There are many different techniques and mechanisms by which circumcision occurs. Since the purpose of this series of posts on circumcision is to address routine infant circumcision in the hospital environment, I will not be addressing alternate circumcision practices, including non-hospital (religious ritual) circumcision.
Photo by Robert Valette, Creative Commons
Last week, I addressed the scientific evidence as it pertained to the benefits of circumcision. My conclusion was that there was no strong scientific evidence to support routine infant circumcision in the United States.
This week, I want to address the issue of harm; that is to say, is there evidence that routine infant circumcision carries significant, scientifically documented risks?
There are four common arguments given in opposition to routine infant circumcision. These are:
1) It is painful, and therefore cruel and/or damaging to the infant;
2) It results in diminished sexual function;
3) It is associated with a high rate of complications;
4) It results in long-term psychological trauma.
In this post, I will address the evidence for each of these in turn.
At one time, it was thought that neonates didn’t experience pain, didn’t distinguish it from non-painful stimulus, or couldn’t encode it. This was used as a justification for circumcision without analgesic. Later, it was thought that the injection of analgesic would be just as painful as circumcision without analgesia. Many studies have shown these notions to be false, including a study addressed in a previous post (see, for instance, AAP Statement, Fabrizi et al, Taddio et al). Pain-relieving options include a numbing topical cream and a dorsal nerve block (Brady-Fryer et al). However, neither of these completely eliminates pain during the procedure. Another nerve block, called a ring block, appears to be quite effective (Lander et al, Shockley et al). Further, in combination with other pain-relief methods, oral sucrose (sugar) also helps reduce discomfort (Razmus et al). The Lander study points out that not only does the ring block provide very effective analgesia during the circumcision procedure, the block injection itself is significantly less painful than non-anesthetized circumcision. Other analgesic options, including oral sucrose and topical numbing creams, can reduce the discomfort associated with the nerve block injection.
With regard to the notion that circumcision results in lasting damage due to the physical pain, there is some scientific evidence to support this in the case of circumcision with no analgesic. According to Taddio et al, infants circumcised with no analgesia had a greater pain response to subsequent noxious stimulus (vaccination) than infants circumcised with topical cream pain relief, who showed a greater response to the painful stimulus of vaccination than uncircumcised infants. The study did not examine the responses of infants circumcised with a ring block, however. Neither did the study note any effect persisting beyond the neonatal period. A review of the literature suggests that there is no scientific evidence to support the notion that circumcision (with or without analgesia) causes changes to pain response that persist beyond the neonatal period. Further, while some anti-circumcision advocates (sometimes called “intactivists”) suggest that circumcision causes brain damage and/or physical changes to the brain, there is no scientific evidence to support this notion. Studies that show a correlation between neonatal pain and changes in brain structure/function (such as Anand et al) are based upon repetitive exposure to pain, and can’t be generalized to one-time medical procedures.
Some argue that circumcision results in diminished sexual sensation and/or function. This is actually an untestable claim. It’s possible to compare the sexual function of men circumcised as infants with that of men not circumcised as infants, and it’s possible to compare the sexual experience of an uncircumcised adult male with his experience post-circumcision (in the case of a man circumcised as an adult), but it’s not possible to know what a man circumcised in infancy would have experienced had he never been circumcised. As such, none of the scientific evidence regarding sexual function and infant circumcision is particularly relevant or helpful, and can’t be used to support a strong argument either for or against the statement that circumcision affects sexual function.
One study of men circumcised as adults suggests that function may be affected, but finds that more men experience improved function than diminished function after circumcision (Fink et al). Of 123 men circumcised during adulthood, 38% reported harm in the form of perceived diminished function. 50%, however, reported improved function. Unfortunately, since 93% of the study participants underwent circumcision for medical reasons, the results of this study can’t be generalized to the population.
Unbiased studies have uncovered only anecdotal accounts (Moses et al) of sexual effects, which can’t be taken as scientific evidence (see this post for an explanation of why anecdotes aren’t scientific evidence). There are men who attribute their sexual dysfunction to infant circumcision, but there is no scientific evidence to support these claims. Some “intactivist” arguments suggest that female sexual partners of uncircumcised males derive greater sexual pleasure than do the partners of circumcised males. There are no scientific studies to support this. In fact, the few scientific studies that exist suggest the opposite. Ugandan women report greater sexual satisfaction from intercourse with circumcised men, despite the fact that circumcision is not routine practice in Uganda (Bailey et al). Surveys of college-aged American women show overwhelming preference (87%) for the appearance of a circumcised penis (Williamson et al).
There are a few survey studies of sexual function and attitudes about circumcision. One such survey (Hammond) showed strong evidence of sexual dysfunction and psychological trauma as the result of infant circumcision. However, it must be noted that the Hammond study did not sample the population randomly. Instead, study participants were asked to respond to a survey from the National Organization to Halt the Abuse and Routine Mutilation of Males (NOHARMM), an organization whose very name betrays its bias. As such, it’s not reasonable to generalize the findings of the Hammond study to the population at large, since the men most likely to participate in the voluntary survey would have been those who were dissatisfied with their circumcision. A much larger survey by Laumann et al found that of 1400 American men, those who were circumcised were actually less likely than uncircumcised men to report a sexual dysfunction. While the foreskin has sensory function (Taylor et al), there is no scientific evidence to suggest that the loss of these receptors affects sexual satisfaction or the intensity of the sexual experience for men. One study even goes so far as to suggest that while there isn’t currently evidence to support the notion that circumcision somewhat desensitizes men, even if such evidence existed, it wouldn’t necessarily be a bad thing, given that more men (and their partners) complain of premature ejaculation than complain of inability to achieve orgasm (Burger et al). While Burger doesn’t go so far as to suggest circumcision to prevent problems with premature ejaculation, these observations do put into perspective the “intactivist” argument that circumcised men don’t enjoy sex as much as they otherwise would; clearly, for the vast majority of men, enjoying sex isn’t a problem. The scientific evidence does not support the notion that male circumcision diminishes sexual performance in men, nor sexual satisfaction in men or women.
