It is the "norm" to circumcise right? You want your son to fit in? You want him to look like other male family members? It's so much cleaner, right?
These are all emotional reactions. Let's sit down and really discuss what you're not being told.
There’s no good reason to circumcise a healthy infant. Not tradition. Not culture. Not aesthetics. Not health.
Circumcision of newborn babies is medically unnecessary.Circumcision is neither guaranteed nor necessary to prevent any disease – behavior matters much more.The evidence on the alleged medical benefits of circumcision is conflicting, inconclusive, and often methodologically flawed.Most health reasons given for circumcision, such as STIs, are not relevant to babies.Effective conservative treatments exist for most penile problems – amputation should always be a last resort.The intact penis needs no special care or attention.Most intact men are happy to be whole, regardless of whether their fathers or friends are.
There are so many reasons not to:
No medical organization in the world recommends circumcision for all males.Circumcision causes unnecessary pain, stress, and trauma.Circumcision exposes a healthy child to unnecessary surgical risks, such as hemorrhage, infection, and surgical errors.Later complications are not uncommon, including adhesions and meatal stenosis.Some complications, though rare, can be catastrophic – including death.Many boys will need a repeat surgical procedure.Circumcised males often experience long-term emotional and sexual effects.Circumcision irreversibly takes away the child’s own right of choice.Circumcision violates the principles of medical ethics and human rights.
Circumcision myths and facts
MYTH: Everyone circumcises.
FACT: Most of the world has never practiced medical circumcision. The United States is the only country that circumcises the majority of its newborn baby boys for non-religious reasons – and only for the last couple of generations. In recent decades, the rate has dropped in the US to under 60%, and much lower in some parts of the country.
MYTH: The foreskin is just a piece of skin.
FACT: The foreskin is a complex, specialized tissue – a mobile, double-layered fold of skin, mucous membrane, and muscle, containing dense concentrations of erogenous nerve endings. It is an integral part of the penile skin system, not something “extra.” The foreskin amounts to half of the skin the penis is naturally designed to have (15 square inches in an adult). It has many protective and sexual functions.
MYTH: The foreskin is dirty, prone to disease, and hard to take care of.
FACT: The foreskin is a normal, healthy body part. It is no more prone to disease or problems than any other body part, and is well-designed to protect itself. The occasional foreskin problem can be easily treated without surgery. Care of the foreskin is simple.
MYTH: Circumcision makes no difference in sex.
FACT: Circumcision removes the most fine-touch sensitive parts of the penis, and eliminates the mobility of the penile skin sheath. This drastically changes the natural sensations and dynamics of sex, and decreases the pleasure of both the man and his partner. It also results in reduced lubrication, reduced female comfort, and tighter, possibly painful erections. Without the foreskin, sex is drastically altered from what nature intended.
MYTH: Circumcision is just a painless little snip.
FACT: Circumcision is excruciatingly painful. It involves multiple tissue-damaging steps, including tearing, crushing, and slicing of a highly sensitive part of the body – often without adequate anesthesia – while the baby is restrained on a board. Babies have continuing pain during the healing period, when the wound is exposed to feces, urine, and irritation from the diaper.
MYTH: Circumcision is safe and harmless.
FACT: Circumcision destroys the protective and sexual functions of the foreskin. Many men experience emotional harms later in life. Surgical complications are numerous, including bleeding, infection, meatal stenosis, and adhesions, ranging from minor to severe. Many circumcised boys will need a repeat surgery. Death and loss of the penis, although rare, do occur. Breastfeeding and the relationship of the mother and child may be impacted. The true risk rates are not fully known, and are likely underestimated.
MYTH: Circumcision is medically beneficial.
FACT: No medical organization in the world recommends routine infant circumcision. Circumcision is neither necessary nor guaranteed to prevent any disease. A person’s behavior is always going to be more important in preventing disease than whether or not he has a foreskin.
MYTH: A boy should look like his circumcised father or friends.
FACT: There is no evidence of harm when a boy does not “match” his father, brothers, or peers. Differences are easily explained. A child’s emotional well-being is best supported through good parenting, not cosmetic surgery. Many families with circumcised fathers or older brothers are choosing to keep younger sons whole, without any problems whatsoever.
MYTH: Circumcision should be the parent’s choice.
FACT: Ethically, the only person who should be choosing circumcision is the person whose body and life will be most affected by it, that is, the boy himself – and not till he is old enough to give his own fully informed consent. Baby boys deserve the same rights to body integrity and self-determination as any other human being – no matter what the beliefs or preferences of the parents.
“Cutting off a functional, protective, and sensitive body part is a far-reaching decision that the vast majority of Europeans believe should be left to its owner when he becomes old enough to understand the consequences. Despite the recent, backward-looking statements by U.S. medical organizations, more and more Americans are beginning to agree.”
Morten Frisch, M.D., Danish epidemiologist
Medical Organization Statements on Circumcision
Medical organizations outside the U.S. have taken official positions on medical circumcision, despite the rarity of this practice in most non-English-speaking countries. European pronouncements, for instance, are noteworthy for scientific caution, reliance on evidence-based medicine, rejection of mere tradition or parental preference, and a thoughtful concern for the human rights of the child.
By contrast, U.S. medical associations – especially the American Academy of Pediatrics, the lead broker of this cultural practice for decades – have been strategically deferential to parental choice and tradition. The AAP has been equivocal on the medical evidence since declaring circumcision “unnecessary” in 1971 – then walking that disavowal back ever since. The AAP has consistently dangled the specter of unpleasant, even dangerous (but highly unlikely) outcomes for intact boys, while disingenuously leaving it up to frightened young parents to make an immediate ‘decision.’ The rare mention by the AAP of the human rights of the child to an intact body has been, at best, parenthetical, and at worst, disdainful and dismissive.
The AAP’s 2012 statement – its most pro-circumcision statement to date – is drastically out of line with numerous ethical, legal, and medical authorities in Europe and Australasia that have looked at the exact same evidence and come to opposite conclusions.
While the AAP has persistently focused on justifications for genital cutting of boys, the International Coalition for Genital Integrity has produced a position statement that focuses on genital wholeness and children’s rights, which D.O.C. endorses.
Benefit vs. Risk
The AAP makes the key claim, repeated numerous times, that “the benefits of newborn male circumcision outweigh the risks,” without ever quantitatively comparing them. Indeed, it admits multiple times that the true rate and impact of circumcision complications is unknown, but still illogically makes this claim.“The true incidence of complications after newborn circumcision is unknown.” p. e772“It is unknown how often these late complications require surgical repair; this area requires further study.” p. e772“Based on the data reviewed, it is difficult, if not impossible to adequately assess the total impact of complications.” p. e775“Financial costs of care [after complications], emotional tolls, or the need for future corrective surgery are unknown.” p. e775
A guiding principle of medicine, however, suggests that a procedure should not be recommended until its complications, losses, and harms are fully understood.
It exaggerates the benefits of circumcision and minimizes its risks and harms. It selectively cites or emphasizes studies that favor circumcision, and omits or rejects those that disfavor it, e.g.:It citesSorrells et al.’s (2007) penile touch-testing study, but ignores its key finding that “circumcision ablates [removes] the most sensitive parts of the penis.”It fails to cite Taylor’s (1996) groundbreaking anatomical paper, “The prepuce: specialized mucosa of the penis and its loss to circumcision.”It admits the African HIV findings may not be applicable to the USA, but applies them anyway. It admits that many of the diseases studied vis à vis circumcision are rare in the USA, but nonetheless cites these to pad its ‘benefits’ discussion.In three pages discussing STIs and HIV, it fails to mention the word “condom” as a preventative even once.It cites a study suggesting circumcising men increases the HIV risk to women, and ignores that finding in its risk:benefit conclusion.It dismisses major complications and death from circumcision as “anecdotal.” Case reports were excluded from the AAP’s review, so individual reports of deaths and catastrophic outcomes of circumcision were simply ignored. It further fails to admit that there is no national reporting system for serious outcomes of circumcision, and fails to call for such a system.[4]It ignores psycho-emotional harms, and the possibility that men circumcised as infants might be distressed that their genitals had been diminished unnecessarily without their consent.It discusses the use of the Mogen circumcision clamp as a “commonly used technique” without mentioning that the manufacturer has been driven out of business due to a number of multi-million-dollar lawsuits following amputation of the glans penis with this method.
