Axiom²

Male circumcision before being able to consent, an unbiased perspective

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The practice of male circumcision (surgical removal of the foreskin of the penis), especially in the newborn period (0-28 days old), is still common in the United States, where it has been suffering a slight decline in popularity, and most common in Africa and the Middle East. In this article I’ll be evaluating arguments that are typically put forth for doing or not doing this procedure. My perspective will be biased towards developed nations.

Disclaimer

This article may attract very opinionated individuals, if you think that your opinion is worth more than facts please don’t bother commenting as you’re only going to make a fool out of yourself. If you have any genuine objection to the information that is presented here and wish for me to correct it or add to it, quote what you disagree with, show me how you’d correct it, make sure that your information is of higher quality and do feel free to leave it in the comments. If there’s enough interest from people to see this post updated I’ll eventually do it and as many times as necessary.

Morality

Forcing someone to have a surgery that will modify his genitals permanently and irreversibly surely seems immoral, but, considering that parents are supposed to decide for the well-being of their offspring, it can certainly be said that if the health benefits were very significant it could potentially be immoral not to circumcise.

There are more reasons to circumcise apart from medical ones, but, unfortunately, they’re just the wrong reasons, most of which can’t stand basic scrutiny, like, religion, when babies don’t even know what that is, hygiene, even though removing skin to avoid washing it in the future is absurd, the father being circumcised, even though the importance of comparing missing body parts is very questionable, and because it looks better, even though the target of the procedure never complained about that. Sometimes I wonder if these parents don’t think that 1 week old is just too soon to start doing cosmetic surgery or what they would do if the father was missing a leg instead of the foreskin, but I digress. The last reason I’m going to discuss is almost perfect to morally frame this dilemma, the popularity with the opposing sex sounds like a reasonable concern because rejection might inflict a serious blow to one’s self-esteem, but it isn’t reasonable at all, I’ll explain…

Female Genital Mutilation is a procedure that can involve removing the clitoris of a female (greatly reducing the ability to feel sexual pleasure), has no medical benefits at all, it’s common and even routine in some African countries, and is acknowledged globally as a human rights violation in all of it’s types. FGM of type 1a is the equivalent of circumcision as it consists in the removal of the clitoral hood which is the female analogue of the male foreskin. In FGM cultures, among other motives, it’s believed that FGM prevents extramarital sex and ensures virginity (which is probably true for types 1b and 3, respectively). In these cultures many men will reject marrying a female due to lack of FGM, this is enough social pressure that women will often swallow their self-respect and undergo  the surgery, other times they’ll be forced by their parents while young to do so because “it looks better” or due to “better marriage prospects”, does this remind you of anything? Circumcision, obviously.

Assuming that both FGM type 1a and circumcision have no health benefits, would it be immoral if someone that was mature wanted to have one of the procedures if that person wasn’t pressured or lied to about it? Obviously not. What would make this scenario immoral would be pressuring people and lying as if the procedures have actual benefits until they submit to it and/or force their young to do so. For now it should already be blatantly obvious that circumcision before being able to consent is immoral if it doesn’t have enough health benefits to justify it and that the same can be said if the problems cancel or outweigh said benefits, indeed circumcision without proper medical justification can be seen as violating various codes of ethics.

In short, the morality of circumcision will hinge on the positive balance of benefits and issues in health and lifestyle that may arise from the procedure and on the subjective moral importance that parents attribute to the right of their son to decide over his own body on this matter.

Physical health

The foreskin provides, under itself, a place in which microorganisms can thrive, so it should come as no surprise that it’s easier for the uncircumcised to become infected with something during their lives, but this alone isn’t enough to advocate “away with the foreskin” as the advantages and disadvantages need to be considered first, after all, there are more body parts that people could live without that are affected by illnesses. Indeed most pediatric societies in the industrialized world only recommend circumcision under very specific circumstances, not as routine.

