What is circumcision?

Circumcision is the surgical amputation of the foreskin - the soft, sensitive double-sleeve of tissue which covers the lower half of the penis shaft and the head (glans) and usually extends beyond to end in a tapering spout or nipple. There is no agreed anatomical definition about where the foreskin ends and the skin of the penis shaft begins, and hence no exact surgical definition of what circumcision is meant to remove. As a consequence, the amount of tissue cut off by the operation is highly variable (some doctors take more, some less), but a typical circumcision carried out in a western hospital will remove about 50 per cent of the surface tissue of the penis.

The foreskin is not just a flap of skin, but an important part of the penis. It is a complex web of mucous membrane, muscle fibres, blood vessels and nerves: in fact, it supports one of the densest concentrations of nerves in the whole body. Amputating it is not a simple "snip", but a delicate and often bloody operation, particularly difficult to do neatly in infants, when the parts are very small and not even fully formed. An early practitioner likened the operation to "resecting the femur of a grasshopper".

In a baby boy the lower end of the foreskin (including the tapering spout or nipple which extends beyond the glans) can represent more than half the total length and bulk of the penis. This proportion decreases as the boy grows up and the rest of the penis grows into the foreskin. In infancy the foreskin is very tight and is normally fused to the glans, thus guarding the urethra (the urine passage) against the entry of dirt and protecting the glans from irritation by urine or faeces and from abrasion. It was never meant to be pulled back at this early stage. The first injury inflicted by circumcision in infancy is caused by forcibly separating the foreskin from the glans, a process which can be similar to tearing off a baby's fingernail.

Further information.

Importance of the foreskin

Little is known about the anatomy and neurology of the foreskin because medical researchers have been more interested in finding justifications for cutting it off than in studying it objectively. The state of medical knowledge is so poor that no doctor can say with confidence that circumcision does no harm, much less that it can do significant good. Common sense teaches that the foreskin has many important functions.

• It contributes to the hygiene and cleanliness of the penis. Its long, tapering, spout-like shape works like a valve, letting urine out and keeping it away from the baby's body, but also blocking the entry of dirt.

• It protects and lubricates the glans, which is an internal organ that was never meant to be exposed to the abrasion of clothes etc. The foreskin works in much the same way as the eyelid protects and lubricates the eyeball: would your eyeball be cleaner if the eyelid was cut off? Further information.

• It provides the slack tissue necessary to accommodate the enlargement of the penis during erection This is particularly important after puberty, when the difference between the flaccid and the erect organ may be several hundred per cent.

• Recent research suggests that the natural secretions which lubricate the foreskin have useful anti-fungal and anti-bacterial properties. Further information here.

• It is so densely packed with nerve endings that it is by far the most sensitive part of the penis. It thus plays a major role in the generation of sexual pleasure. Unlike the nerve endings of the foreskin, which specialise in the reception of pleasure, the nerve endings of the glans specialise in the detection of pain and discomfort - another reason why it should not be exposed to abrasion and irritation.

• As a glance at any ancient Greek statue or Renaissance painting will prove, the normal penis, covered in its foreskin, is a beautiful part of the male body. Circumcision completely changes the look of the penis. In addition, it always leaves an ugly scar and either ragged flaps of skin or a shiny, scarred patch where the tissue was cut away. Bodily aesthetics may be a matter of personal taste, but if that is true, then the only person who can make a decision about how he wants his penis to look is its owner.

A fuller list of the functions of the foreskin is available here.

Where did circumcision come from?

Circumcision began as a puberty initiation rite among a number of tribal peoples, all with an authoritarian and highly patriarchal social structure, in north-east Africa and central Australia. Later the Arab and then the Jewish peoples of the Middle East adopted the practice, followed by the Moslems, though they started performing the operation at a younger age: the Jews at eight days, the Moslems at between six and ten years. The reasons why these cultures adopted circumcision is not fully understood, but it had nothing to do with practical concerns like hygiene. Cutting flesh in primitive conditions was the about the least hygienic thing anybody could do, carrying a high risk of bleeding and infection.

The orthodox position had been put in the thirteenth century by Moses ben Maimon, who insisted that for Jews circumcision was strictly a test of faith, carried out not to correct a defect but to injure and chasten the penis, thus curbing sexual desire. Until this step was abolished in the late nineteenth century, Jewish circumcision also required the Mohel to suck the bleeding penis after he had cut the foreskin (the metsitsah phase); far from being a hygienic measure, this operation was a significant vector for the transmission of fatal diseases from the operator to the child, including tuberculosis and syphilis. The reason why metsitsah was abolished was because it was realised that many boys were being infected with these disease and a high proportion dying from them.

