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Meta © 2022 Why are we including the ethics as well as the evidence in this article? The focus of our blog is “Evidence Based Birth®.” So why are we discussing the ethics along with the medical evidence on circumcision? We believe a discussion about this particular topic cannot take place without ethical context. Routine male newborn circumcision is the irreversible, surgical removal of tissue from the sexual organ of a healthy minor. It goes without saying that there are ethical questions about removing or altering any minor’s genital tissue, regardless of whether or not there is research examining purported medical benefits. Medical ethics is also called bioethics: “bio” (from the Greek word for “life”) and “ethics” (the discipline concerned with what is morally good and bad, right and wrong). So, bioethics is the study of ethics as it relates to living beings. The major principles of bioethics include (McCormick, 2013):
We’ll revisit these principles later on in the article when we discuss bioethics as it relates to circumcision. The prepuce in human anatomyDevelopment of the sexual organsHuman embryos start out with the same sex-neutral genital structure and then go on to develop more stereotypically male or female genitals through a process called sexual differentiation (Betts et al. 2018). In males, embryonic cells normally develop into a glans penis covered by protective tissue called the male prepuce, or foreskin, which covers the head of the penis when it is flaccid (not erect). Similarly, the equivalent embryonic cells in females develop into a glans clitoris covered by the female prepuce, better known as the clitoral hood.  It’s important to point out that sex is a spectrum—not binary. Some people are born intersex, in which differences in sexual development mean that they do not fall neatly into a male or female category (Ainsworth, 2015). In some cases, the prepuce covers the person’s “ambiguous” cliteropenis, thereby eliminating the distinction between “penile foreskin” and “clitoral hood.” This Evidence Based Birth® article applies to circumcision on typical male infants, not procedures on intersex children, although there are common bioethical themes around performing genital surgery on children. In addition, EBB recognizes that people who are trans, non-binary, and gender nonconforming can also be personally affected by penile circumcision. Newborn males are normally born with their prepuce fused to their glans penis by a membrane. This tissue connection is normal at birth, making it so that the prepuce cannot be retracted, or pulled back from the glans. A study of 100 newborns found that less than 5% could fully retract their prepuce (Gairdner, 1949). If left intact (uncircumcised), the prepuce usually becomes less attached and more retractable over childhood and adolescence. By 10 years of age, more than 50% of boys can completely retract their prepuce (Kayaba et al. 1996), and by 17 years of age, less than 1% of boys will be unable to retract their prepuce with gentle manipulation (Oster, 1968). In this article, we use the term intact instead of uncircumcised, since referring to a penis as uncircumcised suggests that circumcision is the normal or default state and the absence of circumcision is an abnormal or alternative state (compare to “unlabiaplastied,” which would not be used to describe a girl’s surgically unmodified vulva) (Wallace, 2015). Functions of the prepuceThe prepuce is a normal part of the body’s genitals, common to males and females, human and non-human primates, and all mammals. Where the innermost layer and the outermost layer of the prepuce meet is called a mucocutaneous junction, or a boundary between typical skin and moist, fluid-secreting tissue (mucosa). In this way, it is similar to the nose, lips, eyelids, and labia minora (inner folds at the opening of the vagina). The prepuce is nerve-laden tissue that, in males, covers and protects the glans penis and the male urinary opening from irritation, such as soiled diapers or tight clothing (Cold and Taylor, 1999). In newborns, removing the prepuce through circumcision exposes the head of the penis to urine and bowel movements in the diaper. After wound healing and during later development, the glans penis is exposed to air and to friction from clothing. As a result, the circumcised penis goes through a process called keratinization, which changes the skin on the glans penis from shiny, smooth, and moist to dry and slightly more toughened, or callused. In an intact adult male, the average prepuce is around 37 square centimeters of skin (about the size of a credit card), but varies considerably between men (Kigozi et al. 2009). When an intact man’s penis is flaccid (not erect), his prepuce covers his glans penis, so the head of his penis is at least partially hidden. However, during erection, the prepuce retracts back along the shaft exposing the glans, and the intact penis looks nearly identical to a circumcised penis with the exception of a band of pleated tissue gathered behind the glans. Later in this article, we’ll discuss the limited research available on circumcision and sexual function, as well as discuss the bioethics of removing the prepuce. Care of the intact penisCare of the intact penis is simple. It can be washed with water during the infant’s bath (non-irritating soapy water may also be used). The main thing to remember is that when the prepuce is still attached to the glans, it should never be retracted, or pulled back toward the abdomen by force (for example, during a bath or a medical check-up). Forced retraction can cause pain, tearing and bleeding (Dave et al. 2017). There is no need to wash beneath the prepuce until it is more easily retractable later in childhood or adolescence. In fact, the natural buildup of oils and old skin cells beneath the prepuce (called smegma), along with occasional erections, helps the prepuce to gradually separate from the glans until it is fully retractable. The white substance called smegma that builds up in moist folds of genital tissue is normal for males and females (where it can build up between the labia and around the hood of the clitoris) and can be wiped away with washing. Once a boy discovers (on his own) that he can pull his prepuce back, he can be taught to clean the area between the prepuce and the glans as part of a regular bathing or showering routine. Simply pull back the prepuce gently and rinse underneath with water (National Health Service, 2018, How to Keep a Penis Clean.) Where did circumcision come from?Ancient originsExperts do not agree on the origins of circumcision, other than that it predates written history. Scholars think that circumcision is probably one of humankind’s most ancient rituals! We know from Egyptian mummies and wall paintings that circumcision goes back at least as far as ancient Egypt. It is possible that the practice came about in different cultures for different reasons. There is very little evidence for any of the theories of the ancient origins of circumcision, but following is a partial list of those theories:
Circumcision is also performed as a religious rite. Observant Jewish parents have carried out the ritual for more than 3,000 years in a ceremony called Brit milah (or Bris). According to Genesis 17: 9-14, Abraham received divine instruction to circumcise himself, all male members of his household, his descendants and slaves on the eighth day after birth. Although some U.S. Jews do not consider themselves religious (about 1 in 5 according to a Pew Research Center survey), they “may identify as Jewish on the basis of ancestry, ethnicity or culture.” In these cases, circumcision might be characterized as a cultural or ethnic practice rather than a strictly religious one (Brusa and Barilan, 2009; Earp et al. 2017). Finally, a small number of Jews do not practice circumcision as a religious rite, adopting an alternative life cycle ritual such as Brit shalom (a naming ceremony) containing the symbolic elements of a traditional Bris, but without circumcision. Most male circumcisions around the world are performed in Muslim communities (roughly two-thirds of all circumcisions) (WHO/UNAIDS, 2007). For Muslims, circumcision is not mentioned in the Qur’an, but Prophet Muhammad recommended it in his teachings and the sayings of Muhammad (hadith) became the basis for Islamic law and practice. Islam also draws from the Old Testament as a source of authority and honors Abraham as a guide and model for the people (Gollaher, 2000). For most Muslims, circumcision is a given; however, Islamic scholars disagree over whether the ritual is a required part of the faith or just recommended (Dabbagh, 2017). Some Christians also practice circumcision; however, the New Testament specifically states that non-Jewish Christians do not need to be circumcised: “For in Christ Jesus neither circumcision nor uncircumcision has any value. The only thing that counts is faith expressing itself through love” (Galatians 5:6, New International Version). So, among Christians, circumcision is usually done for cultural rather than scriptural reasons (see below). Modern non-religious circumcisionAccording to David Gollaher, author of Circumcision: A History of the World’s Most Controversial Surgery, we can trace the origins of routine, non-religious circumcision on healthy newborn males back to the U.S. in the 1870s. At that time, Dr. Lewis A. Sayre, a leading orthopedic surgeon in New York, future president of the American Medical Association and founder of the Journal of the American Medical Association, developed a theory that circumcision could cure many types of paralysis and hip-joint disease by “quieting the nervous system.” He believed that the prepuce agitated the nervous system and circumcision was a means of “relieving the irritated and imprisoned penis.” At the time, reflex neurosis theory attributed many health problems to “irritation.” Sayre and many other doctors also recommended clitoridectomy (the removal of the external part of the clitoris) to treat genital irritation thought to cause female “nervousness.” Circumcision’s first modern medical advocates were U.S. and British medical professionals who believed Sayre’s claims that circumcision could cure diseases. Soon after, other physicians began to argue that preventing disease is even better than curing disease, and they insisted that circumcision would benefit any male and even society at large. Early physicians claimed wide-ranging benefits from circumcision—that it could prevent or “cure” impotence, phimosis, sexually transmitted diseases, seizure disorders, bed-wetting, homosexuality, paralysis, masturbation, and more (Darby, 2003). As we’ll discuss, there is limited supporting evidence for a couple of these early claims, but most were completely unfounded. Also around 1890, germ theory of disease (which linked microscopic bacteria to infectious diseases) caused the public to greatly fear germs. Genitals were thought to be especially dirty and many came to believe that circumcision was necessary to keep the penis clean. The intact or “uncircumcised” penis came to be associated with recent immigrants, people of color, and the poor. These groups were accused of lacking culture, hygiene, manners, and intelligence and were called uncivilized. There were also overtly racist proposals to forcibly circumcise Black males. For example, the prominent physician Peter Charles Remondino, vice president of the California Medical Society, accused Black boys and men of being inherently promiscuous and advocated that circumcision is an “efficient remedy” for this behavior (Remondino, 1894). During this time period, midwives rarely performed circumcisions, so a circumcised newborn was also a status symbol of having given birth with a physician in hospital. While modern circumcision began in part for perceived hygienic benefits and social class distinction, medical historians argue that one of the main reasons circumcision became routine in the nineteenth century was because of a major effort to stop masturbation. At the time, many people feared that masturbation was a cause of both mental and physical illness (Darby, 2003). Since masturbation with an intact penis involves moving the prepuce back and forth over the glans for stimulation, removing the prepuce seemed like a way to prevent masturbation, or at least make it less desirable. So, circumcision was done as a preventive measure, treatment, and punishment for masturbation as well as for the “moral” benefit of the child (Gollaher, 2000). John Harvey Kellogg, M.D., the founder of Kellogg’s Corn Flakes®, was a leader in the anti-masturbation movement (Kellogg, 1881). Dr. Kellogg advised that children should be watched at all times, night and day, for fear that they might “defile themselves” if left alone. To prevent and treat masturbation, he recommended several strategies: bandages, tying the hands, electrical shock therapy, caging the genitals, and especially circumcision, as this “remedy [is] almost always successful in small boys.” Kellogg wrote: ‘The operation should be performed by a surgeon without administering an anesthetic, as the brief pain attending the operation will have a salutary effect upon the mind, especially if it be connected with the idea of punishment, as it may well be in some cases.’ According to the following quote, Kellogg may have even invented his dry breakfast cereals as a substitute for other breakfast foods that might be dangerously “stimulating,” in hopes that cereal would help curb masturbation! “Eat fruits, grains, and vegetables. There is a rich variety of these kinds of food, and they are wholesome and unstimulating. Graham flour, oatmeal, and ripe fruit are the indispensables of a dietary for those who are suffering from sexual excesses.” (Kellogg, 1881) So, why did circumcision become widely popular in U.S. culture but fall in popularity among the British? In his book, Gollaher explains that Britain was in a serious economic recession in the 1940s after World War II. The government-funded National Health Service (NHS) was established to provide affordable healthcare in times of scarcity. Every medical procedure was subjected to careful study so as not to waste precious resources. In 1949, Douglas Gairdner, a respected English pediatrician, published a paper critiquing the practice and confirming the wisdom of the 1948 NHS decision to stop covering the costs of routine circumcision. Soon after, circumcision was largely abandoned and never became embedded in British culture the way it has in U.S. culture. Why do parents choose non-religious circumcision today?Most people today are not aware that non-religious circumcision became popular in the U.S. in large part as a way of reducing male masturbation (as satirically depicted in this video released by College Humor). Instead, modern parents who choose non-religious circumcision for their sons do so for a variety of reasons, such as concerns about hygiene and social norms. In the U.S., some parents may choose circumcision because it is a procedure that their care providers routinely offer to them, so it is seen as the default choice. We were able to find three recent survey studies on why parents choose circumcision. In Canada, researchers surveyed parents attending prenatal classes about their single most important reason for supporting or not supporting circumcision for their child (Rediger and Muller, 2013). The 143 parents that supported circumcision cited hygiene (51%), prevention of infection or cancer (15%), father is circumcised (8%), personal preference (8%), religion (6%), doctor advises it (4%), looks better (2%), it just seems right (2%), to look like other boys (1%), and other reasons (2%). The 92 parents in the study that did not support circumcision gave their main reason to be that it is not medically necessary (54%), concerns about infection or bleeding (14%), father is intact (10%), it hurts too much (10%), baby has no input in the decision (7%), and intact looks better (5%). Although only 8% of supportive parents listed the father being circumcised as their single most important reason for supporting the procedure, 41% listed it as one of several reasons. In a data analysis of the survey responses, the researchers found that the father’s circumcision status was a significant predictor of whether or not parents supported circumcision for their child. If the father of the expected baby was circumcised, 82% were in favor of circumcision for their child. When the father of the expected baby was not circumcised, only 15% desired circumcision. The researchers concluded that the circumcision status of the father is the most important influence on parents’ plans to pursue or avoid circumcision for their child. A U.S. survey of 200 parents in Texas also found that the circumcision status of the father was the most highly correlated or connected factor with regard to the infant also being circumcised (Spense et al. 2015). This study didn’t ask parents about their reasons, but they compared the groups and found that intact infants were more likely to be Hispanic, with Medicaid insurance, and Catholic. Another 2015 U.S. study by Sardi and Livingston surveyed 60 parents and expecting parents of boys who chose or planned to choose circumcision. Overall, they found that the parents’ responses fell into two main categories of beliefs, health-related and personal/cultural, and most parents gave a mixture of beliefs from these categories to support their decision. The analysis showed that perceived health benefits were closely tied to cultural beliefs supporting circumcision. This means that parents’ beliefs about potential health benefits from circumcision are greatly influenced by their cultural beliefs about the practice. Scholars who study social norms have theorized that norms affect the way individuals understand information, so that an individual’s behavior is “weighted in favor of the predominant social norm” (Waldeck, 2004). Therefore, if newborn circumcision is perceived as socially normal, then an individual is more likely to exaggerate the significance of health benefits and diminish risks, or vice versa if newborn circumcision is perceived as socially abnormal. Given that there was so little recent research on this topic, we looked for information in other types of media about why parents may choose non-religious circumcision. In a podcast episode on the topic published by Medical Ethics, a group of 3 parents discussed why they chose circumcision. A man said, “I didn’t give it any thought at all when my son was born. It’s what everybody did. It happened.” A woman said, “I didn’t want to have him circumcised. I worried about causing my baby pain. And he [the father] wanted his son to be circumcised because he was circumcised. And so, I made him go watch it and he said that it was awful and that he almost threw up.” Another man on the episode said, “I’m circumcised and my son is circumcised…the pro side is you look like your dad and so you don’t feel different. Of course, there are many other ways in which you don’t look like your dad… but that is one argument. It’s cultural identification… So, you’re ‘in the group’ when you get it done.” Using a search on Google for “Why I chose circumcision for my son,” a variety of mom blog results were found, all from the U.S. Some of the bloggers explained why they chose circumcision, and others explained why they chose not to circumcise. It was interesting that, even when parents felt uncertain about their decision, they frequently listed perceived medical benefits as a justification for choosing circumcision. For example, one blogger cited the American Academy of Pediatrics’ (AAP) 2012 statement that “the benefits of newborn male circumcision outweigh the risks.” This blogger contrasted male circumcision with female circumcision, a practice we’ll discuss in more detail later on, which she labeled “a barbaric, scientifically unsound practice.” Another blogger stated, “there is a rather lengthy list of studies that support the medical benefits of circumcision,” and again cited the AAP, as well as the U.S. Centers for Disease Control (CDC). Another blogger on Parenting.com said, “We respected both sides of the argument, but the medical evidence supporting the use of circumcision to prevent sexually transmitted diseases (STDs) and penile cancer, and to reduce urinary tract infections (UTIs) compelled us. We were finally persuaded when the World Health Organization and UNAIDS issued a joint statement in 2007 supporting the link between male circumcision and HIV prevention. Suddenly we felt that we were making a decision that could not only protect the health of our child, but could save his life. We spoke with the pediatrician we’d chosen and our OB/GYN, who would be performing the surgery, and both agreed with our position.” Clearly, in addition to social norms, perceptions about research evidence may also factor into parents’ decision making about routine male newborn circumcision in the U.S. We will explore this research in depth later on. Worries about teasing or bullyingA common reason that parents in the U.S. give doctors for wanting circumcision is that their child may be teased (or even bullied) later in life if their penis is not circumcised, especially in regions like the Midwestern U.S. where circumcision is still common (Alexander et al. 2015). We only found one study on the topic of teasing/bullying about penile appearance. Researchers surveyed 290 undergraduate men at the University of Iowa about penile teasing during middle and high school (Alexander et al. 2015). Most of the men in the study were circumcised (251 circumcised men versus 39 intact men), and the majority of participants reported being naked often in a locker room. Of all the men in the study, 10% reported that they had been teased about their penis and 47% reported that they had seen someone else get teased about their penis at some point in the locker room. Penis size was the reason most often identified by those who were personally teased (75%) or witnessed teasing (83%). Aside from size, the participants reported that 24% of the teasing they witnessed in the locker room was about being intact instead of circumcised. When the authors compared the rates of personally experiencing penile teasing in the intact group versus the circumcised group, they found no difference in the rates of experiencing teasing between the groups. While this study only included a small sample of intact men (39 men), the findings are still informative because nearly half of the 290 total participants were able to report on teasing that they had witnessed, and they reported that locker room teasing was far more related to penile size than penile appearance. As we’ll discuss next, whether it’s a circumcised or an intact penis that gets teased for a “funny appearance” in the locker room depends on where you live, even within the U.S.! How common is circumcision around the world?Another statement that we hear from parents in the U.S. is that “I want my son to look like everyone else.” Parents may be surprised to learn that most men around the world are not circumcised, as well as that there has been a decline in male newborn circumcision rates in the U.S. Circumcision rates vary widely between and within countries, but the true rates are not clear and can only be estimated. The World Health Organization published a report in which it estimated that 30-33% of the world’s males aged 15 years or older are circumcised (WHO/UNAIDS, 2007). Of these circumcised men, about 69% are Muslim, 1% are Jewish, and 30% are circumcised for non-religious reasons. Of the men circumcised for non-religious reasons, 43% are in the U.S., and 57% are in every other country combined. Another way to look at it is that only about 10% of the world’s males are circumcised for non-religious reasons, and more of those men live in the U.S. than in any other single country. A more recent review by Morris et al. (2016) estimated the global prevalence of circumcision to be slightly higher, about 38%. However, this may be an overestimate as he assumes that the circumcision rate in China, the most populated country in the world, is 14% (a high estimate). The rates of circumcised men in each country range widely, for example: about 99.8% of men in Afghanistan are circumcised, 92% in the Philippines, 91% in Kenya, 71% in the U.S., 11% in Germany, 9% in Japan, 6% in Switzerland, 3% in Italy, 0.9% in Ireland, and 0.1% in Iceland and Puerto Rico (Morris et al. 2016). A striking example of what a strong influence culture has on circumcision rates is North and South Korea. Only 0.1% of men are circumcised in N. Korea but 77% of men are circumcised in S. Korea (which seems to have picked up the practice from the U.S. military during its occupation after the Korean war) (Kim et al. 1999). In the U.S., an estimated 71% of adult men are circumcised, but the current rate of routine newborn circumcision is much lower and research suggests that the rate continues to decline. The Centers for Disease Control (CDC) published a report in 2013 tracking trends in male newborn circumcision from 1979 to 2010 (Owings et al. 2013). The overall rate of U.S. newborn circumcision before hospital discharge fell from 65% to 58% over the 32-year period. So, as of 2010, only 58% of newborn males in the U.S. were being circumcised in the hospital before discharge. Given the downward trend, it’s possible that the number has fallen more since then (the CDC has not yet reported data from 2011-2019). Now, the CDC data only capture circumcisions done in hospitals immediately after birth, not the minority of circumcisions done after hospital discharge (e.g., religious ritual circumcisions or outpatient procedures), so the total rate of newborn circumcision is somewhat higher than the hospital rate. Researchers debate what the total rate of newborn circumcision would be if you include those that occur after hospital discharge. However, there is general agreement that the overall rate of U.S. newborn circumcision is declining. There is an interesting amount of geographic variation in newborn circumcision rates in the U.S. that occur before hospital discharge (Owings et al. 2013). The Midwestern states have the highest regional rate with a high of 83% in 1998 and a low of 69% in 2009. The Western U.S. states have the lowest rate of routine circumcision in the U.S., with a high of 64% in 1979 and a low of 31% in 2003. This means that as of 2003, seven out of ten male babies in the Western U.S. are not circumcised in the hospital after birth. Circumcision has become so rare in some Western states, that some hospitals no longer offer the procedure because there is no demand for it (Personal communication, attendees at AWHONN conference, 2019). U.S. insurance coverage for newborn circumcision varies among public and private insurance policies. As of 2015, Medicaid has discontinued coverage in 18 states (Warner et al. 2015). The circumcision procedureIn a typical