HIV / STD’s / STI’s

The AAP (American Academy of Pediatrics) states that the risk of being infected with HIV is 40-60% lower in the circumcised and many are the studies and authorities that affirm what numerically to the untrained eye seem like fantastic, almost miraculous results.

The point being, 40-60% is great sometimes, while other times it’s merely better that nothing, this is such a case. Condoms work by setting up an impenetrable barrier for all STI (Sexualy Transmitted Infections) pathogens around the whole penis, for this reason, condoms are highly effective, so much that 15000 rounds of intercourse between HIV negative and HIV positive persons that used condoms consistently resulted in no HIV transmission, thus making whatever protective benefit from STI’s that might be had from circumcision completely irrelevant for someone that practices safe sex. Also, in contrast with condoms, there’s no evidence that circumcision has a protective effect against all types of STI pathogens, only against some of them, and with much inferior effectiveness.

Certain STI’s, like HPV (Human Papillomavirus), have diverse methods of transmission and points of entry that condoms can’t cover, and so neither can circumcision as the protective effects from both methods are restricted to the penis. HPV is known to be a factor in a variety of cancers and that’s precisely why vaccination against the most problematic strains of the virus is recommended.

For countries where STI’s are epidemic and it’s still difficult to ensure decent healthcare, sexual education, and hygiene, the recommendation of circumcision might be warranted, unsurprisingly, that’s also the only circumstance where the WHO (World Health Organization) considers male circumcision to be an acceptable means of STI prevention.

On top of all this, using STI prevention as an argument for neonatal male circumcision is preposterous as prepubescent (before puberty) males don’t have sex.

Phimosis

The inability to retract the foreskin over the glans penis (head of the penis) is commonly used as a medical reason to circumcise, however, this is typically misdiagnosed and actually a part of normal penile development.

Only 4% of males have a retractable foreskin at birth in contrast with 94% when they’re 9 years old and 99% when they’re 14, there are methods to solve even severe cases of phimosis using methods like topical steroid ointments and skin stretching instead of surgery.

Smegma is a buildup of dead skin cells and skin oils between the foreskin and the glans penis that should be washed off during the course of a proper hygiene, but it’s hard to do so if phimosis occurs, however, seeing as smegma is virtually non-existent up to 9 years old it naturally follows that phimosis isn’t a cause for alarm up to that age (unless it’s severe).

In 3% of the neonatally circumcised, the characteristic constriction of phimosis will appear due to scarring from circumcision and lead to trapped penis (penis gets trapped inside the body behind a narrowing in the skin). This problem can typically resolve itself over time without the need for surgery.

Balanitis

This inflammation of the penis is roughly twice as prevalent in the uncircumcised resulting in a total risk of 6% from 4 months to 12 years old, often due to deficient hygiene (the uncircumcised typically exhibit worse hygiene habits), it’s thus debatable if the lack of circumcision is actually the cause of any significant number or cases. Balanitis is very easily treatable.

Penile cancer

This is a rare cancer, the lifetime risk is approximately 0.17% for uncircumcised Americans down to 0.06% for Danish (almost all uncircumcised). The lifetime risk of penile cancer in neonatally circumcised Americans is hard to know with even relative certainty due to its rarity but the overall lifetime risk in Israelis (almost all circumcised) is 0.0075% which is about 12.5% that of Danish males. The 5 year survival rate for someone that developed penile cancer is 50%.

Phimosis may be one of the biggest risk factors for penile cancer, HPV is thought to be responsible for around 36% of them and smoking can increase the risk by 4.5 fold. Other causes are inflammations (like balanitis), smegma, congenital anomalies of the urinary tract, STI’s, hygiene and many sexual partners (in no particular order). In short, most risk factors of this rare cancer can be addressed voluntarily through proper hygiene, reduction of risk behaviors, and HPV vaccination while only some of them might warrant circumcision.

As opposed to developed nations, penile cancer is a common condition in certain African and South American countries, which further reinforces the notion that circumcision can have a situational rather than global importance.

