From: an130890@anon.penet.fi THE MOTHER OF ALL CIRCUMCISION POSTS I have been watching the circumcision debate recurrently raging in several news groups, with unfounded assertions and counter-assertions from both sides. Thus (un)inspired, I went digging through the literature to find out what the prevailing opinion on the subject was. For the most part, I have limited myself to general medical books, family "doctor books" put out by reputable institutions, "baby books", and general reference works. I did not attempt to dig through the medical journals; both sides have engaged in "abstracts wars" that seemed to prove nothing. Apparently, there are scores of articles that prove/disprove a correlation between circumcision and a host of diseases. Few of the articles take a comprehensive view and attempt to balance the risks and benefits of the procedure and the severity of the problems it purportedly prevents to answer the question "Should I have my kid circumcised?" Anything between {curly braces} is mine; you may, if you wish, regard it as biased; for the most part it just explains what I left out. If you have friends who are having a baby, you might wish to show them this, and strongly encourage them to go on their own reading expedition before they listen to anyone's advice, including their doctor's, and certainly before they heed any of the rantings they might read on Usenet. Because this question comes up so often, people interested in the subject might want to save this off and repost it when the topic comes up again. .............................................................. .............................................................. Book: The Merck Manual, 16th ed, 1992, Merck and Co. Note: a standard quick-reference for medical personell p 1928 Circumcision, if indicated, is generally performed within the first few days of life but should be delayed indefinitely if there is displacement of the urethal meatus,...,or any other abnormality of the penis, since the prepuce may be used later in plastic repair. Circumcision usually is requested by the parents, and is rarely indicated medically. An increase in UTI {urinary tract infection} is cited as an indication by some. {instances when it shouldn't be done deleted} .............................................................. Book: The Columbia College of Physicians and Surgeons Complete Home Medical Guide, 1985 Note: popular medical guide p 192 {definition, religious origin deleted} While the procedure is probably painful for the baby (no anesthesia can be used) {the bit about "no anesthesia" is contradicted elsewhere}, it does not take long and healing is quick. Circumcision became an almost routine procedure in this country in the years after WWII. It is, however, not medically necessary to have a son circumcised, nor is circumcision required by any law. The procedure does not prevent penile infection or penile cancer. Moreover, the rate of cervical cancer among the sexual partners of circumcised men is no higher than usual, provided that the men practice good hygiene. ............................................................... Book: Encyclopedia Americana, "Circumcision" 1987 Note: The article was written by Wallerstein, who wrote the book "Circumcision, an American Health Fallacy." His work has also appeared in medical journals, and he is referenced by some the authors (incl. MD's) mentioned here. {history deleted} In the late 19th century, circumcision came to be viewed in the English-speaking world as a panacea to stop masturbation, which was thought to cause many illnesses. The American physician P.C. Remondino, in his once oft-quoted and highly regarded book "History of Circumcision from the Earliest Times to the Present" (1891), claimed that circumcision prevented or cured about 100 ailments, including alcoholism, epilepsy, hernia, and lunacy. Circumcision for reasons of health continued in all English-speaking countries well into the mid 20th century. Today, however, the practice has been virtually abandoned in Britain and New Zealand, and circumcision rates have been reduced markedly in Canada and Australia. But in the United States about 80% {most say 60%; perhaps article is old} of infant boys still are circumcised in spite of authoritative medical opposition to the practice. In 1975, the American Academy of Pediatrics reported that "there are no valid medical indications for circumcision in the neonatal period." In 1978, the American College of Obstetricians endorsed the academy's position. Both of these groups reaffirmed this judgement in a 1983 report "Guidelines for Perinatal Care." Nevertheless, some U.S. physicians claim that circumcision is essential for penile hygeine; that it prevents venereal disease and premature ejaculation; and that smegma (the normal sebaceous gland secretion under the foreskin) is a carcinogen, causing cancer of the penis, prostate, and cervix. These claims are not supported by epidemiological data. Moreover, smegma is found under the clitoral foreskin of women, as well as under the foreskins of other mammals of both sexes, with no apparent harm. Circumcision occasionally is a medical necessity, and is so recognized worldwide. However, among the 80% of the world's population where circumcision is not practiced, the initial approach to foreskin problems is usually medical and rarely surgical. As a surgical procudure, circumcision may result in hemorrhage, infection, and even (very rarely) in death. {description of female "circumcision" deleted} ................................................................. Book: Encyclopaedia Britannica, Micropaedia, 1984 Note: mostly deals with ritual, not medical, practice {History deleted; very