male routine infant circumcision (RIC) or genital mutilation (MGM)

Marianne Baker Ph.D

A friend recently handed me a leaflet she’d picked up over in Tower Hamlets, which is a relatively intensely studied area of East London. It has a dense, ethnically diverse population and is quite deprived in some areas. As a result
the local NHS provides a range of services directed towards these varied communities and one of those is the “Religious and Cultural Male Circumcision Service”. My friend picked up the leaflet for me because she is well aware of my views on the practice; in my opinion, it belongs as decidedly in the same bin of woo as chiropractic, colonic irrigation and other such potentially harmful non-medicines.

Before I go further into that, obviously if there is a genuine medical need for circumcision (which there very rarely is, it is overprescribed particularly in cases of suspected or actual phimosis, where steroid creams and/or lesser surgical procedures would suffice [1]) then I don’t have a problem. I’m talking strictly about routine infant male circumcision (or RIC for short), performed for no other reason than the parents giving consent for it – or in the case of some US hospitals, failing to withdraw presumed consent.

Fortunately I’m stumbling upon more people who completely understand why I am vehemently opposed to RIC, but there are still plenty who are confused, loudly disagree or couldn’t care less. I’d like to make a few basic points to explain my stance that will hopefully trigger more conversations and interest in the subject; I believe it is a subject ripe for criticism, yet severely neglected by the skeptic community.

Circumcision is a fairly unique surgical phenomenon. Let’s be clear: RIC is a cosmetic surgery chosen for young boys, not by the individuals whose genitals are being altered. The oft-cited “benefits” are not supported by evidence; UTIs (urinary tract infections) are both more common in girls and easily treated with antibiotics – there’s no other such transient infection that is held up as a reason to elect for permanent surgery. People are reluctant to remove tonsils now, and they’re not even involved in our most pleasurable and intimate act. I am referring to sex, though I suppose you could argue for eating good food as well, but tonsils aren’t even involved in the enjoyment of tasty things so are inadequate for comparison anyway.

Biological ignorance

I think a lack of education about the functions of our sex organs is largely to blame here. Doctors and nurses are too often unaware that the foreskin is fused to the glans usually until puberty; as a result they may forcibly retract it unnecessarily and cause problems in doing so, then recommend circumcision to “fix” it. This lack of education is passed to parents who then repeat the myths that it’s “cleaner”, “easier” – but imagine if any of these excuses were used to justify non-medically necessary surgery on girls’ genitalia. People tend to react by saying the foreskin is useless and it makes no difference. There are two main problems with this.

First, it is purely false. Some semi-graphic description to follow. The foreskin contains thousands of touch-sensitive nerve endings, similar to those of the fingertips and lips: highly sensitive and pleasurable. Severing these is an irreversible act that, obviously, reduces the ability to experience sensations from the area for life. In addition, the glans penis that is protected by the foreskin naturally becomes exposed – to air and friction from clothing, not to mention faeces and urine in the case of infants. The glans is flesh, not external skin (compare the gums to the outside of one’s cheek, perhaps) and is not meant to be permanently exposed. This change causes keratinisation (hardening) of the glans and further diminishes feeling. Also, the foreskin is an integral part of the penis, not an “extra flap of skin” – during an erection and intercourse, the skin accommodates the shaft and allows a gliding movement within it that is lost after circumcision. This means increased friction within the vagina, and exposure of the coronal ridge of the glans causes removal of natural moisture and further increased friction. Use of artificial lubrication for sex and masturbation appears to be more common in the US, quite possibly due to the higher proportion of circumcised men there [2].

Ultimately, circumcision inevitably alters the sexual experience and parents make this choice for their children generally without considering this, or believe it to be untrue. Men happily living without apparent complications will of course dispute this (more on that later*), and none of what I write is intended to belittle them, their experiences or relationships. I simply do not believe this is a choice that should be made for others for cultural or religious reasons alone, people can do whatever they wish with their own bodies. My argument is with forcing it upon children.

Second, people tend to hold up examples of people who have no natural experience to compare to. If you do this to a baby, they will never have a natural sexual experience for reference. In addition, when looking at adults who choose the procedure, the fact that they may have needed it is often ignored, and they are not followed up long-term. At first, the exposure of the glans can lead to increased sexual sensation, but this diminishes with time, as per the reasons outlined above. Some women with experience of both natural and cut penises report obvious differences, others less so. But some studies suggest the damages are very real and may increase the rate of erectile dysfunction [3].