Costs
The AAP’s report calls repeatedly for “access” and “third-party reimbursement” for circumcision, based on its flawed risk:benefit analysis, ignoring its own acknowledgment of insufficient information on the costs of circumcision. The report fully ignores the costs of follow-up care for complications and repeat procedures. p. e775It repeats the common claim that it is safer to circumcise babies than adults, but offers no evidence for that claim. It compares the costs of circumcising at birth versus later in life, but fails to compare these with the option of doing nothing at all.The only cost-effectiveness study cited did not consider circumcision complication rates. The report ignores a recent comprehensive cost:utility analysis that concluded, “Neonatal circumcision is not good health policy and support for it as a medical procedure cannot be justified either financially or medically.”
Ethics
The AAP’s discussion of the ethical questions relating to removing healthy genital tissue from a non-consenting person – versus leaving it for him to decide himself – assigns no value to the child’s future autonomy or his human rights to bodily integrity.It explicitly argues against deferring circumcision until the child can make his own decisions (p. e760), without providing information on the disadvantages of immediate circumcision. Informational manipulation of this kind – particularly for a procedure that is medically unnecessary and elective – violates medical ethics. Furthermore, it contravenes the AAP’s own statement on pediatric proxy consent.The AAP’s ethical consultant has said elsewhere that “circumcision is not medically essential and poses a risk of harm,” and that a parental request is not sufficient to justify doing any surgery, and the statement ignores these.
“We justify male infant circumcision by pretending that the babies don’t feel it because they’re too young and it will have no consequences when they are older. This is not true. Women who experience memories of abuse in childhood know how deeply and painfully early experiences leave their marks in the body. Why wouldn’t the same thing apply to boys?”
Christiane Northrup, M.D
The Psychological Impact of Circumcision
The psychological effects of circumcision on the child – and the man he will become – are an often overlooked harm of the practice, with serious implications for mental health, emotional and relational well-being, and the health of society.
Psychological effects
Evidence indicates that the ability to learn and remember is present from before birth [1,2] and that newborn infants have fully functioning pain pathways.[3] Therefore, one would expect to find psychological effects associated with genital cutting of newborns.
Changes in infant-maternal interaction have been observed after circumcision, including disrupted feeding and weaker attachment between the infant and mother.[4,5] The American Academy of Pediatrics Task Force on Circumcision (1989) noted behavioral changes resulting from circumcision in their report.[6] The behavior of nearly 90 percent of circumcised infants has been found to be significantly changed after the circumcision.[7] Differences in sleep patterns and more irritability – both signs of stress – have been observed among circumcised infants [8,9,10].
Post-traumatic stress disorder (PTSD) is a normal response to an event in which a person’s physical integrity has been threatened or violated. Forced genital cutting is a direct experience of sexual violence, so it fulfills the criteria as a psychogenic cause for PTSD.[11] Taddio et al. studied the behavior of babies at first vaccination. They found that circumcised boys have a much stronger reaction to the pain of vaccination than do girls and intact (non-circumcised) boys, which the authors suggested is an “infant analogue” of PTSD.[12] Other authors also have reported PTSD in circumcised males.[13] Rhinehart reported on four cases of PTSD connected with neonatal circumcision in middle-aged men that he encountered in his psychiatric practice.[14] Ramos and Boyle reported PTSD in 70 percent of Filipino boys who experienced ritual circumcision and 51 percent of Filipino boys who experienced medical circumcision.[15]
Cansever tested young boys before and after ritual circumcision and reported that these children had a tendency to seek safety afterwards through emotional withdrawal.[16] Based on relevant literature, clinical experience, and statements from circumcised men, Goldman suggests that reduced emotional expression is the primary potential long-term psychological effect of circumcision.[17] A subsequent study found that circumcised men had significantly increased alexithymia (difficulty identifying and expressing feelings) compared to intact men.[18]
A large Danish study found that circumcised boys may have a greater risk of developing autism spectrum disorder before age ten and a higher risk for infantile autism before age five. Circumcised boys were also more likely to develop hyperactivity disorder.[19] While, causally, autism is considered to be a multifactorial disorder,[20] the link with circumcision may in part explain why the incidence of autism is almost five times more common in boys in the United States.[21] Hyperactivity disorder (attention deficit disorder) is about three times more common in boys.[22] More research is needed to replicate and better understand the Danish findings.
Based on growing reports from circumcised men, other potential long-term psychological effects of circumcision include excessive or inappropriate anger, shame, shyness, fear, powerlessness, distrust, low self-esteem, and decreased ability for emotional intimacy.[14,17,13-25] Because circumcision is generally performed shortly after birth, it is a perinatal trauma, and several authors report that perinatal trauma may contribute to self-destructive behavior in adult life.[26-30] Lack of awareness and understanding of circumcision, emotional repression, fear of disclosure, and nonverbal expression explain why we do not hear from more circumcised men about how they truly feel.[17,31,32]
Van der Kolk reports that trauma often results in a compulsion to reenact or repeat the trauma on others.[26] For example, a circumcised father often irrationally insists that a son undergo circumcision, even against a spouse’s wishes and knowing that there is no medical necessity.[33] As another example of the compulsion, a survey of randomly selected physicians showed that circumcision was more often supported by doctors who were older, male, and circumcised.[34,35] In addition, some American doctors have apparently tried to coerce parents to circumcise their sons.[36,37] Circumcision status and its associated psychological and social factors may also bias circumcision studies and circumcision policy statements in favor of circumcision.[38]
With increased awareness of the psychological effects of circumcision, there is a growing need for some circumcised men to seek professional psychological help. Clinicians who are themselves circumcised, deny their own harm and associated effects, and/or have chosen circumcision for their sons may be less likely to be empathetic to men in distress about circumcision harm, in order to avoid the discomfort of cognitive dissonance.[39] Clinicians should regard circumcision-related feelings and behaviors seriously and refer clients as appropriate.[40]
Broader social implications
Laumann reported that 77 percent of the American adult males in the 1992 National Health and Social Life Survey were circumcised.[41] The effects of this sexual wounding – both neonatal and lifelong, intra- and interpersonal – have been discussed above. Goldman argues that having so many emotionally and sexually injured males in a culture could potentially produce undesirable social outcomes.[17] Despite many disquieting indications,[17,23,42,43] there has been but limited longitudinal research – and remarkably little professional concern – about the potential social effects of circumcision.
“What’s done to children, they will do to society.”
Karl A. Menninger, M.D.
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[B]y taking off the most sensitive part of the penis, we are really interfering with the way nature designed sex to be.”
Morris Sorrells, M.D.
The Sexual Impact of Circumcision
Anatomical considerations
The prepuce is an integral part of the penile skin system and has been characterized by anatomical researchers as “primary erogenous tissue necessary for normal sexual function.” Amputation of the prepuce (foreskin) by circumcision alters the anatomy of the penis from its natural design in a number of fundamental ways. Form and function go hand in hand in anatomy. Thus the alterations that circumcision causes in the natural mechanical and sensory capacities of the penis inevitably affect the sexual experience of both the man and his partners.
Loss of penile surface area – The foreskin is not just a “flap” of skin, but a double-layered fold of densely innervated skin and mucosa, of considerable area. Circumcision ablates what will become, in the adult, up to 90cm2 (~14in2) of tissue, approximately half of the skin the penis.
In the flaccid penis, this tissue folds over on itself, covering the glans to varying degrees in each individual. As the penile shaft elongates with erection, the foreskin fold everts and is taken up along the shaft, while still retaining enough slack to maintain mobility of the penile skin sheath. With circumcision, however, the extensive loss of penile skin leaves insufficient tissue for comfortable expansion of the penis with erection. This can result in tight, painful, or bowed erections; tearing or bleeding at the scar site or on the shaft skin; or pulling of hairy skin from the scrotum and pubic area onto the shaft of the erect penis. Australian researchers found that circumcised men had shorter erect penises by a mean length of 8mm than intact men ,which may be due to tethering of the penis by excess skin tension.