widespread ritual practice mentioned} From the medical aspect, the operation of removing the foreskin prevents the accumulation from a number of glands of an odoriferous cheese-like substance called smegma, which can cause infection. Routine medical circumcision of newborn males has been practiced primarily in English speaking countries, especially the United States, though the practice is in decline. Cancer of the penis is rare in circumcised males, but it is also rare in uncircumcised males with high standards of hygiene. {description of female "circumcision" deleted} ................................................................. Book: The Pocket Book of Baby and Child Care, 1946 and Dr. Spock's Baby and Child Care, 1992 by (the late) Benjamin Spock, MD Note: The most famous baby book of all; I have included the 1946 edition and the 1992 edition because it is interesting to see how attitudes have evolved. 1946 Edition, p 154 {description of what it it, and definition of smegma, which can cause "irritation or mild infection" if germs get into it} I think circumcision is a good idea, especially if most boys in the neighborhood are circumcised--then a boy feels "regular." However, it is not absolutely necessary. {advises against the practice of forcing the foreskin back to wash it (if uncircumcised); instead, advises to leave the foreskin alone until it retracts by itself; Advises, for psychological reasons, that the operation not be done after infancy "especially as a treatment for masturbation"} 1992 Edition, p 225 The foreskin is a sleeve of skin that covers the head (glans) of the penis. The open end of the foreskin is already large enough to let the baby's urine out, but small enough to protect the opening (meatus) of the penis from diaper rash. ...... As the baby grows, the foreskin normally begins to separate from the glans, and starts to become retractable. It usually takes about 3 years for this separation and retractability to become complete. It may take longer for some boys, even until adolescence, to have a completely retractable foreskin, but this is no cause for concern. Routine washing, even without retracting the foreskin, will keep the penis clean and healthy. If you do retract the foreskin up as far as it will go, you will see a white, waxy material (smegma) on the head of the penis. This is perfectly normal. Smegma is secreted by the cells on the inside of the foreskin, as a natural lubricant between the foreskin and the glans (It also lubricates the head of the penis during intercourse.) {definition, history of circumcision deleted} In the United States, in the twentieth century, circumcision has commonly been performed for several reasons. Some parents worry that it will upset their uncircumcised son to look different from his circumcised father, or older brothers, or friends at school. In fact, it's not upsetting to the boy, if the parents are comfortable with their decision. You can explain how you learned that circumcision wasn't necessary for his good health, so you didn't want him to have a painful operation right after he was born. Many doctors believe that the normal accumulation of smegma under the foreskin may cause occasional mild inflammation or infection, In fact, routine washing can be just as effective in preventing these problems as circumcision. Scientists used to think that the wives of uncircumcised men were more likely to get cervical cancer, but modern research has disproven this. Studies in the late 1980's suggested that uncircumcised boys might get more urinary tract infections during childhood. But this research didn't take into account whether the boys had good routine hygiene, so there's no conclusive proof that circumcision would prevent urinary tract infections. (Circumcised boys also get urinary tract infections.) When caught early, these infections are easily treated with antibiotics. So it's best to keep in mind that good genital hygiene (routine washing during the bath) is more important than whether he's circumcised or not. In the ten years from 1980 to 1990, the number of boys being circumcised in the United States decreased from 90 percent to 60 percent. If you're considering circumcision, you should know that it's a relatively safe operation. There are some risks from the procedure, such as bleeding or infection, which usually can be treated easily. Circumcision is clearly painful for the baby, but anesthesia is not used because of its own risk to newborns. In general, babies recover from the stress of the operation in about 24 hours. If your baby seems uncomfortable for longer than this, or has unusual bleeding or swelling on his penis, report it to your doctor promptly. I feel that there is no solid medical evidence at this time to support routine circumcision. Some parents may choose circumcision for religious reasons. In other cases I recommend leaving the foreskin the way Nature meant it to be. {Care of penis, circumcised and not; usual warning about not pulling back foreskin prematurely; how to deal with a child who has to be circumcised later in life} ................................................................. Book: Mayo Clinic Family Health Book, 1990, William Morrow pub. Note: The entire discussion of circumcision contained in the book. p 32, Circumcision: {in a text box} Not long ago, male infants were circumcised routinely at birth. It was believed that circumcision--the surgical removal of the foreskin of the penis--helped prevent problems such as penile infection and cancer because a circumcised penis could be kept cleaner than an uncircumcised one. Today, however, we know that circumcision is usually not medically necessary. Good hygiene offers the advantages