Notes: When I speak of lifetime risks, if the figure isn’t in the linked resource it’s because it was calculated from yearly odds using 75 years old as average life expectancy or lifetime odds or raw figures.

Urinary Tract Infections

This review has calculated that the lifetime risk of UTI in the uncircumcised is 32% (probably overestimated) and in the circumcised is 9%, according to this, 4.3 circumcisions would be needed to treat 1 UTI. UTI’s are typically easy to treat with antibiotics and only very rarely they can lead to significant problems like sepsis (that can lead to death), these sorts of problems are so difficult to quantify that I couldn’t even find a ballpark figure. For a healthy degree of perspective on this matter, 84% of UTI’s occur in females, thus, even the uncircumcised are at significantly inferior risk than females.

Notes: The 32% and 9% figures are probably quite different from reality because there was only one study of adults in the review and it used a small non-random sample, the other studies only had males below 18 years old, and there were no studies on the elderly. The reason why the difference between the quantity of UTI’s in circumcised and uncircumcised males is probably overestimated is that one study that reported a significantly smaller difference (from birth to 3 years old) had a much better quality than any of the other studies. I’ve used this review because I couldn’t find a better one that estimated the lifetime risk of UTI in circumcised and uncircumcised males. I’ve tried to find data about the mortality and severe effects of UTI’s but couldn’t find anything useful, many UTI’s and related deaths happen due to hospitalization (which implies a pre-existing health condition) and usage of catheters which complicates getting usable data.

Immediate surgery complications

Circumcision is surgery, and as such, it entails risks. When done neonatally and properly the risk of immediate surgical complications is 0.2 to 0.6%. Serious immediate complications are very rare but they do exist in the form of, for example, hospital-acquired infections, death, removing almost all of the skin of the penis (de-gloving) and necrosis/amputation of the glans penis.

Late physical complications

Meatal stenosis (narrowing of the urethral opening of the penis) occurs in 9-10% of circumcised boys and needs surgery (meatotomy) to fix, this condition is rare in the uncircumcised. One study reports that meatal stenosis is preventable in those circumcised before reaching 2 years old if petroleum jelly is applied to the circumcision site after each diaper change for 6 months, unfortunately it doesn’t supply any information for those over 3 years old which apparently is when most cases of meatal stenosis develop.

Revision circumcision (having to circumcise for a second time) is very common and in 2009 it happened for approximately 22% of recently circumcised Americans up from 10% in 2004. Revision is mostly done in cases of redundant foreskin (when the first circumcision removed “too little” skin).

Penile adhesions (skin connections between parts of the penis that aren’t supposed to be connected) occur in 71% of circumcised males under 1 year old but resolve themselves over time down to 2% by 9 years old. At least 2% of the circumcised develop skin bridges by the time they reach 9 years old (a type of penile adhesion) involving the circumcision line for which surgical intervention is recommended.  Skin bridges are often considered to be “an uncommon complication of circumcision” which probably explains why I couldn’t find a number for the uncircumcised even though this problem is known to affect them as well. It’s possible to reduce the reincidence of these adhesions by pressing the suprapubic fat pad (the fat on the groin) to force the penis to protrude and then applying petroleum jelly (it makes mechanical sense that the primary incidence can also be reduced via this method). In recent years 12% of the circumcised eventually have a surgical intervention due to penile adhesions.

Pain

There’s a lot of pain if no anesthetics are used but there are also some very efficient techniques for mitigating pain. Of the physicians performing circumcisions in the U.S. only 45% use anesthesia for circumcision (the questionnaire was made in 1998 so it might not correctly represent nowadays practices). I’ve seen bigger percentages being mentioned but wasn’t able to confirm them, anyway, it’s still shocking that this number isn’t 100% or close to that, only a normal intelligence plus a working eye and ear are needed to understand that babies suffer a lot of pain if circumcision is performed without anesthesia, just search some videos of it and you’ll see, also, endorsement of the practice of torturing newborns (or any human being) isn’t in any known code of medical ethics. Maybe some infants don’t feel much pain (as per anecdotal evidence) but because we can’t tell those that won’t from those that will it’s always wise to request that the procedure is performed under adequate anesthesia.

