First, Do No Harm | The Gruesome Truth about American Circumcision

When I was pregnant with my first child, I wanted to research all the things. I wanted to make the most informed decisions I could, from vaccines and car seats, to the type of birth I wanted to have. But one thing that slipped right under the radar was circumcision. That wasn’t really something to question – it was just something you didSeeing the words on the screen now are cringe-inducing. To know that I blindly trusted “modern medicine” and unfounded medical claims at the expense of my newborn son. But we can only move forward, and I feel compelled to share with you the information and truth I now know. 

So hold on tight, it’s about to get bumpy.

Why do we Circumcise in the First Place?

I find it best to start from the very beginning, and go from there. As the whole history of circumcision is deeply complex, religious, and often differs greatly from how we do it in the Western world, for time’s sake, our post today is going to focus on American circumcision[1]. In the late 1800s, medical professionals and researchers were still learning a great deal about the human body, and utilizing electricity and injection of the poisonous herb Strychnos nux-vomica to treat tons of different ailments. It was in that time that Dr. Lewis A. Sayre also began experimenting with using circumcision as a treatment for paralysis, and even epilepsy, in children and teenagers[2]. Until his death in 1900 Sayre, a highly respected doctor, was extremely vocal about his belief that circumcision could cure just about anything, from behavioral issues, hernia, and even lunacy[3]. Though most of the male population remained intact until about 1870, circumcision began growing in popularity due to the belief that it would stop young boys from masturbating. And masturbation, already viewed as seriously taboo, had the ability to cause disease, nervous system disorders, and even loss of sperm due to excessive ejaculation[4,5].

By the turn of the 20th century, a growing number of physicians were opting for circumcision in an effort to treat ailments like cancer, venereal diseases, like syphilis and gonorrhea, and of course masturbation[6]. And, because not many adult men were signing up to be circumcised (obviously) the target was focused primarily on babies and children[7]. Though its medical benefits were actually quickly dispelled, circumcision quickly became a mark of class among upper-class white boys whose parents were shifting from home birth with midwives to hospital births. Circumcision continued gaining popularity, and by the 1930s, nearly 60% of US-born boys were circumcised. In 2012, approximately 75% of boys were circumcised in America prior to hospital discharge, despite the fact that more than 60% of the world remains intact[8,9].

 

What is Circumcision?

Plainly put, circumcision is the surgical removal of the male foreskin – the skin covering the tip of the penis. In the US, it is most often done in the first day or two of life, before they even leave the hospital, and there are a number of different ways it’s done, primarily depending on doctor preference. 

To begin, all infants are first placed into a newborn immobilizer, commonly known as a “circumstraint”, preventing him from moving his arms or legs, and making his penis perfectly and easily accessible to the health professional (typically a family doctor, pediatrician, or OB/GYN). As this procedure always involves some sort of clamping, ripping, cutting, or other painful action, most parents expect their son is properly anasthetized during the surgery. Unfortunately, research shows that just 45% of physicians used some form of anesthesia (injected or cream), and OB/GYNs – who perform 70% of all neonatal circumcisions – used anesthesia only 25% of the time[10].

In the US, neonatal circumcision is typically performed using one of three methods:

Gomco Clamp: Introduced in 1935 by Dr. Hiram Yeller, the Gomco Clamp still remains a popular method of circumcision throughout the United States, over 70 years later[11]. It is a 4-piece device that includes a bell-shaped plunger to protect the glans (head of the penis), and a clamp (to make it “blood-free”). The one performing the procedure uses their own discretion to “judge the amount of shaft skin left” before using a blade to cut the chosen amount of skin from the body[12]. To watch a video of the Gomco Technique performed, click here.

Mogen Clamp: Designed by Rabbi Harry Bronstein in 1954, the Mogen Clamp is most often seen used by mohels during Jewish ceromonial circumcision[13]. The Mogen Clamp, a metal hinge-shaped device, does not require a cut in the foreskin before its placement, and is said to be the fastest form of circumcision. Though it is least likely to lead to infection or excessive bleeding, most doctors aren’t familiar with the Mogen Clamp, and don’t use it because of its greater risk of accidental removal of the tip of the penis[14]. To watch a video of the Mogen Clamp Technique performed, click here.

