Male Circumcision Is Dangerous and Completely Unnecessary

Male Circumcision Is Dangerous and Completely Unnecessary myth. Despite the fact that this is only the third myth out of 50 — and many issues in sexuality are the subject of debate — we are going to make a prediction that this will be the most controversial entry in the whole book. Public opinion of male circumcision — an age-old practice of removing the foreskin (or prepuce) from the head of the penis — has swung wildly throughout history.

Male Circumcision Is Dangerous and Completely Unnecessary
Male Circumcision Is Dangerous and Completely Unnecessary

While it was once primarily a religious practice for Muslim and Jewish men, it became an accepted medical procedure that was more common than not in the United States and parts of Europe during the twentieth century.

In recent years, however, the percentage of male infants who are circumcised has been dropping and a heated debate has been taking place between those who believe this is a medically beneficial (or even a medically necessary) procedure and those who see it as an immoral form of bodily mutilation without consent.

The debate is so heated that even the science becomes controversial, with those who want to see an end to circumcision casting doubt on the research methods and even the motives of the researchers. We don’t believe that we can solve this debate within the confines of this entry, nor is that our goal. Instead, we will attempt to explain it thoroughly so that you have the best information and thinking on the topic.

Our aim is to fairly represent all sides of the debate. That said, we are not neutral on the topic, as sexual health educators we naturally put a lot of weight on the science of public health — especially those studies that show circumcision reduces the risk of contracting and/or transmitting STIs, including HIV. We believe that as of now the scientific evidence on the benefits and risks of male circumcision is strong enough to suggest that this practice is neither dangerous nor completely unnecessary.

Male Circumcision Is Dangerous and Completely Unnecessary

The Scientific Debate Over Circumcision
Medical science has been in favor of male circumcision since the Victorian era though the earliest rationales for it were less scientific and more, well, ridiculous. (This is no doubt part of the reason that some people are suspect of today’s research.) At the end of the nineteenth century, doctors suggested that circumcision would cure everything from “masturbation to epilepsy to bed- wetting” (DeLaet, 2009).

By the mid-twentieth century, however, medicine was focusing on more reasonable benefits such as a reduction in certain kinds of cancers. Interestingly, Dr. Abraham Ravich, Martha’s great grandfather, was among the physicians who began making these arguments. Ravich was an urologist in Brooklyn starting in the 1920s.

Many of his patients were Jewish immigrants from Eastern Europe who were circumcised because of their religion. He noted that these men had fewer incidences of penile cancer, prostate cancer, and venereal disease (VD, or what we now refer to as sexually transmitted infections, STIs). He published his results in a book, Preventing V.D. and Cancer by Circumcision, in the early 1970s.

In our research, we have found that some anticircumcision activists (who like to call themselves intactivists) refer to Ravich as a zealot who invented his research to advance the practice of circumcision.

Male Circumcision Is Dangerous and Completely Unnecessary

There are similar complaints about even the most recent research. Some say that the studies are unreliable because of their retrospective design, the small sample sizes, the indirect approach to obtaining data, and the reliance on self-report to determine if participants were, in fact, circumcised. Others argue that the results of studies about HIV in Africa are irrelevant to babies born in the United States because the HIV epidemic here (not just the incidence of HIV but the ways in which it is commonly transmitted) are so very different.

The American Academy of Pediatrics (AAP) released a new committee opinion on circumcision in 2012. In order to develop this opinion, AAP created a task force of experts to review the research that had been published between its last review in 1995 and 2011. The task force assigned each article an evidence rating of “excellent,” “good,” “fair,” or “poor” based on the methodology used and how well it was applied.

In writing their review of the research — and ultimately developing the committee’s decision — the task force took these ratings into account (AAP, 2012). Though we understand that some in the medical world do not agree with the task force’s findings, we believe that the technical report represents a comprehensive and thoughtful look at the research and are relying on it in our summary of what the research says.

Low Risk Procedure
In determining the cost–benefit of an invasive procedure, the first thing to understand is whether the procedure itself has risks or complications and how serious those are. The AAP points to two large hospital-based studies with good evidence that the risk of significant acute complications is very low, 0.19–0.22%, and most were not serious. Acute complications mean those that happen right away: bleeding, infection, and penile injury. There are other complications that can happen later, such as adhesions, but these are also quite rare (AAP).

Male Circumcision Is Dangerous and Completely Unnecessary

The complication rate may be slightly higher if the procedure is performed by a traditional or ritual provider outside of the hospital but there are few data about this. The complications are also higher when circumcision is performed after the newborn period (AAP).

One of the complaints that those opposed to circumcision have is that the procedure is painful and that it has historically been carried out with no pain medication. In the past, infants were just given a sugar-covered pacifier. The AAP acknowledges that this is not sufficient pain management, even for an infant, and suggests that “adequate analgesia” be used.

