Monday, June 20, 2011

Cutting Without a Cause: The Less Than Compelling Case for Routine Infant Circumcision

You may have heard something about circumcision in the news lately. This is because there have been active ballot initiatives to ban routine male circumcision, first in San Francisco and then Santa Monica (though it has since been dropped there due to association with charges of antisemitism). I looked into the arguments surrounding the issue, and I’ve come to the conclusion that routine circumcision should not be allowed to continue.

Note: Due to the nature of the topic, some of the links in this post include explicit images of male anatomy, though no images are embedded in the post itself.

Function of the foreskin

Male circumcision involves removal of the foreskin (prepuce), from the penis. The foreskin is a double-layer of specialized skin and mucosa covering the head (glans) of the penis, held in place by a frenulum on the underside.

The primary purpose of the foreskin is to protect the highly sensitive mucosa of the glans from the environment, including keeping it moist. There is also evidence that the foreskin may generally have nerve endings involved in sexual pleasure, though this is disputed. The frenulum, which is often damaged or removed during circumcision, is highly sensitive and involved in triggering orgasm. Lastly, the foreskin allows for a “gliding mechanism” in which the foreskin can essentially form a seal within the vagina while the shaft moves, reducing friction and preventing loss of lubrication during intercourse.

The arguments for routine male circumcision/against the ban

  1. Cultural tradition and/or religious custom
  2. Health benefits (hygiene, reduced infections, STDs, cancer)
  3. Avoid needing to be circumcised later in life
  4. Aesthetics and self-consciousness
  5. The foreskin is unnecessary
  6. No different than other parental decisions

Let's take a look at each of these arguments to see whether they are compelling.

Argument 1: Religious and cultural views

Cultural tradition and religious custom are among the least compelling reasons to allow the removal of a body part of a minor. Consider what this argument actually implies: That as long as some act has been done for a long time, or as long as a group believes it has been commanded by their god, it should be allowed.

Religious freedom has its limits, especially when it comes to actions affecting another person. We would not allow an Aztec to perform a ritual human sacrifice required by their religion, for instance.

And what if the child grows up and decides to leave the religion/culture that required this?

Argument 2: Circumcision provides significant health benefits

Better hygiene, reduced urinary tract infections, higher resistance to sexually-transmitted diseases (STDs), and reduced incidence of cancer are all cited as benefits of circumcision. But how large are these benefits?

Hygiene is hard to defend on its own because it essentially comes down to convenience. The premise is that the foreskin provides a warm, moist space which is difficult to clean and collects a natural secretion called “smegma.” However, we are not living in an ancient desert society—we have ready access to soap and water. And as I’ll discuss later, the hygiene situation is not much different than in female genitalia. In any case, if a guy has a hygiene problem, do you think it would be limited to his penis?

Reduced urinary tract infections might be the most well-supported argument. However, the risk in an uncircumcised boy is actually fairly low to begin with, around 1%, and the risk in circumcised boys is around 0.2%. Even then, most UTIs are highly treatable.

STD transmission is somewhat supported. However, condoms are much more effective, blocking nearly all transmission, and the benefits of a condom do not depend on whether the male is circumcised. Advocating routine circumcision would make some sense in a society where STD rates are very high and condom access/use is very low, but it won’t help men who practice safe sex and judiciously select their partners.

Finally, penile cancer is extremely rare, and of course if you remove tissue you automatically are unable to get cancer resulting from that tissue. The same could be said of removing breast tissue or any other tissue in the body.

Argument 3: Neonatal circumcision is preferable to circumcision later in life

Circumcision soon after birth does have fewer complications and has the additional benefit of the individual not remembering the procedure. So it is quite true that if a male had to have a circumcision, doing it soon after birth would be preferable to doing it later in life.

However, this argument depends on predicting the future. It would only make sense if there was some basis on which to think that a particular male would be likely to need a circumcision at some point in his life, rather than just a fear that he could need it.

Most circumcisions required later in life are due to foreskin-related medical problems, primarily phimosis and paraphimosis, where the foreskin becomes inflamed and either cannot retract (note that the foreskin naturally won’t retract until adolescence) or won’t resheath, respectively. However, both of these are largely preventable with hygiene and proper care, occur in only 1-5% of males over a lifetime, and there are a number of treatments available before cutting or circumcision may become necessary.

Argument 4: Uncircumcised penises look worse and/or may make a child self-conscious.

Some people just think the penis looks better circumcised, and some parents might be rightly concerned that their child could feel self-conscious about looking different than their peers or father.

But are either of these really good reasons to cut off a perfectly good body part?

It is worth pointing out that a normal, uncircumcised penis looks just like a circumcised penis when erect. And if a prospective partner is so disgusted by the fact that a man is uncircumcised that it overrides everything else, that relationship probably wasn’t going to last long anyway. Even then, the man could decide to get circumcised on his own.

As far as self-consciousness goes, it’s rather sad that it even has to be considered. But perhaps it would help parents to know that infant circumcision rates today (2008) are estimated to be at only ~56% in the United States, meaning that there are plenty of boys around who will also not be circumcised.

Argument 5: The foreskin has no/minimal function, so there are no downsides

Many of the above arguments are predicated on the idea that the foreskin is unnecessary, and that as long as a man can still have sex and reproduce, there is nothing lost. As should be clear from the anatomy discussion, it does have a function.

