Circumcision rates in the U.S. have been falling since the 1960s, when the vast majority of infant boys had their foreskins removed before leaving the hospital.
These days, approximately 57% of boys are circumcised in U.S. hospitals, with the procedure generally being more common among whites and less common among black and Hispanic populations, according to estimates. Other boys are circumcised in religious ceremonies shortly after birth.
While many factors likely influence circumcision rates, part of the decline occurred after 1999, when the American Academy of Pediatrics issued a policy statement saying the potential medical benefits of neonatal circumcision weren't strong enough to recommend it as a routine procedure. The group shifted its stance last year, however, saying newer studies indicate the health benefits of circumcision do outweigh the risks and that parents should be told of its protective effects.
Nevertheless, debate about the practice continues to swirl, with both sides citing competing studies as evidence for their positions. Critics say we shouldn't be removing healthy body parts from infants, calling circumcision a trauma that can lead to decreased sexual function later in life. Proponents say circumcision helps prevent urinary tract infections, HIV and penile cancer.
Ronald Gray, a physician and professor in the Johns Hopkins Bloomberg School of Public Health, makes the case in favor of neonatal circumcision. Arguing against it is Ronald Goldman, a physician, psychological researcher and educator who is the executive director of the Circumcision Resource Center in Boston and the author of two books on circumcision.
Yes: The Benefits Are Many, While the Risks Are Few
By Ronald Gray
The health benefits of newborn male circumcision outweigh the risks, and the procedure should be accessible to all families who want it.
So said a task force convened by the American Academy of Pediatrics to review the latest scientific evidence on circumcision and update the group's policy stance
The task force, which released its findings last year, also made clear that "parents are entitled to factually correct, nonbiased information" from health-care providers about the pros and cons of circumcision, so they can make an informed decision about what is best for their child in the context of their personal circumstances and cultural/religious beliefs.
Here are the facts, based on published, peer-reviewed and independently monitored studies
The risk of complications from newborn circumcision in U.S. hospitals is estimated to be about 0.2%. The most common complication is bleeding, which can be readily controlled. Infection and penile injuries are very rare.
The benefits of circumcision that accrue during childhood include a marked reduction in urinary-tract infections, which affect one in 100 uncircumcised boys, mainly during the first two years of life, and inflammation or infection under the foreskin, which affects around 17 in 100 uncircumcised boys before the age of 8. Circumcision reduces the risk of these problems by around 60%. In adulthood, circumcision has been shown to reduce the risk of HIV infection in men by 50% to 60%, and is now recommended by the World Health Organization as an HIV prevention strategy.
Circumcision also lowers the risk of acquiring herpes infection and genital ulcers in men. It reduces infection with human papilloma viruses, or HPV, in both men and their female partners. HPV is one of the most common sexually transmitted infections in the U.S., causing cervical, penile and anal cancers, as well as genital warts. Female partners of circumcised men have lower rates of vaginal infections and genital ulcers.
Circumcision doesn't impair sexual potency or pleasure, according to randomized controlled trials. These studies are considered the most credible because they compare men who are circumcised at random versus men who aren't, and the men who are circumcised during the trial can assess whether their pleasure or potency is affected by the procedure.
Waiting Is a Bad Idea
The risks and benefits of circumcision should be conveyed to parents early in pregnancy so they have time to make an informed decision, and the procedure should be covered by health insurance, including Medicaid, so that cost isn't an impediment for families who may not be able to afford it.
There is debate over the ethics of male circumcision because infants themselves cannot consent to the procedure, and the effects are permanent. But parents consent to many health decisions, such as immunization, on behalf of their children, and the law explicitly recognizes this parental right.
Delaying circumcision until boys are 18 years old and can legally provide consent is a bad idea because at that point the procedure is more complex and has a higher rate of complications. It also would deprive boys of circumcisions's benefits during childhood and adolescence.
The claim that circumcision is painful and traumatic enough to interfere with mother-child bonding and a boy's future relationships is speculation, not a finding based on scientific research. Indeed, the Academy of Pediatrics concluded that adequate anesthesia, especially injectable local anesthesia with 1% lidocaine, "is effective in mitigating pain and its consequences."