Health Benefits of Circumcision
According to the AAP, the current research suggests that newborn circumcision can help prevent urinary tract infections (UTIs), penile cancers, HIV, human papillomavirus (HPV), and other STIs.

Urinary tract infections: there is good evidence from two studies that the task force describes as “well-conducted” that newborn circumcision reduces the incidence of UTIs in boys under the age of 2 years. The results of another study suggest that 7–14 out of 1000 uncircumcised boys will develop a UTI during their first year of life compared to 1–2 out of 1000 circumcised boys.
UTIs are not usually serious though they are uncomfortable and can require a visit to a physician, medication, and possibly even a hospital stay or an invasive procedure (AAP, 2012).

Male Circumcision Is Dangerous and Completely Unnecessary

Penile cancers: there is some evidence that circumcision prevents penile cancer and even more evidence that it prevents the most invasive form of penile cancer. However, penile cancer is so rare in the United States that it would take 990 circumcisions to prevent one case of penile cancer.

Some would argue that this negates any prevention benefit when it comes to penile cancer because 990 circumcisions would likely lead to two complications.

HIV: some of the best evidence on the health benefits of circumcision comes from studies in areas where HIV rates are high. The AAP task force states: “Review of the literature revealed a consistently reported protective effect of 40 percent to 60 percent for male circumcision in reducing the risk of HIV acquisition among heterosexual males in areas with high HIV prevalence due to heterosexual transmission (i.e. Africa)”. There is less research on the protective effect in the United States where the overall HIV rate is lower and transmission is more common among men who have sex with men.

A recently released study from the Centers for Disease Control and Prevention (CDC), however, put the findings from these African studies into mathematical models and suggested that male circumcision before sexual debut would reduce the lifetime risk of HIV transmission by 15.7% for all males (Samson et al., 2010).

This projection takes into account that circumcision seems less likely to protect men who have sex with men (MSM) from HIV transmission. The task force explains: “It is not known to what extent circumcision may be protective against HIV transmission from MSM who practice insertive sex versus for those who engage in receptive sex”.

Researchers also offer an explanation of how circumcision protects men against HIV. One possible reason is that the inside surface of the foreskin is easily to rn especially during sex and this could provide an entry point for HIV (and other germs).

The foreskin also contains “a high density of HIV target cells (i.e., Langerhans cells, CD4 T cells, macrophages) which facilitates HIV infection of host cells.” And, finally, germs may get trapped under the foreskin giving them more time to replicate.

Male Circumcision Is Dangerous and Completely Unnecessary

HPV and cervical cancer: this last explanation has been shown to be a possibility in HPV infection as well. As a reminder, HPV is the virus that causes genital warts. It also causes cervical cancer in women. HPV is one of the most common STIs in the United States.

The task force found two studies with good evidence of 30–40% reduction in risk among circumcised men. There are four other studies that provide fair evidence of risk reduction. A study by Australian researchers found that the foreskin can provide a reservoir for HPV cells (a place for them to collect) (Ladurner Rennau et al.,2011).

However, the authors of that study caution that just because those cells are there does not mean they’re transmissible. Still, there is good evidence that circumcision reduces the rate of male-to female transmission of high risk HPV (the types of the virus that are most likely to cause cervical cancer) from men who were not infected with HIV.

Male Circumcision Is Dangerous and Completely Unnecessary
Male Circumcision Is Dangerous and Completely Unnecessary
Male Circumcision Is Dangerous and Completely Unnecessary

Moreover, there is some evidence (rated as fair) that male circumcision has a protective effect against cervical cancer for female partners as well if the man has multiple female partners (AAP, 2012).

Other STIs: finally, there is evidence that circumcision is protective against syphilis, herpes, chancroid (a rare bacterial infection), and BV (a bacterial infection of the vagina that is not necessarily sexually transmitted). The evidence suggests that circumcision provides no protection against chlamydia or gonorrhea.

Impact on Sex
One of the claims of those who are opposed to male circumcision is that it negatively impacts sexual function and reduces sexual pleasure. As most males are circumcised as infants (long before they become sexually active), it is hard to measure the direct impact of the procedure on sensitivity or function. Some studies have looked at the impact on sexual satisfaction for men who are circumcised as adults.

Male Circumcision Is Dangerous and Completely Unnecessary

The AAP task force found two good quality studies of these men. In the first study of 5000 Ugandan men, circumcised men reported significantly less pain on intercourse than uncircumcised men and 2 years after the procedure the men’s sexual satisfaction remained the same as it had been at baseline (98.4% compared to 98.5%). Interestingly, the satisfaction level in the control group went up from 98% at baseline to 99.9% 2 years later.