PlastibellThis type of circumcision was introduced to the US in the mid-1950s, and is still used today[15]. The Plastibell, as its name suggests, is a bell-shaped plastic device that sits over the head of the penis, and is secured with a string tied around the foreskin. The Plastibell remains in place until the foreskin falls off, and depending on the age of the patient, this can take a week or two[16]. To watch a video of the Plastibell Technique performed, click here

What is the Foreskin?

Contrary to popular belief, the foreskin is far more than just “a snip of skin.” In fact, if unfolded and spread out flat, the adult foreskin measures 15-20 square inches. The prepuce (foreskin) is an integral, protective part of the anatomy in both males and females[17]. In females, it surrounds the clitoris, and in males it surrounds the glans. In males, the prepuce is an extremely important part of the body, housing thousands of nerve-endings, and has even been regarded as a principal organ in the body, capable of perceiving a sixth sense, erogeny[18]. While there are countless, many unknown, functions of the male foreskin, we’re going to look at three of the big ones here today. 

Provides Lubrication During Intercourse: “Every mammal has a foreskin” says Dr. George Denniston “You take the foreskin away…and you end up irritating the hell out of the vaginal mucosa. Everyone in the US uses lubricants because the basic function of sexual intercourse has been disrupted.”[19] Obviously, as a result of its intended purpose, circumcision makes masturbation more difficult, and the act almost always requires some sort of lubrication, but the procedure can also make actual sex more difficult for both the man and his partner[20]. Women are more likely to experience vaginal dryness, and need additional lubrication, when having sex with a circumcised partner, are more likely to prefer an intact partner, and are more likely to achieve orgasm when with an intact partner[21].

Provides Protection for the GlansSadly, incredible protective properties are lost when the foreskin is taken away. The glans (head), which is naturally an internal mucousal structure, is exposed and left uncovered, leaving it susceptible to abrasion, drying and callousing, as well as contamination from the environment[22]. In circumcised men, because the glans is constantly never protected, it becomes more rough and calloused after years of rubbing on clothing. This toughening of the skin can result in decreased sexual pleasure, lower orgasm intensity, pain or discomfort during intercourse, and even unusual tingling sensations in the glans[23].

Houses Thousands of Nerve EndingsIt’s obvious, but I think it’s worth reiterating here that circumcision is a permanent decision. It forever alters and disrupts the natural function and appearance of the whole penis. Through circumcision, nearly 30-50% of the penile skin is lost, and most parents don’t realize the tens of thousands of nerve-endings that go with it. It is estimated that circumcision takes approximation 10,000-20,000 specialized erogenous nerve endings, and this can contribute to desensitization and frequent orgasm difficulties[24,25].

 

Is Infant Circumcision Recommended?

Not one medical agency in the world recommends routine infant circumcision. While agencies in the United States tend to slate their words in a pro-circumcision fashion, it has mostly been accepted as an elective procedure and for this reason, many insurance companies are refusing to cover the surgery. 

American Medical Association: This agency regards infant circumcision as “non-therapeutic” procedure whose benefits do not outweigh the risks. The AMA argues that neonatal circumcision is a surgery that is not medically justifiable, and can lead to damage like trauma and pain, complications, and sexual harm. The AMA appropriately labels infant circumcision as ethically problematic[26].

American Academy of Pediatrics: The AAP recognizes routine infant circumcision as “not essential to the child’s current wellbeing”, and encourages that physicians ensure the parents understand that it is an elective procedure. The AAP argues that the “data are not sufficient to recommend routine neonatal circumcision.”[27]

The American College of Obstetrics and Gynecologists: The ACOG identifies circumcision as an elective procedure, often not covered by insurance policies, that carries the risk of complication. ACOG echoes the AAP’s inability to recommend the procedure[28].