The idea that Semitic and other tribal circumcision had a health or medical rationale was the invention of nineteenth century English and American doctors who wanted to introduce the operation for their own reasons and thought that the antiquity of the procedure conferred legitimacy. Nobody has ever suggested that circumcision as carried out by the Australian desert Aborigines had a hygienic rationale.

Further information.

Circumcision was first introduced as a medically-justified procedure on unwilling boys in the mid-nineteenth century, mainly as a means of discouraging masturbation, then wrongly regarded as the cause of many serious diseases. Many other medical reasons for doing it have been advanced over the last century and a half. These include prevention of syphilis, tuberculosis, polio, bed-wetting, epilepsy, burping, night terrors, phimosis, and cancer of the penis and cervix - and just any other problem that lay beyond doctors' power to cure. All these claims have been disproved. Recent assertions that circumcision may confer a degree of protection against HIV-AIDS and urinary tract infections (UTIs) are controversial and doubtful. Even if they were true, UTIs are easily cured with antibiotics, and babies do not engage in the sexual activities from which they can contract the AIDS virus. As for cleanliness, to amputate the foreskin to improve bodily hygiene is like extracting teeth or pulling off fingernails instead of cleaning them. Because it prevents the normal lubrication processes from occurring, circumcision actually makes the penis less hygienic than if it is left as nature intended.

How common is it?

Circumcision became common in Britain (though never affected more than about a third of boys) in the Edwardian period (just before World War I) and spread from there to Australia, where it became a normal or "routine" procedure carried out on newborn babies, usually within the first week of life. Britain dropped circumcision in the late 1940s, but in Australia it remained widespread until the 1970s (see table). As a result of better medical knowledge, its incidence has declined from about 50 per cent of babies in the 1970s to less than 12 per cent today.

The United States, Canada, Australia and South Korea are the only countries in the world where parents and doctors continue to carry out routine circumcision, and in all these places the procedure is under attack and in decline. In Australia the practice is now rare, though there is a strong push from circumcision advocates to restore it to the levels of the 1950s, supposedly as a public health measure. The vast majority of the world's people are not circumcised and never have been. The largest single group of circumcised men in the world today are Moslems, among whom the operation is carried out as a religious custom, not a medical procedure. Many Moslem cultures also prescribe and carry out various forms of circumcision on girls and women.

Risks and complications

Circumcision is a surgical procedure involving the cutting of skin, muscle, nerves and blood vessels, and it carries inherent risks, including bleeding, infection, gangrene and ulcers. Quite often too much tissue is removed and the growing boy experiences uncomfortable and even painful erections; in extreme cases erection may be impossible, as in the tragic case of Shane Peterson. Doctors recognise that serious complications occur in at least five per cent of operations, but the real figure is probably much higher. Sometimes the glans is damaged or cut off, and occasionally the entire penis is a amputated. Even death can occur as a result of bleeding or infection, or in consequence of human errors, particularly when anaesthetics are used, or as a result of pain control drugs administered following the operation.

As the circumcision wound is healing the raw edges can fuse to the glans, thus leaving skin bridges which have to be surgically removed later. Infections are common. Because the glans is no longer protected from urine, faeces and other dirt, ulcerations can form around the urinary opening and may be followed by scar tissue. Since there is rarely any follow-up with circumcision cases, the true level of complications and later problems is not known, and there has been no attempt to measure customer satisfaction.

Since the foreskin represents at least one third of the sensation-receiving regions of the penis, its removal means a severe loss of sexual sensitivity. In addition, the glans itself becomes hard, dry and insensitive, when nature meant it to be soft and moist. The end result is a strikingly different-looking penis which usually carries an obvious and often ugly scar. Further information.

Care of the normal penis

Rule 1: Leave it alone

The normal (uncut) penis requires no special care. Primitive humans managed to thrive with it in that condition for hundreds of thousands of years before circumcision was invented, and if primitive hunter gatherers were able to care for the natural penis of their babies, so can parents today.