The second study looked at men in Kenya and found that 64% reported greater sensitivity after the procedure and that 55% of circumcised men reported having an easier time reaching orgasm than they did before the procedure (though this change was not statistically significant; AAP, 2012).

According to the AAP, a study of Korean men found fair evidence of decreased pleasure from masturbation after adult circumcision. For the most part, though, studies have failed to show any evidence that circumcision decreases sexual sensitivity compared to uncircumcised penises. Most evidence suggests that there is no difference in sexual sensation and satisfaction for men regardless of whether they are circumcised (AAP, 2012).

As with the task force’s conclusion on health benefits, many disagree with its conclusions on sexual pleasure and function. Christopher L. Guest, the cofounder of Children’s Health & Human Rights Partnership, writes in his rebuttal to the AAP report: “the foreskin is richly innervated, erogenous tissue which enhances sexual pleasure and it also provides a unique, linear gliding mechanism during sexual intercourse.” He points out that, in 2009, the College of Physicians and Surgeons of British Columbia stated “the foreskin is rich in specialized sensory nerve endings.”

In 2010, the Royal Australian College of Physicians stated “the foreskin is a primary sensory part of the penis, containing some of the most sensitive areas of the penis” and, in the same year, the Royal Dutch Medical Association concluded “the foreskin is a complex erotogenic structure that plays an important role in the mechanical function of the penis during sexual acts” (Guest, 2012).

Male Circumcision Is Dangerous and Completely Unnecessary

The Ethical Debate over Circumcision
It is clear that the debate over circumcision is very heated and growing more so. Georganne Chapin, the executive director of the anticircumcision group Intact America, said this about the practice: “About a million people a year, newborn babies, lose a normal, healthy, functional, pleasurable, protective body part without their consent” (Bristol, 2011).

Chapin and other anticircumcision activists dismiss the AAP task force’s report as being biased and profit-driven. She suggests that the report represents “a trade association agenda that desperately seeks to justify and secure reimbursement for a medically-unnecessary surgery that harms children and violates their basic human rights” (Chapin, 2012).

She further dismisses the science suggesting that the African studies on HIV are being used as “an after-the-fact justification for a custom that is increasingly being rejected by those who see it as violating children’s rights to bodily autonomy and their own future freedom of religion” (Chapin, 2012).

After dismissing the current science, those who oppose circumcision frequently argue that the procedure is unethical because infants cannot give informed consent, infants are not at immediate risk if they do not get circumcised, and as such parents are unfairly imposing their cultural values on children in a way that cannot be revoked. They also suggest that those in the Western world who support circumcision — including the medical community — are blinded by their own cultural values that see female circumcision as an abhorrent, primitive ritual but see no moral parallels when boys are subjected to a similar procedure.

Informed Consent and Immediate Risk
One of the basic premises in the practice of medicine is physicians cannot perform any procedure on a patient without first getting his/her informed consent. To do this, health care providers must clearly explain the risks and benefits before getting the patient’s explicit permission.

There is widespread agreement that children are not capable of giving consent and as such their parents or guardians are in charge of their health throughout childhood and adolescence. Those who oppose circumcision, however, argue that parents should not have the right to permanently alter their child’s body unless it is immediately necessary for their health and well-being.

Certainly, many people would agree that it would be inappropriate for a parent to consent to a nose job for their 10-year-old; that since the procedure is not immediately (if ever) medically necessary, the decision should be deferred until the child is old enough to decide for him or herself.

The issue is not as clear-cut when children are born with facial deformities or even large birthmarks in visible areas — many parents find it morally acceptable to consent to certain plastic surgery procedures (even those that are for purely aesthetic reasons) if they feel it will improve their child’s quality of life.

Male Circumcision Is Dangerous and Completely Unnecessary

Circumcision presents an additional complication because the procedure cannot necessarily be postponed. Delaying circumcision makes it more complicated, more painful, more risky, and more psychologically difficult. So, while ideally surgical procedures would wait until the infant grew and was able to make his own decisions, this is not really possible with circumcision.

Moreover, the health benefits of circumcision, though not immediate, may only be seen if the procedure is done at an early age. From a public health perspective it is important that protective measures against STIs, such as vaccines for HPV and hepatitis B, be given before an individual is sexually active and subject to exposure.

Chapin and others argue that even if the studies of HIV in Africa are scientifically valid, they are irrelevant to infants in the United States who are not and will not be sexually active for more than a decade.

While this is true, parents make decisions not just for their children’s current health, but for their future health as well. Vaccines are actually a good example; children may not be at risk for the measles at the moment they receive the measles, mumps, and rubella (MMR) inoculation but parents choose the shot anyhow to protect them throughout their lives.