Without the foreskin, the glans dries and callouses over—a necessary protective response to being exposed all the time that reduces sensitivity (which may not be the same thing as pleasure). Circumcision also removes and/or damages tissue important in the sexual act.

In fact, there is some research suggesting that women and men both report more frequent sexual problems (difficulty reaching orgasm, painful intercourse, feeling unsatisfied) when the male is circumcised. But of course those circumcised at birth have no basis for comparison. Studies of adult males before and after circumcision are somewhat mixed as to changes in reported sexual pleasure, but they do find that a significant percentage say that the pleasure has decreased as a result.

Argument 6: Parents make decisions for their children all the time

It is true that parents make many choices for their kids that affect them for life. However, most of these decisions are unavoidably part of parenting, and usually don’t involve amputation of a part of the body.

Proponents of circumcision like to bring up the fact that parents are able to choose to give vaccines to children, which also affects them for life. However, the intended result of a vaccine is entirely positive—nearly everyone who gets a vaccine becomes immune while a small portion experience unintended side effects. Circumcision, on the other hand, has a negative effect (loss of foreskin) on everyone who receives it, but only a small percentage of those circumcised would have ever benefited from it.

Another common rebuttal proponents like to use is ear piercing of infants. They bring it up as if ear piercing of a baby is something that should be considered universally acceptable. First, I don’t think anyone who is anti-circumcision would find putting a hole in a baby’s ear for purely aesthetic reasons to be in good taste. Second, ear piercing is different in that it does not impact any biological function.

Female genital mutilation and comparisons to male circumcision

Any discussion of male circumcision naturally leads to comparisons to female genital mutilation (FGM). FGM is the practice of removing part or all of the female genitalia. There are four general types as defined by the World Health Organization:

  1. Partial or total removal of the clitoris and/or prepuce (clitoral hood)
  2. Partial or total removal of the clitoris and/or the labia minora, if not also the labia majora
  3. Infibulation with excision—essentially narrowing the vagina to only allow urination
  4. Other rare forms that include a small nick or prick

The reasons why societies practice any of these are diverse: cultural tradition, fear of a child being an outcast, to reduce a woman’s libido, religious thought, hygiene, and aesthetics. (These reasons sound very familiar, don’t they?)

We call these various acts “mutilation”, but those that practice it prefer the term “circumcision” because they believe “mutilation” is prejudicial. However, any form of FGM fits the definition of the word. According to the Oxford English Dictionary:

2. trans. To deprive (a person or animal) of the use of a limb or bodily organ, by dismemberment or otherwise; to cut off or destroy (a limb or organ); to wound severely, inflict violent or disfiguring injury on.

It should not escape anyone's notice that this debate over terminology exactly mirrors the one surrounding male circumcision.

All of these practices are banned when performed without medical necessity on minors in the United States under 18 U.S.C. 116 (the clitoral hood is considered part of the labia minora), including those comparable to male circumcision (removal of the prepuce) and those less severe than it (nicking or pricking). Now there are a lot of circumstances surrounding the practice that contribute to how bad it is, but I think you would be hard-pressed to find someone who would support it even if it was one of the minor forms of FGM done under anesthesia and performed by trained doctors, as some have tried to suggest in the past.

The clitoral hood is the anatomical analog of the foreskin, and the same fetal structure gives rise to both. Of course there are differences, but as far as circumcision is concerned, the main difference seems to be one of accessibility of the tissue. The clitoral hood serves the same protective function for the clitoris as the foreskin does for the glans. Both organs are covered with mucosa which is meant to be kept moist. The female prepuce produces and collects smegma, just like the foreskin, and the whole of the female genitalia is composed of multiple folds of mucosal tissue—more than is present in intact males—that could be similarly susceptible to STD transmission and/or promote UTIs. Yet we consider removing any of this tissue in a minor to be barbaric.

A personal note

Like most males in the United States, I was circumcised as a baby for the health benefits, avoidance of possibly needing it later, and possible self-consciousness over being different. Until I started researching the topic, I wouldn’t have thought that I was missing anything. After reading about it and filtering out the more hyperbolic and less-supported claims on both sides of the issue, it has become clear to me that I am missing a functional part of my body which would most likely have never posed a problem for me. I don’t fault my parents, or anyone's parents, for deciding to do it when given the option, but the option should not be given in the first place.

Routine circumcision should be banned

Circumcision is the excision of a normal, functional part of the male genitalia and the benefits of circumcision are decidedly marginal. It seems obvious to me that we should hold, as a general principle, that all individuals have a right to anatomical integrity. Children should not be subjected to permanent* physical modifications they do not medically require. It is unfortunate that this conflicts with what some religions think they need to do to stay right with God, but that cannot be helped.

*There is an active movement around ‘foreskin restoration’ which uses stretching techniques to stimulate the growth of remaining foreskin tissue. Over years and intense effort, apparently some have regained partial foreskin function, though obviously any specialized nerve endings and the frenulum would not be restored.


  1. Well, well written! As a parent who bucked years of family tradition and chose to leave her boys intact instead, I applaud your position.

  2. I liked the article very much. I also agree with you.