.Introduction to Male Circumcision.
The Foreskin constitutes half of the penile
skin system. The foreskin has three known functions: protective, sensory and
sexual. The foreskin is the fold of skin that covers the glans of the penis
(the head of the penis). The inside fold of the foreskin is a mucous membrane
that functions somewhat like a mouth, designed to keep moisture in so that the
glans is soft, moist and sensitive. The foreskin is the most sensitive part
of the penis. "It represents 50% to 80% of the skin system of the penis,
depending on the length of the penile shaft. The average foreskin has over three
feet of veins, arteries, and capillaries, 240 feet of nerve fibers, and over
1,000 nerve endings. If unfolded, the adult [penile] foreskin would measure
20 to 30 square inches" (Hodges,
1995). When the penis is erect
the foreskin unrolls over the glans. "The glans stimulates the foreskin,
and the foreskin stimulates the glans. The foreskin has glands that produce
a natural moisturizer and lubricant called smegma. Smegma. serves [to] keep
[the penis] moist, clean, and lubricated"(Hodges,1995). The word smegma is derived from the Greek and Latin
words meaning cleansing and soap.
Circumcision is the surgical removal of the fold of skin known as the foreskin and medically named the prepuce.
At birth the foreskin and glans are attached to each other. The foreskin normally covers the glans of the penis
before it is removed surgically (nocirc,
1997). The membrane on the underside of the penis that holds the
foreskin in its place is called the frenulum (nocirc,
1997).
Circumcision is practiced for both religious and non-religious reasons. It is a cultural phenomenon. Male circumcision is often associated with corresponding development of Female circumcision and infibulation, these are practiced throughout the world and by over one sixth of its population(Gairdner, 1994). Male circumcision is practiced by all Muslims and Jews and also by some Christians, as is the case for Christians in Egypt (Aldeeb, 1994). Circumcision has always been practiced according to oral and written history for religious or ritual rites of passage reasons in tribal Africa, amongst the Moslem people of India, and the aborigines in Australia. The United States is the only country that practices routine neonatal circumcision for medical reasons rather than religious reasons.
.References and Links for Introduction.
"Answer to Your Questions about your young son's intact penis"
Drawings Courtesy of Circumcision Information and Resource Page (CIRP).
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Intact Adult Penis | |
Circumcised Penis |
.Sacrificial Origin of Circumcision.
The actual origins, how or when circumcision began, are unkown. The first evidence that exists is the depiction of male circumcision in Egyptian tombs from an estimated 5,000 years ago(FRCP, 1994). The first Egyptian mummies, around 2,300 B.C. were circumcised(Gairdner, 1994). Circumcision has been practiced by Jews for over 3,700 years (Shechet, 1996).
Theorists have speculated that circumcision began as a sacrificial rite(Gairdner, 1994 & (FRCP, 1994). An important property of sacrifice is the shedding of blood. Circumcision was a bloody operation until recent medical procedures but hemorrhaging is still a complication of the surgery (FRCP, 1994). A second property of sacrifice is that the assets, commodity or thing that is given to the sacrifice should be valued (FRCP, 1994). "The greater the value of object sacrificed the more" important the sacrifice (FRCP, 1994). The sacrifice of the foreskin is said to reduce the penile sensitivity and reduce the pleasure achieved by intercourse, while leaving a permanent life-long remembrance of the sacrifice committed. Thus, "circumcision makes the ideal sacrificial object"(FRCP, 1994).
Religious Circumcision Click here.
.References and Links for sacrificial origin of circumcision.
FRCP, JP Warren, J. Bigelow, and R. Stuart. "Sacrifice and Male Circumcision: Theory and Refuted Theory". 1994
Gairdner D. "The Fate of the Foreskin. British Medical Journal. 1949. V.2: pgs. 1433-7
.How Male circumcision evolved in the U.S.
"The
historical factors that are responsible for the [practice of routine medical
circumcision] in the US are varied and complex. No one factor can be upheld
than any other. Among these factors are the masturbation hysteria, allopathic
medicine, the medicalization of childbirth, the rise of obstetrics, the demographic
and cultural anxieties and changes brought about by the industrial revolution,
the rise of harsh forms of Protestant Christianity, Cold War xenophobia, and
especially, the rise of the middle class and its psychological compulsion for
strictly enforced and organized conformity"(1.