hospital circumcision procedure, the baby being circumcised is placed on his back in a holding device with his arms and legs restrained (Caldwell et al. 2018). The skin around the baby’s penis is cleaned and pain medication is applied around his penis as a cream or injected. We’ll go into more details about pain treatments with the procedure later on in the article. There are several different devices that providers use to circumcise a baby’s penis, including the Gomco clamp, the Mogen clamp, and the Plastibell ring device, WARNING: these links take you to graphic videos of real circumcisions published by Stanford Medicine for educational purposes. We do not cover the research on each of these techniques in this article, but UpToDate guidance for clinicians states that none of these three circumcision techniques is clearly superior to the others (Caldwell et al. 2018). However, the Mogen clamp has a key disadvantage in that it does not directly protect the glans penis while the prepuce is being cut during the procedure. In fact, the company that manufactures the Mogen clamp in the U.S. went bankrupt following two multimillion dollar judgments after accidental penile amputations. After the baby’s prepuce has been separated from his glans, the provider uses one of the three techniques. The provider either removes the baby’s prepuce during the procedure with the Gomco clamp or the Mogen clamp, or they send the baby home with the Plastibell ring device tied tightly around his prepuce to cut off circulation. The procedure takes about 15 to 30 minutes from preparation to completion (Baskin, 2019). To stop the bleeding, the provider covers the baby’s wound in a dressing (gauze) and applies pressure. Parents are instructed to replace the baby’s lubricated dressing with every diaper change for 24 hours. They are told to clean the baby’s wound with warm water and a cotton ball daily. After 24 hours, the lubricant is applied directly to the baby’s wound (without gauze) with each diaper change for the next three weeks, and within a few days a scab will form (Baskin, 2019). What is the evidence on circumcision to prevent infection or disease?Despite growing ethical concerns in recent years, researchers have carried out many studies examining the medical effects of male circumcision. In the following sections, we will discuss the evidence from these studies—first those that looked at circumcision to reduce the risk of infection or disease, and then those that looked at potential health risks from the procedure. We will conclude by discussing circumcision in an ethical context. Cultural Bias in the Medical ResearchAs we conducted our literature review, it became clear that most researchers based in the United States, where the majority of medical research is done, took the cultural and ethical acceptability of male circumcision for granted. Accordingly, the explicit goal of most studies was to ‘verify’ the perceived benefits of the surgery. This research approach contrasts sharply with U.S.-funded studies on female genital cutting (FGC) practices throughout Africa, the Middle East, and parts of Southeast Asia. As we’ll discuss, some types of FGC are much more invasive than male circumcision and have devastating health consequences, and other types are much less invasive (a “prick” without tissue loss), but all types of FGC have been defined as unethical mutilations by the World Health Organization (Darby, 2016). Indeed, the Western research community on male newborn circumcision seems, as a whole, to be biased towards emphasizing benefits to newborn male circumcision, while downplaying risks or harms. This bias may even be quite personal, down to the circumcision status of the researcher conducting or interpreting the research. In a survey of 572 doctors, Muller (2010) found that “although most respondents stated that they based their decisions on medical evidence, the circumcision status of, especially, the male respondents played a huge role in whether they were in support of circumcisions or not. Another factor that had an influence was the circumcision status of the respondents’ sons.” On a wider scale, if a research community consists of a majority of circumcised men (or circumcising parents), it may simply view the practice as normal or expected. This kind of bias can in turn influence what variables are studied, how the studies are carried out, and even whether or not potential harms or risks are studied at all (Earp and Shaw, 2017). As Darby (2016) notes: since no official body is interested in researching the harm and long term adverse consequences of [male circumcision] definitive knowledge in this area remains elusive. To gather the evidence included here, we conducted a search on PubMed for research on male circumcision in English from within the last 10 years. For each subtopic, we focused on the highest level of evidence available. For example, whenever possible, we reported results from meta-analyses that pooled evidence from multiple studies; however, we also considered the quality of the included studies in the meta-analyses. We reviewed the most recent publications on the topic, as well as every practice guideline from around the world that we could locate in English. The reference sections of each study and our reviewers sometimes led us to other work that has been influential. Limitations of the researchOne of the main problems with the research on the proposed benefits of the routine male circumcision of healthy newborns is that much of the research comes from contexts in which circumcision was performed on males during adulthood. For example, there have been several randomized controlled trials (RCTs) on HIV infection after adult male circumcision in Africa, but those men were also provided with individualized counseling on safe sex practices and free access to condoms—which wouldn’t be possible with newborn circumcision in Africa or elsewhere. So, even within the same geographic region (Sub-Saharan Africa), the study findings aren’t generalizable to newborns because the intervention isn’t the same. In our search, we went back to the beginning of the medical research on circumcision and found that routine newborn circumcision became widely promoted by medical professionals without ever being tested first in randomized controlled trials. There was never any requirement to randomly assign newborns to routine circumcision or no circumcision before recommending the surgical procedure as beneficial. Still today, none of the proposed benefits are supported by data from a randomized controlled trial of healthy newborns assigned to routine circumcision or no circumcision. And it’s unlikely a trial of this sort will ever take place because of the ethical questions and because few parents would want their newborns to participate. Therefore, any research on the proposed benefits of circumcision that involves healthy newborns who were circumcised is observational. For example, there have been several observational studies and reviews looking at the effectiveness of routine newborn circumcision to prevent UTIs in infancy, but these studies only provide limited evidence of an association between circumcision and protection from UTIs. Because observational studies are not randomized, we cannot rule out that other factors may be at least partially responsible for the observed effects of circumcision. For example, preterm infants with low birth weight may be more likely to get a UTI and more likely to be intact (if they were considered too fragile for the circumcision surgery after birth), and this would show an increase in UTIs among intact infants (Van Howe, 2005). Below we’ve listed a table summarizing the research on each proposed benefit, along with whether or not a non-invasive alternative to circumcision is available. Listing alternatives is important, because circumcision is often presented as having benefits, without discussing potential alternatives. But informed consent (including proxy consent) requires knowing not only the benefits and risks of a proposed intervention, but also the benefits and risks of any feasible alternatives, including no intervention. Whenever possible, we will present the GRADE recommendations from the Canadian Urological Association. The GRADE system is a common way of rating the quality (or certainty) of the evidence in a review (Dave et al. 2017). Overall, the research on proposed benefits from newborn male circumcision amounts to a weak recommendation for practice. Continue reading below the table for references and a more extensive look at each proposed benefit. Finally, throughout this entire section on the medical evidence, please be aware that the research on circumcision is still so contested that we are nowhere close to a scientific consensus on the evidence (Collier, 2011). Urinary tract infections (UTIs)Regarding the use of male newborn circumcision to prevent UTIs in children, the GRADE system found that the evidence is low quality and any strength of recommending circumcision for routine practice is weak (Dave et al. 2017). The strength of the recommendation for practice is considered to be stronger in situations involving newborns with actual medical problems. Both the Canadian and American Urological Associations recommend that the option of circumcision should be discussed with parents as a surgical treatment for males with an abnormal urinary tract who are more at risk for complications from repeated UTIs (Awais et al. 2015). However, this recommendation is based primarily on expert opinion. UTIs occur in about 8% of girls and 2% of intact boys before the age seven (Hellström et al. 1991). They occur more frequently among girls because their urethra (the tube that carries urine out of the body) is shorter. The infection is treatable with oral antibiotics and usually resolves without complications. However, in rare instances (usually among people with abnormal urinary tracts predisposing them to illness from UTIs), UTIs can lead to severe infection and kidney problems (Jagannath et al. 2012). Medical providers often advise parents and guardians that circumcision helps prevent UTIs in male children (CDC, 2018). The theory is that bacteria are less likely to grow on the keratinized (dry, tougher) skin of the circumcised glans penis (Dave et al. 2017). The authors of the most recent Cochrane review on this topic were not able to identify any randomized trials on the use of routine newborn male circumcision to prevent UTIs (Jagannath et al. 2012). We also searched but did not find any RCTs on the effects of routine circumcision on risk of UTI among healthy newborns. Therefore, the only research we have on this topic comes from observational studies. In a 2008 meta-analysis and review, researchers combined the results from 14 studies involving children with fevers who were less than 2 years of age, including data on their rates of UTI (Shaikh et al. 2008). This was the first study to combine data that examined rates of UTI based on circumcision status and other factors that could potentially affect UTI risk. Overall, 7% of the children with fevers had a UTI. Four of the included studies contributed data on UTI rates by circumcision status among boys less than 3 months of age. Out of all of the children presenting with a fever, the rate of UTI was highest among intact boys under the age of 3 months (20%) followed by girls aged 6 to 12 months (8%). In contrast, circumcised boys under 3 months of age had one of the lowest rates of UTI (2%). In this same review, one study looked at UTI and circumcision status in boys with a fever who were 6 to 12 months of age and found that the rate of UTI in intact versus circumcised boys was 7.3% and 0.3%, respectively. Another study looked at UTI by race and found an overall higher rate of UTI among boys of Hispanic descent. The authors think this could be because Hispanic males are more likely to be intact. The higher rate of UTIs detected in intact boys may also be related to more frequent testing for UTIs in this population (they’re tested more frequently because of the medical literature suggesting that intact boys are more likely to have UTIs). The rate of UTI among all males in the review decreased with age starting at around 6 to 12 months, regardless of circumcision status. An earlier systematic review by Singh-Grewal et al. (2005) included 12 studies with data on over 400,000 males, most of whom were less than one year of age. They found that UTIs were uncommon among males regardless of their circumcision status—1.38% of intact males got a UTI versus 0.14% of circumcised males. The authors discuss how increased UTIs among intact males might be due to more bacteria around the prepuce (more colonization); however, they also mention that increased colonization may have led to more false positive results among intact males, potentially overestimating their rate of UTI. About 111 circumcisions would need to be done in order to prevent one episode of UTI, which the authors concluded does not justify routine circumcision for all male infants. In 2013, Morris and Wiswell combined data from 22 studies in the first meta-analysis to estimate the lifetime risk of UTI in circumcised versus intact males. They found that, in every age group, the risk of UTI was higher among intact males: 10 times higher among babies less than 1 year, 7 times higher among boys aged 1 to 16 years, and 3 times higher among men over 16. They estimated that 32% of intact males experience at least one UTI in their lifetime compared with 9% of circumcised