Psychological trauma

There are concerns over psychological traumas that may arise due to circumcision and anecdotal evidence of suicide and depression, but, in general, there just haven’t been enough studies on this matter to be able to say much about it. It’s a fact that extremely distressful events (circumcision without anesthesia certainly qualifies) can potentially be traumatic and thus lead to abnormal behavior (like PTSD). Neonatal circumcision (especially without anesthesia) has been correlated with altered pain response 6 months after the procedure hinting to permanent or long-lasting psychological changes. 10% of the circumcised resent having been.

Sex

No arguments of improved sexual function/pleasure are valid for neonatal circumcision because, as stated above, prepubescent males don’t have sex.

Pro-circumcision advocates try to dismiss the foreskin as an erogenous zone (places that generate sexual arousal) while intactivists seek to include it. This division is deeply unhelpful, yes, the foreskin is very innervated and capable of transmitting many sorts of stimuli, but, our knowledge of it and how it relates to sexual pleasure is still clearly not complete enough. Sexuality is very complex and subjective, some people don’t feel much of anything when stimulated in the nipples or can’t experience a vaginal orgasm, others can reach an orgasm due to a foot massage or while experiencing intense pain, it would be totally unsurprising if the stimuli from the foreskin, even if it was mostly unconnected to sexual pleasure, would be very important to it for some people. Indeed there’s anecdotal evidence of increased pleasure after foreskin restoration (stretching shaft skin to make a crude foreskin replacement), so, it’s quite possible that that’s the case.

A way to predict or test the sexual outcome of circumcision for an individual would prove valuable for males facing this dilemma later in life as the reduced quality of sexual life, depending on how severe, might be far more difficult to accept than an increased chance of certain health problems, this same tool could also be used to promote circumcision for those that would sexually benefit from it.

Studies remain controversial as to what are the implications of circumcision in erectile dysfunction, premature ejaculation, sexual pleasure and overall sexual satisfaction. Much less studies were made that attempt to evaluate the effects of circumcision not in the circumcised but in their sexual partners. The WHO reports that the impacts of circumcision on sexual function remain unclear due to substantial bias.

Some of the effects of circumcision can be predicted using a bit of logic and understanding of the mechanical properties of the penis. The foreskin is part of the mobile skin of the penis, the more mobile skin is removed (due to circumcision), the less mobile the remaining skin becomes. In an uncircumcised penis this mobility allows for masturbation through vigorous comfortable stroking as the foreskin will roll over the glans penis repeatedly, stimulating it and producing sexual pleasure. The less mobile the skin is the shorter the strokes can be and the less it can roll over the glans penis and stimulate it. Sometimes there isn’t enough skin mobility remaining after circumcision to stimulate the glans penis and so other strategies like applying friction directly with the hand to the glans penis in a stroking motion are necessary, often with the aid of a lubricant to avoid chafing (you can confirm all of this by just watching some videos of it). Circumcision objectively limits males masturbatory options which might explain why it was advocated for masturbation prevention long ago when it was believed that masturbation was a mental disorder.

The mobile skin will reduce friction in the glans penis when penetration starts and in the shaft of the penis during thrusting. More friction means that more lubricant is required for the same action. In a scenario where only vaginal fluids are being used as sexual lubricant, and being produced in just enough quantity for the needs of comfortable intercourse with an uncircumcised male, a circumcised penis would cause chafing. I’ve searched for studies that talked about dyspareunia (painful intercourse), chafing, and unusual sensations in relation to circumcision status, unfortunately, none of them questioned the participants about their use of lubricants (like the always available saliva), which means that the findings are totally useless. Anyway, lubrication concerns can probably be considered minor as they’re easily solved by buying single use personal lubricant in bulk in the same way that’s typically done with condoms.