In the case of heterosexual intercourse, once the intact penis is inserted, the vaginal walls hold the skin of the penis relatively stable, allowing the shaft of the penis to glide in and out of its own skin sheath. In contrast, the taut, immobile skin of the erect circumcised penis lacks this natural gliding action with the motions of intercourse, creating an excess of friction directly on the vaginal walls, and potentially causing increased discomfort for both partners. These dynamics also apply to anal intercourse.
The mobility of the intact penile skin also plays a facilitative role in foreplay, masturbation, and intromission (insertion of the penis), all of which are adversely impacted by circumcision. One physician described the latter function in this way: “Penetration in the circumcised man has been compared to thrusting the foot into a sock held open at the top, while, on the other hand, in the intact counterpart it has been likened to slipping the foot into a sock that has been previously rolled up.” Several researchers have noted that circumcision causes compensatory changes in masturbatory technique. Whereas the intact male can slide the touch-sensitive foreskin back and forth over the glans to self-stimulate, the circumcised male must apply friction directly to the less sensitive glans and shaft of the penis. When masturbating, circumcised men have been found to significantly more often require the use of artificial lubrication, and stimulation to the point of pain to achieve ejaculation.
Loss of nerve endings – In the 1950s, Winkelman noted the dense innervation of the prepuce, and classified the prepuce as a “specific erogenous zone,” along with other mucocutaneous regions (such as the lips, nipples, and vulva), areas in which the anatomy is specifically organized to “favor acute sensation.” In the 1980s, Moldwin and Valderrama documented “an extensive neuronal network within prepucial tissue.” Taylor et al. (1996) documented dense concentrations of fine-touch-sensing Meissner’s corpuscles in a band of ridged mucosa encircling the preputial outlet, and identified the prepuce as a “a large and important platform” for input into the nervous system. Sorrells et al. (2007), using micro-filament touch-testing on 19 points on the penises of intact versus circumcised men, found that the most fine-touch-sensitive regions of the penis are those removed by circumcision.
The several sensory testing studies that claim to have found no difference between the sensitivity of the intact and the circumcised penis have significant methodological limitations. Some only tested the glans, but failed to test sensation in the prepuce itself. Anatomically, the glans has been shown to have primarily protopathic sensitivity (able to feel only crude, poorly localized sensations), and is the least light-touch-sensitive part of the penis in both circumcised and intact men. While sensory differences are already less likely to be detectable in such a low sensitivity area, ignoring any comparison with the sensitivity of the foreskin itself is a crucial oversight.
Two studies that reported no difference in sensitivity did test, in addition to the glans, a single point on the dorsal midline of the outer foreskin. This point is an area that Sorrells et al. found to be the least sensitive to fine touch compared to other parts of the foreskin (such as the preputial outlet, the frenulum, and the inner foreskin). Testing only the least sensitive part of the foreskin inaccurately weights the results against finding any difference between the sensitivity of the foreskin and parts of the parts of the penis that remain after circumcision.
Perhaps surprisingly then, the authors of one of these studies, Bossio et al., still found that the foreskin of intact men was more sensitive to tactile stimulation than any other part of the penis (circumcised or not), and also that it was more sensitive to warmth than the glans (both results statistically significant). However, ignoring their own findings, these authors reported the contradictory conclusion that neonatal circumcision has “minimal long-term implications for penile sensitivity.” This pronouncement further ignores the fact that static, single-point testing in a laboratory may be very different from real-life sexual stimulation, in which all parts of the foreskin are likely to be stimulated via moving, rather than static, gestures. Bossio et al.’s study has been critiqued in detail elsewhere.
Anatomically, excision of the foreskin by circumcision removes the majority of the fine-touch range of the penis’s sensory spectrum, an important component of sexual experience. In an online survey, intact males predominantly identified the foreskin, not the glans, as the main site of sexual pleasure. Cold and Taylor state that “the complex interaction between the protopathic sensitivity of the corpuscular-receptor-deficient glans penis and the corpuscular-receptor-rich ridged band of the male prepuce is required for normal copulatory behavior.”
Nerve damage – Beyond the simple loss of nerve endings, several other forms of neuronal damage can occur with circumcision, due to the severing of nerves. Circumcision scars have been shown to contain amputation neuromas (tangles of nerve tissue resulting from abnormal regrowth) which do not transmit normal sensations, but typically produce pain. In animal studies, extirpation of the external genitalia has been found to result in acute retrograde degeneration of the sexual nerve axons back to the spinal cord.
Podnar found a significantly reduced ability to elicit the penilo-cavernosus reflex (muscle contractions associated with the ejaculation reflex in circumcised men compared to intact men. Measurement of this reflex is widely used to diagnose underlying neurogenic disorders in erectile dysfunction. Podnar was able to elicit the reflex in 92% of intact men, but only in 27% of circumcised men. A survey by Meislahn and Taylor similarly found that stretching of the penile skin in intact men (which includes the foreskin) more often produced erection and contractions of the bulbo-cavernosal muscle, as compared with stretching the remnant skin in circumcised men.
Keratinization – Circumcision permanently exposes the normally covered, mucosal surface of the glans to air and friction, causing the glans to become abnormally dried out and thickened. Sorrells et al. found the already light-touch-insensitive glans to be significantly less sensitive in the circumcised male, an adverse effect that was found to increase over time.
Summary – The anatomical effects of circumcision alter the mechanical dynamics of erection and intercourse, and produce an abnormal and deficient sensory input into the nervous system. Given this, it is hard to imagine that one would not find changes in sexual function and experience. A number of studies have found this to be the case, showing statistically significant evidence of degradation of male sexual performance and satisfaction, as discussed in the next section.
Impact on sexual performance and satisfaction
Besides anatomical studies and those testing penile sensory capacities such as those discussed above, further evidence on the sexual functionality of the foreskin comes from others types of investigations. Among others, these include surveys of adult men before and after circumcision; surveys comparing circumcised and intact populations; surveys of circumcision harm reported by circumcised men; surveys on the sexual experiences of women with circumcised versus intact partners; studies of effects on lubrication and intromission; and collections of personal reports from men who have non-surgically restored their foreskins, thereby regaining coverage of the glans and mobility of the penile skin.
Before and after studies of adult circumcision – Studies of sexual outcomes before and after adult circumcision are subject to several methodological limitations that may bias the results toward an underestimation of harm.
First, men who choose to be circumcised as adults are already predisposed to view the outcome as positive, either because they have a physical problem that circumcision resolves, or because they are seeking circumcision out of a pre-existing preference. The limited length of follow-up of before and after studies is another potential source of underestimation of harm. If circumcision has a desensitizing effect on the glans (whether due to keratinization or some other process, and the desensitizing effect is progressive with age, the 24 months or less of typical follow-up time might not be sufficient to detect a difference.For this latter reason, studies finding no difference in penile sensitivity after adult circumcision cannot appropriately be extrapolated to individuals circumcised as infants, in which there is a much longer period before sexual debut than is ever studied in adults.
Despite these built-in biases, a Korean survey found that a man was twice as likely to report diminished rather than improved sexuality after adult circumcision.Overall, a worsening in sex life has been found in about one third of reported adult circumcision cases.
Studies of men’s sexual performance and satisfaction before and after adult circumcision reveal an array of possible negative effects. Statistically significant increases have been found after adult circumcision in problems with erection,prolonged time to ejaculation,penile sensation, difficult intromission, and masturbatory ease and pleasure.