of circumcision without the potential risks. Thus, most circumcisions are performed for cultural and religious reasons. In considering whether to have your infant son circumcised, consider the pros and cons. One of the advantages of is that the glans (the end of the penis) is easier to keep clean. Also, a small percentage of males have to be circumcised because of problems that surface later in childhood and even adulthood. The disadvantages include the possibility of complications, even though circumcision is a relatively easy procedure. Complications include bleeding that may require a dressing and occasionally stitches or an infection that may result in scarring or injury to the penis. Also, the procedure is painful. If you choose not to have your child circumcised, be assured that the foreskin is easy to clean. Understand, however, that at birth, the foreskin is firmly attached to the glans. Over time-an average is 3 years but often longer-the foreskin separates from the glans. Do not attempt to retract the foreskin during cleaning or you could cause an injury. Clean the uncircumcised penis as you would any other part of the newborn's body. Simply wash the genitals thoroughly with a soft washcloth and soap and water. Rinse thoroughly. As your child grows and the foreskin separates from the glans, you can teach him the importance of keeping clean. The foreskin should be retracted and the surface underneath cleaned during the daily bath or shower. ................................................................. Book: The Parent's Pediatric Companion, 1985, Gilbert Simon & Marcia Cohen Note: Another baby book p 92, Circumcision: There's no _medical_ reason for circumcision, but if you decide to have your son circumcised, get ready to deal with the healing foreskin. Infections in this area are very rare, but freshly circumcised penises often look as if they were infected. The circumcised penis appears ominous because, in the first place, the foreskin consists of loose tissue, and can, therefore, swell massively when traumatized. Secondly, the healing skin is exposed to wet diaper irritation repeatedly. As a result, the cut heals slowly and often develops a soft spongy puffiness around the wound, as well as a heavy, soggy, yellow-gray scab at the healing point. When the loose scab is dislodged by diaper changes, the healing tissues may ooze a thin bloody fluid. All this is the normal healing of a circumcision. An abnormally healing circumcision is quite different. For starters, infected wounds are red, warm, hard, and painful, and the discharge is foul, yellow-green, and creamy. Fortunately, this is rare. What isn't rare is the suspicion of infection, since the freshly circumcised penis can look awful even when it's doing fine. Uncircumcised foreskin (Physiologic Phymosis): Practically all mothers of circumcised babies are given detailed instructions on the care of the penis. Practically all mothers of uncircumcised babies are given practically no instructions on the care of the baby's foreskin. To fill this void in doctor- patient communication, I'll tell you everything you have to do. Don't do a blessed thing. Once it has been determined that the urinary opening on the head of your baby boy's penis, the meatus, is in the correct position, the foreskin should be left alone. You'll probably find that the newborn's foreskin is tightly plastered to the head of the penis. Only 6 percent of baby boys have foreskins that can be retracted from the head of the penis, called the glans. The foreskin covering your baby boy's glans is a good protection. Irritations of the urinary opening occur in 8 to 31 percent of circumcised boys, and virtually never in boys with intact foreskins. In the past, doctors have maintained that circumcision makes hygienic care easier. This is certainly true. What's questionable is whether or not the baby gains anything by early hygienic care. (In my opinion, if there is no ritualistic or symbolic reason to uncover the glans, why do so?) Is there any reason not to retract the baby's foreskin? Yes, indeed. Besides hurting your baby, you can produce dense scar tissue between the foreskin and the head that won't spontaneously loosen later on. The natural connection between the foreskin and the head loosens by itself. Baby boys start out the world with tight foreskins, but only 8 percent of boys 6 to 7 years old, and 1 percent of boys at 14, have foreskins that are too tight to be easily pulled back behind the head of the penis. The tightness of the newborn's foreskin is a natural condition and it loosens without any help from us. Which proves once again that nature is wonderful, especially when we don't look for ways to botch things up. {discusses "Monk's hood foreskin", which is a cosmetic abnormality found in association with (but not causing) a somewhat serious defect of the opening of the urethra; usual discussion about not worrying about smegma trapped under a not-yet-retracted foreskin} ................................................................. Book: Babyhood, stage by stage, from babyhood to age 3, 1983, Penelope Leach, Random House Note: Leach seems to have written a major series of books on child care; this contains a long discussion of circumcision, which I have reprinted in its entirety. This edition is a bit older than I would prefer, but the one currently on sale in bookstores seems to be very similar (I could only copy the one in the library) If a newborn baby is a boy, he will almost certainly be circumcised by the hospital staff {now 60%; old edition?