The Royal Australasian College of Physicians: “After reviewing the currently available evidence, the RACP believes that the frequency of diseases modifiable by circumcision, the level of protection offered by circumcision and the complication rates of circumcision do not warrant routine infant circumcision in Australia and New Zealand.”[29]

Canadian Paediatric Society: The CPS recognizes the potential risks associated with circumcision, including excessive pain, meatal stenosis, re-adherence, and even partial amputation, hemorrhage, and death. The CPS “does not recommend the routine circumcision of every newborn male.”[30

Potential Complications of Circumcision

Complications are a part of any medical procedure, and in young babies, concerns about potential complications are even greater and require close attention. When it comes to surgery, possible hemorrhage is the greatest worry, as babies have very little blood to begin with. A typical newborn’s entire blood volume is between 200-300 mL (or, about a can of soda), so any blood loss is going to be substantial[31]. But, most parents don’t realize there are many more potential complications to be aware of. 

Bleeding: As stated above, excessive bleeding is the most pressing immediate concern when it comes to circumcision. While most circumcision tools have been designed to help control bleeding, complete glans amputation, and even death from blood loss, has been recorded[32]. Often, these adverse events come from improper use of the clamp, or the practitioner failing to tie the string to the Plastibell tightly enough[33]. And while the number of deaths caused by circumcision seem to be written off as “extremely rare”, and therefore not looked into, it is unknown how many infants die as a result of this elective procedure. Some independent researchers have taken it upon themselves to research this issue, and estimates that 117 boys lose their life to circumcision here in America every single year, mostly due to loss of blood[34].

Infection: As with any open wound to the body, infection is definitely a concern during the circumcision healing process – even moreso, considering the wound is sitting in a diaper. The Plastibell is associated with a higher risk of infection, and its use has even led to life-threatening infections like necrotizing fasciitis, meningitis, gangrene, and sepsis[35]. The reason the Plastibell causes more issues is probably because a foreign object is left at the surgical site, so for this reason, parents should pay close attention to their son’s healing wound, and alert medical professional to any signs of infection[36].

Surgical Error: The facts are these: doctors are human, and doctors make mistakes. In fact, physician error remains the third leading cause of death in this country[37]. And, as stated above, all circumcision procedures rely on the physician’s judgement as to just how much skin should be taken. Of course, those familiar with the procedure probably carry a lower rate of complication, but every child is different, and every penis unique. Sometimes, by misjudgment of the practitioner, too much skin is removed from the infant penis. Even with proper technique, the clamp devices often make it difficult to estimate the amount of skin that will be removed. In many cases, this complication doesn’t reveal itself until puberty, and because of that “the removal of too much skin is so common that many practitioners may view the results as normal.”[38] The lack of necessary skin can cause tight, painful erections later in life for circumcised boys. When a circumcision is especially tight, this can also result in a condition known as “buried penis”, where the shaft skin is so tight that it pulls the entire penis into the pubic skin[39]. To see examples of buried penis, click here and here

On the far end of the spectrum (though its rarity wouldn’t matter, should it happen to your son), there have been cases of accidental glans amputation, and even total amputation of the penis[40]. This has most commonly been reported with the Mogen Clamp.

Healing Complications: The body’s natural response after a traumatic event is to attempt to heal itself, and this is typically seen as a good thing, though it can present as a complication when it comes to purposeful amputation. Penile adhesions and skin bridges happen when the skin around the circumcision scar starts growing back up over the glans. This can lead to tight, painful erections, and even buried penis[41]. To see an example of a penile skin bridge, click here.

During healing, a number of unsightly complications may arise as the body learns how to operate without a piece it used to have. Inclusion cysts, granulomas, keloids, phimosis, and even fistula development have been reported during circumcision healing[36].