Two before and after studies, carried out in conjunction with the African HIV trials, claim to have found no difference in sexual satisfaction and performance. While these studies are initially suspect due to the implausibly low rates of sexual dysfunction found both before and after circumcision (much lower than studies performed outside of Africa, nonetheless they have been accorded particular attention and credibility, presumably because of their randomized controlled design. However, RCTs are not immune to various sources of bias, for example:
A strong study design does not eliminate the need for high-quality questionnaires. In one of these studies, the survey questions were so poorly designed that they could not have detected a difference in sexual outcomes, even if one existed.The studies were carried out by the same researchers who ran the HIV trials in which the subjects had already participated, i.e. they were not impartial, independent investigators, nor blinded to the circumcision status of the subjects.The subjects themselves may have tended towards socially desirable responding, the tendency to provide answers that make one look good in relation to social norms and expectations, especially with self-reporting of sex data in face-to-face interviews.[56,57]Drop-out rates were significant for the HIV trial populations,[58] which could have affected the outcome results if men who experienced sexual problems after circumcision, or were reluctant to report them, were disproportionately present in the drop-out group.
Large European surveys – Two large surveys recently compared sexual outcomes for circumcised versus intact men. Frisch et al. found that circumcised men in Denmark were more likely to report frequent orgasm difficulties than intact men. In a survey from Belgium, Bronselaer et al. found that circumcised men reported decreased sexual pleasure and lower orgasm intensity at the glans compared to intact men, more effort required to achieve orgasm, and a higher percentage experienced unusual penile sensations (such as burning, prickling, itching, tingling, numbness, or pain).
Premature ejaculation (PE) – A survey of men circumcised as adults in the UK about their sexual function before and after circumcision found no difference in premature ejaculation rates overall, however, the subjects were almost 3 times as likely to report worsening of PE after circumcision than improvement. A study examining the correlates of premature ejaculation found that having been circumcised was significantly associated with PE among Malaysian men. However, other PE studies have not shown this association, reporting, instead, reduced rates of PE and longer time to ejaculation following adult circumcision.
Effect on male sexual behavior
Several large surveys point to behavioral differences between circumcised and intact men. Laumann et al. found among circumcised American males a “more highly elaborated set of sexual practices,” including more frequent masturbation and a greater preference for oral sex. The British National Survey of Sexual Attitudes and Lifestyles reported that circumcised males were more likely to report homosexual partners and partners from abroad. Frisch et al. found that circumcised men were more likely to have had ten or more sexual partners compared to intact men. Several studies have shown significantly lower rates of condom usage in circumcised men.
Effect on partners of circumcised men
Circumcision not only impacts the sexual experience of the man himself, but also has appreciable effects on the experience of his sexual partners.
Circumcision has been found to significantly increase vaginal dryness during intercourse. As described above, in the intact penis, once inserted, the penile skin sheath stays relatively stable as it is held in place by the friction with the vaginal walls, while the shaft glides in and out of its own skin sheath. On the outstroke, the foreskin bunches up in a cuff around the glans, acting as a dam to retain natural lubrication, followed by redistribution of lubrication with the inward stroke. In the circumcised penis, without the foreskin cuff, the exposed coronal rim acts as a one-way valve to pull lubrication out of the vagina, while the taut shaft skin carries moisture out of the body with each outstroke where it is repeatedly exposed to air drying. One group of researchers advises “it is imperative that future studies of female arousal disorder report and control [for] the circumcision status of male sexual partners,” and suggests that ‘female arousal disorder’ may be a normal response to sex with a circumcised partner.
The loss of the gliding action of the foreskin can lead to difficulties with intromission,with an increased amount of force required for penetration. The loss of gliding action can also lead to greater discomfort with intercourse due to the application of friction directly to the vaginal walls. Discomfort from friction would be exacerbated by loss of natural lubrication or the presence of scrotal or pubic hair drawn onto the shaft by too tight an erection. These factors may have a particularly significant impact on women’s comfort during menopause, when reduced natural lubrication and tissue atrophy commonly result in dyspareunia (painful intercourse).
O’Hara et al. surveyed women with sexual experience with both circumcised and intact partners.While this survey may have some limitations due to selection bias (since the participants were in part recruited through an anti-circumcision newsletter), participants’ responses did not differ with the source of recruitment. Participants overall reported, with circumcised partners as compared to intact, a decreased ability to experience orgasm with vaginal intercourse, decreased experience of multiple orgasms, decreased enjoyment of prolonged intercourse, and a decreased sense of intimacy with the partner. Even women who expressed a preference for circumcised partners reported more frequent experience of discomfort and progressively decreasing vaginal lubrication with intercourse.
The survey also found a difference in the mechanics of intercourse with circumcised versus intact partners. Participants reported that circumcised men “tend[ed] to thrust harder and deeper, using elongated strokes,” while intact men “tended to thrust more gently, to have shorter strokes, and tended to be in contact with the mons pubis and clitoris more.”[10] This dynamic reflects the self-stimulating action of the light-touch sensitive foreskin, which does not have to move very far back and forth to generate pleasurable sensations. The closer contact with the female pubic area may explain the association of greater ease of orgasm for women during intercourse with intact partners.
O’Hara’s qualitative results have been confirmed by subsequent studies. The large survey of the effects of circumcision on sexual function in Denmark, by Frisch et al., found circumcision significantly associated with a range of frequent sexual difficulties in women, notably orgasm difficulties, dyspareunia, and “incomplete sexual needs fulfilment”. A survey of Greek men circumcised as adults found that 46% of participants reported a worsened sex life for their female partner compared to 33% who reported an improvement for their partner.[Bossio et al., surveying Canadian and American women, found that women with a current intact partner reported higher levels of sexual satisfaction than women with a current circumcised partner, independent of whether they reported a preference for the circumcised penis for selected sexual acts. On the other hand, a study based on the African HIV RCTs claimed similar or greater levels of sexual satisfaction among female partners after the spouse’s circumcision, however, some of the same methodological limitations exist here as in the sexual satisfaction study in the same population of circumcised men, discussed above.
Studies claiming to show a preference of women for one or the other circumcision status have reported differing results, and results appear to be related to pre-existing experience with and beliefs about the circumcised or intact penis.
Few studies have examined the effects of circumcision on the partners of gay men. In an Australian survey, gay men reported a progressive decline in the sensitivity of the glans more often in their circumcised partners, and reported that their circumcised partners were less likely to ask respondents to be gentler on their penis during sex. In a survey of American and Canadian populations, gay men preferred an intact partner for all sexual activities, and held more positive beliefs about the intact penis than did women in this population.
Summary
It is incontestable that circumcision eliminates from a man’s sexual experience any sensation in the foreskin itself, as well as any sexual functions that involve the manipulation of the foreskin, such as during foreplay or masturbation. That such pleasurable activities might have significant subjective value to genitally intact men and their partners is also uncontroversial.Therefore, according to one commentator, to say that circumcision has little or no effect on sexual experience is to adopt “an extremely narrow conception of that term.”
The contention that circumcision causes deficits in sexual sensation and function is supported by the fact that several products have been developed specifically for circumcised men to help overcome problems with penile sensation and function) by the association of circumcision with the need for artificial lubrication and erectile dysfunction drugs;and by the fact that many circumcised men have sought out foreskin restoration techniques.
Scientific evidence points to numerous deleterious effects of circumcision on the sensory and mechanical dimensions of sexuality, both for the man and for his sexual partners. For this reason, a number of authors have concluded that fully informed consent for circumcision must include disclosure of its potentially harmful effects on sexual satisfaction and performance. The highly personal and subjective nature of sexuality argues all the more against irreversibly altering the genitals of children, before an age at which they are able to judge their own preferences and make their own mature decisions.
Non-U.S. medical organization statements on circumcision
Canadian Paediatric Society (CPS) (2015) The CPS does not recommend the routine circumcision of every newborn male. It further states that when “medical necessity is not established, …interventions should be deferred until the individual concerned is able to make their own choices.”
Royal Dutch Medical Association (KNMG) (2010) The KNMG states “there is no convincing evidence that circumcision is useful or necessary in terms of prevention or hygiene.” It regards the non-therapeutic circumcision of male minors as a violation of physical integrity, and argues that boys should be able to make their own decisions about circumcision.
The Royal Australasian College of Physicians (RACP) (2010) The RACP states that routine infant circumcision is not warranted in Australia and New Zealand. It argues that, since cutting children involves physical risks which are undertaken for the sake of merely psychosocial benefits or debatable medical benefits, it is ethically questionable whether parents ought to be able to make such a decision for a child.