Some claim removing the foreskin can reduce the risk of penile cancer, an incredibly rare cancer in the first place (an incidence of only 400-500 per year in the UK, according to Cancer Research UK statistics). We don’t remove any other organs at much higher risk of developing cancer, though – not from healthy children anyway. Penile cancer incidence is reduced simply by good hygiene practices and access to sanitation [4]; a few seconds in the shower or bath is all it takes, as approximately 80% of men can attest to (the majority of the world’s male population is “intact”, though the exact figure is unknown). If you’d volunteer to have your foreskin permanently removed to see whether your penis is magically “easier to take care of”, as some American parents will say, do step up.

That is one of the strangest things about circumcision; that it has been touted as a miracle fix for all kinds of problems through the years. From epilepsy and bed-wetting to the more obvious masturbation (as if it’s even an illness, but that’s the Victorian mindset for you) and general sexual desire [5]. Once again that common fear of human sexuality and the wish to repress it is a culprit. Similar reasons exist for female genital mutilation (FGM), which used to be common in the West, too, and it remains an important issue to tackle given increasing proportions of the population who continue to believe it is their right to force such barbaric ideas on their unknowing, unwilling children. The Cameroonian practice of breast ironing [6] is a horrifying and misguided reaction to teenage pregnancy rates that apparently occurs in the UK as well. Fearful mothers inflict pain on their girls to try to make them less attractive and “save” them from the horrors of a sexually active life. Male genital mutilation has also been used to prevent boys from enjoying their own bodies. If we could only get over our fear of sex and enjoy it, sensibly, for what it is – I’m sure we could avoid a great deal of suffering.

A human rights issue

It is a fundamental human right to have our bodily integrity protected, particularly when we are infants incapable of defending ourselves or protesting beyond screams and easily suppressed thrashing. The very image of the circumstraint™ patented baby-restraining board commonly used in American hospitals should make anyone uneasy. We know instinctively that babies’ limbs are not meant to be stretched away from their bodies and tethered. Why are people so prepared to defend unnecessary penile surgery?

Image: Olympic Circumstraint™ – “For fast immobilization of newborns. Use for circumcision, transfusion, infusion and much more” – from http://www.alimed.com/circumstraint.html

Plenty of parents will say “he didn’t cry! He was quiet!” – sometimes when they weren’t even in the room. That’s called passing out from shock, it’s a protective mechanism. Many children will cry and scream themselves to exhaustion. One cannot sufficiently anaesthetize a baby and the sugar or topical cream (such as EMLA) given is nowhere near enough to dull the pain of ripping and crushing and cutting the foreskin. It’s graphic and shocking, and anyone who wishes to argue for it should at least observe a procedure – they can be found on Youtube. Not that surgery is generally a pleasant viewing experience, but it is usually performed only when it is required, because it is laden with risks. Or when people have signed consent forms allowing people to operate on them. Not so with RIC.

Other equipment to look up includes the Gomco and Mogen clamps, devices used to aid severing the foreskin from the glans of the infant, followed by stretching and cutting it. There is a misconception that the newer PlastiBell device [7] does not involve cutting. The foreskin must be cut in order to separate it from the glans, since the two are fused in infants, before inserting the plastic ring part of the device. Similar to docking the tails of animals (banned in many countries [8], yet it’s apparently still fine to dock your baby’s genitals!), it involves cutting off the blood supply by tightly tying the foreskin stretched over the plastic bell-ring, crushing it, then cutting off the protruding skin. The lists of complications from these procedures are extensive, and while perhaps relatively rare (under 10% depending on the result), they are to me entirely unacceptable given the infant is healthy to begin with. Babies do die [9] and in reality there are likely more deaths than are reported, as conditions resulting from the procedure (such as haemorrhaging, cardiac arrest, etc.) are often cited as the cause of death, rather than the circumcision itself – even though these conditions would either not have occurred or not have been life threatening without it. Men end up with skin bridges, meatal stenosis, glans amputation or loss of the entire penis in some cases, for what? Culture, ignorance, even profit.

We are so innately against FGM in all its forms – which range from “lesser” than standard RIC (such as a pinprick to the clitoris, for example) right up to infibulation that can be fatal, while forms of MGM found around the globe are also potentially fatal, though many are ignorant of this fact – yet we seem desperate to protect parents’ “right” to do this to their baby if it happens to be a boy. Why? It’s a thorny issue, but the support is clearly perpetuated mainly by an unwillingness to accept that people are allowing their child to be damaged, and in many cases that they are themselves. People will always avoid seeing themselves as victims wherever possible, and this often leads to them inflicting the same injustices they have suffered on future generations, rather than coming to terms with their lot and addressing the problems.