Hodges, 1995).
The practice of circumcising babies began in Western society in the mid-1800's as a means of preventing masturbation. "Circumcision was used as a deliberate surgical intervention to debilitate and desensitize the penis" (2. Hodges, 1995). Masturbation was said to cause epilepsy, tuberculosis and insanity (nocirc, 1997). "Masturbation was viewed as the most dangerous form of sexuality and was named as the cause for every known disease, from blindness to nervousness, insanity, venereal disease, tuberculosis and death" (2. Hodges, 1995) . The influential Dr. John Harvey Kellogg, the founder of Kellogg's Corn Flakes, preached that the reason that young boys masturbate is because the foreskin rubs on the head of the penis. Dr. Kellogg believed that boys who were circumcised at birth would be less likely to masturbate (Joannids, 1996). "In 1928, the American Medical Association (AMA), published an editorial in its journal calling for routine circumcision of all male infants at birth. The primary justification ..was the prevention of masturbation"(2. Hodges, 1995).
Hodges wrote, "In the US there is a myth that the natural human penis is a self-destructing time-bomb, ready to go off at any time in an explosion of disease, filth, and horrible stenches, an inevitable disaster which only immediate surgery at birth can prevent" (2. Hodges, 1995).
In the nineteenth century Americans changed their standards of personal cleanliness and hygiene. "John Wesley's famous quotation that cleanliness is godliness"(Gollaher, 1994). The Victorians were fond of social classes, established through hierarchies. In England especially but throughout the Victorian period, there was an "allure to ranking civilizations and peoples" distinguished not only by money, and power but by distinguishing the "social groups from clean to dirty"(Gollaher, 1994). Middle class Victorians used "as a caliper of moral judgment and evidence of material prosperity, cleanliness indicated control, spiritual refinement, [good] breeding; the unclean were vulgar, course, [and] animalistic. Cleanliness, in other words, became an essential criterion of social respectability. Dirt was seen as a moral, and thus a social hazard whose dangers people would strive assiduously to avoid"(Gollaher, 1994). Victorians physicians as also did the public commonly believed that all sexual activity was dangerous to physical and emotional health(2. Hodges, 1995) . One of the accepted reasons for circumcision in the past as in the present, is for good hygienic purposes; circumcision was said to prevent such things as masturbation, which was considered a very dirty practice, and presently, urinary tract infections. At the end of the century and the beginning of the nineteenth century, "dirt was associated with bodily functions of human beings: their excrement, urine, blood, pus, and other secretions. Owing to their function.. genital organs were closely identified with dirt"(Gollaher, 1994). Medical writers of the time claimed that the penis was a source of contamination. Through these extreme associations with dirt one could understand the adoption of a method that purified the penis, such as circumcision.
As cleanliness became a social boundary so did circumcision. As in the past as it is the present, newborns who are born into the middle class and white have a greater propensity that will be circumcised. In the past, this was likely to occur do to the extreme desire to disassociate with the poor and dirt. Today the reason why more middle class newborn are circumcised is due to the fact that daddy is more likely to be circumcised and the parents therefore want the newborn to look like daddy and the other reason is that they are more likely to have health insurance that will cover the procedure than the impoverished. The divisions of class are not unique to the United States and studies have found that, whites are more likely to be circumcised than are African-Americans or Hispanics. "The odds of an African-American being circumcised is roughly half that of whites; the odds for Hispanics are about one third that of whites" in the US (Laumann, 1997).
.References and links how circumcision evolved in the US.
Joannids, Paul. "The Guide to Getting it on". USA: The Goofy Foot Press, 1996.