males. For perspective, half of all women will experience at least one UTI during their lifetime (Foxman, 2002). Morris and Wiswell estimate that 4 to 5 male newborn circumcisions would prevent one UTI over a lifetime. However, we would caution that the lifetime risk estimate from this study is not reliable, since the estimate for men over 16 years of age was based on a single small study of young men attending an STD clinic. In this study, 20% of the men were bisexual or gay and all of the men were experiencing urinary symptoms. So this group is not representative of the general male population. To calculate a lifetime estimate of UTI, the risk of UTI for circumcised versus intact men in this study was applied to men later in life, when UTIs become more common because of prostate gland enlargement regardless of circumcision status, which may be an inappropriate generalization. Phimosis and balanitis (inflammation)The GRADE of the evidence for using one or more courses of topical steroids instead of circumcision as a first-line treatment for problems with phimosis is moderate to high quality (Dave et al. 2017). There is strong evidence to use one or more courses of topical steroids to treat problems with phimosis before any surgery is medically indicated. Normal penile development in young boys usually involves adhesions between the inner foreskin and glans. This normal development may also involve tightness at the opening of the prepuce that can make the prepuce unretractable until that tightness resolves over time (Cold & Taylor, 1999). Recall that about 50% of intact boys can retract their prepuce by 10 years of age (Kayabata et al., 1996), and 99% can fully retract by age 17 (Hayashi et al. 2011). On the other hand, true pathologic phimosis that requires treatment only affects about 0.6% of boys between 5 and 14 years of age (Shankar and Rickwood, 1999). The usual cause of pathologic phimosis is a skin condition called male genital (penis) lichen sclerosus or balanitis xerotica obliterans. This condition causes tightening of genital tissue that decreases tissue elasticity. Circumcision early in life appears to protect against this rare condition. Scarring at the end of the prepuce from repeated inflammations (often linked to poor hygiene) can also cause pathologic phimosis. Inflammation or skin irritation of the glans penis is called balanitis (Dave et al. 2017). Both circumcised and intact males can experience balanitis–good hygiene is the most important prevention. Balanitis occurs more often in circumcised boys while in diapers (Van Howe, 1997), and is more common in intact males later in life (Köhn et al. 1999). Other risk factors include being diabetic, having a Body Mass Index (BMI) over 35-40, having a compromised immune system, sexually transmitted infections, fungal infections, chemical irritants (e.g., spermicides, soaps, laundry detergents), allergic reaction (e.g. condom latex), and trauma (e.g., zipper injury) (Wray and Khetarpal, 2019). Inflammation is treated with medicated ointments specific to the cause of the inflammation (e.g., anti-fungal cream if the balanitis is caused by an overgrowth of yeast). Unfortunately, doctors are not always trained enough to distinguish between these two types of phimosis—one that is normal development and usually resolves on its own, and the other that is an actual medical problem that requires medical or surgical treatment, and this leads to needless referrals to urologists for circumcisions (Shahid, 2012). Newborn male circumcision (when there are no complications) is thought to prevent potential future problems with phimosis by surgically removing the prepuce before any problems can occur. Unfortunately, one of the potential complications of newborn male circumcision is a tightening of the circumcision scar tissue over the glans. The phimosis that results from circumcision has been shown to occur in about 1% of boys, while the rate of persistent phimosis in intact adult males is between 0.5% and 1% (Blalock et al. 2003; Kidger et al. 2012; Oster, 1968). Thus, one of the purported benefits of circumcision is that the risk of experiencing future problems with phimosis has been avoided, but it can bring with it an equal risk of phimosis as a complication following the procedure. In the majority of cases, problems with phimosis in intact boys can be treated with noninvasive means. Our PubMed search for the latest research on phimosis and circumcision turned up two recent meta-analyses on using topical steroids to treat phimosis (Moreno et al. 2014; Liu et al. 2016). A Cochrane review by Moreno et al. (2014) included 12 studies with 1,395 intact boys who had physician-diagnosed phimosis. Importantly, many of the children in this meta-analysis were still in infancy and early childhood when they were diagnosed with phimosis in need of medical intervention. So, most of these young participants probably had normal penile development that was improperly diagnosed as pathologic phimosis. The researchers compared treatment with a steroid cream versus a placebo cream or no treatment for 4 to 8 weeks. Most of the studies also recommended gentle stretching of the prepuce for both the treatment and placebo groups. Eight of the included studies reported on whether phimosis was completely cured in the steroid group versus the placebo group. By the end of the observation period, about 63% of the boys who received steroid cream were completely cured of their phimosis versus 18% of the boys who received the placebo. There were no reported adverse effects. This Cochrane review gave the evidence on topical steroid creams for phimosis a low quality rating, because the included studies found mixed results and had unclear risk of bias. However, the authors concluded that the findings still have implications for practice, since steroid creams seem to be a safe and effective alternative to surgery to treat phimosis in intact boys and men. The meta-analysis by Liu et al. (2016) had similar findings—they found that steroid treatment was preferable to placebo for phimosis. It’s also important to mention that complete circumcision is not the only option when steroid creams do not work to treat phimosis. A dorsal slit preputioplasty (using plastic surgical techniques) can widen the prepuce and treat the phimosis without removing tissue, or a partial circumcision can remove only enough tissue to make retraction possible (Informed Health, Germany, 2018; Arora et al. 2016). Human immunodeficiency virus (HIV)For adult men living in Sub-Saharan Africa, the GRADE of the evidence for circumcision leading to a decreased risk of HIV infection is high quality and there is a strong recommendation for practice (Dave et al. 2017). However, there is no evidence that these studies can be applied to newborns or other areas of the world, such as the U.S. or Canada. Of the studies published to date, none have found a link between circumcisions performed on infants or circumcisions performed in North America and lower risk of heterosexually transmitted HIV. In the U.S. and Canada, the rates of HIV are much lower than in Sub-Saharan Africa. Also, the burden of HIV in the U.S. falls heavily on men who have sex with men and people who use intravenous (IV) drugs, and less so on male-female sexual contact (Dave et al. 2017; HIV.gov 2018). It’s also important to consider that circumcision does not provide complete protection for men who have sex with infected female partners. Even with a reduced risk, it is essential that circumcised men still follow safe sex practices in order to avoid sexually transmitted diseases. These same safe sex practices can also help prevent HIV infection among intact males. Several theories have been proposed to explain how circumcision might lower the risk of getting HIV; however, these are theories, not conclusive research findings (Sharma et al. 2018):
We found five meta-analyses that focused on male circumcision and HIV from within the last ten years. All of the randomized trials were carried out with adult men, but the participants’ age at the time of their circumcision varied between the observational studies. Two Cochrane meta-analyses have looked at the evidence on this topic. One review looked at HIV risk among men who have sex with women, and the other looked at HIV risk among men who have sex with men (Siegfried et al. 2009; Wiysonge et al. 2011). The meta-analysis on men who have sex with men could not find any randomized trials to include, but included 21 observational studies with more than 70,000 participants. Overall, they did not find any evidence that circumcision status lowers HIV risk among men who have sex with men. The meta-analysis on men who have sex with women pooled the results from three large randomized trials conducted in South Africa (Auvert et al. 2005), Uganda (Gray et al. 2007), and Kenya (Bailey et al. 2007). Combined, there were more than 11,000 male participants from the general population in these studies. In two of the trials, the men were between 18 and 24 years old, and in one of the trials they were between 15 and 49 years old. Only HIV-negative men at the time of enrollment were included in the analysis. Total follow up time was planned for 21 months in one of the trials and 24 months in the other two—however, all three of the trials were stopped early after early results showed significant HIV protection from circumcision. The researchers used a method called time-to-event-analysis to include the results from everyone who completed the trial and some of the observation time for those who did not finish the trial. They found that the relative risk of getting HIV (comparing the risk in one group to the other) was 54% less at 21 or 24 months for the circumcised men versus the intact men. The absolute risk (the actual chance of getting infected with HIV over 21 or 24 months) was about 1% for the circumcised men versus just under 3% for the intact men. Based on those figures, the authors estimate that circumcising 56 men in sub-Saharan Africa would prevent about 17 HIV infections over two years per 1,000 men in the population. The most recent meta-analysis on this topic, published by Sharma et al. in 2018, combined 49 studies from around the world (nearly 200,000 people) on men who have sex with men, as well as men who have sex with women. Only three of the studies were randomized, controlled trials (6% of total meta-analysis participants), and these were the three trials conducted on men in sub-Saharan Africa. The researchers found that circumcised men were 42% less likely to get HIV compared to intact men. They divided the men by sexual preference and found that the risk of HIV was reduced by 20% for men who have sex with men, and 72% for men who have sex with women. However, when the meta-analysis looked only at the observational studies conducted in the U.S., there was no evidence that circumcision offered protection against HIV, suggesting that there might be differences in the effectiveness of circumcision against HIV in different regions. In other words, circumcision may only have a significant impact on a man’s risk of getting HIV in a region with especially high rates of female-to-male sexually transmitted HIV infection. Similarly, a different analysis of over 100 studies evaluating the impact of circumcision status on HIV found that studies of high-risk populations (as opposed to general populations not at high-risk for HIV) had a significantly stronger link between being intact and being HIV-infected (Van Howe 2015). In other words, a man’s circumcision status doesn’t appear to impact his HIV-risk if he is in a population with low rates of HIV. In addition, in general populations with low rates of circumcision, circumcision status did not show a significant impact on HIV-risk. For example, the Dutch have a low rate of circumcision, and they also have a low prevalence of HIV/AIDS. As such, behavioral factors appear to play a far more important role in risk of HIV than circumcision status. Lei et al. (2015) published the next most recent meta-analysis. In this study, researchers combined 15 studies on HIV transmission by circumcision status among men who have sex with women. Four of the included studies were randomized trials: the three large randomized trials of men in sub-Saharan Africa, and one randomized trial of women in Uganda with HIV positive male partners. Lei et al. found that circumcision was linked to a 70% reduced risk of HIV among men. However, circumcision status did not lower the risk of women getting HIV from their male partners. In fact, the one RCT on male-to-female transmission of HIV showed that women were more than 3 times as likely to get HIV from a circumcised male partner if they resumed sex before the wound had completely healed, compared to women with intact HIV positive partners (Wawer et al. 2009). The authors of the meta-analysis concluded that male circumcision helps to protect men from getting HIV from an infected female partner, but not the other way around. The conclusion by Lei et al. (2015) was consistent with a previous meta-analysis performed by Weiss et al. in 2009 that also found no direct benefit of male circumcision for reducing risk of HIV among female partners. The three African RCTs that give us the best evidence on circumcision and risk of HIV have several limitations. First, stopping all of the trials early meant that many people did not complete the trials. It is standard practice to stop trials early for significant benefits, and the researchers accounted for this in