}. Most American parents will take this procedure as much for granted as the cutting of the cord or putting drops in the newborn baby's eyes. Those who do discuss the circumcision with their obstetrician or pediatrician will probably be doing so because the ritual operation is a part of their Jewish faith. Circumcision for religious reasons is beyond the scope of this book; indeed, it is beyond the scope of an atheist. Circumcision for deeply felt but less describable reasons is beyond this book's scope, too. If a father feels that, it this respect, his son should be like himself; a mother feels that she would not like to handle an uncircumcised son; a grandparent would be likely to love the child less because he was left as nature make him, then these are good reasons for having the baby circumcised. But many circumcisions in the United States are carried out without any of these reasons. And that seems a pity. The facts that follow are for people to think about if, having read this far, they find that they are not sure that they feel strongly that boys should be circumcised. Circumcision has an interesting history. It is practiced by about one sixth of the world's population and dates back at least 6000 years, having been started, according to Herodotus, by the Egyptians. It has been used variously as a secret tribal marking, a way of marking slaves, part of puberty initiation ceremonies, and, of course, as a religious rite. But most people today have none of these reasons for circumcision. The most usual medical reason is a tight (ie, non-retractable) foreskin. But prepuce are not meant to be retractable at infancy. D. Girder, in his paper called "The Fate of the Foreskin", found almost no baby boys whose foreskins were retractable in the first six months. Only half could be retracted after one year, while a fifth were still non-retractable at 2 years. Normal or not, many people would maintain that an uncircumcised penis is difficult to keep clean; circumcision is more hygienic. If one can manage to separate that argument from thousands of years of powerful tradition, it is a curious one. There are many parts of our bodies which would be easier to keep clean of their normal secretions if we opened them up--our nostrils, for instance. Yet we do not. A few years ago, the hygiene argument got a powerful boost from research data which suggested that cancer of the penis was less frequent in circumcised males, and cancer of the cervix far less likely in their partners. But these findings are now very much open to doubt. Recent work suggests that the findings of low cancer rates in certain populations are due to chance rather than to cause and effect. If little boys are not circumcised at birth, a few will, medically, need circumcision later on. On the face of it this is a the strongest practical reason for the newborn operation. Upsetting though it can be, physically and psychologically, for a 3-day-old baby, it is far more upsetting to a 5-year-old. But even here the argument is not simple. Doctors who are not basically in favor of circumcising everybody consider than many of these later operations are carried out unnecessarily by doctors who are. Bed-wetting and masturbation are two of the reasons still occasionally given. Neither, of course, could possibly be helped by circumcision. Both would be likely to be made worse by the trauma. Certainly, though, many late circumcisions are caused by parents' attempts to retract the non-retractable prepuce. If such attempts are made with any force at all, they tend to make minute splits in the skin between the prepuce and the glans. The splits heal leaving scar tissue which sticks the two together, so that when the prepuce ought to retract in later life it cannot. Attempts at retraction are often the cause for the other main reason for late circumcision: recurrent infection under the foreskin. So it does seem that parents who do decide _not_ to have a newborn boy circumcised should be very sure that they are able to go the whole way with this idea and leave the infant penis strictly alone; simply giving it the ordinary external hygiene the rest of the boy gets. If this is done there is no greater chance of later trouble than of, say, peritonitis. We do not whip out newborns' appendixes in case of that. Circumcision is not a dangerous operation, but, like all surgical procedures, however small, it carries certain risks. Although the risks are obviously necessary and acceptable when the procedure is _needed_ by the patient, few newborn babies _need_ circumcision. In many countries, including Britain, doctors decided long ago that while those who felt strongly in favor of circumcision should, of course, be able to arrange it, the operation should no longer be carried out routinely. They saw no benefit to the babies, and some bad side effects. They felt that the net sum balanced against the routine operation. Actual figures on side effects are difficult to assess. In a country such as Great Britain, where doctors are largely against the operation, every little problem is recorded. In a country such as the United States where it is taken for granted, only serious side effects like sepsis or hemorrhage will reach the statistics. In fact the actual reported figures for these two countries are 22 percent for Britain and 6 percent for America. An emotionally laden subject produces emotionally biased statistics! Probably, it is only safe to say that while serious side effects are extremely rare, minor ones are quite frequent. The baby is bound to be sore for at least a few days and may be so for much longer if mild infection or diaper irritation sets in. Certainly the circumcised baby boy will need much more careful diaper care than his uncircumcised friend. The foreskin protects the delicate end of the penis from the abrasive effects of ammonia in the