British Medical Association (BMA) (2006) The BMA considers that the evidence concerning health benefits from non-therapeutic circumcision is insufficient as a justification for doing it. It suggests that it is “unethical and inappropriate” to circumcise for therapeutic reasons when effective and less invasive alternatives exist.
Expert statement from the German Association of Pediatricians (BVKJ) (2012) In testimony to the German legislature, the President of the BVKJ has stated, “there is no reason from a medical point of view to remove an intact foreskin from …boys unable to give their consent.” It asserts that boys have the same right to physical integrity as girls in German law, and, regarding non-therapeutic circumcision, that parents’ right to freedom of religion ends at the point where the child’s right to physical integrity is infringed upon.
In addition, medical organizations and children’s ombudsmen from a number of other countries, including Belgium, Finland, Norway, Slovenia, South Africa, Denmark, and Sweden, have gone on record in opposition to non-therapeutic circumcision of boys.
“The hundreds of boys I have seen who needed surgery to repair problems caused by their circumcisions are real. The men who lost more parts of their penis than the foreskin are real. The thousands of adult men saying they wish they hadn’t been cut are real. Not recognizing that circumcision is harmful is either ignorance or denial.”
Adrienne Carmack, M.D., urologist
Complications
Introduction
Infants undergoing non-therapeutic circumcision are unnecessarily put at risk for a wide range of unintended adverse outcomes from the procedure. Though the risks of circumcision are often blandly characterized as being “minor and rare,” some while relatively minor, such as adhesions, are quite common and still distressing, and some, like death, while rare, can be catastrophic. Adverse events following circumcision include not only the general risks of any surgery (bleeding, infection, and pain), but also many problems specific to the different circumcision techniques and affected by variations in penile anatomy. Babies circumcised in the neonatal intensive care unit or the special care nursery are at four times greater risk for complications than are babies circumcised in the well-baby nursery. Physicians learning the procedure often receive little or no formal training,nor is there any legal requirement for such.
There is no nationwide, standardized, prospective system in the United States or Canada for collecting data on circumcision complications in children, not even for the most serious outcomes. Therefore, no one actually knows how many babies require re-hospitalization, intravenous antibiotics, or a blood transfusion; how many lose all or part of their penis (beyond the foreskin); how many need repeat surgery; or how many boys die as a result of having been circumcised.
This has both ethical and practical implications, for without such information healthcare professionals are unable to adequately inform parents of the procedure’s risks, and parents are subsequently unable to give truly informed consent.[9] Furthermore, without this information, there is no way to validly compare the benefits and risks of the procedure – though this is what the American Academy of Pediatrics has nonetheless dared to do, by illogically asserting that “the benefits of circumcision outweigh the risks” even as they admit that they do not know the incidence, impact, or added costs of circumcision complications.
For over a century, the complications of circumcision have been repeatedly documented in hundreds and hundreds of case reports and case series, plus dozens of retrospective and prospective studies. In addition, a number of review articles have attempted to summarize the medical literature and/or give overall descriptions, rates, and management information on the various complications.
Despite all this, it is difficult to pinpoint the incidence and impact of circumcision complications, due to a variety of problems:
Case reports are crucial for documenting the range and seriousness of the less common complications. However, they cannot be used to estimate accurately the overall incidence of such problems. To capture rates of the more common circumcision complications, other kinds of studies are required.Study design has an effect on the estimation of complication rates. Prospective studies, in which complications are tracked going forward from the circumcision via follow-up examinations, theoretically should capture the incidence of complications most accurately. On the other hand, retrospective studies typically rely on a review of patient charts, a form of data that was recorded for a purpose other than research. Inaccuracies in the medical record (e.g. the not uncommon possibility that the complication was not charted in the first place) tend to lead to underestimation of complication incidence. Even less reliable are retrospective database studies which can only capture events that have had an actual diagnostic or procedure code listed upon discharge. It has been estimated that database studies may miss up to 90-95% of complications.Imprecise and inconsistent definitions for what constitutes a complication are reflected in widely varying study results. For example, Williams and Kapila estimate that “a realistic figure is 2-10%,”whereas Gee and Ansell report a rate of “really significant” complications of 1/500.[15]cess residual foreskin or inadequate circumcision” as a complication because these were “not medical complications per se” (while admitting, at the same time, that these are adverse outcomes of circumcision that may be serious enough to involve further surgery).[16] This inconsistency makes it difficult to interpret what the various numbers really mean. It also makes it possible for authors to manipulate readers’ understanding of the risks of circumcision, by selectively reporting only the results that are most consistent with their underlying bias.The length of follow-up can limit the value of a study’s results. Studies that track problems for only the immediate post-birth hospital stay,[e.g. 17] or for only a month from the procedure,[e.g. 18] fail to account for a host of more long-term complications that may not manifest for many months or years. Short-term studies are unreliable indicators of the true impact of circumcision complications.Studies of circumcision complications are typically blind to adverse outcomes that are not strictly medical or surgical. By failing to consider as “complications,” for example, the impact on psycho-emotional or sexual well-being, or simply the harm of losing a normal, functional body part (which has an incidence of 100%), most published studies paint a very limited picture of circumcision’s damage.[19]
The practice of informed consent for circumcision is woefully inadequate,[20] as evidenced by provider survey results, content analysis,[21] and expressed parental desire for more information.[22] Regarding disclosure of circumcision risks, Christensen-Szalanski et al. found that pediatric and obstetric residents routinely informed parents of only three of the many possible complications associated with circumcision (bleeding, infection, and pain).[23] In a survey of mostly family practice physicians, Fletcher found these same three risks were the only complications discussed more than half of the time, and that the most serious complications were the least often covered (e.g. only 8% of physicians disclosed that death was a possible complication).[24]
As a medically unnecessary, non-therapeutic procedure, disclosure for infant circumcision must include the full range of possible complications, including rare but potentially serious outcomes,[25] for consent to be ethically valid.[20] Parents should be informed of the potential for harm to a male’s sexuality and to his emotional health. And somehow the idea must be conveyed that, even if no physical complications ensue, the loss of a normal body part and the violation of a person’s right to choice over his body are guaranteed harms.
Still, even if disclosure were complete and unvarnished, there are deeper ethical problems within the issue of complications. The question is whether any level of harm or risk is acceptable for a medically unnecessary, elective, cosmetic surgery, especially when the person whose body and life will be most affected cannot give their own considered consent. Doctors Opposing Circumcision unequivocally believes the answer to this question is NO.
Due to the large number of case reports and other publications on circumcision complications, this page can only provide a representative selection of citations. An exhaustive compilation of the medical literature on complications may be found in Van Howe’s monograph on circumcision [14, p. 75-97]. Extensive galleries of pictures of circumcision damage are also available online.[26]
Bleeding
Bleeding is the most common immediate problem associated with circumcision.[1,2] This is not surprising, since the penis and the foreskin are highly vascularized,[27] and circumcision often truncates the frenular artery, a frequent source of post-circumcision bleeding.
Bleeding can be minor, or significant enough to require clotting agents, cautery, suturing, and/or blood transfusions. Severe blood loss can result in cardiac arrest[28] or death from exsanguination.[29,30] Newborns have a blood volume of about 90ml/kg; the loss of a quarter of this volume (little more than 2 oz. for a 7 lb. baby) can cause an infant to go into shock.[31] Modern super-absorbent diapers may mask hemorrhage, making it difficult for caregivers to assess when bleeding is excessive.[32]
Circumcision devices have design features to provide hemostasis (control of bleeding) with the procedure, through crushing or strangulation of blood vessels. However, old Mogen, Gomco, or counterfeit clamps may be worn or deformed, or parts may be mismatched, failing to adequately crush the tissue,[33,34] or the tissue may not be crushed for a sufficient period of time. With the Plastibell device, failure to tie the ligature tightly or securely enough may result in bleeding.[35] Blood vessels that appear to be adequately crushed at the time of the procedure may open up at a later time. Patel found bleeding to be about twice as common with the Gomco clamp than with the Plastibell,[36] however, Gee and Ansell found the rate to be about the same for the two devices.[1]
The rate of bleeding complications varies widely depending on the study design and the definition of excessive bleeding. For example, in one prospective study, 9.87% of circumcisions resulted in abnormal bleeding,[37] whereas a retrospective chart review found a rate for “hemorrhage” of 1.0%,[1], and a database search found excessive bleeding in 0.083%.[18]
The risk of excessive bleeding after circumcision is increased in the presence of blood clotting disorders, although these are not routinely tested for prior to newborn circumcision.