their analysis; however, the general practice of stopping trials early because of benefits has been linked to overestimating the benefits when the number of events is small, as it is in these trials (Montori et al. 2005). So it’s possible that the size of the protective effect of circumcision may be overestimated. On the other hand, all three of the trials found a remarkably similar protective effect, which strengthens the evidence that adult male circumcision does reduce the risk of getting HIV from infected female partners. Follow-up studies have found that the protective effect of male circumcision against HIV continues with time (Auvert et al., 2013; Gray et al., 2012; Mehta et al., 2013). These trials resulted in high-profile support (Bill Clinton and Bill Gates referred to the data), large donations from philanthropists (the Bill & Melinda Gates Foundation gave $50 million in 2009) and led to mass circumcision programs in several African countries (Collier, 2012). However, these studies have also been accused of multiple biases and other problems. In 2011, Boyle and Hill accused the trials of “methodological, ethical and legal concerns” and Van Howe and Storms made the case that “the circumcision solution in Africa will increase the risk of HIV infection.” Supporters of the studies replied that the “criticisms of African trials fail to withstand scrutiny: male circumcision does prevent HIV infection” and responded to what they called “misleading claims that male circumcision will increase HIV infections in Africa” (Wamai et al. 2012; Morris et al. 2011). The complexity of this debate is outside the scope of our review article on newborn circumcision, but if you’re interested, we encourage you to read the cited publications that highlight the opposing views surrounding the methodology of these three African RCTs on adult male circumcision. Even if everyone accepted the evidence that adult circumcision in Sub-Saharan Africa truly does lower a man’s risk of getting HIV from an infected female partner, there are still concerns with promoting genital surgery as a public health measure in developing countries:
Human papillomavirus (HPV)The current evidence shows a modest decrease in having HPV infection with circumcision; the GRADE is moderate quality and the strength of the recommendation for practice is weak. It is likely that HPV vaccination and safe sex practices (e.g., condom use) are more effective than circumcision at preventing HPV infection (Dave et al. 2017). HPV is the most common sexually transmitted viral infection in the world, although rates have fallen since the introduction of the HPV vaccine (Aung et al. 2018). Some types of HPV cause genital warts and other types can cause cervical cancer (the second most common cancer among women in the world), as well as penile and anal cancer in men (Zhu et al. 2017). We found six meta-analyses that focused on circumcision status and HPV. The most recent meta-analysis, by Zhu et al. (2017), included 39 studies involving more than 12,000 circumcised men and more than 12,000 intact men. Out of these, 24 studies (including 5 randomized trials from Africa) examined the link between circumcision status and rates of HPV. HPV-positive rates among circumcised and intact men in the studies ranged from 2% to 78% and 7% to 81%, respectively. When they pooled the data, there was no significant difference between intact men and circumcised men when it came to acquiring a new infection or in the ability to clear the infection. Prevalence of HPV was higher in intact men; however, the quality of the meta-analysis is weak because the studies were very heterogeneous, or mixed. Of the 24 studies, 10 showed lower HPV prevalence with circumcision, 1 showed higher HPV prevalence with circumcision, and 13 showed no effect. Albero et al. (2012) combined data from 21 studies (14 observational studies and two randomized, controlled trials from Africa). Overall, circumcised men had lower odds of being HPV positive. The combined data from the two RCTs also showed that circumcised men were 33% less likely to have HPV infections with high-risk strains of the virus. The authors concluded that circumcision might help to lower the burden of HPV-associated diseases, especially in countries where HPV vaccination and cervical cancer screening are not available. The earlier meta-analyses by Larke et al. (2011a) and Bosch et al. (2009) also found lower odds of HPV prevalence with circumcision. Two meta-analyses by Van Howe (2007, 2013) reported serious methodological problems with most of the published studies on HPV and circumcision status. When statistical techniques were applied to adjust for various biases, there was no statistically significant increase in risk of HPV infection in intact men. The largest prospective study of genital HPV infection in 4,033 healthy men found no difference in how frequently they acquired HPV or cleared their HPV infection between intact and circumcised men (Albero et al., 2014). Herpes Simplex Virus (HSV)The GRADE quality of the evidence for adult circumcision leading to a decreased risk of getting HSV infection is moderate-quality and the GRADE strength of the recommendation for practice is weak. There is not enough evidence to show that male newborn circumcision can prevent circumcised males and their sexual partners later in life from getting STIs that cause genital ulcers, such as HSV (Dave et al. 2017). The evidence on circumcision protecting against genital herpes is still conflicting; some studies have found no evidence of an effect and others have found a low level of protection with circumcision (Mehta et al. 2012; Tobian et al. 2009). There is weak evidence from men participating in two RCTs of adult circumcision in Uganda that circumcised men had a 30% lower risk of getting herpes simplex virus type-2 (HSV-2) over two years of follow-up compared to the intact men (Tobian et al. 2009). However, as we discussed with HIV-risk, these trial findings are not generalizable to newborns or to countries with a lower prevalence of HSV-2 infection. In Uganda, the prevalence of HSV-2 infection is 34% among men aged 15-49 years, while only 8% of men are infected with HSV-2 in the U.S, as reported by the CDC. Consistent condom use also provides 30% protection from HSV-2, because herpes virus shedding can occur in areas not covered by the condom (Martin et al. 2009). One way to look at it is that both circumcision and condom use are not very effective strategies to prevent genital herpes. The only really effective ways to avoid genital herpes are to abstain from sexual contact or to be in a mutually monogamous relationship with a partner who is known to be uninfected. Other Sexually Transmitted Infections (STIs)There is no evidence to conclude that male circumcision protects against gonorrhea, chlamydia, or trichomonas (Dave et al. 2017). These STIs were studied in the African RCTs and they did not find significant evidence that circumcision was protective. Intact men may be at greater risk for genital infections that involved ulcers (genital herpes, syphilis, chancroid), while circumcised men may be at greater risk for genital infections that involve a discharge (chlamydia, gonorrhea, inflammation of the urethra). One systematic review and meta-analysis concluded that because the discharge infections are more common, overall, the risk of developing an STI of any kind is statistically significantly greater in circumcised men (Van Howe, 2013). Since the evidence on using adult male circumcision (not to mention newborn circumcision) to prevent non-HIV, non-HPV, and non-HSV STIs is still so conflicting, we will not be covering this evidence in detail. Penile cancerCircumcision appears to offer some protection against rare penile cancer, but the GRADE of the evidence is low quality and the strength of the recommendation for practice is weak (Dave et al. 2017). Penile cancer is extremely rare. It’s the 24th most common cancer among men and occurs in less than 1 man in every 100,000. It’s even less common than male breast cancer. According to the American Academy of Family Physicians (AAFP), 300,000 circumcisions would need to be done to prevent one case of penile cancer. The average age that men are diagnosed with penile cancer is about 68. Research suggests that there is a link between some types of infections and cancer. For example, HPV DNA has been found in cervical cancer and about half of the cases of penile cancer. We found one recent meta-analysis that focused on circumcision status and penile cancer. In a meta-analysis of eight studies on invasive penile cancer, Larke et al. (2011b) showed that childhood circumcision (<18 years of age) was protective. However, the authors think that the protective effect of circumcision might in fact be due to eliminating the risk of phimosis that persists into adulthood, since there was no evidence of a benefit when the data was restricted to men with no history of phimosis problems. Phimosis that extends into adulthood is one of the strongest risk factors for penile cancer since it can cause repeated inflammations, so removing the risk of phimosis with circumcision also reduces the risk of penile cancer. However, as we discussed, persistent phimosis is rare and there are non-invasive treatment options. Other risk factors for penile cancer include HPV infection, poor penile hygiene, and smoking. What are the potential health risks from circumcision?Like any surgical procedure, there is a risk of complications with newborn circumcision. We’ll cover the potential short-term risks for the baby, as well as potential risks for circumcised men later in life. Complications that can occur during and soon after circumcisionThe true rate of complications after newborn circumcision is not known. Part of the reason for this is that researchers are focused on finding the potential benefits from circumcision (e.g., protection from HIV), not the potential harms. For example, bleeding complications are one of the most common risks from circumcision, but there is almost no research on this topic (Litwiller et al. 2017). When observational studies on circumcision-related complications are combined, most of the data comes from large hospital-based studies that look back at medical records to estimate how often bad outcomes occurred (Weiss et al. 2010). These retrospective studies tend to greatly underestimate the true rate of complications because they only capture the poor outcomes that occur before hospital discharge (Frisch and Earp, 2018). Prospective studies (that follow circumcised males over a period of time) provide more useful data. However, surprisingly few studies have assessed the rate of complications a few months to years after routine newborn circumcision. Out of 16 prospective studies on newborn circumcision included in a review by Weiss et al. (2010), only two followed infants for a whole year. The accuracy of the data on poor outcomes following circumcision may also be impacted by the unwillingness of practitioners to report their complications. The fact that we have limited research on risks and complications would be important to include in informed consent discussions with parents. In 2010, Weiss et al. carried out a systematic review on poor outcomes after circumcision in childhood. This review included 52 studies in 21 countries. Out of these 52 studies, 16 were prospective studies of infant circumcision from 12 countries, mostly using the Plastibell device. The researchers found that complication rates ranged from 0‒16%, with most around 2%. The most common early complications were pain, bleeding, swelling, and cosmetic concerns about the amount of skin removed. The range of serious adverse events was 0% to 2%, with most rates closer to 0%. Most of the prospective studies reported no serious adverse events, but three studies (one from Canada and two from Nigeria) reported that 1% to 2% of the babies had a serious complication. In the Canadian study of 100 newborns, there was one baby with a severe infection requiring antibiotics, and one baby with a severe meatal ulcer (a painful sore on the opening of the urethra). The serious complications in the Nigerian studies included three babies with cuts to the urethra, two babies with amputation of the glans penis (where the head of the penis was amputated), and one baby with a buried penis—so much skin was removed, that the scar tissue pulled the remaining skin forward, hiding the penis in the folds of the skin. The Weiss et al. review also included ten retrospective studies on newborn circumcision that looked back at hospital records. As to be expected, the estimated frequency of complications was lower than with the prospective studies, probably due to underreporting. Five of the studies found rates of complications <0.6% and four studies found rates of complications between 2% to 4%. Very few serious events were reported (<0.2%), except in one U.S. study where three babies (1.3%) required repeat surgery to revise the circumcision. Reoperation is one of the more common risks from circumcision. Parents sometimes think that not enough skin was removed, and they are not satisfied with the appearance of the baby’s penis after the procedure. Studies have reported rates of reoperation ranging from as low as 0.1% to as high as 4.5% (Talini et al. 2018). Some of the common reasons for reoperation are due to problems with how the tissue grows back together. During healing, the skin can form adhesions (scar tissue) on the glans penis. This can occur following 25% of