The reduction or lack of mobile skin leaves the glans penis more exposed during intercourse and thus more susceptible to stimulation which might explain why in certain studies many of the circumcised report a more pleasurable intercourse.

Other lifestyle implications

Both circumcised and uncircumcised should practice safe sex, keep their health in check and clean regularly, it’s easy and avoids most problems.
For the uncircumcised, while the foreskin is non-retractable, only clean what is seen, when it’s retractable, retract and clean.
For the circumcised, apart from everything that was already stated, there are still two more logical consequences of removing the foreskin. One is glans penis skin dryness as the foreskin keeps the glans penis moist (solved by moisturizing regularly) and the other is discomfort/pain in the glans penis during daily activities. The glans penis is very sensitive to pain and circumcision leaves it exposed to aggressions, more commonly it’ll be friction with clothing. There’s no shortage of circumcised males in Q&A websites and forums complaining about all of this, and, from the hundreds of testimonies that I’ve read, only very rarely someone that’s uncircumcised had the same complaints (it would be nice to have actual figures but I couldn’t find any).

Weighing the evidence

For this step I’ll exclude the STI’s, finding numbers for all of them divided by sex plus knowing which of those were caused by lack/improper condom use or lack of circumcision is a daunting task and completely unnecessary seeing as the effectiveness of circumcision can’t even compare to that of condoms and not using condoms nowadays completely defies rationality. I’ll be using the data collected above, only a small portion of it isn’t representative of a lifetime and I’ll be ignoring detail for the sake of achieving a comparison.

In 1,000 Uncircumcised males throughout their lives:
Phimosis – 10-60 cases that require treatment (1-6%)
Balanitis – 30-60 cases from 4mo-12yo (3-6%)
Penile cancer – 1-2 cases with 50% 5-year survival rate (0.06-0.17%)
UTI – 320 cases, an overestimation, associated deaths unknown (32%)

In 1,000  Neonatally circumcised males throughout their lives:
Balanitis – 30 cases from 4mo-12yo (3%)
Penile cancer – 0 cases (0.0075%)
UTI – 90 cases, associated deaths unknown (9%)
Immediate complications – 2-6 cases, deaths unknown but probably none (0.2–0.6%)
Meatal stenosis – 90-100 cases that require surgery, probable overestimation (9-10%)
Revision circumcision – 100-220 additional circumcisions (10-22%)
Adhesions – 20-120 cases that result in surgery (2-12%)
Circumcision – 1000 surgeries

Overall
Uncircumcised: 361-442 cases, 0-1 deaths, 361-442 treatments, 0 surgeries
Neonatally circumcised: 232-346 cases, 0 deaths, 122-126 treatments, 1210-1440 surgeries
Circumcision results in: 15-210 cases, 0-1 deaths and 235-320 treatments prevented with 1210-1440 surgeries for every 1000 people.

Conclusions

For each 1000 neonatally circumcised males in the U.S, it’s possible that 1 of them is saved from dying with penile cancer to go die from something else a few years later as the median age of diagnostic is 68 years old, which means, that in terms of preventing mortality in developed nations, circumcision is just a bad joke, especially seeing that from those 1000, 16 would kill themselves at some point during their lives.

The number of problems that are prevented with circumcision, the overwhelming majority of them minor and easily treatable, are at least 83% less than the number of circumcisions and associated surgeries, which means that it’s wiser to treat when there’s actually something to treat and only perform circumcision as a preventive measure in cases that truly justify it.

In developing nations where penile cancer and STI’s are a big concern the surgery can probably be postponed to puberty where the opinion of the minor will weigh on the parents decision as all of the protection from STI’s and the vast majority of penile cancers is still obtainable by then.

Unsurprisingly, the consensus of most health professionals is correct in not recommending routine neonatal circumcision on ethical grounds because the health benefits are too small to warrant a violation of bodily integrity.

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