Infection
Infection is the second most frequent early complication of circumcision.[1] The circumcised newborn is at particular risk for infection because of his immature immune system, and the exposure of the open wound (involving the whole glans) to urine and feces in the diaper. Infection may be mild and localized, or it may be more serious, systemic, and life-threatening, requiring intravenous antibiotics, surgical debridement, and other support measures.
Gee and Ansell reported an infection rate in newborns in the immediate post-circumcision period of 0.4%.[1] Patel, reporting on a series of 100 consecutive circumcisions, found infection in 8 cases (8%), with 1 serious enough to require antibiotics, and 1 progressing to fibrosis and phimosis.[36] Gee and Ansell found a 5-fold increase in infection risk in boys circumcised with the Plastibell device compared to the Gomco clamp (p<0.005).[1] This may be explained by the fact that this method leaves a foreign body (the Plastibell ring) applied to the wound, as the adjacent foreskin remnant undergoes necrosis (tissue death).[1,38]
Serious local infections following newborn circumcision reported in the literature include: scalded skin syndrome (2.7% in a series of 75 Plastibell circumcisions[39]), erysipelas, necrotizing fasciitis,[38,40,41] Fournier’s gangrene, and impetigo[42] (10.7% of a series of Plastibell circumcisions [39]), among others.[14, p. 79]
Numerous studies have found a higher rate of staphylococcal skin infections in the first weeks of life in males, especially among those circumcised, as compared to females.[43-53] In recent decades, several outbreaks of neonatal cutaneous methicillin-resistant Staphylococcus aureus (MRSA) infections have been reported, primarily in circumcised boys.[54-63] Infections with antibiotic-resistant bacteria are difficult to treat, resulting in higher morbidity and mortality.[64] One case-control study found that newborn boys diagnosed with a MRSA infection were 12.2 times more likely to have been circumcised than were the matched controls who did not have MRSA.[65] In one case report, MRSA was recovered from the circumcision wound of a newborn infant whose mother had staphylococcal toxic shock syndrome.[66]
An increased incidence of urinary tract infections in the early post-circumcision period has been reported in association with ritual circumcision.[67-74]
Systemic infections associated with circumcision include: generalized septicemia, meningitis, osteomyelitis, bronchopneumonia, acute post-streptococcal glomerulonephritis, tetanus, diphtheria, syphilis, tuberculosis, and herpes simplex virus, among others.[14, p. 80] Sepsis following circumcision has been reported to lead to disseminated intravascular coagulopathy, jaundice, hypothermia, congestive heart failure, peripheral circulatory collapse, and death.[14, p. 80]
Neonatal herpes simplex virus (HSV) infections can cause death or brain damage.[75] The CDC reported HSV infections in 11 newborn boys in the weeks following Jewish ritual circumcision in New York City between 2000-2011; 10 were hospitalized and 2 died.[76] All the cases were associated with the ultra-Orthodox practice known as metzitzah b’peh, in which the operator applies suction by mouth to the fresh penile wound. Authorities have not yet applied effective measures to curtail these preventable infections,[77] and the practice continues, with 6 more circumcision-associated HSV cases reported in New York City since 2011.[77] Historically, tuberculosis and syphilis have also been transmitted to newborns during ritual circumcision, in this same manner.[14, p. 80]
Pain
Research confirms that babies have the neurological capacity to feel and remember pain,[78] and that they may feel pain as much or more than adults.[78,79] According to the American Academy of Pediatrics, “exposure to repeated painful stimuli early in life is known to have short- and long-term adverse sequelae […including] physiological instability, altered brain development, and abnormal neurodevelopment, somatosensory, and stress response systems…”[80] Little to no research has been done on the long-term neurological or psychological effects of circumcision pain.
The American Academy of Pediatrics has recommended the use of anesthesia for circumcision since 1999.[81] Since that time, more practitioners than formerly are being taught the use of anesthesia for circumcision,[82] however, a fair proportion of circumcisions continue to be performed without any pain relief.[82-84]
Pain – whether intra- or post-operative – is an inevitable consequence of circumcision, whether or not anesthesia is used. A Cochrane Review of pain relief for neonatal circumcision based on 35 clinical trials involving 1,997 newborns concluded that “DPNB [dorsal penile nerve block] and EMLA [topical lidocaine-prilocaine anesthetic cream] do not eliminate circumcision pain [emphasis added], but are both more effective than placebo or no treatment in diminishing it.”[85] A study of 59 circumcisions, in which all of the infants had a DPNB, concluded that “60% of the infants had pain or discomfort associated with the procedure that was excessive.”[86]
More effective methods of anesthesia, such as general anesthesia and caudal blocks, are not used for neonatal circumcision because of the increased risks of using them in infants.
The most common complications of local anesthesia include bruising and hematoma formation.[85] Local anesthesia containing epinephrine can cause vasoconstriction and penile ischemia (tissue deoxygenation),[87] and, in at least one reported case, gangrene of the penis.[88] In several case reports, generalized tonic-clonic seizures were attributed to the use of lidocaine (termed “severe intoxication to local anesthesia” in one of these reports),[89,90] complicated in one case by cardiac arrest.[90]
The use of EMLA cream has been associated with methemoglobinemia in numerous case reports (excess of an abnormal form of hemoglobin in the blood, leading to decreased availability of oxygen to the tissues, including the heart and brain).[14, p.95]
Complications associated with circumcision without pain relief include gagging, choking, apnea, vomiting, and “apparent life-threatening events.”[85,91] Cases of gastric rupture[92] and pneumothorax[93] have been reported in association with vigorous crying from unanesthetized circumcisions.
Surgical complications
The infant penis is very small, and the devices commonly used to excise the foreskin are imprecise tools. Even with proper technique it may be difficult to judge the amount of skin to remove and it is easy for surgical problems to occur.
Removal of too much or too little skin – One common surgical risk of circumcision is the removal of too much skin, involving partial or total denudation of the penile shaft.[14, p. 81] Corrective surgery by a specialist, including possible need for skin grafting, may be required.[2] This may happen more easily with the Gomco technique, in which too much penile skin may be drawn up through the device.[3] Removal of excessive shaft skin can lead to tight, painful erections later in life, or pulling of scrotal tissue onto the shaft due to excess tension on the penile skin sheath.[94-97]
Sometimes so little skin is removed that the penis does not appear to be circumcised. This may generate parental complaints and requests for a repeat circumcision,[3,98,99] although there is no medical indication for the second circumcision. A “loose” circumcision may predispose to adhesions and skin bridges (see below).