Legality

Some countries, such as Australia and South Africa, have already outlawed cultural, non-medical circumcision [10]. Norway appears to be moving towards a ban. Earlier this year, Germany made a controversial ruling against the religious act, stimulating a torrent of accusations that the country had created an intolerant environment and, somewhat ironically, violated parental rights. Some American states have seen controversies, lawsuits and campaigns for bans. Withdrawal of Medicaid financial support for circumcision could be a significant driving factor in its decreasing popularity in the US, similar to the introduction of the NHS in the UK seeing circumcision of baby boys all but disappear from British families.

No medical organisation in the world recommends RIC but the American Academy of Paediatrics (AAP) has come close to doing so, shockingly, for both MGM and FGM – in 2010, they appeared to relax their position on FGM, suggesting that it would be acceptable for physicians to perform a “ritual nick” to a baby girls’ clitoris (also known as Type IV FGM) if the parents wished it, a “minor procedure” akin to ear-piercing, in order to be culturally sensitive – much like our Tower Hamlets NHS – avoid families performing more serious mutilations in private. I am confident few people would condone relaxing FGM positions (and indeed the AAP later retracted their statements) but I presume this is why circumcision is available in some UK hospitals. FGM is of course illegal here, while no prosecutions have actually occurred despite its apparent disturbing frequency in some communities, as recently highlighted by a Channel 4 documentary The Day I Will Never Forget. I do not feel it is a compelling argument to allow and provide an unethical, unnecessary medical procedure to families using “cultural sensitivity” as justification; the sex of the child is irrelevant to me.

General questions about the ethics of the procedure are fuelling the debate worldwide. I do not wish to get into the debate around the use of circumcision as a preventative measure in developing countries where HIV/AIDS is prevalent [12]; the issue is slightly different given that it is being offered to adults and other issues exist in such nations that are distinct from, for example, the USA – where, incidentally, HIV is far more common than in Europe where circumcision is not popular.

The Intactivists

Fortunately people are addressing this issue: outspoken parents, parents-to-be and childless folks (myself included), as well as men who resent what was taken from them, that which they can never regain. In addition, in terms of the “religious tradition” angle, groups such as Jews Against Circumcision [13], and the muslim equivalent QuranicPath [14], are helping to fight the notion that RIC is a requirement if you hold a certain faith position. A Jewish ritual that does not involve circumcision is gaining popularity, the Brit shalom, as opposed to the circumcision ceremony Brit milah. Intact America [15] is a growing US organisation working hard to educate people. We also have NORM-UK [16], whose website I highly recommend as a source of information on foreskin functions (which people are largely ignorant of, perpetuating the “useless flap of skin” falsehood), negative consequences of circumcision and even foreskin restoration – lots of men are trying to regain some semblance of what they should have retained since birth. While it’s never going to be the same as we cannot regrow severed nerves, men have positive experiences to report. Perhaps most importantly, there’s Doctors Opposing Circumcision.

Of course, as skeptical types we are going to be scrutinising all kinds of claims. Unfortunately the anti-circumcision movement (or Intactivism as it was coined) is rife with other anti-medical-establishment ideas such as anti-vaccination, natural fallacies left right and centre and the usual parental superiority complex that is standard in any mother-heavy fora. However, it is usually agreed that circumcision is the most important topic and the rule is enforced to keep conversations on track. It is unfortunate that this profitable practice has endured in the American health system, fostering a more general distrust of physicians, which can lead to other dangerous family health ideas.

Speaking out

Skeptics are wont to demand data over anecdotes. However, I am inclined to believe that in this debate, anecdotes may well play a powerful role. People believe in stories and that’s why we have alternative medicine usage in the first place. So, if the “it’s cleaner!” people are going to be listened to, then the men who are not happy with what happened to them also need their voices to be heard. I often share a site that has collated many such stories in order to illustrate the point that *there are plenty of circumcised men around who are not fine and suffer sometimes daily for the decision that was made on their behalf [17].