Meatal Stenosis is one of the most common complications during the healing process, and it requires intervention in at least 10% of boys circumcised during the newborn period[42]. Because this complaint is so common, physicians have been encouraged to disclose this potential risk to parents while obtaining informed consent, though I never heard anything about it when my son was being circumcised[43]. Meatal Stenosis is an abnormal narrowing of the urethral opening (pee hole), and can cause symptoms like trouble urinating, urinating often, prolonged urination, urine sprays instead of streams, and the presence of several urine streams instead of just one. This condition typically requires surgical intervention[44]. This is typically seen in circumcised males as the exposed glans builds callousing and tough skin to protect itself from constant environmental disruption, like rubbing against clothing. To see an example of meatal stenosis, click here

 

Restoring the Foreskin

While most people have never heard of such a thing, foreskin restoration (commonly known historically as uncircumcision) is a very old practice that has been done by men for thousands of years. In Classical Greece, exposing the penile glans was considered offensive, so those with naturally short foreskins, or those who had been circumcised, could often be seen wearing a leather strip that attached the foreskin to the base of the penis, or even the waist[45]. While there has been documentation of operations done to help men restore their foreskins, an untold number of them have taken it into their own hands. There is text from the 1800s that discusses men who would apply tension to the foreskin with straps and weights, over the glans, to encourage tissue expansion and skin growth.

While foreskin restoration will never regrow the nerves and structures lost, it can help men whose circumcision was cut too tight, and can also protect the glans to improve sensitivity by removing the calloused layer of cells. There are a number of charities and resources out there to help give men guidance and information on restoring their own foreskins. They can be found here and here, and here.  

There are even devices created to help make this process easier, like this one here.

Caring for an Intact Son

While it may seem silly, the male foreskin remains a mysterious and confusing part of the human anatomy, and many people look at it as a part of the body just waiting to cause trouble. But, the truth of the matter is that caring for an intact (not circumcised) son is easy and straightforward. And caring for a natural penis is much easier than protecting a surgical site, cleaning a painful wound, and watching closely for infection – like you would with a circumcised baby.

As the group Doctors Opposing Circumcision simply states:

Only Clean What is Seen

Yep, it’s as simple as that. Clean the penis, with a wipe or washcloth, like you would a finger – from base to tip, gently and swiftly. There is no reason whatsoever that you, your doctor, your midwife, your mother-in-law, or your best friend should be forcefully retracting an intact penis. In early childhood, the prepuce is fused to the glans in an effort to protect it while its use is not yet necessary. Somewhere between 3 and puberty, the foreskin will retract on its own. Think of the intact baby like you would a fingernail. There is no reason to clean underneath it, because there is no underneath. The first person to ever retract the foreskin should be the boy himself. 

Conclusion

Though a common part of American culture, circumcision is not normal, not necessary, and not safe. It carries very real risks, and the boy can always make the decision to be circumcised later in life, if that’s what he wants. Though foreskin restoration is a possibility, it can take years of effort, and the function will never be the same as if you’d just left it alone in the first place. 

“While the reality of immediate surgical error, such as injury to the glans, loss of the entire penis, gangrene, severe hemorrhage, and even death are grudgingly acknowledged, though downplayed as rare, advocates for circumcision refuse to acknowledge the large body of scientific research showing long-term and permanent negative sequelae to the penis and to sexual function caused by destruction and amputation of the prepuce.”[46]

Teach yourself to love your whole baby. 

Until next time, 
Savannah

 

References:

1. Shulman, Moshe Rabbi Brit Milah (Ritual Circumcision)
https://www.milah.net/
2. Medical Society of the State of Pennsylvania Thirtieth Annual Session 
https://books.google.com/books?id=FHM3AQAAMAAJ&pg=PA297&lpg=PA297&dq=Sayre,+%22Partial+Paralysis+from+Reflect+Irritation,&source=bl&ots=CIeI-KPVfG&sig=xM5vnDuMi4daf_q47VNyU7LFs94&hl=en&sa=X&ved=2ahUKEwiTsd7C2tffAhW2IDQIHUMzBr4Q6AEwAHoECAsQAQ#v=onepage&q=Sayre%2C%20%22Partial%20Paralysis%20from%20Reflect%20Irritation%2C&f=false
3. The Boston Medical and Surgical Journal Volume CIII
https://books.google.com/books?id=Ta01AQAAMAAJ&pg=PA427&lpg=PA427&dq=Spinal+Anemia+with+Partial+Paralysis+and+Want+of+Co-operation+from+Irritation+of+the+Genital+Organs&source=bl&ots=2HdeWaw92G&sig=MI0fDNAEyAlHyq-221Ep6XQJ1dw&hl=en&sa=X&ved=2ahUKEwiM6JKJ49ffAhW7GDQIHesuAWkQ6AEwDnoECAMQAQ#v=onepage&q=Spinal%20Anemia%20with%20Partial%20Paralysis%20and%20Want%20of%20Co-operation%20from%20Irritation%20of%20the%20Genital%20Organs&f=false
4. White, Kevin The First Sexual Revolution
https://books.google.com/books?hl=en&lr=&id=7ygVCgAAQBAJ&oi=fnd&pg=PP11&ots=0rQetta0zF&sig=tNVf8cIq0dYvw4Mp3BSedTj–Tk#v=snippet&q=masturbation&f=false
5. Darby, Robert A Surgical Temptation
https://books.google.com/books?hl=en&lr=&id=xYdoAAAAQBAJ&oi=fnd&pg=PR2&ots=xgU0PGFAB4&sig=gsIORHnFF2hCx1Q-iDpUatbM64s#v=onepage&q=organic%20disease&f=false
6. Glick, Leonard Marked in Your Flesh
https://books.google.com/books?hl=en&lr=&id=SF6fbjNe0yYC&oi=fnd&pg=PR13&ots=J0_eqBEzZf&sig=mAB5CiBH-ksdrFwPT7MkUjum_0E#v=onepage&q&f=false
7. Wiley Online Library On Remedicalisation: Male Circumcision in the United States and Great Britain
https://onlinelibrary.wiley.com/doi/full/10.1111/j.1467-9566.2009.01233.x#b31
8. ScienceDirect Circumcision Rates in the United States: Rising or Falling? What Effect Might the New Affirmative Pediatric Policy Statement Have?
https://www.sciencedirect.com/science/article/pii/S0025619614000366
9. NCBI Estimation of Country-Specific and Global Prevalence of Male Circumcision 
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4772313/
10. Stang, Howard MD Circumcision Practice Patterns in the United States
http://pediatrics.aappublications.org/content/pediatrics/101/6/e5.full.pdf?download=true
11. Stanford Medicine Circumcision: Gomco Technique
https://med.stanford.edu/newborns/professional-education/circumcision/gomco-clamp-technique.html
12. The Circumcision Reference Library Circumcision Procedure (Gomco Clamp Method)
http://www.cirp.org/library/procedure/gomco/
13. Stanford Medicine Circumcision: Mogen Technique
https://med.stanford.edu/newborns/professional-education/circumcision/mogen-clamp-technique.html
14. CS Mott Children’s Hospital Circumcision: Mogen Clamp
https://www.mottchildren.org/health-library/hw142336
15. Stanford Medicine Circumcision: Plastibell Technique 
https://med.stanford.edu/newborns/professional-education/circumcision/plastibell-technique.html
16. My Virtual Medical Centre The Circumcision Procedure
https://www.myvmc.com/treatme nts/the-circumcision-procedure/
17. The Circumcision Reference Library The Prepuce
http://www.cirp.org/library/anatomy/cold-taylor/
18. The Circumcision Reference Library The Penis and the Foreskin: Preputial Anatomy and Sexual Function
http://www.cirp.org/library/anatomy/#n18
19. NCBI Vital or Vestigial? The Foreskin has its Fans and Foes
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3225416/
20. The BMJ Is Infant Male Circumcision an Abuse of the Rights of the Child? Yes
https://www.bmj.com/content/335/7631/1180
21. Bensley, Gillian Effects of male Circumcision on Female Arousal and Orgasm
https://pdfs.semanticscholar.org/dc50/922a85608b93970fc7a1a5ad79b50e06f2f6.pdf
22. The BMJ Prepuce: Anatomy and Functions
https://www.bmj.com/rapid-response/2011/10/28/prepuceanatomy-and-functions