McLaren, Carrie. "Porn Flakes: Kellogg, Graham and the Crusade for Moral Fiber"
.A comparison of risks and benefits of circumcision.
| # | Benefits/Advantages of Neonatal Circumcision | Risks/Disadvantages of Neonatal Circumcision |
| 1. | Prevent infection of the glans (blanitis) and inability to retract foreskin due to narrowing of the prepuce (phimosis). | Pain, bleeding and infection from the operation. |
| 2. | Decreased incidence of urinary tract infections in infants and possibly adults. | Technical surgical problems, with removal of too little or too much skin. Development of penile adhesions. |
| 3. | Decrease the chance of acquiring STD and possibly HIV/AIDS. | meatitis,meatal stenosis,and preputial stenosis. |
| 4. | Prevents penile cancer (rare disease) | Complications due to surgery, local anesthesia, and inexperienced doctor, such as death or loss of penis as the extreme examples. |
| 5. | Prevents the need for circumcision later in life due to medical problems that arise. | Impaired sexual functioning. |
| 6. | Social reasons (60% of all babies born in the US today will be circumcised). | Feelings of violation and having been mutilated. |
.Risks and Complications.
.Immediate adverse outcomes of circumcision.
pain, bleeding, and infection from the operation.
Complication due to local anesthesia
hemorrhage, redness, swelling, urinary retention, penile adhesions (skin attachments), Chordee (bending of the penis), Lacerations of the glans
Technical surgical problems removal of too much or too little foreskin. Removal of too much foreskin produces a shortened penis is called a buried penis, in which the penis retract into the pubic fat or can cause the penis to look hidden in the lower abdominal fat
Meatitis, infection at urethra opening. "After circumcision, the urinary meatus no longer has its protective foreskin covering and may become irritated or infected, leading to meatits, ulcers around the meatus. As the ulcers heal, scar tissue forms, constricting the meatus and causing a condition known as meatal stenosis"(nocirc, 1997).
Meatal stenosis, " constriction of the meatus impedes and sometimes blocks the flow of urine. Urine backed up into the bladder can cause painful urination and obstructive renal disease. Urine retained in the bladder is breeding ground for bacteria and can lead to infection"(nocirc, 1997).
Preputial stenosis, "the circumcision scar sometimes forms as a tight, constricted, inelastic ring that traps the glans behind it. It may require corrective surgery"(nocirc, 1997).
.Long term Adverse effects of Circumcision.
Discomfort, due to the constant abrasion against the glans.
Painful erections; the foreskin provides the necessary skin for an erection. If too much skin is removed, erections can become painful (nocirc, 1997).
Impotence, difficulty ejactulating.
Scarring.
Desensitization; removal of the foreskin causes the surface of the exposed glans to dry out, thicken, and toughen, causing desensitization. Removal of erogenous tissue (nocirc, 1997). When sexually functioning tissue is removed, sexual functioning is altered (Eskimo, 1995).
Sense of loss and violation; some males regret that part of their penis was cut off without their permission. For example a study found that "of 313 circumcised male respondents, 49.5% cited a sense of parental violation, 62% expressed feelings of mutilation, and 84% reported some degree of sexual harm, progressive loss of glans sensitivity, excess stimulation needed to reach orgasm, painful coitus and impotence"(Eskimo, 1995).
.References and Links.
Johnson, Niel A. M.D. "Circumcision Care". Webmasters of Eisenhower Army Medical Center. 2/11/02
It is highly debated and not necessarily proven in medical studies, but these are the stated benefits to why male circumcision should be a routine neonatal procedure.
1. a decrease in likelihood of developing phimosis. Phimosis is when children develop narrowing prepuce so that the foreskin cannot be retracted.
2. reduction of banalities (inflammation of the glans).
3. reduced urinary tract infections (usually in the first year of life).
4. less susceptibility to STDs and HIV/AIDS
5. decreased likelihood or possible elimination of penile cancer in middle age or older men.
Two drawings depicting intact infant and adult penises or non-circumcised penises, from the National organization of Circumcision Information Resource Center (NOCIRC)Web page.
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Infant Penis 1.Foreskin outside of fold . 2.Foreskin opening |
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Adult Penis 1. Foreskin's outside fold. 2. Meatus 3. Glans 4. Frenulum 5. Foreskin's inner fold. 6.Ridged Band and Mucocutaneous Junction. |
.The American Medical Debate over Routine Neonatal Circumcision - Is circumcision medically Unnecessary?.
