CIRCUMCISION, MALE

Male circumcision entails the surgical removal of the fore-skin that covers the glans of the penis. The relative simplicity of the surgical procedure itself belies the complexity of the conflicting values surrounding this minor operation. The primary ethical question is whether the pain, risks, and costs of routine neonatal circumcision are justified by the potential medical and social benefits to infants who undergo this procedure. Given the strong opposing opinions surrounding circumcision, there is some question as to whether children should undergo the procedure prior to an age when they can provide informed consent on their own behalf. Circumcision in adults is less common and will not be the focus of discussion here.

The Prevalence of Male Circumcision

Circumcision is the most common procedure performed on males in the United States—an estimated one million procedures are performed per year. Only about 20 percent of the procedures are performed for religious reasons; the majority are performed in newborns for medical, cultural, or aesthetic reasons. Estimates suggest that circumcision is performed on 60 to 90 percent of boys in the United States. Although observers have noted some variations by region and by cultural group in the use of this procedure, accurate rates for circumcision are not available (Wallerstein). The best documented rates of newborn circumcision in the United States come from a study of infants delivered in U.S. military hospitals (Wiswell, 1992). The rate of circumcision in 1971 was estimated to be 89 percent, falling to 70 percent in 1984, with a subsequent rise to 80 percent in 1990. These differences suggest that parents' decisions about circumcision are influenced by the ebb and flow of social debate over the procedure.

The high rate of nonritual circumcision places the United States in a unique position in the world. In regions where the majority of the world's population lives, including western Europe, the former Soviet Union, China, and Japan, male circumcision is not performed. In 1985, Edward Wallerstein provided the following estimates of circumcision rates: In Great Britain an estimated 1 percent of the male population is circumcised; in New Zealand the figure is about 10 percent; in Australia, 35 to 40 percent; and in Canada, 35 to 40 percent. Circumcision is performed commonly as a religious ritual by Jews, Muslims, many black Africans, and nonwhite Australians.

The History of Circumcision

The walls of Egyptian tombs depict male circumcision, so the practice is known to be at least 5, 000 years old. The Jewish and Muslim traditions of circumcision have their origin in the Old Testament. Jews accept the practice as a sign of the covenant between God and Abraham. In Genesis 17:12, God instructs Abraham: "He that is eight days old shall be circumcised among you, every male throughout your generations." As a Jew, Jesus was circumcised, and the early Christian church debated the need for circumcision as a criterion for joining the Christian fellowship; it was decided that circumcision was not necessary for salvation. According to the apostle Paul, "For in Jesus Christ neither circumcision availeth nor uncircumcision; but faith which worketh by love" (Gal. 5:6). These religious traditions remain strong, although the health debate has led to a questioning of the religious practice by a few members of the Jewish community (Milos and Macris).

The practice of routine neonatal circumcision has been debated within the U.S. medical profession for over a century. Circumcision was initially advocated in the Victorian era as a measure that would reduce masturbation. Medical benefits from the procedure were first widely proposed in 1891 by P. C. Remondino, who claimed that circumcision prevented or cured a host of diseases, including alcoholism, epilepsy, asthma, and renal disease (Wallerstein). More scientific studies of the potential medical benefits of circumcision began to appear in the professional literature in the 1930s. Urologists observed an association between penile cancer and an intact foreskin (Schoen, 1992). During World War II, American troops stationed in the Pacific and in desert climates had problems with irritation and infection of the penis because of sand and the inability to maintain adequate hygiene. The military response was to circumcise many of the affected soldiers. However, the Japanese did not use circumcision despite their war experience in the same environments (Wallerstein).

Circumcision became popular, indeed almost universal, after the war. Rates remained high until the 1970s, when both the medical profession and the general public began to question the widespread use of the procedure for newborns. The American Academy of Pediatrics issued two separate statements, in 1971 and 1975, declaring that there were no valid medical indications for neonatal circumcision (Committee on Fetus and Newborn). Specific concerns were raised over the pain of the procedure and over potential complications in the face of questionable medical benefits. In 1985, the first in a series of papers was published that documented an increased risk of urinary tract infections in uncircumcised neonates (Wiswell et al., 1985). These reports came in association with an apparent increased risk of sexually transmitted disease, specifically the human immunodeficiency virus (HIV), in uncircumcised males (Schoen; Bailey). In 1989 the American Academy of Pediatrics issued a revised statement that concluded that there were both medical advantages and medical disadvantages to the procedure and that full information and informed consent were important for parents who were making this decision.

Medical and Ethical Issues

The basic ethical question regarding circumcision is whether it is justified to perform a surgical procedure on a healthy, unconsenting child to prevent the possibility of future disease. The primary ethical task is to balance the pain and potential complications with the potential benefits. In addition, there is a strong tradition of respecting parental wishes when their decisions are not clearly contrary to the welfare of the child. Although the full details of the risks and benefits are beyond the scope of this discussion, key issues will be outlined.