Damage to the urethra – Injuries to the urethra can occur with circumcision, and may require corrective surgery. During the dorsal slit phase of the procedure, the blade of the hemostat or scissors may inadvertently be placed into the urethra, leading to damage or even bivalving of the glans penis. Urethral damage can also occur due to pressure necrosis from the Plastibell ring.[3] Urethral fistula following circumcision has been reported in multiple case reports and case series.[14, p. 81]
Partial or complete loss of the glans or penis – Several of the devices used to perform circumcision involve a “blind” amputation of the foreskin, leading to multiple case reports and case series of partial or complete amputation of the glans.[14, p. 81] The Mogen clamp in particular has been associated with loss of all or part of the glans.[3,100-102] The use of electrocautery devices has led in several reported instances to necrosis and complete loss of the penis.[103-105] In some cases, it was decided to raise these boys as girls.[104,106,107 These amputations are often the source of malpractice cases.[108-110] While the makers of the Mogen clamp are in default for payment of several large settlements against them, the Mogen device remains in use.[110]
Penile necrosis and ischemia, resulting in sloughing of penile skin or even loss of all or part of the penis, are serious complications[111] reported in multiple case reports and case series.[14, p. 81] In one series, the rate of necrosis was 0.8% with the Plastibell device.[112]
Urinary retention – Urinary retention has been reported, typically from bandages that are too tightly wrapped around the wound, or from a Plastibell ring obstructing the meatus, or from pain. Urinary retention has been associated with further complications such as bladder rupture, obstructive uropathy, acute renal failure, urine advancing in subcutaneous fascial planes, and interruption of circulation to the lower extremities.[14, p. 82] One reported case of Plastibell-induced urinary retention resulted in septicemia and death.[9]
Dislocation of Plastibell ring – The Plastibell ring can sometimes migrate past the glans onto the shaft of the penis and be retained there,[113] constricting the shaft in a manner similar to paraphimosis (trapping of the foreskin behind the glans). The dislocated ring can cause compression damage, extensive skin loss, erosion of the corona and proximal glans, swelling and vascular congestion distal to the ring, and ischemic necrosis. Reports in the medical literature have included associated urinary obstruction, urethrocutaneous fistulae, and significant long-term penile deformities.[14, p. 81] The incidence of this pseudo-paraphimosis following Plastibell circumcision has been reported to range between 0.27%[1] and 1.6%.[114]
Hematoma following circumcision is fairly common, with rates reported to be 0.46%,[111] 0.98%,[115] 6.1%,[116] and 7.7%.[117] Hematoma is common enough that it may not be considered out of the ordinary and, therefore, fail to be accounted for as a “complication.”
Other surgical complications have been reported following circumcision, including multiple pyogenic granulomas, subglanular stricture, and scrotal trauma.[14, p. 81] Leg cyanosis, gastric rupture, pulmonary embolism, pneumothorax, erythema multiforme, myocardial injury, tachycardia, and heart failure have all been reported as sequelae of circumcision.[14, p. 82]
Delayed complications
Some circumcision complications may not manifest until months or years after the immediate surgical period. Most studies attempting to track circumcision complication rates do not collect data long enough to capture long-term complications.
Meatitis and meatal stenosis have been associated with circumcision in the medical literature for nearly 100 years.[118] These pathologies of the urinary opening (meatus) are almost exclusively found in circumcised boys,[118-123] and are an iatrogenic result of the loss of the protective functions of the foreskin. Direct exposure of the glans to chemical and mechanical irritation in the diaper can lead to meatal inflammation, resulting in meatal ulceration, and ultimately scarring and stenosis (pathological narrowing) of the meatus.[122] Reduced circulation to the glans penis, caused by damage to the frenular artery with circumcision, may also be a causal factor.[124]
Meatitis is a common finding, with several studies reporting an incidence of about 20% in circumcised boys.[125,126] Meatal stenosis may be the most common longer-term complication following circumcision,[14, p. 83-84) with an incidence variously reported to be 0.9% (most subjects circumcised after 2 years of age),[127], 2.8%,[128] 3.6%,[129] 7.3%,[125,130] 8%[36], 20.4%.[131] and 32.1%.[132]
Symptoms of meatal stenosis include a narrow high-velocity urine stream, difficult-to-aim stream, split stream, pain with voiding, and urinary urgency, frequency, straining, dribbling, and retention. Meatal stenosis obstructs the flow of urine and can lead to further complications including urinary tract infections, vesicoureteral reflux, hydronephrosis, obstructive uropathy, and renal failure.[14, p. 83-84] The definitive treatment for meatal stenosis is meatotomy, a surgical procedure in which an incision is made into the edge of the urinary opening, followed by separation and lubrication of the healing wound several times daily by the parents, over a number of weeks.[122]
Adhesions and skin bridges – Circumcision leaves raw surfaces on the glans and the foreskin remnant. Where these surfaces interface, the tissue may grow back together, forming adhesions and skin bridges between the foreskin remnant and the glans.[133,134] Skin bridges can cause tethering of the penis, entrapment of debris, curvature of the penis, and pain on erection.[133,135] Adhesions have been noted in 8%,[136] 10%[135]and 15% of infants,[133] and in about 25% of circumcised boys overall.[125] While the adhesions which form following circumcision are more dense than the connections normally found between the inner prepuce and the glans,[135] they tend to resolve with time,[125,137] although surgical intervention may be required in some cases.[133,137] The prevalence of skin bridges has been reported to be 4.1% in circumcised boys under 3 years of age,[125] and 12.7% among adult circumcised males.[138]
Phimosis – The skin remaining after circumcision can develop a contracted circular scar that entraps the glans behind an iatrogenic phimosis (stenosis of the foreskin opening). Multiple case reports have appeared in the literature for more than 100 years.[139] The incidence has been reported as 1.7%[140] and 2% in children,[116] 0.3% in infants using the Mogen clamp,[141] 2.9% using the Gomco clamp,[142] and 0.9% in a mixed age clinic population of circumcised boys.[125] Thus, phimosis following circumcision occurs at least as often as true pathological phimosis cumulatively occurs in boys who are not circumcised (0.6% by one estimate).[143]
Buried or trapped penis – Although buried penis can be present congenitally in newborns,[144] iatrogenic buried penis can occur after circumcision[2] when the penile shaft, no longer tethered forward by the attachment between the inner foreskin and the glans, retreats into the pubic fat pad or into the scrotum. There are multiple case reports of buried penis following circumcision, and most case series of patients undergoing repairs for this problem are populated with males circumcised as infants.[14, p. 84-85] As the young child begins to walk, the fat pad may recede, allowing the condition to resolve on its own,[145,146] however surgical intervention may be required. In one series of healthy boys, 0.9% were considered to have a buried penis with preputial stenosis.[125]
A boy with a congenitally buried penis is at greater risk of having excessive skin removed with circumcision, because the glans naturally resides proximal to the majority of the penile shaft skin. Thus, nearly all the shaft skin is in a position to be removed by the circumcision device. Also, with the penis completely buried, the circular circumcision scar can more easily constrict, entrapping the glans. Congenital buried penis is considered a contraindication for circumcision.[147-151]
Need for repeat surgery – Boys who undergo circumcision are at risk for needing a repeat surgical procedure (sometimes more than one) to repair damage from the original circumcision, to resolve delayed problems such as meatal stenosis or adhesions, or for reasons of appearance. A recent review found that out of nearly 9000 operations of all types at a large children’s hospital, 4.7% were for complications resulting from previous neonatal circumcision.[152] The most frequent reasons given for these repeat surgeries were adhesions, skin bridges, meatal stenosis, redundant foreskin (incomplete circumcision with uncircumcised appearance), recurrent phimosis, buried penis, and penile rotation.[152]
A study of 56 cases of circumcision revisions identified “redundant foreskin” as the most common indication given for repeat surgery.[98] In one study, the rate of “inadequate circumcision” requiring repair or re-circumcision was 2.8%.[153] In a series of 200 circumcisions of children in Australia, 9.5% were re-circumcisions (3.5% of the series for “too little skin removed,” 5.5% for post-circumcision phimosis).[154] In a series of 315 circumcisions of children in Denmark, 2% required repeat surgery (1% for “incomplete circumcision,” 0.6% for fibrotic phimosis, 0.6% meatotomy for meatal stenosis).[155] In a series of 79 hospital circumcisions in South Africa, 2.5% required surgical revision.[156] A comprehensive Utah database, tracking selected complications following 6298 circumcisions over a 2-year period, found the cumulative incidence of surgical revision or lysis of penile adhesions to be 1.6%.[177] In other studies, the rate of re-circumcision (reasons not specified) was reported as about 1%.[157-159]
A large database study found that, between 2004-2009, the rate of circumcision revisions at pediatric hospitals increased 119%.[160] The authors concluded that “the reasons for this trend are uncertain, but possible explanations include decreased quality of newborn circumcision, increases in the total number of circumcisions being performed, or changing expectations regarding ‘normal’ penile appearance after circumcision.”[160]
Other complications – Miscellaneous post-operative complications reported include chordee,[1] penile torsion,[161] keloid formation,[162] epidermal inclusion cysts,[163] lymphedema,[164] and cancer in the circumcision scar.[165] Subcutaneous granuloma has been reported to occur after circumcision in childhood at a rate of 5%.[166]
Death
Death is the ultimate harm entailed with any surgical procedure. In cases of true medical necessity, a certain risk of death may be legitimately acceptable to the patient in the overall picture, in balance with the hoped-for benefits. However, when a surgery is medically unnecessary, elective, non-therapeutic, cosmetic, and undertaken without the consent of the patient – as is virtually always the case with infant circumcision – any risk of death, no matter how small, is unacceptable and unethical.