newborn circumcisions (Van Howe, 1997). The risk of these complications after circumcision can be reduced with gentle retraction and barrier ointments until the wound has healed. Another potential problem, as discussed earlier, is phimosis following circumcision, in which the scar tissue covers the glans penis. The largest retrospective study of complications after newborn circumcision looked at outcomes after about 1.4 million circumcisions in the U.S. during 2001 to 2010 (El Bcheraoui et al. 2014). The study relied on data from a health care reimbursement claims database that captured diagnoses and procedures billed to third parties. If a circumcision or a resulting bad outcome was not covered by a third-party payer, then it would not have been included in this analysis. Overall, they determined that the rate of complications is probably fewer than 1 in 200 babies. The most common complications were related to correctional procedures (stitches, reconstruction and repairs of the penis) and bleeding. Pain was not included as one of the complications in this study. This study has been criticized for assessing certain complications over too short of a follow-up window and relying on a type of database thought to underestimate the rate of complications (Frisch and Earp, 2018). As we will discuss, potential complications such as a narrowing of the urethral meatus (opening) can take many years for doctors and parents to detect. Some babies are at increased risk of complications from circumcision. An observational study found that babies who had spent a few days in the NICU had more bleeding complications (22%) compared to babies admitted to the newborn nursery (10%) (Litwiller et al. 2017). The authors think this finding may be related to NICU babies having lower levels of vitamin K in their system by the time they are circumcised. There are several health problems that should be considered potential contraindications, or medical reasons to avoid newborn circumcision (Earp et al. 2018). A recent study looked back at a huge sample of hospital births in the U.S. between 2001-2010, in a database called the Nationwide Inpatient Sample (NIS). This study included almost ten million male newborns who were circumcised in the hospital within 30 days of birth. Among these, there were 200 deaths before hospital discharge, or 10.2 deaths per 500,000 newborn inpatient circumcisions. We can’t tell from these data whether circumcision caused or contributed to these deaths. However, the authors did find an increased risk of death after circumcision among babies with certain health problems, including heart problems, blood clotting disorders, fluid and electrolyte disorders, and respiratory disorders. Certainly, the most vulnerable infants are at extra risk of complications from exposure to surgical procedures. New research from the United Kingdom (U.K.) proposes that newborn circumcision might increase risk of SIDS, or Sudden Infant Death Syndrome, once called crib death (Elhaik, 2018). SIDS occurs when a seemingly healthy baby under one year of age dies unexpectedly in sleep, with no cause of death to be found. SIDS is the leading cause of infant death in many developed countries, and more common among males. The theory is that the trauma of a painful surgery adds to the infant’s stress level, or allostatic load. The allostatic load hypothesis proposes that SIDS results from the combined load of all stressful exposures during pregnancy, birth, and after the birth. The study from the U.K. included data on rates of SIDS and newborn male circumcision across 15 countries (including 40 U.S. states) and reported a strong correlation between newborn circumcision and SIDS. Thus, in places where newborn male circumcision rates are high, higher rates of SIDS occur, and vice versa. This type of evidence does not tell us if circumcision actually causes deaths from SIDS—but it means that we need more research on this topic. Researchers who are designing future studies on SIDS could consider circumcision among other potential risk factors that they are studying. Recent Case ReportsWe searched PubMed for case reports on complications from routine male newborn circumcision from within the last five years and found six results:
Complications with newborn circumcision versus older male circumcisionResearchers who advocate for routine newborn circumcision point to infancy as the optimal time to circumcise. Morris et al. (2012), a staunch advocate of newborn circumcision, cites fewer complications with infants and points out that infant circumcisions are less expensive and can be done more quickly. In addition, the paper speculates that the wound heals faster in an infant, stitches are not required as often, and there is no need to take time off work or abstain from sex after the surgery. The authors go on to say, “A desirable feature of infant male circumcision is the surgical ease of performing a circumcision on an immobile newborn…facilitating the use of local anesthesia.” However, those opposed to infant circumcision argue that the infant’s immobility (due to being strapped into a restraining device, and being unable to defend itself) actually makes infant circumcision less desirable than circumcision on someone who can provide consent for the procedure. Weiss et al. (2010) combined prospective studies and found that circumcisions done with children aged one or older are associated with more complications compared to newborn circumcision (6% versus 2%); however, many of the older boys in the studies were circumcised for medical reasons (unlike the newborns), and complications are more common after medically-indicated circumcisions. The three African randomized trials on adult circumcision and HIV found rates of complications ranging from 2% to 4%. Critics of newborn circumcision argue that the absolute risk of complications is not very different between adults and newborns, so it’s more ethical to wait until a man can decide for himself if he wants the procedure (Earp and Darby, 2017). In Africa, for example, those conducting well-funded public health campaigns to circumcise healthy men consider the rate of complications low enough to be acceptable. Pain with circumcisionThe surgical removal of the nerve-laden male prepuce is an invasive, painful procedure and requires pain treatment. Researchers have described that when there is inadequate pain treatment during circumcision, newborns can experience stress chemicals in the body, increased heart rate and breathing rate, decreased oxygen, skin turning red or blue, vomiting, increased crying, gagging/choking, and withdrawing (becoming less responsive to parents) (Brady-Fryer et al. 2004). In 2004, a Cochrane review and meta-analysis examined 35 randomized trials with nearly 2,000 newborns (Brady-Fryer et al. 2004). In these studies, researchers had compared pain treatments with placebo or no treatment, or compared two different pain treatments. Today, randomly assigning babies to no pain relief during a surgical procedure would not be considered ethical, although undertreating infant pain can still happen in practice. In these trials, researchers used a variety of ways to measure the baby’s pain, including crying time, facial expression, sweating palms, heart rate, breathing rate, blood pressure, and levels of stress chemicals in blood or saliva. They found that dorsal penile nerve block, which involves injecting anesthetic to the base of the penis, was the most effective treatment. Anesthetic creams applied to the penis were more effective than placebo or no treatment, but less effective than the penile nerve block. None of the treatment options completely prevented noticeable pain in response to circumcision. A systematic review by Perera et al. (2010) included two randomized trials that compared pain responses after routine newborn circumcision. One of the studies reported on the effect that circumcision had on a baby’s subsequent pain response at vaccination (Taddio et al. 1997). This study included babies who were randomly assigned to an anesthetic cream (29 babies) or a placebo cream/no pain treatment (26 babies) during circumcision. The researchers also included 32 babies whose parents had chosen not to circumcise, to serve as a comparison group. A research assistant who was trained to measure infant pain response (facial expressions, crying) rated videotapes of the babies receiving vaccinations. The assistant was blinded to the baby’s circumcision status. The infants who were circumcised without pain treatment showed the strongest pain responses to routine vaccinations during the first six months of life, followed by the babies who were circumcised with anesthetic cream. The intact babies showed the least amount of pain response to vaccination. The researchers theorized that painful events in early life (such as circumcision) may have long-lasting consequences on the child’s behavior, and that the increased pain response to vaccination may represent an infant version of post-traumatic stress disorder. The other randomized trial in the systematic review randomly assigned 29 babies to circumcision with acetaminophen (Tylenol) and 31 babies to circumcision with a placebo (no pain treatment) (Macke, 2001). The babies were all healthy, full-term and had experienced a spontaneous vaginal birth. A blinded observer reported increased pain response (crying and heart rate) in both groups with the circumcision, with no difference between groups. It was clear that both placebo and Tylenol were not effective in controlling pain during the operation. The babies in both groups experienced an increase in their heart rate (beats per minute) from about 130 during the first diaper change to 165 with the pain of circumcision. Similarly, babies in both groups cried on average for 70% of the procedure. However, after the circumcision, the treated babies showed significantly less pain response during a diaper change and were more alert and responsive to their mothers during a feeding session. The mothers of the treated babies were more responsive in return (more eye contact, changing expression) compared to the mothers of the untreated, withdrawn babies. The authors concluded that mother-infant interactions are reciprocal and may be harmed by untreated pain. Given the findings of the previous study, it’s possible that pain after circumcision could interfere with early breastfeeding. However, at this time, there is no strong evidence linking modern routine circumcisions to problems with breastfeeding. A large retrospective study in California found no significant link between the timing of newborn circumcision and the rate of exclusive breastfeeding over the first two weeks of life (Mondzelewski et al. 2016). Another large retrospective study from New Zealand found that rates of breastfeeding were similar for circumcised and intact children (Fergusson et al. 2007). More research is needed, especially from prospective studies that follow intact and circumcised infants from the first feeding after birth over many months to compare measures of breastfeeding between groups. It’s possible that circumcision harms infant feeding when pain is vastly undertreated, as was seen in one small study of infants circumcised with Tylenol or placebo only (Howard et al. 1994), but has less of an impact when effective pain medications are used. Amazingly, the fact that babies can experience pain like older children and adults is a relatively new idea. It wasn’t until the late 1980s that doctors started routinely giving babies pain treatment during procedures—during newborn circumcision, and even during major surgery (de Lima et al. 1996). Therefore, if a man was circumcised as a newborn in the U.S. before the mid 1980s, he probably did not receive any pain medication at all during the procedure. Now, practice guidelines recommend that all infants have pain medication during and after surgical procedures (AAP, 2016). According to the American Academy of Pediatrics (AAP), exposure to repeated painful events early in life is known to cause short- and long-term harm. The AAP therefore recommends that every health care facility caring for newborns should implement a pain-prevention program that includes strategies for minimizing the number of painful procedures performed. Ronald Goldman, Ph.D., is a critic of newborn circumcision and well-known psychological researcher in this field. He believes circumcision trauma in early life can lead to long-term psychological effects. He and other critics of newborn circumcision propose that since it is a painful surgery that is not medically necessary, it is a clear candidate for a procedure that should be used less frequently (Earp et al. 2018). The bottom line is that although pain treatments are available, no treatment can completely eliminate pain during the procedure, and pain may continue afterwards as the wound heals. Meatal stenosisIn males, the urethra is the tube that carries urine and semen out of the body. Around 7% to 20% of circumcised males develop a condition called meatal stenosis, which is where the opening of the urethra becomes abnormally narrow (Van Howe, 2006; Koenig et al. 2019). Circumcision is considered the most important cause of meatal stenosis; this condition rarely (if ever) occurs among intact males. The theory is that circumcision severs the major source of blood flow to the urethral opening and this lack of blood flow results in scarring and thus narrowing of the urethra. Another theory is that scarring results from exposure to irritants (e.g., urine