Proponents of circumcision claim several advantages for the procedure, including decreased incidence of urinary tract infections in infancy, decreased risk of penile cancer in adults, and decreased risk of sexually transmitted diseases (Wiswell, 1992; Wiswell et al., 1985). In addition, routine circumcision prevents occasional penile problems such as phimosis (a narrowing of the foreskin that prevents its retraction), balanitis (an infection of the head of the penis), and posthitis (an infection of the foreskin). Significant complications of the procedure are quite rare, occurring in less than 1 percent of circumcised neonates (Kaplan). Until the mid-1980s, circumcision was performed commonly without anesthesia. Current techniques permit the pain of circumcision to be reduced with a number of simple techniques. In contrast to female circumcision, the procedure has no significant effect on sexual function or pleasure (Collins et al.).

Social issues are a significant element in the debate. Many parents would like their sons to look like the majority of their peers, and many parents would like their sons to look like their fathers, the majority of whom are circumcised. Finally, parents who have grown up in a society of circumcised men may find a circumcised penis to be more aesthetically agreeable.

Those who question the value of the procedure counter that the case for reductions in urinary tract infections, cancer rates, and sexually transmitted diseases is not convincing, or that many of the same benefits may be achieved through better personal hygiene (Poland; Milos and Macris). While the procedure is generally safe, according to George Kaplan, there are risks of excessive bleeding, infection, removal of too much tissue, tissue damage and scarring, reactions to anesthetic agents, and retention of urine. It is also argued that the penile problems that may arise in uncircumcised males, such as phimosis or balanitis, can be prevented or effectively treated when they occur. Further, it is noted that pain-control measures are not consistently effective, carry their own risks, and are associated with some pain as well. Marilyn Milos and Donna Macris note that some have claimed that the foreskin provides a protective covering for the glans, making the uncircumcised penis more sensitive during sexual activity.

Since the 1960s, a cultural shift has placed a higher value on preserving the natural look. Uncircumcised males are common enough, the argument goes, that the appearance of an uncircumcised penis in a high school locker room will not be cause for embarrassment. Finally, it is claimed that a simple explanation from father to son will prevent a son's confusion about a different look to his penis.

Of all of the potential medical advantages of circumcision, the reduced risk of urinary tract infection in the infant is the best documented, and this is the benefit most likely to be experienced by the child (Wiswell, 1992; Schoen). Urinary tract infections in neonates are potentially serious infections that may be life-threatening and, if recurrent, may lead to the later development of renal insufficiency and hypertension. However, the risk of urinary tract infection in uncircumcised infants is still relatively small, occurring in approximately 1 to 4 percent of infants. Of those infected, only a small minority will suffer long-term kidney damage (Chessare). Further, it is estimated that eighty infants would need to be circumcised to prevent one urinary tract infection (Lerman and Liao).

Parents are thus left with a difficult decision. Circumcision might be delayed until the child is old enough to make his own choice, but this alternative obviates the primary medical advantage of decreasing the risk of urinary tract infection in infancy. In addition, performing the procedure beyond the newborn period may be associated with greater risks (Wiswell et al., 1993). Therefore, reliance on surrogate decision making by the parents for the newborn boy remains an ethically appropriate approach. With all of the current data in hand, many physicians and parents find themselves falling between the polar positions in this debate. The AAP drew the following conclusions in its 1999 policy statement on circumcision:

Existing scientific evidence demonstrates potential medical benefits of newborn male circumcision; however, these data are not sufficient to recommend routine neonatal circumcision. In the case of circumcision, in which there are potential benefits and risks, yet the procedure is not essential to the child's current well-being, parents should determine what is in the best interest of the child. To make an informed choice, parents of all male infants should be given accurate and unbiased information and be provided the opportunity to discuss this decision. It is legitimate for parents to take into account cultural, religious, and ethnic traditions, in addition to the medical factors, when making this decision. Analgesia is safe and effective in reducing the procedural pain associated with circumcision; therefore, if a decision for circumcision is made, procedural analgesia should be provided.

For many parents the final decision will be made primarily on cultural and social grounds, with less weight placed on the potential health benefits or risks. Fortunately, there is some evidence that most adult men like the way they are, whether circumcised or not (Lee).

There has also been a vocal debate over the practice of female circumcision (AAP, 1998), which has led some to draws parallels between male and female procedures. While both procedures are performed primarily for cultural reasons, there are dissimilarities worthy of note. There are a few well-documented medical benefits to male circumcision and no long-term morbidities, unlike the female procedure. Further, male circumcision is not associated with sexual control and subjugation, cultural attitudes that are at the foundation of the tradition of female circumcision.

The social debate over the procedure in the United States is likely to continue. In this context, the responsibilities of both the physician and the parents are to make sure that all are fully informed about the benefits and risks of this procedure, and that the procedure, if elected, is performed in a competent and humane manner.

jeffrey r. botkin (1995)

revised by author

SEE ALSO: Anthropology and Bioethics; Body: Cultural and Religious Perspectives; Children: Rights of; Circumcision, Female; Circumcision, Religious Aspects of; Coercion; Harm; Medicine, Anthropology of; Sexual Behavior, Social Control of

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