Deaths following circumcision have been acknowledged for a long time, as noted in the Talmud,[167] and continuing to the present day, as documented in published medical case reports, newspaper articles, published coroner’s reports, and posts on social media.[e.g. 168] Most deaths are related to excessive bleeding and to infection, as well as to less frequent causes, such as anesthesia accidents and cardiac arrest.[14, p. 90-92,169]
There is no prospective systematic collection of mortality statistics associated with non-therapeutic circumcision in the United States, therefore, the true rate of death after infant circumcision is not known. The primary obstacle to obtaining an accurate estimate of the incidence of death from circumcision is the underreporting of circumcision as a cause or contributor to death.[14] Instead of listing circumcision as a cause of death, the sepsis or hemorrhage/exsanguination that led to the baby’s demise may instead be listed. Incomplete and inaccurate death certificates for pediatric deaths are not uncommon.[170]
The 1999 circumcision statement by the American Academy of Pediatrics failed to mention death as a risk.[171] The AAP’s 2012 statement characterizes the risk of death as “rare.”[10] Often cited is a rate from the 1940s of 1 death in 500,000+ circumcisions (0.2/100,000) according to retrospective review of New York City Health Department records.[172] However, in the same era, Gairdner reported a rate of 16 deaths per year in some 90,000 circumcisions performed annually in England and Wales on children under 5 years old (17.7/100,000).[173] Since then, there have been several more recent attempts to ascertain the death rate from circumcision.
Bollinger, calculating from assumptions about general death rates for male newborns and post-hospital complication rates, estimated a circumcision death rate of 9.0/100,000 for the first 30 days of life.[169] O’Donnell, adjusting Bollinger’s methods with a different set of statistical assumptions, projected a rate of 1.4/100,000.[174]
A study of medically necessary circumcisions in Brazil (where non-therapeutic circumcision is not performed) found zero deaths out of the small number of circumcisions performed on boys less than a year old (averaging <900/year over a 19-year period).[175] However, taking the death rate for the more numerous circumcisions of older boys into account, the overall circumcision death rate for all children under age 10 was 1.5/100,000.[175]
Earp, et al. analyzed data from the largest U.S. inpatient database on nearly 10 million circumcisions over a 10 year period, looking for excess early mortality in infants who had undergone circumcision.[176] The early death rate attributable to circumcision was found to be 2.0/100,000, with infants circumcised in teaching hospitals and those with co-morbid conditions such as bleeding, cardiovascular, or fluid/electrolyte disorders having a significantly higher risk of death.[176] It should be noted that only deaths that occurred within the same hospital admission as the circumcision could be tracked from this database, thus an unknown number of deaths occurring after initial hospital discharge are not accounted for in this estimate.
Diurnal Cortisol Patterns and Dexamethasone Suppression Test Responses in Healthy Young Adults Born Preterm at Very Low Birth Weight
Nina Kaseva ,Riikka Pyhälä,Anu-Katriina Pesonen,Katri Räikkönen,Anna-Liisa Järvenpää,Sture Andersson,Johan G. Eriksson,Petteri Hovi,Eero Kajantie
Published: September 12, 2016https://doi.org/10.1371/journal.pone.0162650
Abstract
Background
Early life stress, such as painful and stressful procedures during neonatal intensive care after preterm birth, can permanently affect physiological, hormonal and neurobiological systems. This may contribute to altered programming of the hypothalamic-pituitary-adrenal axis (HPAA) and provoke changes in HPAA function with long-term health impacts. Previous studies suggest a lower HPAA response to stress in young adults born preterm compared with controls born at term. We assessed whether these differences in HPAA stress responsiveness are reflected in everyday life HPAA functioning, i.e. in diurnal salivary cortisol patterns, and reactivity to a low-dose dexamethasone suppression test (DST), in unimpaired young adults born preterm at very low birth weight (VLBW; <1500 g).
Methods
The participants were recruited from the Helsinki Study of Very Low Birth Weight Adults cohort study. At mean age 23.3 years (2.1 SD), 49 VLBW and 36 controls born at term participated in the study. For cortisol analyzes, saliva samples were collected on two consecutive days at 0, 15, 30 and 60 min after wake-up, at 12:00 h, 17:00 h and 22:00 h. After the last salivary sample of the first study day the participants were instructed to take a 0.5 mg dexamethasone tablet.
Results
With mixed-effects model no difference was seen in overall diurnal salivary cortisol between VLBW and control groups [13.9% (95% CI: -11.6, 47.0), P = 0.31]. Salivary cortisol increased similarly after awakening in both VLBW and control participants [mean difference -2.9% (29.2, 33.0), P = 0.85]. Also reactivity to the low-dose DST (awakening cortisol ratio day2/day1) was similar between VLBW and control groups [-1.1% (-53.5, 103.8), P = 0.97)].
Conclusions
Diurnal cortisol patterns and reactivity to a low-dose DST in young adulthood were not associated with preterm birth.
Introduction
Cortisol secretion shows a diurnal pattern with a decrease from morning to evening levels [1]. This diurnal rhythm is an important marker of hypothalamic-pituitary-adrenal axis (HPAA) regulation [2], and it is established during the first year of life [3], in some infants even at 2 months of age [4]. It has been suggested that pre- and postnatal stress, and subsequent cortisol exposure, could alter and “program” HPAA function and thus affect health over the life course [5]. In infants born preterm, frequent invasive, painful and stressful treatment procedures performed during neonatal intensive care, are examples of such early life stress. Furthermore, the preterm infant with immature physiological systems, is particularly vulnerable during this time of early life stress and simultaneous programming of the stress systems [6].
Increased cortisol exposure, normally tightly regulated by the HPAA, is associated with development of several adverse health outcomes, including cardiovascular disease, osteoporosis and insulin resistance [7]. Similarly, preterm birth is linked with an increased risk for these conditions. As adults, individuals born preterm at very low birth weight (VLBW, ≤ 1500 g), have higher blood pressure [8,9], changes in lipid profile [9,10], lower mineral bone density [11,12] and impaired glucose regulation [12,13], compared with peers born at term. Based on current literature, HPAA functioning, especially in relation to stress responses, may be altered in those born preterm [14–20], although the results have been inconsistent. Assuming that preterm birth provokes durable changes in adult HPAA function, this could modify adult health. To clarify the role of preterm birth on adult HPAA function we examined diurnal cortisol patterns and cortisol feedback inhibition by a low-dose dexamethasone suppression test (DST) in healthy young adults born preterm at VLBW and controls born at term.
Methods
Participants
The data come from the Helsinki Study of Very Low Birth Weight Adults, a case-control cohort which has previously been described in detail [13]. The original cohort included 335 subjects born preterm at VLBW during 1978–1985 and discharged alive from the neonatal intensive care unit serving one regional area in southern Finland, and 314 controls born at term, group-matched for sex, age and birth hospital. In 2004–2005, those 255 VLBW and 314 control subjects who were residing in the greater Helsinki area were invited to participate in a clinical examination. Of these invited subjects, 166 VLBW and 172 controls chose to participate. During 2005 a random sample among the participants (166 VLBW and 172 controls) of the cohort’s first clinical visit in 2004–2005 was invited to participate in the current study, selected as previously described [20]. Briefly, we excluded individuals who 1) used glucocorticoids, 2) had a nightshift during the previous week or 3) were unable to stand or manage without an assistant. A total of 49 VLBW (26 men and 23 women) and 36 controls (14 men and 22 women) provided adequate salivary samples and were included in the analyses (Fig 1). Anthropometry was measured and all participants completed a detailed questionnaire regarding health status, including smoking habits, medical history and medications.