Suggestions that a doctor's own circumcision status might influence his research into or support of circumcision are unwarranted and have no basis in science. Randomized trials are the objective "gold standard" in medicine, and aren't dependent on the investigator's personal experience with the procedure.
In short, infant male circumcision has lifelong health benefits that outweigh the immediate risks, and parents should be counseled so they can decide what is best for their child.
Dr. Gray is a professor in the Johns Hopkins Bloomberg School of Public Health. Email him at email@example.com.
No: It's Unnecessary, Causes Pain and Reduces Pleasure
By Ronald Goldman
Most of the world instinctively rejects routine neonatal circumcision as harmful genital surgery, like removing other natural, healthy, functioning body parts.
Thirty-eight leading physicians from Europe, Canada and Australia say that some American doctors support circumcision because of cultural bias, and that the claimed health benefits are either questionable or too weak to justify surgery on boys before they are old enough to provide consent.
No medical organization says circumcision offers immediate health benefits, and only American-influenced groups claim it offers debatable potential benefits. The conditions the procedure supposedly reduces the risk of acquiring are either rare (penile cancer), easily treatable (urinary tract infections) or can be prevented in less intrusive and more effective ways (condoms in the case of sexually transmitted diseases).
Studies show that circumcision is significantly painful and traumatic, resulting in large increases in heart rate, blood pressure and stress hormone levels. Some infants don't cry because they go into shock. Penile anesthetic injections, if used, don't completely eliminate pain. The trauma can cause behavioral and neurological changes and disrupt mother-child bonding and feeding.
Circumcision carries dozens of surgical risks, including in rare cases death. The American Academy of Pediatrics says "the true incidence of complications after newborn circumcision is unknown." Therefore, it can't credibly compare benefits and risks. Some doctors refuse to circumcise on ethical grounds.
Advocates of circumcision say it doesn't affect sexual function, but they haven't satisfied their burden of proof, and common sense and multiple studies say otherwise. Circumcision removes over a third of the erogenous tissue on the penile shaft, including several kinds of specialized nerves. The adult foreskin, a double-layer movable sleeve of about 12 square inches, enhances sexual pleasure and facilitates intercourse.
One man compared having sex after an adult circumcision to "seeing in black and white instead of in color." According to some studies, circumcised men are more likely to have erectile dysfunction (4.5 times higher likelihood of using ED drugs), orgasm difficulties and premature ejaculation, while their female partners have more problems with sexual function, fulfillment, and painful intercourse. A survey of women with comparative sexual experience showed they strongly prefer genitally intact men.
Psychological harms are reported by clinicians and circumcised men. They include anger toward parents and others, sexual anxieties, reduced emotional expression and empathy, low self-esteem and avoidance of intimacy. Other circumcised men may seem satisfied because they don't know what they're missing or are suppressing their feelings out of discomfort or fear of being dismissed.
Questions about potential harms remain, yet researchers defending circumcision avoid studying them. Since psychological harms can disrupt relationships, could circumcision be connected to America's uniquely high divorce rate? Is circumcision trauma linked to autism and attention deficit hyperactivity disorder, which occur about three to four times more often in boys? The rise and fall of male infant mortality correlates with the rise and fall of the circumcision rate. Is there a connection? An MRI showed permanent brain changes in a circumcised infant. What are the effects of circumcision trauma on the brain?
Rather than admit a serious mistake, we ignore the harm and produce endless inflated medical claims to defend our bias. Some research shows that circumcision is favored more often by circumcised physicians. If they participate in pro-circumcision studies or committees, circumcision status could influence their work.
Watch a circumcision video and trust your feelings, instincts, common sense and nature. You will want to keep your baby safe from specious genital surgery and trauma.
Dr. Goldman, a psychological researcher and educator, is executive director of the Circumcision Resource Center in Boston and the author of two books on circumcision. Email him at firstname.lastname@example.org.