For example, one man has submitted this post:

“I was circumcised as an infant and my mother was not informed of the great injustice being performed on her only son. Not only has it caused great physical trauma but psychological and emotional as well. Damages are immeasurable. I want justice for what was done to me, and I never want another child to be sexually assaulted and butchered in their first moments of life. It has long lasting horrid affects. How can you ever trust when the first thing you know is pain and the most pleasurable part of your body is taken away?”

Indeed, I have read some explorations of the idea that such severe pain in early infancy can have permanent neurological effects. Association between pain and the sexual organs, actions later in life, attitudes towards women (for heterosexual men) and sex itself, post-traumatic stress disorder and other psychological issues may exist. It is hard to pin down these things, though many men admit to suffering as a direct result of their infant circumcision and I see no reason why they should be ignored in favour of purported benefits that can be achieved through lesser interventions or simple education.

In addition to anecdotes such as these, I am heartened to see and hear of anti-circumcision celebrities, such as Colin Farrell, Ben Affleck, Adam Levine (lead singer of Maroon 5), members of One Direction (no pun intended) and others. Unfortunately, celeb support can work wonders for causes, and I certainly won’t pass it up in this case.

I have written more about this issue on my personal weblog** and frequently share relevant articles on Twitter (@noodlemaz).

My hope is that some who read this would want to learn more, will participate in conversations and educate others. Perhaps someday a friend will tell you they decided to spare their baby. This happened to me recently and has made me extremely happy. Be skeptical about circumcision!

 

 

Footnotes:

[1] Conservative Treatment of Phimosis: Alternatives to Radical Circumcision
http://www.cirp.org/library/treatment/phimosis/
[2] Circumcision: Male – Effects Upon Human Sexuality
http://www.cirp.org/library/anatomy/milos-macris2/
[3] Alexithymia and Circumcision Trauma: A Preliminary Investigation http://www.mensstudies.com/content/2772r13175400432/?p=a7068101fbdd48819f10dd04dc1e19fb&pi=4
[4] Circumcision and/or vaccination against human papillomavirus in the male to prevent infection with uman immunodeficiency virus: an early surrogate endpoint for the later prevention of penile, prostate, anal and oral cancer? http://onlinelibrary.wiley.com/doi/10.1111/j.1464-410X.2009.08596.x/full
[5] Circumcision Timeline – A History of Medical Error, Medical Fraud, and Medical Abuse by Frederick Hodges in issue 71 of The Complete Mother http://www.whale.to/a/timeline.html
[6] Cameroonian breast ironing http://www.womensviewsonnews.org/2012/08/what-is-breast-ironing-and-why-is-no-one-talking-about-it/ and http://www.cawogido.org/what-we-do.html
[7] The Plastibell circumcision apparatus and procedure: http://en.wikipedia.org/wiki/Plastibell
[8] On the legality of dog tail docking and ear cropping in various countries: http://en.wikipedia.org/wiki/Docking_%28dog%29#Legal_status_of_dog_tail_docking_and_ear_cropping_by_country
[9] Deaths from circumcision http://www.circumstitions.com/death.html
[10] The legality of circumcision globally http://en.wikipedia.org/wiki/Circumcision_and_law
[11] Practical Ethics (Brian D. Earp): The AAP report on circumcision: Bad science + bad ethics = bad medicine http://blog.practicalethics.ox.ac.uk/2012/08/the-aap-report-on-circumcision-bad-science-bad-ethics-bad-medicine/
[12] Practical Ethics (Brian D. Earp): A fatal irony: Why the “circumcision solution” to the AIDS epidemic in Africa will increase transmission of HIV
http://blog.practicalethics.ox.ac.uk/2012/05/when-bad-science-kills-or-how-to-spread-aids/
[13] Jews Against Circumcision www.jewsagainstcircumcision.org
[14] Muslims against circumcision www.quranicpath.com/misconceptions/circumcision.html and www.facebook.com/muslimsagainstcirc on Facebook
[15] Intact America http://intactamerica.org/
[16] NORM-UK http://www.norm-uk.co.uk/
[17] Circumcision class action lawsuit “Circumcision is sexual abuse, torture and mutilation” http://www.sueeasy.com/class_action_detail.php?case_id=258

** http://noodlemaz.wordpress.com/2010/11/09/my-no-1-overlooked-issue-in-skepticism/ and
http://noodlemaz.wordpress.com/2010/05/08/fgm-and-mgm-still-a-long-way-to-go/ and http://noodlemaz.wordpress.com/2010/03/18/a-gm-that-i-do-oppose/