23. Wiley Online Library Male Circumcision Decreases Penile Sensitivity as Measured in a Large Cohort
https://onlinelibrary.wiley.com/doi/full/10.1111/j.1464-410X.2012.11761.x
24. ResearchGate Physical Effects of Circumcision 
https://www.researchgate.net/publication/227011336_Physical_Effects_of_Circumcision
25. Oxford Academic Male Circumcision and Sexual Function in Men and Women, a Survey-Based, Cross-Sectional Study in Denmark
https://academic.oup.com/ije/article/40/5/1367/658163
26. AMA Journal of Ethics Nontherapeutic Circumcision of Minors as an Ethically Problematic Form of Iatrogenic Injury 
https://journalofethics.ama-assn.org/article/nontherapeutic-circumcision-minors-ethically-problematic-form-iatrogenic-injury/2017-08
27. AAP Circumcision Policy Statement 
http://pediatrics.aappublications.org/content/103/3/686
28. ACOG Newborn Male Circumcision 
https://www.acog.org/Patients/FAQs/Newborn-Male-Circumcision?IsMobileSet=false
29. The Royal Australasian College of Physicians Circumcision of Infant Males
https://www.racp.edu.au/docs/default-source/advocacy-library/circumcision-of-infant-males.pdf
30. Canadian Paediatric Society Newborn Male Circumcision
https://www.cps.ca/en/documents/position/circumcision
31. The Journal of Pediatrics The Blood Volume of Infants 
https://www.jpeds.com/article/S0022-3476(59)80281-X/abstract
32. UNAIDS Neonatal and child Male Circumcision: A Global Review
https://www.who.int/hiv/pub/malecircumcision/neonatal_child_MC_UNAIDS.pdf
33. The Circumcision Reference Library Early Complications of Circumcision Performed in the Community 
http://www.cirp.org/library/complications/FDA/
34. Janssen, Diederik An Estimate of US Circumcision-Related Infant Deaths
https://www.berghahnjournals.com/view/journals/boyhood-studies/4/1/bhs040106.xml
35. NCBI Complications of Circumcision 
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3253617/
36. Stanford Medicine Complications of Circumcision
https://med.stanford.edu/newborns/professional-education/circumcision/complications.html
37. NPR Medical Errors are No. 3 Cause of US Deaths, Researchers Say
https://www.npr.org/sections/health-shots/2016/05/03/476636183/death-certificates-undercount-toll-of-medical-errors
38. Howe, Robert A CDC-Requested, Evidence-Based Critique of the Centers for Disease Control and Prevention 2014 Draft on Male Circumcision
http://www.academia.edu/10553782/A_CDC-requested_Evidence-based_Critique_of_the_Centers_for_Disease_Control_and_Prevention_2014_Draft_on_Male_Circumcision_How_Ideology_and_Selective_Science_Lead_to_Superficial_Culturally-biased_Recommendations_by_the_CDC
39. Hindawi Buried Penis: Evaluation of Outcomes in Children and Adults, Modification of a Unified Treatment Algorithm, and Review of the Literature
https://www.hindawi.com/journals/isrn/2013/109349/
40. Hindawi Traumatic Penile Injury: From Circumcision Injury to Penile Amputatiion
https://www.hindawi.com/journals/bmri/2014/375285/
41. Cleveland Clinic Penile Adhesions & Skin Bridges 
https://my.clevelandclinic.org/health/diseases/16280-penile-adhesions-and-skin-bridges
42. NCBI Routine Circumcision: The Opposing View
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2422979/
43. Sage Journals Incidence of Meatal Stenosis Following Neonatal Circumcision in a Primary Care Setting
https://journals.sagepub.com/doi/abs/10.1177/000992280604500108
44. Cincinnati Children’s Meatal Stenosis 
https://www.cincinnatichildrens.org/health/m/meatal-stenosis
45. European Urology Supplements It’s a Cover-Up: The History of Foreskin Restoration
https://www.eusupplements.europeanurology.com/article/S1569-9056(14)60321-3/pdf
46. Springer Link The Harm of Circumcision
https://link.springer.com/chapter/10.1007/978-94-007-6407-1_4