urine; without it, irritation of the glans is much more likely and will remain so until he abandons diapers for good. Some pain on passing urine, or when bathed, is also likely; it will last until the wound is healed. But these practical considerations are not the only ones which will sway many parents one way or another. It is hard to see why anyone should have a newborn boy circumcised for _practical_ reasons alone, so the basic reason must be traditional, cultural. I am not concerned to persuade parents one way or another, but I am concerned to persuade them to _think_ about circumcision. At present {1983}, in the United States, hospitals circumcise babies because they assume that parents will want it done. Parents accept it perhaps partly because they assume the hospital knows best. There may be a failure in communication here. It may that the hospitals are taking upon themselves a decision that should really be made, positively, by each set of parents for each son. After all, if you had a baby who was born with a tooth, would you expect the hospital to extract it without asking you whether you would prefer to have it left alone? If the operation is to be carried out, even as early as the third or fourth day, non-Jewish parents may like to discuss the question of analgesia with their obstetrician. Babies feel pain from birth. Of course, they do not _anticipate_ pain, nor as far as we know do the _remember_ it. But at the time when it is inflicted, they feel pain and respond to it. Many authorities feel that circumcision without pain prevention is thoughtlessly cruel. However, the prevention of pain is not an easy matter, which is why discussion is necessary. To give a baby of this age a general anesthetic is to introduce well-known if minor dangers. On the other hand, the infiltration of the penis with local anesthetic may well cause as much pain as the removal of the foreskin itself. In some centers techniques have been developed by which the skin which must be removed is frozen with a topical application of a local anesthetic spray. It may be that this will become the pain prevention method of choice in circumcision. ................................................................. Book: Oxford Textbook of Medicine, 1987, Oxford Univ. Press Note: What appears here is the entire discussion of circumcision in the book, in the context of penile and cervical cancer. This excerpt violates a bit my rule about sticking to general references, but the cancer question has come up before and this at least contains some numbers. I've appended some back-of-the-envelope type calculations at the end. 4.109 {Cancer of the cervix} The rarity of the disease {cervical cancer} in Jewesses and its relative rarity in Moslem women suggest that male circumcision might materially reduce the risk of its development, but this is unlikely to be true as the state of circumcision of her husband has no substantial effect on the risk a woman runs of developing the disease in religious communities where only some of the men are circumcised. Cleanliness is likely to an important factor, as the disease may be relatively uncommon in communities that practise ritual ablution before and after intercourse and, within each community, it becomes less common with increasing economic status. 4.111 {Cancer of the Penis} 0.1% of all cancers, and 0.1% of all cancer deaths {apparently refers to the British population; also a plot of the annual incidence of the disease, starting at <1 per 100,000 at age 40, rising to 10 per 100,000 at age 80; the age of onset, from this plot, and from two other sources, is typically >60, at least in developed countries} The most striking fact about the epidemiology of this disease is that circumcision protects against its development. Carried out within a week or two of birth, the protection is almost complete; carried out later in boyhood, the effect is obvious, but less marked. Circumcision is not the only way of preventing disease, as marked variations in incidence occur among tribal groups in Africa who are alike in not practicing circumcision, but otherwise have different social customs. In some the disease accounts for as much as 10% of all cancers in males; in others it is only slightly more common than in developed countries. Personal cleanliness may be an important factor, as it is in relation to some forms of cancer of the skin, and it seems that as long as the glans, coronary sulcus, and foreskin are kept clean, the risk of developing the disease is remote. An observation that suggests the possibility of venereal (and hence perhaps a viral) origin is an association between cancers of the penis and cervix uteri in marital pairs. The association is not strong, but it has been observed in several countries and cannot be accounted for simply by confounding with socio-economic class. The human papilloma virus (types 16 and 18) is commonly found in the malignant cells, and probably causes the disease. {My Comment, as well as some more info about penis cancer, since the subject has been discussed before, with few actual facts being presented. Readers are encouraged to visit the original sources, because they are rather complex and a mite difficult to simplify. It might be of interest to perform the following (rather cold and clinical) economic exercise, allowing for the possibility that all males will _not_ practice the hygiene necessary to ward off penile cancer. Suppose we have 2000 babies. If we circumcise them, assume that none of them will get penis cancer. If we don't circumcise them, about 1 of them will get penis cancer, typically at the age of 60 (In Japan, it would be 0.6 men, in Poland, 1.0, in Denmark, 1.2, according to Cancer_Medicine, by