The U.S. is the only country that surgically alters most of their male infants for non-religious reasons. Statistics from the 1980's state that over 80% of the world's males are intact; or not circumcised. The majority of circumcised men in the world are Muslim or Jewish (Goldman,1997). "It was estimated in 1970 that 69% to 97% of all boys and men in the U.S. had been circumcised, in comparison with 70% of those in Australia, 48% of those in Canada and 24% of those in the United Kingdom"(nocirc,1997).
"During the 1970's it has been estimated that as many as 80% of American males were circumcised [during] infancy. For roughly the first two-thirds of the twentieth century routine circumcision was an unquestioned aspect of ordinary pediatrics. Around the turn of the century, American medical textbooks and journals that used illustration began to adopt the convention of depicting the normal penis as circumcised - a convention subsequently adopted by publishers of medical books for lay readers... [It was] not until 1960 did the American doctors seriously question the medical legitimacy of routine neonatal circumcision (Gollaher, 1994). . In 1969 the first article written to critique this medical procedure appeared in the prestigious New England Journal of Medicine, entitled "Ritualistic Surgery - Circumcision and Tonsillectomy" and written by a pediatrician named Robert Bolande. The article declared that there was insufficient evidence to justify the universal usage of circumcision as a preventative measure. It was also stated that this violated the medical ethics, "first do not harm"(Gollaher, 1994).
In 1971 and then again in 1975 the American Academy of Pediatrics officially concluded that there were no medical grounds for routine neonatal circumcision (Gollaher, 1994 & Hodges, 1995, Canadian Medical Association Journal, 1996). In 1983 in a joint article entitled "Guidelines for prenatal care" written by the AAP and the American College of Obstetricians and Gynecologists reiterated this same position (Canadian Medical Association Journal, 1996).
In comparison, up until World War II Britain's experience of circumcision was very similar to that of the US. In 1945 Britain instituted a universal health insurance system. The British physicians could not agree if circumcision was a medically effective surgery, so they dropped the procedure from the listed of covered procedures(Gollaher, 1994). Before W.W.II the army records indicated that 50% of the middle class was circumcised, while 85% of the upper class were. After the universal health care system was in place, circumcision rates dropped to an all time low in the 1960's to an estimated less than half a percent.
New theories are constantly being brought up as old ones are disproved. For example a few of the benefits of circumcision are a decrease in likelihood of developing phimosis, reduction of banalities (inflammation of the glans), reduced urinary tract infections (usually in the first year of life), less susceptibility to STDs and HIV/AIDS, decrease likelihood or possible elimination of penile cancer in middle age or older men. If these are the reasons for why circumcision is performed then there should be scientific studies to prove their effectiveness. Although such studies exist, there are just as many studies claiming that the reasons for circumcision are invalid. In the following I will examine three of the reasons stated as benefits to circumcision, first, Urinary Tract Infections (UTI) , secondly, Sexually Transmitted Diseases (STDs), HIV/AIDS, and finally, cancer of the penis.
.Urinary Tract Infections.
"An association between an increased incidence of UTI and uncircumcised status has been reported" (Canadian Medical Association Journal, 1996). Current studies have found that urinary tract infections are up to ten times more common in uncircumcised boys(Journal of Family Practice, 1990 as shown in American Family Physician, 1991). A study of "427,698 infants (219, 698 whom were boys) born in US Armed Forces hospitals from 1975 to 1979 supported these findings, showing a ten fold higher incidence rate of UTI among uncircumcised boys 1.03% than among circumcised boys 0.10%. By comparison, the incidence rate among the female infants was 0.52%" (Canadian Medical Association Journal, 1996). Even though the higher incidence rate of ten-fold sounds impressive but when one compares this rate to the overall low incident rate of UTI among infant boys is calculated to be between 1%-2% (Canadian Medical Association Journal, 1996).