and feces in the diaper). In some cases, the narrowing of the urethra can make it difficult for a boy to urinate and may cause his bladder to swell and not empty completely. There is some evidence that the risk can be reduced for circumcised boys by daily application of petroleum jelly to the glans penis for three months following circumcision (Mondal et al., 2013). Meatal stenosis is thought to be one of the more common, under-reported complications from circumcision, since many cases with no or only mild symptoms may remain undiagnosed for a long time after the circumcision (Dave et al. 2017). According to UpToDate guidance for clinicians, doctors typically diagnose meatal stenosis in children during toilet training when parents report that a boy seems to be having trouble directing his urine stream into the toilet (Yiee et al. 2018). Boys with meatal stenosis will often push their penis between their legs to try and direct an upward or difficult-to-aim stream of urine into the toilet. Other signs are when boys take a long time to empty the bladder with a small stream of urine, or if the meatus (opening) appears visibly scarred and has a small diameter. Some boys with meatal stenosis will present with abdominal pain from swollen bladders. In 2017, a systematic review and meta-analysis by Morris and Krieger included 27 observational studies with 350 cases of meatal stenosis in over 1.4 million males. They found that the risk of meatal stenosis in circumcised males was about 0.7%, or just under 1 in 100 circumcised males. Other researchers think that figure underestimates the true rate of meatal stenosis, as it is a delayed complication, typically surfacing three to five years after the procedure, and 99% of the data in the Morris and Krieger study was collected within six months following the circumcision (Van Howe, 2018). The largest study with long-term follow-up included over 1,000 circumcised boys in the U.S. and found a rate of meatal stenosis with symptoms in 7.3% of the boys over three years of age (Van Howe, 2006). Another study (Joudi et al. 2011) found that meatal stenosis might occur in up to 20% of circumcised boys when it is strictly defined as a meatal diameter of less than 5 French (a way to measure sizes of catheters); however, simply having a narrow meatal diameter may not be clinically relevant if the boy is not experiencing symptoms. Loss of sexual function and sensitivityThe role of the male prepuce in sensation and sexual function is a subject of ongoing debate. It’s well agreed upon that the prepuce has sensory nerves that are completely removed during circumcision. However, the main question is whether this loss of sensation actually leads to a decrease in a man’s sexual pleasure later in life (Dave et al. 2017). In the U.K., the National Health Service (NHS) informs parents that the main risk of circumcision is reduced sensation or a permanent change in the sensitivity of their child’s penis (NHS, 2018). They go on to say that circumcision shouldn’t affect the child’s ability to have a fulfilling sex life in the future, but that the loss of sensation is one of the reasons why they only recommend circumcision for medical problems. In the U.S., recent guidelines from the Centers for Disease Control minimize the effect of sensation loss with circumcision (CDC, 2018). They say that on average, adult men who undergo circumcision generally report minimal or no change in sexual satisfaction or function. However, they do caution that those who enjoy the sensation of the prepuce during sexual relations will no longer experience that sensation. The most recent meta-analysis on this topic included 12 studies (including two RCTs of adult male circumcision) with over 20,000 men (Yang et al. 2018). They only included studies that looked at premature ejaculation by circumcision status, but many of these studies also examined other sexual impacts of circumcision. Overall, the meta-analysis concluded that circumcision has no statistically significant impact on premature ejaculation or difficulty of orgasm. The circumcised men had a longer time from insertion to ejaculation, less erectile dysfunction, and less pain during sex. However, the authors explained that there were probably untreated prepuce-related problems in the intact men that caused pain during sex and may have contributed to these outcomes. We found two studies that measured sensation of the penis—including the male prepuce—in sexually healthy men who were either circumcised as newborns or intact (Sorrells et al. 2007; Bossio et al. 2016). The Sorrells et al. study assessed fine touch sensitivity of 19 locations on the penis. Participants included 91 circumcised men and 68 intact men. The region most sensitive to fine touch was the prepuce of intact men and the circumcision scar on the underside of the penis of circumcised men. They concluded that the most sensitive regions of the penis are those removed by circumcision—five locations on the intact penis that are removed during circumcision were more sensitive to fine-touch pressure than the most sensitive location of circumcised men (the scar on the underside of the penis). The highly sensitive nature of the prepuce is due to specialized nerves for fine touch sensation, such as Meissner’s corpuscles, which are also found in the fingertips (Cold and Taylor, 1999). They give that tickling sensation when you flex your hands and very lightly rub your fingertips together. Like Sorrells, Bossio et al. (2016) also found that the male prepuce is the part of the penis most sensitive to fine touch pressure. The prepuce was significantly more sensitive than any other site on the intact or circumcised male penis. However, in addition to fine touch pressure, Bossio also examined sensation to touch-pain, heat-pain, and warmth detection in 30 circumcised and 32 intact men. Pain thresholds (from touch or heat) were not statistically different between circumcised and intact men. When the prepuce of intact men was compared to the glans penis and the shaft of both intact and circumcised men, it was more sensitive to warmth than the glans penis but not the shaft of the penis. The authors speculate that the nerve fibers activated by pain and warmth are more linked to sexual pleasure than those activated by fine touch pressure. So, the two studies agree that the male prepuce is the most sensitive to fine touch pressure, but they disagree about how relevant they think this sensation is for sexual pleasure. One large survey on penile sensitivity by circumcision status was conducted in Belgium on 1,059 intact and 310 circumcised men (mostly circumcised in childhood) (Bronselaer et al. 2013). Overall, the two groups significantly differed in their experience of sexual pleasure (greater among intact men) and discomfort/pain (greater among circumcised men). The authors concluded that circumcision led to a decrease in sensitivity, decreased sexual pleasure, lower orgasm intensity and more difficulty achieving orgasm, and more uncomfortable sensations (i.e. numbness, tingling). Taylor et al. (1996) studied the genitals of 22 adult men after autopsy. He postulated that the ‘ridged band,’ or the band of pleated tissue that gathers behind an intact man’s glans during erection, is especially important for sensation because it contains such a dense amount of Meissner’s corpuscles. Tissue that is especially sensitive to sexual stimulation is called erogenous tissue. We found one recent study on satisfaction with circumcision status. Bossio and Pukall (2018) surveyed 811 men from around the globe about their attitudes towards their circumcision status, body image, and sexual functioning. Of the men, 367 were circumcised as newborns, 107 were circumcised in childhood, 47 were circumcised in adulthood, and 290 were intact. Men who were circumcised as adults and intact men reported higher satisfaction with their status compared with those who were circumcised in infancy or childhood. Lower satisfaction with one’s status (but not one’s actual status) was linked to worse body image and sexual functioning. The authors speculate that choice plays an important role in how men feel about their circumcision status. The findings may also reflect how individuals are more prone to defend the consequences of their own decisions. Men’s attitudes were highly variable within this sample, suggesting that men develop wide-ranging feelings about their circumcision status (which can’t be predicted). The bottom line is that circumcision does reduce penile sensitivity by removing sensitive tissue. Circumcision also changes sexual function—it removes the ability of the shaft to glide within its own naturally lubricated sleeve of skin. Furthermore, any sexual acts that involve the prepuce are necessarily precluded by its removal (Earp, 2016b). However, the research evidence is conflicting on how important this loss of sensation and sexual function is to the sexual lives of men, and outcomes appear to be influenced by how individual men interpret their circumcision status. There is a lack of data on this topic that measures different types of sensations by circumcision status and collects qualitative (interview) data from men and their partners about which sensations are most relevant to their sexual pleasure. Future studies must distinguish men who were circumcised in infancy or early childhood from those circumcised as adults, since the timing could have different effects on penile sensation. In addition, it is important to consider that the value of different sexual sensations is highly individualized, so a favored sensation to one man may not be seen as valuable to other men in a study (Earp, 2016b). Discussion of the evidence in light of ethics and human rightsFor this section of our review, we examined 86 articles in English on ‘circumcision’ and ‘ethics’ that were published within the last 10 years. Most of the search results focused on the ethics of female circumcision/female genital cutting/female genital mutilation and some focused on the rights of children born into religions that practice circumcision. For the purposes of this Signature Article, we narrowed the results down to the 21 articles that discussed routine male newborn circumcision and grouped them according to whether the author’s viewpoint suggested they found the practice to be unethical or ethically justified. Of these, 13 papers portrayed routine newborn male circumcision as unethical, 5 papers made the case that it is ethically justified, and 3 papers discussed both viewpoints. We summarized the main points from these papers below to show their diverse views on how circumcision relates to the bioethics principles that we introduced at the beginning of this article: respect for autonomy, nonmaleficence (do no harm), beneficence (do good), and justice. View that routine newborn male circumcision is not ethicalThe papers on ethics that we found opposing routine male infant circumcision came from authors in the U.S. (5), Germany (3), Australia (3), Italy (1), and Israel (1). The majority view in recent bioethics research is that routine newborn male circumcision is not ethical because:
On this last point, we found frequent comparison of male circumcision and female genital cutting in the ethics literature (Earp, 2015; Johnsdotter, 2017). It would be impossible to share the main ethical argument around bodily integrity from our literature search without some discussion of this comparison. Some researchers used the term “male genital mutilation” in place of male circumcision. But others find this comparison and choice of words extremely offensive. The language or terms people use to discuss genital surgery often reveals their beliefs about the ethics of the practice. For example, people who support female genital cutting usually prefer the term “female circumcision” since “mutilation” implies that the practice is wrong (Shahvisi and Earp, 2019; Earp, 2016a). According to the World Health Organization (WHO), female genital cutting (FGC) is an ancient practice that is still common in parts of Africa and in some countries in the Middle East and Asia, as well as among migrants from these areas. Prevalence rates are over 80% in eight African countries. It is usually conducted by older women in the communities on young girls between infancy and 15 years of age. The WHO says that reasons for the practice vary, but the most commonly cited reasons are because it is socially normal, beliefs that some types of FGC will protect virginity before marriage, the desire to reduce a woman’s sexual drive, and cultural ideals of femininity, cleanliness, and beauty. Some Islamic communities that practice FGC believe that it is a part of their faith. For example, in Malaysia, an interview study found that 99% of participants had undergone FGC and 88% believed that it was compulsory in Islam (Rashid and Iguchi, 2019). According to the people interviewed, the girls’ genitals must be scratched to draw out a single drop of blood in order to fulfill the ritual. However, FGC is not mentioned in the Qur’an and many scholars refute the view that it is an Islamic religious practice. The WHO classifies FGC into four major types (not classified by order of severity). Type 3, often referred to as infibulation, involves narrowing the vaginal opening with or without removal of the external part of the clitoris. Infibulation accounts for about 10% of all FGC and is the most severe form of FGC, with devastating health consequences. Infibulation causes many health problems including sexual pain, increased risk of complications during childbirth, menstrual problems, and urinary problems. The other types of FGC range in severity. Type 4 includes any injury to the female genitalia for non-medical purposes, e.g. pricking, piercing, or scratching tissue. In some cases (Type 1a), FGC involves removal of the female prepuce, or clitoral hood (hoodectomy or clitoral unhooding). Every type of female genital cutting is recognized internationally as a violation of the human rights of girls and women, even when it does not remove any tissue (i.e. a “prick”) and even when it is “medicalized,” or performed by health care providers in a clinical setting with anesthetics. There are no known health benefits from FGC and significant harms. Researchers are not looking for any evidence of health benefits (a reduced risk of infection from removing the labia, for example) because it is not considered ethical to do so (Earp, 2017; Earp et al. 2017). Of the papers that portrayed male circumcision as unethical, 12 out of 13 authors compared male circumcision to female genital cutting in such a way as to suggest that both practices are unethical. Even though some types of FGC are much more severe than male circumcision, the authors shared a view that all people have a common right to physical integrity, regardless of sex or gender, and regardless of the degree of cutting. One author called it a “moral hypocrisy or intellectual inconsistency” that there is total protection for females but no such protection for males, and claimed that people in the U.S. show a cultural bias favoring Western cultural practices over those of “other” cultures (Darby, 2016). View that routine newborn male circumcision is ethicalThe papers on ethics that we found supporting routine male infant circumcision as an ethically sound practice came from authors in the U.S. (3), Saudi Arabia (1), and Canada (1). Some of the reasons they gave for supporting the practice as ethical include:
Please refer to the extensive sections above on the proposed medical benefits from circumcision for the basis of the view that routine newborn circumcision is a medically beneficial practice. How does newborn male circumcision relate to the bioethics principles?Autonomy in this case can be thought of as referring to the autonomy of the child or the autonomy of the child’s parents. If we consider the autonomy of the child, non-therapeutic circumcision violates the principle of autonomy because infants cannot make informed decisions about their bodies. If we focus on the autonomy of the child’s parents, then proxy consent is a way for them to exercise their autonomy to make medical decisions on behalf of their child. However, some ethicists argue that proxy consent is not valid for routine circumcision since it is not treatment for an existing medical problem. They argue that the ethical course of action would be to preserve the child’s autonomy by leaving him intact, i.e. not removing part of his penis, and letting him decide for himself when he’s older if he would like to modify his genitals. The principle of non-maleficence, or “do no harm,” dictates that a provider must not intentionally inflict harm on a patient. Some ethicists argue that circumcision violates this principle since it is an unnecessary surgery that causes injury to an otherwise healthy child and introduces the risk of surgical complications whether or not they occur (Svoboda, 2017). Others disagree and believe that circumcision results in a net benefit for the patient because of reduced risk of some health problems (Brady, 2016). However, there is an ethical distinction between a procedure that may be “medically beneficial” versus one that is clearly “medically necessary” (The Brussels Collaboration on Bodily Integrity, 2019). To further complicate matters, the health problems that circumcision may protect against can be prevented and/or treated through non-invasive means. Furthermore, some parents choose circumcision for social reasons, and in these cases the surgical procedure is done to the child more for cosmetic reasons or cultural ideals of cleanliness rather than out of health concerns. When children have actual medical problems that require surgical intervention, parents usually have the authority to decide what is necessary (what is for the greater good of the child). However, it’s a different ethical situation when the child is healthy and not experiencing any medical problems. Beneficence means “do good.” When applied to non-therapeutic circumcision, this means that the benefits from the procedure should clearly outweigh its harms. Some researchers and medical groups in the U.S. believe they do. But, as we will discuss, the majority of medical groups that have issued practice guidelines on this topic have not found that the benefits outweigh the harms. This is especially true considering that the harms are largely unknown and it is difficult to assign a value to keeping a healthy sexual organ intact. Not a single medical group in the world believes that the potential medical benefits justify recommending circumcision for all male infants. The principle of justice holds that individuals should not experience discrimination in health care on the basis of sex, race, religion, etc. Interestingly, the dominant view in U.S. culture holds that routine male and intersex genital surgery is normal, appropriate, and even beneficial during infancy, but procedures to alter the female genitals—no matter how minor, and regardless of the reason—is foreign and a horrendous violation of a young girl’s right to bodily integrity. Brian Earp, Associate Director of the Yale-Hastings Program in Ethics and Health Policy at Yale University and The Hastings Center, explains his view that male circumcision of minors is so familiar in U.S. culture that it was “grandfathered in” to be perceived as an ethically sound practice, whereas new proposals to prevent future medical problems by removing tissue from healthy infants would never get ethical approval today. Practice guidelinesThere is wide disagreement among professional organizations in different countries about the benefits, risks, and ethics of circumcision—although all professional organizations that have studied the issue agree that circumcision should not be recommended for all newborns. Among the rest of the world, the U.S. stands alone in terms of widespread professional preference for non-religious circumcision. For instance, the American Academy of Pediatrics’ position statement (AAP, 2012) on newborn circumcision (now expired) concluded “the health benefits of newborn male circumcision outweigh the risks; furthermore, the benefits of newborn male circumcision justify access to this procedure for families who choose it.” However, the AAP adds, “the true incidence of complications after newborn circumcision is unknown, in part due to differing definitions of ‘complication’ and differing standards for determining the timing of when a complication has occurred (i.e., early or late).” They also say that “parents should weigh the health benefits and risks in light of their own religious, cultural, and personal preferences, as the medical benefits alone may not outweigh these other considerations for individual families.” Physicians from over a dozen countries (38 co-authors) published a rebuttal to the AAP statement in the Pediatrics journal, arguing that cultural bias can cause people from a circumcising nation to interpret the same evidence differently from non-circumcising nations. The AAP opted not to reaffirm or revise their statement when it expired at the five-year mark, and has not released a statement since then. Professional statements in the U.S. appear to be highly influenced by U.S. culture. For example:
Outside of the U.S., professional organizations have issued statements on male circumcision even though circumcisions are rarely performed for non-religious reasons in their countries:
* On the subject of refusing to perform circumcision, Doctors Opposing Circumcision provides free legal advice to any medical professional struggling with whether or how to assert conscientious objection status for circumcision. As you can see from this sampling of professional recommendations, the rest of the international community stands apart from the more favorable position on circumcision seen in the U.S. In general, outside the U.S., it is thought that, although parents’ preferences should be honored, the procedure does not offer obvious benefits over risks, so it should not be encouraged. To be clear, professional associations in the U.S. also do not consider circumcision to be medically necessary. However, these organizations are unique in promoting the practice as having more benefits than risks, and providers in the U.S. are unique in that they routinely offer circumcision to the parents of every male infant born in a hospital setting. It’s worth mentioning that the AAP task force did not follow objective criteria for assessing risks and benefits. In a commentary published in Pediatrics, Andrew Freedman (former AAP task force member) explains his view that parents choose circumcision for a wide variety of non-medical reasons (e.g., religion, culture, cosmetic preferences, family tradition) and that physicians have no authority to judge these nonmedical reasons (Freedman, 2016). He says “protecting this option was not an idle concern at a time when there are serious efforts in both the United States and Europe to ban the procedure outright.” So it appears that the AAP task force was at least partially motivated by a desire to keep circumcision available as a parental choice when it published its 2012 statement about “benefits and risks.” The Royal Dutch Medical Association (KNMG) in the Netherlands has one of the strongest statements opposing circumcision. They adopted the position (2010) that doctors should actively discourage circumcision because it is unethical. They even raise the possibility of making circumcision without a medical indication illegal in the future, but mentioned that a prohibition might lead to circumcisions happening in unsafe conditions. On an interesting side note, in 2010, the American Academy of Pediatrics had similar concerns with regard to keeping all forms of female genital cutting illegal, which led them to suggest doctors could perform a ritual “nick” or “pinprick on girls’ genitals” to keep their families from sending them overseas for an even more invasive procedure in less safe conditions. They withdrew this policy on female genital cutting a month later after public backlash. So, depending on where you live, care providers will discourage, encourage, or take more of a neutral stance on newborn male circumcision. Even within countries, individual doctors vary in whether they promote or discourage the procedure. As far as we are aware, no country has yet made the practice illegal, although its legality has been disputed. In Germany in 2012, a regional judge in Cologne ruled that circumcision is already illegal under German law because it violates a boy’s right to bodily integrity, which is outside of the bounds of lawful parental discretion and therefore is physical assault (Merkel and Putzke, 2013). The judgment drew harsh criticism from Jewish and Muslim communities. Facing the heat, the German legislature responded by enacting a special new statute protecting male circumcision. Most recently, Iceland introduced a bill in 2018 that proposed a penalty of up to six years in prison for anyone who “removes part or all of (a child’s) sexual organs” for non-medical reasons. It was dismissed in parliament after religious leaders spoke against the bill and people raised the issue that no such bill protects intersex children from cosmetic surgery on their genitals without their consent. Denmark is also considering a ban on circumcising boys. In the U.S., a citizen’s ballot initiative to ban the non-therapeutic circumcision of minors in the city of San Francisco received enough signatures to appear on the ballot but pressure from pro-circumcision forces resulted in a local judge removing the initiative from the ballot. Whenever the issue of banning circumcision is raised, it ignites a fierce controversy over human rights and parental religious freedom. At the other extreme, no country has yet recommended universal circumcision, or circumcising all newborns for health reasons. Which assessment is the most important for the nurse caring for an infant after circumcision?A newborn who has had a circumcision should be assessed for excessive bleeding or signs of infection.
What teaching should the nurse incorporate into infant care of the uncircumcised male infant?What should the nurse teach regarding care for the uncircumcised infant? Avoid retracting the foreskin.
What measures will the nurse implement to help ensure that a newborn is not misidentified in the hospital?Place an identification band on both the mother and the newborn immediately after birth, before separating them.
Which action will the nurse avoid when performing basic care for a newborn male?Which action will the nurse avoid when performing basic care for a newborn male? -The foreskin in male newborns does not normally retract and should not be forced. The nurse will inspect the genital area for irritated skin to prevent and/or treat possible skin irritations.
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Which benefits would the nurse include in the teaching session about infant circumcision
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