Holland & Frei. The rates for the white US men, Canadians, and Brits are no higher, but it is not clear whether the 60 year old men in these countries who were getting penile cancer when these numbers were compiled circa 1970 were circumcised or not, because they were born circa 1910, when the practice may not have been widespread. I got these numbers by muliplying the annual incidence per 100,000 men as given in Cancer_Medicine by a 75 year life span.) The two possibilities are circumcise, and get no penile cancer, or don't circumcise, and get one case. If we circumcise, at $250 per circumcision, we pay $500,000 up front, and in 60 years we have no penile cancer. If we don't circumcise, we can (hypothetically) place the same money into the bank at 5% per annum (above inflation) interest. In 60 years we would then have 9.3 million inflation-adjusted dollars in the bank, and one case of penile cancer. An economist, I believe, would argue from this gedankenexperiment that the cost of prophylaxis is $9 million per cancer, in large part because you have to pay in advance for a payoff that comes much later. If we assume a 100% mortality rate from penile cancer, and we assume that a person who dies of penile cancer at age 60 would have been dead at 80 of something else anyway, a bit of arithmetic shows that circumcision adds an average of 3.7 days to the male lifespan. I suspect that the difference in longevity between a society that circumcised and one that didn't would be quite undetectable. Penis cancer is dicussed in some detail in the "Comprehensive Textbook of Oncology", (1991,Satterfield ed., Williams & Wilkins pub). Evidently, if caught early (StageI/StageII, defined by a surface tumor and a tumor that has invaded the body of the penis but not the lymph nodes, respectively), it has a 95%/75% 5 year survival rate. The problem is that reporting is often delayed because of fear and embarassment. The treatment of choice seems to be radiation, to try to preserve normal sexual and urinary function, with amputation of the penis if radiation fails or if the cancer is caught late. From the Oxford text, penile cancer is about as common as lip cancer or male breast cancer; Prostate cancer is about 20 to 100 times more common (increases with age), bladder cancer is about 40 times more common.} .................................................................... Book: 300 Questions New Parents Ask, 1991, William Sears MD Note: baby book, in Q&A format Q13 We are still undecided as to whether or not to have our baby circumcised. Can you give us some pros and cons to help us make the right decision? A13 The Am.Acad. of Ped. advises that routine circumcision is medically unnecessary and we agree with this decision. First the cons: Circumcision is a surgical procedure and generally a very safe one, but, as with any surgical procedure, there are occasional problems, such as injury of the shaft of the penis, bleeding, or infection. Circumcision without the use of an anesthetic clearly causes pain to the baby. Lastly, circumcised babies often experience more irritation to the tip of the penis from strong urine or abrasive diapers. Normally, the foreskin covers the glans (the tip) of the penis and protects the glans from irritation. Now the arguments in favor of circumcision: Parents feel the foreskin is easier to keep clean when the baby is circumcised (Actually, this is not true-see question 15). Parents want to make him look like all of the other males in his circle or like dad. In response to this concern, I feel parents need not worry about the baby being different. If the current trend toward fewer circumcisions continues, our guess is that within the next decade about half the males will be circumcised and half will not. In our experience boys do not compare circumcised versus intact foreskins. Modern teenagers have a much more mature outlook about individual differences than we give them credit for. Parents may worry about the possibility of the uncircumcised child needing circumcision later on when it is a much more painful procedure. It is true that some boys need circumcision when they are older, but it is rare. Even so, if circumcision is necessary later in childhood or adulthood, the boy is involved in the decision-making process and anesthesia is used. Except in cultural or religious customs, routine circumcision is unnecessary. Your decision for your baby should be given the same attention that you would give to any other cosmetic surgery. Q14 We would like to have our baby circumcised, but don't want to put him through the pain. I've heard about using a local anesthetic. Is this possible? A14 Yes. It is a myth that newborns do not feel pain during circumcision. Studies comparing the physiologic effects of circumcision on anesthetized and unanesthetized babies show the following: Babies who did not receive a local anesthetic cried more, developed higher heart rates, had higher levels of stress hormone, showed a drop in blood oxygen, and generally seemed much more stressed. {Description of local anesthesia, and reference to journal article deleted} Q15 We have chosen not to circumcise our child. How do we care for the foreskin? A15 We call this the "uncare" of the foreskin. {In brief: leave it alone until it retracts, don't force it back, wash it as it retracts, don't worry about smegma that might accumulate because the foreskin doesn't retract yet, teach the kid to wash it when he takes a bath} .................................................................. Book: Take Charge of Your Child's Health, 1992, George Wootan MD, Crown Note: typical child care book {Foreskin care: warns parents, rather sharply, about doctors who might try to force