According to a meta-analysis performed by a review of nine studies, found that the "absolute risk of UTI in uncircumcised boys is approximately 1 in 25 or 0.05 and in circumcised boys is 1 in 500 or 0.002, the absolute risk reduction is 0.048"[; therefore,] 20 baby boys need to be circumcised to prevent one UTI. However, the potential [of the] seriousness and pain of UTI, [should be considered because] UTI in rare cases [can] even lead to death..The complications of UTI that can lead to death are: kidney failure, meningitis and infection of bone marrow"(Morris, 1996). The question that is raised is whether or not mutilation of the penis is necessary across an entire population as a preventive measure for UTI? The conclusions that reviewers of medical literature have drawn is that the routine neonatal circumcision was not justified, but that the association between lower UTI rates and circumcision should be discussed with parents to obtain their full consent (Canadian Medical Association Journal, 1996).
.Sexually Transmitted Diseases (STDs).
Studies have indicated that a higher risk of nongonococcal urethrities among circumcised men than among uncircumcised men (Morris, 1996&Canadian Medical Association Journal, 1996). "A resent cross-sectional study of 300 consecutive heterosexual male patients attending [an] STD clinic showed that circumcision had no significant effect on the incidence of common STDs" (Canadian Medical Association Journal, 1996). However, a significantly greater incidence of STDs including genital herpes, gonorrhea and syphilis, was found among uncircumcised men than among intact men had been previously found in other studies. A study by Linda S. Cook and et. al. assessed a Disease Clinic for the relationship between circumcision, syphilis, gonorrhea, chlamydial infection, genital herpes, nongonococcal urethritis, and exphoytic genital warts. The clinic was estimated to have recorded 8034 new problems STDs in 1989. The results of this study found that "a positive relationship was observed between uncircumcised status and both syphilis and gonorrhea. A negative relationship was found between warts and lack of circumcision. No apparent relationship was noted between uncircumcised status and genital herpes, chlamydial infection, or nongonococcal urethritis(Cook, 1994).
Uncircumcised men and the disease causing genital ulceration have been reported to be risk factors in the transmission of HIV to heterosexual men(Canadian Medical Association Journal, 1996).Through a review of literature on this subject a 26 cross-sectional studies were assessed, the meta-analysis showed positive correlation's between the presence of foreskin and the risk of HIV infection(Canadian Medical Association Journal, 1996). Four other studies were said to show positive association but yet another four were said to show no association(Canadian Medical Association Journal, 1996). However, one reviewer noted that some of these studies had inadequacies. The reviewer concluded that further research was needed to ascertain the whether correlations actually exist(Canadian Medical Association Journal, 1996).
More about HIV/AIDS and Blood click here.
.References and links especially for STD and HIV/AIDS.
Cook, Linda S. Laura A. Koutsky, and King K. Holmes. "Circumcision and Sexually Transmitted Diseases". American Journal of Public Health. V.84, Feb, 1994: pgs. 197-201.
Erickson, John A. "Does Male Circumcision Help Spread AIDS". The Backlash!. Sept. 1994
.Cancer of the Penis.
"The incidence rate of cancer of the penis is 0.3 to 1.1 per 100,000 men per year in developed countries and 3 to 6 per 100,000 men per year in developing countries. In the US the statistical rate of penile cancer is 1 per 100,000 per year. This is similar to the rates in Norway and Sweden, where circumcision is rarely performed. Among uncircumcised men in the US the incidence rate is 2.2 per 100,000 per year"(Canadian Medical Association Journal, 1996).
"To me, the idea of performing 100,000 mutilative procedures on newborns to possibly prevent cancer in one elderly man is absurd"(Denniston, 1992).
Men with penile cancer reported more sexual partners than those without cancer(Canadian Medical Association Journal, 1996). This suggests more research needs to include sexual history and practice to see if the correlation between penile cancer is really with how many partners you have versus whether one is circumcised or not.
.References and links for American medical debate of circumcision.
Denniston, George C. "Unnecessary Circumcision". The Female Patient.
Morris, Brian J. M.D. "Medical Benefits from Circumcision"
Preston, Capt E. "Wither the Foreskin?"
"Neonatal Circumcision Revisited". Canadian Medical Association Journal.