Moreover, parents vaccinate infants in order to protect not just their own children but their communities as vaccinations are most effective when the majority of the “herd” is vaccinated (Benatar and Benatar, 2003). The same may be true of circumcision as widespread circumcision is being promoted as a way to reduce HIV in areas with a high prevalence of the disease (Wamai et al., 2011).

Male Circumcision Is Dangerous and Completely Unnecessary

In truth, even the ethical arguments about circumcision hinge on the science and research. If you believe the science that finds circumcision to be low risk and high benefit, then these arguments about informed consent are not issues — parents have always been allowed to consent to medically necessary procedures for their minor children. If you do not believe the procedure is beneficial, or worse you think it is harmful, then your answers to these ethical questions will likely be different.

Role of Culture, Religion, and the Comparison to Female Circumcision
Male circumcision began as a cultural and religious ritual rather than a medical procedure. Many people continue to choose it for their boys not because of the medical benefits but because of the cultural significance. In fact, some argue that male circumcision is morally acceptable simply because of its cultural and religious roots. However, this is not sufficient reason to justify any practice. Benatar and Benatar point out that “simply because a practice is culturally valued does not mean it is morally acceptable” (2003). If the procedure is harmful, for example,

then the cultural value is morally overridden. The case in point for this side of the argument is actually female circumcision which is often called female genital mutilation (FGM). FGM refers to a wide range of practices which the World Health Organization (WHO) has put into four categories.

The first is the removal of the prepuce or outer skin of the clitoris. This procedure is the least invasive and most common form of FGM worldwide and is the most similar to male circumcision. The second involves the removal of the clitoris and may also involve the removal of all or part of the inner vaginal lips (the labia minora). This procedure is much more invasive than male circumcision. Moreover, it prevents clitoral stimulation and may prevent all orgasms in many women.

The third category is called infibulation and is the most extreme and invasive form of FGM. It involves the total or partial removal of the external genitalia as well as stitches in the vagina to narrow the vaginal opening. Infibulation is common in two countries (Sudan and Eritrea) but not common in the rest of the world though it is often what we think of when we hear the term FGM.

Finally, the fourth category is labeled “unclassified” by the WHO and encompasses some of the least invasive forms of FGM (such as ritual nicking of the clitoris) and the most damaging forms (such as putting a caustic substance inside the vagina) (DeLaet, 2009).

Male Circumcision Is Dangerous and Completely Unnecessary

The argument over FGM pits those who say these procedures are integral parts of certain cultures and that women who don’t have them will be shunned by their communities against those who say FGM impinges on basic human rights (DeLaet, 2009 p. 414). Though some women’s rights advocates suggest that certain minimally invasive forms of ritual FGM should be acceptable, there is a large worldwide campaign to eradicate the practice completely.

Male Circumcision Is Dangerous and Completely Unnecessary
Male Circumcision Is Dangerous and Completely Unnecessary
Male Circumcision Is Dangerous and Completely Unnecessary

Many opponents of male circumcision question why there is not the same moral outrage to this procedure. DeLaet acknowledges that “male circumcision as typically practiced is not the physical or moral equivalent of infibulation, and it is not difficult to understand why either defenders of male circumcision or critics of female genital mutilation would resent the comparison”. The most common form of FGM,

However, involves the removal of the prepuce which is analogous to the foreskin on the penis. The procedure is not all that different from male circumcision but the reaction to each procedure is worlds apart. DeLaet notes that, “Critics of the disparate treatment of male and female circumcision argue that it reflects a “Western” double standard in which human rights activists in the West disregard sexual mutilations performed on boy children in their own societies” (DeLaet, 2009).

This is an interesting double standard and we agree that people see the world through their own cultural lenses. It is likely that our opinion on circumcision is colored by our own backgrounds and by growing up and raising our own children in a culture and a religion that supports male circumcision and condemns the practice on women.

Male Circumcision Is Dangerous and Completely Unnecessary

Ultimately, however, we believe that everything comes down to whether the procedure is harmful or beneficial. There is no research to suggest that FGM is beneficial and a great deal of research suggesting that especially the more invasive forms are harmful. Though disagreements remain, today’s research suggests a certain degree of benefit from male circumcision.

Conclusions
As of now, no major medical organizations are suggesting that all newborn infants be circumcised for health reasons. Instead, the view is that the procedure should be available to any family that wants it and should be reimbursed by insurance. Both AAP and the CDC suggest that parents need to be carefully educated about the benefits and risks of the procedure and the ways to make it as safe and painless as possible if they choose it.

We agree that more education about circumcision is necessary as parents should understand the existing science (including the criticisms of this science) and make the best choice for their child. We understand that this is an area that people — both in favor of and opposed to newborn circumcision — feel very strongly about and we hope that a healthy and respectful debate continues.

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