the foreskin back, thereby damaging it; once it retracts, kid should retract it and clean it daily; tells parents not to worry about smegma under an unretracted foreskin} Circumcision: {says that he won't relate pros and cons because they are extensively discussed elsewhere; refers readers to Wallerstein article in "Urologic Clinics of North America" 1985, Vol 12 No 1; see Encyclopedia Americana article above for what Wallerstein thinks} I do have a few points to make on the subject, however. First, while there is no medical reason a male infant needs to be circumcised, in countries where babies are not routinely circumcised, 25 to 30% do require the operation in adolescence and adulthood. When performed after infancy, the operation involves the use of general anesthesia and a two-week recovery period. {the 25-30% figure seems to be contradicted by some other sources, including the next one} At the present time, there is a controversy brewing over a recent study that concluded that the incidence of urinary-tract infections is significantly higher in uncircumcised males than in those who are circumcised. Critics of the study consider its conclusions invalid, and I tend to agree with them. At this writing, however, the issue remains unresolved, and may warrant further investigation on your part if you are considering circumcision for your child. If you decide to circumcise your child, I believe that it should be done according to the traditions of Judaism, most of which make sense for medical or psychological reasons. {parent should hold baby, baby should nurse afterwards, mentions sugar ball dipped in brandy as a sort of anesthetic}. There is no doubt in my mind that babies do feel pain during circumcision. However, I don't agree with those that argue that the pain permanently damages the male psyche. If this were true, we ought to be able to develop a psychological test to distinguish circumcised males from uncircumcised men, but so far this has not been done. .................................................................... Book: Encyclopedia of Childbearing: Critical perspectives, 1993, ed. Barbara Katz Rothman, 1993, Oryz Press Note: medical encyclopedia with a slightly political bent Much of Wallerstein's contribution parallels the Encyclopedia Americana article, so I've abbreviated a lot. I've deleted most of Milos's description of the procedure because it is something of a diatribe; for a more clinical description, see Wallerstein's book. Circumcision, male: {By Wallerstein, and Marlyn Milos, RN} Circumcision is a surgical procedure in which the sleeve of skin that covers and protects the head of the penis is removed. {risks: error, infection, even death; routine practice is unique to U.S., Victorian reasons for doing it mentioned (masturbation, lunacy, etc); rate was 85% in late 1970's, now it is less than 60%} Currently, unsubstantiated assertions that circumcision prevents STDs and AIDS are being made. The Am. College of Ped. neutralized its stand in 1989 by stating that "newborn circumcision has potential medical benefits and advantages as well as disadvantages and risks." Today, almost all circumcisions are performed to prevent potentially and statistically and unlikely future problems. Such thinking is reminiscent of the prophylactic tonisillectomies recommended for children a generation ago.... As the public and the medical profession learn more about the risks and reputed benefits of medical circumcision, it, too, may pass from the scene to join blood-letting and cupping {?} in medical history. Circumcision Surgery: {By Marilyn Milos, RN} During a newborn circumcision, the infant is fastened spread-eagle to a plastic board with straps and the elbows and knees. A nurse scrubs his genitals with antiseptic and covers the groin area with a surgical drape which has a hole in it to expose his penis. If a dorsal penile nerve block is used, two injections are given at the base of the penis. Although not always effective, the anesthetic reduces the stress response - if and while it is working. Once the effect has worn off, though, urination and defecation into the raw wound during the healing period caused obvious discomfort. Usually the surgery is done without anesthesia and is undeniably painful. {rather gory and emotional description of the procedure deleted} Specifically, how often is post-newborn circumcision necessary for therapeutic reasons? Wallerstein (1986) writes "The Finnish Board of National Health in 1970 showed that 0.023% of males required hospitalization for foreskin problems (99.977% of Finnish males did not.) The US rate is at least 50 times or 5000% that of Finland... {ellipsis Milos's} The question is not foreskin problems, but the attitude of the American medical profession in pushing what most physicians throughout the world consider unnecessary surgery. Worldwide, foreskin problems are treated medically, not surgically." {Compares circumcision to tosillectomy, excessive radical mastectomy, and excessive hysterectomies}. .................................................................... Book: Captain Sir Richard Francis Burton, 1990, by Edward Rice, Scribner's Note: This one isn't a med book; it is a biography of the British adventurer R.F. Burton that I read a month or so ago (and that made me perk up my ears at the cirucumcision debates that I saw going on). To be the first European to visit the Islamic holy sites and survive, he adopted the guise of a Moslem, which included obtaining a circumcision. Being an adventurer of more than one sort, he was well equipped to relate (one man's view of) the erotic effects of the operation, which is something none of the medical books discuss. p 105 {Burton's discussion