Some parents favour circumcision because Australia has a past history of widespread circumcision and they are not familiar with the normal (uncircumcised) penis. They may have heard stories that it is difficult to look after in infancy and childhood and are afraid of unknown but suspected problems. In reality nothing is easier: the foreskin should simply be left alone, and nature will do the rest. Because it is usually attached to the glans, an infant's foreskin should never be retracted (pulled back). Separation of the two surfaces occurs gradually during childhood, and the age at which full separation occurs will be different for each boy. The process should not be hurried! Boys naturally play with, tug and fondle their penis, especially the foreskin, and this helps the process along at the individual's own pace.

The most common cause of penis problems in infancy and childhood are misguided attempts to retract the foreskin and wash underneath it. This may cause bleeding, scarring, infection and adhesion of the foreskin to the glans, and sometimes such severe injury that circumcision is necessary later on. The only washing the infant penis requires is (very gently) on the outside. Unless a serious malformation, injury or disease is present, the first person to pull a boy's foreskin back should always be the boy himself.

Minor problems with the penis are not unusual in infancy and early childhood: it is subject to infection and in much the same way as lungs, nose, ears, throat, digestive tract etc, as the child grows up and his body learns to cope with the micro-organic world. These problems can nearly always be fixed by conservative methods. Any good paediatrician can advise on these. If you take your child to a GP and don't like what he says, especially if he seems biased against the foreskin, get a second opinion or arrange to see a specialist paediatrician. Nobody talks about amputating a boy's ears or lungs because he gets earache or bronchitis, or his leg because he often falls over and gets cuts or bruises on it.

Further information from Australian paediatricians.

Phimosis

Phimosis is the name given to a foreskin that cannot be drawn back to expose the glans. All young boys have phimosis, and there is no definite age at which retractability should be achievable. Phimosis used to be regarded as an "indication" for compulsory circumcision, but that was an error arising from ignorance of normal genital anatomy. Even after puberty some men still have a phimotic condition, and most are not worried by it; if a man does experience discomfort he can gently stretch the foreskin opening. If that does not work he can always get himself circumcised if he really thinks it necessary: it does not have to be done for him at an age when the final condition of his penis cannot be known.

Too many boys are still circumcised between the ages of three and six because their foreskins are not easily retractable, but genuine (pathological) phimosis can rarely be identified that early. Most cases of real phimosis can now be treated by topical steroid cream. Recent research shows that 85 per cent of boys with a problem phimosis respond to twice-daily applications of steroid cream within four weeks, and many within two weeks. Real (pathological) phimosis is now recognised as arising from injury or certain rare forms of infection. You can always cut the foreskin off, but once it's gone there is no getting it back. Circumcision should always be the last resort.

Non-surgical treatments of penis problems

For more details and information about how to handle penis problems without amputating anything, see "Alternatives to amputation"

Smegma: beneficial lubrication

In babies and young boys the natural shedding of the skin cells from the inner layer of the foreskin helps the process of separating the two structures. The shed cells form a harmless substance called infant smegma which is regularly extruded from the foreskin opening; it can then be wiped away during the boy's bath. There is nothing dirty or harmful about this. External washing is all that is required at this stage; attempting to wash under the foreskin of young boys can only do harm.

When a boy reaches puberty his sebaceous (sweat) glands begin to function more vigorously, secreting an oily substance. This additional secretion in adult smegma protects and lubricates the glans. By this time most boys are perfectly capable of working out how to keep themselves clean, without the need for direction from adults, and the few who are not informed can be easily be shown what to do. Most boys produce very little or no smegma at all. A heavy accumulation of smegma will eventually get smelly, but a boy's mates will soon let him know if he is causing offence.

Is circumcision ever justified?

In the absence of a serious and health-threatening pathological condition (arising from malformation, disease or injury) it can never be justifiable to circumcise a person without his or her agreement. But any male over the age of consent may have himself circumcised if he prefers to be that way, and younger males too if they can convince their parents that they really want it. Parents may be justified in having their boys circumcised before they are able to give legal consent if they are affected by a seriously health-threatening condition and conservative means of treating it have failed or are not available. Most Australian doctors agree that the only conditions which may meet these criteria are

• acute cases of phimosis and paraphimosis - where the penis is being strangled by an extremely tight foreskin - which do not respond to cortisone cream (Betamethasone valerate) or other conservative treatments;

• recurrent balanitis xerotica obliterans (a fungal infection of the glans) which is not controlled by antibiotics.