"Reevaluating routine neonatal circumcision". American Family Physician. V. 42. Oct. 1990: pg. 1107.
"The debate over routine circumcision". American Family Physician. V. 43. Jan. 1991: pg. 226.
.Circumcision Medical Procedures.
As different cultures have practiced circumcision for different reasons, medical societies have established different medical procedures to perform a circumcision. There are four widely practiced procedures around the world: the Clamp, the Plastibell Device, the Mogen Clamp, and the Tara Klamp.
.Gomco Clamp.
Illustration from The principal methods of circumcision as shown on the web page.
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The Gomco Clamp |  |
The Parts of the Gomco Clamp |
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.Plastibell Device.
The Plastibell technique uses a plastic ring-like apparatus to prevent blood
flow to the distal foreskin (the foreskin being removed). The plastic ring is
left on the end of the penis until the necrotic tissue and the apparatus fall
off, usually sometime between 7-12 days after the procedure. It is designed
to fall off when the healing foreskin is ready. When it does fall off, there
may be a few drops of blood on the foreskin. If a Plastibell device stays on
for more than 3 weeks the baby is at serious risk for infection. The infant
should be brought into a medial facility to have the penis checked and the device
removed safely (Johnson, 1997).
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1. Infant penis after Gomco Clamp Circumcision surgery. 2. Infant penis after Plastibell Circumcision surgery. |
.The Mogen Clamp.
The Mogen Clamp is derived from the traditional Jewish circumcision technique called the "bris". This
procedure has been practiced by the Jews for over 3,700 years (Shechet, 1996). Mogen is the Hebrew word for shield.
The Morgen Clamp is a shield to protect the glans from the scalpel while the foreskin is removed. The Jewish version
of the bris has no moveable parts as is shown in the drawing. The medical version of the Morgen Clamp opens from
1-3 mm, though 3 mm is the maximum that it can open. This constriction of movement of the opening of the clamp
minimizes the possibility of damage done inadvertently to the glans. Before the application of the clamp "the
prepuce is lifted in an upward and outward direction; this causes the glans to retract toward the scrotum, preventing
accidental amputation of the glans" (Holman, 1995). The Morgen Clamp is placed on around the prepuce (Holman,
1995). The clamp is then locked, cutting the circulation from the foreskin (Reynolds, 1996). The clamp is closed
for one to one and half minutes before the foreskin is exercised, and if the infant is older than six months the
clamp should remain for five minutes (Holman, 1995). A scalpel is then used to exercise the distal foreskin (Reynolds,
1995). The clamp is then opened and removed slowly. The remaining foreskin is then pushed downward until the glans
are freed. Gauze is then applied to the penis.
For more on Jewish Circumcision click here:, BRIS MILAH
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The Tara Klamp works in a similar fashion to the Plastibell Device but the procedure "does not require to tie suture material around a groove in the bell, the plastic arms lock into place to force two surfaces into tight contact; with the foreskin trapped between them"(Quaintance, 1996). The Tara klamp is larger than the Plastibell Device. It remains on the penis a shorter amount of time; seven to ten days until it falls off with the dead foreskin or is removed by medical professionals (Quaintance, 1996).
Source of Tara Klamp illustration: Principal Methods of Circumcision
.References and links for procedures and methods of circumcision.
"Circumcision Procedure using the Tara Klamp".
Johnson M.D., CPT Niel A. "Circumcision Care". Feb. 11, 2002.
Reynolds, Ronald D. "Techniques for performing neonatal circumcision". Am Fam Physician. V. 53, Jan. 1996: pgs. 92-106.
Reynolds, Ronald D. "Use of the Mogen Clamp for neonatal circumcision". Am Fam Physician. V.54, July, 1996: pgs.177-182.
Shechet, Jacob. "Traditional Jewish circumcision technique of bris". Am Fam Physician. V. 53, March, 1996: pgs. 1070+.
"The Gomco Technique". Patient Care Magazine. March 15, 1978:pgs. 82-85.
"What Happens during Circumcision?".
Quaintance, Vernon. "The Principal Methods of Circumcision". Feb. 2002.