of ceremonies that precede the procedure deleted} Here Burton added a note, most likely based on his personal experience. No evil results are expected from the circumcision of adults; it has often been tried in the cases of African slaves. The cure, however, is generally protracted for a period of at least six weeks. A few years later Burton expressed a different opinion about the physical results of adult male circumcision, with possible regrets for lost pleasures. Male circumcision makes love slow and difficult. For the softness of the gland {sic} is hardened by friction, hence coitus is painful, slow, and not energetic enough. {An aside: In "Human Sexual Response", Masters and Johnson compare, using standard tests, the tactile response of circumcised and uncircumcised men, and find no clinically significant difference. How such tests relate to subjective erotic pleasure is rather uncertain. Masters and Johnson also state that there no truth to the belief that circumcised males are less susceptible to premature ejaculation.} ..................................................................... ..................................................................... Everything that follows consists of my personal ravings; feel free, if you wish, to ignore it. All of these sources were books that I found in the library; there were other books in the bookstore that I couldn't photocopy that were in a similar vein. I can honestly say that I didn't find a single recent book that could be paraphrased as "We believe that routine neonatal circumcision is medically advisable." Those who support the practice are challenged to find and post such a source (preferably, several such sources). Remember, _recent_ and _general_, and giving an _overall_view_ of the costs and benefits. Clearly, in recent years, the discussions of the practice have become longer, more thoughtful, and increasingly opposed. On the other hand, the anti-circumcisionists will be disappointed because the mainstream literature makes little mention of any severe adverse effects. (though the Leach book should be noted as far as the freqency of less serious side effects is concerned, and Burton's account isn't necessarily to be ignored) I will now take the opportunity to make myself a few enemies, and simplistically divide the Usenet debaters into the "pro" side and the "anti" side, and attack both. The "pro" side seems to be divided into people who delight in sophistic arguments about trees falling in forests, and rights of parents, and manage to turn the discussion in some sort of abstract debating contest; and into people who simply state "I support the practice because it has health benefits" without backing up their assertions with one whit of evidence. I strongly suspect that with many of these people, the dominant factor in their fondness for the practice is an aesthetic preference brought about by a familarity with nothing else, and unspecified medical reasons are really little more than a rationalization. Such people should at least be honest about it, so that people who _are_ interested in the medical truth are not misled. The "anti" side seems to be the very epitome of the "victim" mentality that is so fashionable in current American culture. I would wager that few of them would be willing to trade places with an uncircumcised Chinese peasant or African refugee. They mix some valid medical facts with information gleaned at an Iron John drum beating session to make a farce of the case against circumcision. Their "in your face" attitude is exactly what will convince those who are undecided that the only opposition comes from lunatics. For people who are actually interested in learning more than is covered in general references, one reasonably good book that I came across seems to be Wallerstein's book "Circumcision: An American Health Fallacy." (Springer,1980). It approaches the practice from a health consumer's perspective rather than with the victim mentality of the radical anti-circers. It is certainly not the last word on the practice, and it probably has its own biases, but it gives the only historical examination of medical circumcision that I have seen. Furthermore, it appears that at least some doctors take him seriously, because he was cited in a handful of the sources above. Medical circumcision seems to be very much on the decline. Several of the above books state that the circumcision rate fell from 85 or 90% to under 60% in the decade of 1980-1990. Wallerstein's book, written at the very beginning of this decline, attempts to tabulate the circumcision rate, and finds it to have been steadily rising from 1870 onwards; in this last decade, the rate appears to have fallen back to where it was between 1930 and 1940. The prevailing medical opinion now seems to be that it is an unnecessary, essentially cosmetic surgery that doesn't seem to really prevent anything, and can introduce some problems of its own. I suspect that most parents who read up on the current literature will simply feel disinclined to have unnecessary surgery performed on their son. Once the rate falls below 50%, the "he'll look funny in the locker room" argument will undoubtedly work in the opposite direction. It would be _really_ nice if this debate were taken out of the hands of the fanatics. Perhaps if more parents who decided not to have it done were to post, it would help to demolish some of the mythology that has developed over what seems to have been a hundred years of dubious medicine. Anon ------------------------------------------------------------------------- To find out more about the anon service, send mail to help@anon.penet.fi. 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