posted 03-29-2004 10:12 AM
Taken from The American Council on Science and Health, Inc websites at http://www.acsh.org/publications/priorities/0904/circno.html Is Circumcision Healthy? — No
by Dr. Robert S. Van Howe
Within 48 hours of birth the average American boy is taken from the warmth and security of his mother and strapped to a board. His foreskin—the skin that covers the head of the penis (the glans), serves to protect the penis from irritation and infection, and has the highest density of specialized sensory nerves of that organ—is torn from the glans. Then a bell-shaped device is lowered onto the fresh wound and a thumbscrewlike apparatus is applied. This is tightened until the foreskin is amputated. The discarded nerves would have enabled sensations of fine touch, temperature, and pleasure. All that remains is an open, throbbing wound with nerves that eventually will enable only sensations of deep pressure and pain.
During the operation, the infant's blood oxygen drops. His heart rate and cortisol level (a measure of stress) shoot up. His crying becomes high-pitched, such that one would observe only when a baby is in intense pain. Then he may completely dissociate (a response similar to severe posttraumatic stress disorder) and become quiet—giving up because no one has rescued him. Immediate complications of the operation can include hemorrhage (sometimes fatal or requiring a blood transfusion); minor infections; deadly infections such as meningitis, gangrene, and septicemia (blood poisoning); partial or complete amputation of the penis; urinary retention leading to renal failure; and rupture of the bladder or stomach. (continued on page 27)
The vast majority of neonatal circumcisions are performed without anesthesia. Using local anesthesia during the operation has been disappointing. Research has shown that local anesthesia does not prevent, but merely moderates, the cortisol elevation. Furthermore, local anesthesia does not affect postoperative pain, such as that due to the newborn's urinating and defecating into the open penile wound. In any case, the external application or injection of any local anesthetic involves risk to the patient.
After the operation the baby, exhausted and apprehensive, is returned to his mother. He has difficulty quieting down after disturbances. The time he spends in dreamless (non-REM) sleep is increased. He is less available for interaction with his mother. This hinders the establishment of breast-feeding and maternal bonding and thus leads to weight loss and jaundice. Once he has been brought home, the baby's risk of certain local skin problems—penile infections, inflammation of the penile meatus (passage), and narrowing of the meatus, for example—is higher than that of noncircumcised infants. Half the time, his glans will not be fully exposed and this will prompt further surgery.
The operation's psychological impact on newborns is largely unknown, but performing circumcision without an anesthetic has enabled studying the parameters of extreme pain in experiments that researchers would have been prohibited from performing on lab animals. Researchers who have studied such parameters in infants have concluded that newborns are more susceptible to painful stimuli than are older infants.
Recent research suggests that the operation may have long-lasting effects on the patient's perception of and sensitivity to painful stimuli. The main structures for memory are functional in newborns, and remembrance of pain may figure in pain perception later. For days after the surgery, the circumcised boy will experience a greater change in heart rate when his blood is drawn than will a noncircumcised boy. And regardless of whether an anesthetic was used during circumcision, he will cry louder and longer during inoculations months later.
Boys circumcised when they were five years old showed a decrease in IQ, feelings of insecurity and inferiority, sexual identification disturbances, regressiveness, an increase in self-aggression, and other psychological problems after the operation. The children perceived the operation as castration and perceived females as responsible for the act.
The adverse effects of circumcision on self-esteem and body image appear to increase with age, as circumcised men entering their forties and fifties are increasingly expressing dissatisfaction. Circumcised men report suffering from premature ejaculation, impotence, bleeding at the scar site during erections, desensitization of the glans, pubic hair on the shaft of the penis, painful intercourse, and decreased lubrication. While such evidence is largely anecdotal, the need for further research is clear.
In a recent University of Chicago study, researchers discovered that circumcised men engaged in masturbation and oral and anal sex more often than did noncircumcised men. This suggests that they may be in search of greater direct stimulation than that afforded by coitus. The Committee on Bioethics of the American Academy of Pediatrics and the American Medical Association Council on Ethical and Judicial Affairs consider it unethical to perform nonemergency surgery on individuals who (continued on page 29) are unable to consent. Isn't it prudent to let the person with the foreskin decide whether to have it removed?
Circumcision was introduced as a routine medical practice a century ago to eradicate masturbation and all the illnesses then associated with masturbation, including epilepsy, hydrocephalus, idiocy, and paralysis. Circumcision is still promoted as a "health" measure—and continues to fall short of its billing.
Advocates of circumcision claim that the operation prevents balanitis (inflammation of the head of the penis) and ensures genital hygiene. But not a single study reported in the medical literature supports these claims. On the contrary, studies indicate that balanitis affects circumcised and noncircumcised males equally And it may not be coincidental that the United States, where 80 to 90 percent of the males are circumcised, has one of the highest rates of sexually transmitted diseases and HIV infection in the world: New findings suggest that circumcised men may be more at risk of contracting syphilis, gonorrhea, nongonococcal urethritis, chlamydia, genital warts, and genital herpes. Moreover, the results of combining the data from the 28 published studies comparing HIV status to circumcision indicate that circumcision puts a man at a significantly higher risk of HIV infection.
Penile cancer is more common in the United States than in Denmark, Japan, and Norway—countries in which fewer than 2 percent of the men are circumcised. Research has repeatedly demonstrated that penile and cervical cancer result from viral (human papillomavirus) infection and smoking. Indeed, in 1996 officials of the American Cancer Society stated: "Perpetuating the mistaken belief that circumcision prevents cancer is inappropriate."
Whether urinary tract infections (UTIs)—uncommon in boys overall—are more common in noncircumcised boys is undetermined. The studies published to date that have suggested a higher incidence of UTI among the noncircumcised had methodological flaws: Confounding factors—for example, hygiene habits, outpatient treatment, modes of urine collection, socioeconomic status, race, prematurity, and perinatal health—were not taken into account. Any one of the confounding factors could explain the UTI-incidence difference—a difference of less than 1 percent—between circumcised and noncircumcised boys.
Four studies have shown an increase in UTI risk in circumcised boys during the first week after the operation. No studies have linked the foreskin to serious kidney disease. On the contrary, the data suggest that kidney problems are more likely in circumcised boys with UTIs than in noncircumcised boys with UTIs.
According to published cost-utility analyses, routine neonatal circumcision (a) is not cost-effective and (b) adversely affects general health. Neonatal circumcision and its aftereffects cost the United States $500 million to $800 million annually.
An objective examination of the published findings on circumcision in the scientific literature leads one to conclude that circumcision does more harm than good. The scientific community needs to study properly the psychosexual, human-rights, and long-term medical impact of circumcision. Until the full range of harm is known, prudence demands a moratorium on the surgery.
Robert S. Van Howe, M.D., practices general pediatrics in northern Wisconsin with the Marshfield Clinic. He is a clinical instructor at the Medical College of Wisconsin and a consultant to the American Academy of Pediatrics Task Force on Circumcision.
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