(Martin J. Glasson, "Circumcision: A surgical perspective", Medicine Today, November 2001, p. 108)

Cutting off the foreskin to cure urinary tract infections UTIs is like amputating a toe to fix an ingrowing toenail.

Parental concerns

Parents want the best for their children and would never subject them to the pain and loss of circumcision if they did not think the benefits gained outweighed the deprivation. The small minority of parents who seek to have their boys circumcised today do so for a number of different reasons, including social or religious custom, family tradition or the belief that the operation will immunise against them against certain diseases, particularly STDs. This used to be the big selling point, but it is now realised that pre-emptive amputation of normal body parts is neither ethically acceptable nor an effective disease control strategy. No other part of the body is ever amputated because it might cause trouble or get infected later.

Fears about disease have recently been set to rest by the policy statement issued by the Paediatric and Child Health Division of the Royal Australasian College of Physicians in September 2002. Australian paediatricians have been advising against circumcision since 1971. In the latest review of their policy a working party made up of a broader group of doctors carefully examined the recent medical literature, including risks, harm and adverse outcomes, and claims about the supposed protective effect of circumcision against STDs, AIDS, urinary tract infections (UTIs), cancer of the penis and cervical cancer in female partners. It concluded that there was "no medical indication for routine male circumcision" and that there was "no evidence of benefit outweighing harm for circumcision as a routine procedure". The RACP (representing six Australian and New Zealand medical bodies) has thus sent a clear message to doctors and parents that they should not do it.

The full RACP policy is available here.

STDs like AIDS and human papillomavirus (HPV - wart viruses, some of which cause penile and cervical cancer) can easily be avoided by practising safe sex, and they are certainly not a reason for interfering with a boy's genitals long before he becomes sexually active. Even if circumcision did confer a slightly reduced risk, the loss of such a significant, interesting and beautiful part of the body would far outweigh the gain. The average age of first intercourse in Australia is about 17 years, when boys are old enough to understand the issues and capable of making their own decisions about how to manage risk.

Some parents still say they are worried that their sons may be teased or embarrassed if they are different from other boys, but that is a reason for leaving his penis alone. With the rate of circumcision in Australia at only 12 per cent, it is the circumcised boy who will be the odd man out - and how much worse would he feel if he had been deprived of something other boys enjoyed than to have something extra that other boys lacked?

Conclusion: Boys like their hoods

There is no medical justification for routine circumcision. It is the privilege of parents to have the chance to recognise their children's right to a complete body and to protect them from harm. Circumcision of children and others incapable of giving informed consent to medical treatment is a violation of a person's human rights, a breach of medical ethics and, if it is done to girls in many western countries, an offence against the law. It costs nothing not to cut, and the benefits will last a lifetime. An increasing number of boys are angry at having been circumcised when they were too young to protest, and some of these are turning to the law to seek damages, but few reproach their parents for leaving them as nature intended.

In the late 1980s a group of students at the Australian Defence Force Academy formed an amateur rock band called the 4Skins, so called (as you might guess) because none of the four players had been circumcised. At the annual Jazz and Review concert (a night of satirical sketches and musical numbers) they performed a few songs, and at the end of their segment they made a particular point of thanking their parents for making sure, when they were babies, that they would have foreskins to name their band after when they grew up. The looks of envy on the faces of the minority of other cadets who had not been so lucky was a sad and telling sight.

Further information

Vincent Bach offers a thoughtful discussion of why circumcised men are reluctant to talk about the subject and why some are keen to see their own sons circumcised. He also has useful advice to women on how to raise the subject with their partners and dissuade them from this point of view.
http://www.stopcirc.com/vincent/vulnerability_of_men.html

Parents considering circumcision for their baby should see the video available at www.intact.ca

Other useful advice

The statement on circumcision issued by the Royal Australasian College of physicians is available from

Royal Australasian College of Physicians
145 Macquarie Street
Sydney NSW 2000
Phone 02 9256 5444
paed@racp.edu.au
http://www.racp.edu.au/hpu/paed/circumcision/index.htm

Other useful advice

Information for parents on the CIRP website

Answers to your questions about your young son's penis

Care of the intact penis

A leaflet for parents: It's a boy

Paul Fleiss MD, The case against circumcision

Detailed information on the anatomy and physiology of the penis

Arif Bhimji, Infant male circumcision: A violation of the Canadian Charter of Rights and Freedoms