesgermany.html).
9. Time Magazine , February 15, 1999; page 18.
10. See the Testimonials on this site, ICIRC , and CIRCLIST .
12. Report published in JAMA and reported in CNN Health , April 1997.
13. For a very interesting discussion, see also: I. Goodhart, Parental Rights - Parental Duties on the ICIRC website.
14. See: Teen circumcision survey in the Section "Personal Preferences and Experiences" on the CIRCLIST website.
16. See the Section Circumcision Practices around the World, and the Section "Circumcision Rites, ..." on the CIRCLIST website.
17. R. Stuart, "From Innocence to Ignorance" (http://www.male-initiation.net/).
18. For more Information see the Section Policy Statements from Pediatric Societies.
19.
R. Dagher, M.L. Selzer and J. Lapides,
Carcinoma of the Penis and the Anti-Circumcision Crusade,
J of Urology 1973; 110:79-80.
21. R. Goldman,
Circumcision - the Hidden Trauma.
23. A. Taddio et al.,
Effect of neonatal circumcision on pain response during
subsequent routine vaccination,
Lancet 1997; 349(9052):599-603.
24.
See the Section
The Risks and Disadvantages of Circumcision.
25. B.J. Morris,
In Favour of Circumcision,
USW Press, 1999.
26. B. Kalcev,
Circumcision and personal hygiene in school boys,
Medical Officer 1964; 112:171-173.