Regarding the notion that routine infant circumcision is associated with a high rate of complication, this does not stand up to scrutiny. The American Academy of Physicians (AAP) has reported a complication rate of 0.2-0.6%, though it’s difficult to accurately assess the rate of complication, since different surveys include different symptoms as complications of circumcision. As such, some studies suggest higher rates of complication, though they define “complication” very differently (including aftereffects that can’t necessarily be attributed to circumcision). On the flip side, Wiswell reports that approximately 10-15% of males who are not circumcised as infants have recurrent balanitis (swelling of the foreskin) or phimosis (foreskin that doesn’t retract), and require circumcision later in life. The adult procedure is a more significant surgery than the infant procedure, leading some practitioners to view circumcision as “preventative medicine.” Not all cases of balanitis or phimosis require surgical treatment, however, meaning that Wiswell’s numbers don’t translate directly into a percentage of uncircumcised men who will require adult circumcision. Based upon the numbers, there is not adequate evidence to suggest that routine infant circumcision is particularly risky.
Finally, with regard to the argument that infant circumcision results in psychological trauma, the support for such a notion is anecdotal and unprovable. “Intactivists” argue that many (some even go so far as to say most) circumcised men are traumatized by their circumcision, and that those who don’t acknowledge the trauma are in denial. This is a spurious claim; one could just as easily make the argument that children born by cesarean section are traumatized by not having experienced a vaginal birth, and that those individuals born by cesarean who don’t acknowledge their psychological pain are “in denial.” The denial argument is a powerful-appearing one for the “intactivists,” since by definition, any man who denies being in denial is categorized as…in denial. Still, we can make an attempt to sort through the science. A very large (5000 individuals) British study showed that circumcised men scored no differently than uncircumcised men on a variety of behavioral and psychological tests (Calnan et al), indicating that if the circumcised men were at all “traumatized,” it was undetectable to psychologists and didn’t affect their behavior. In a position paper, a psychiatrist and anti-circumcision activist compares circumcision to sexual abuse and an assault on the body (Goldman), but there’s no evidence to support the validity of the former, and the latter comes from the statements of young Turkish boys ritually circumcised without analgesic in a public ceremony, so it can hardly be generalized to anesthetized neonates in a hospital setting.
Goldman continues by suggesting that infant circumcision is associated with long-term psychological effects. As evidence for this, he cites the reports of men who contacted the Circumcision Resource Center (CRC). There are two problems with using this group, and their anecdotal reports of psychological harm, as evidence that circumcision has a psychological impact upon the general population. First, the men were “self-selected,” meaning they don’t represent a random selection of the population. To consider these individuals representative of the population is tantamount to making the claim that most Americans believe in extraterrestrials on the basis of those select individuals who contact SETI (Search for Extraterrestrial Intelligence) to report them. As with people who feel strongly enough that they’ve seen an alien to warrant a call to SETI, those who contact the CRC represent the small minority who feel particularly strongly about their circumcision. While it would be wrong to discount the intensity of their individual feelings, neither can one reasonably generalize those strong feelings to circumcised men as a whole. Furthermore, though SETI may claim (or even attempt) to be impartial and scientific in their search for evidence of extraterrestrial life, they are nevertheless predisposed to a particular outcome, and therefore their conclusions may reflect a bias. Similarly, the CRC is predisposed to find evidence that circumcision leads to harm. A second important point with regard to those men who contacted the CRC (and again, this is not meant to downplay their psychological pain) is that since no man has a conscious memory of INFANT circumcision (the brain doesn’t work that way), it’s pure conjecture on the part of a man to suggest that his psychic trauma is the result of his circumcision. He might feel regretful that he was circumcised, or he might wish he hadn’t been, but these feelings could as easily be the result of events he experienced post-circumcision (the emotions conjured by which he falsely attributes to the circumcision in a post hoc ergo proctor hoc fallacy). Even Goldman, who is clearly biased toward showing that circumcision causes harm, can only conclude that “the connection between present feelings and circumcision may not be clear.” In essence, that leaves the psychological trauma argument insufficiently supported from a scientific perspective. While some men may be traumatized by circumcision (though again, whether infant circumcision was the root cause of an individual’s feelings of psychological trauma is impossible to determine), there’s no scientific evidence to suggest that routine infant circumcision has lasting psychological effects.
Science Bottom Line:* There is no scientific evidence that strongly links routine infant circumcision with appropriate analgesia to physical or psychological harm.** Because there are many options available for managing pain during infant circumcision, however, there’s simply no justification for medical circumcision without analgesia.
**Obviously, this is not to say that no one is ever hurt by circumcision, or that there are not individuals who wish they hadn’t been circumcised. However, the SCIENTIFIC EVIDENCE does not provide support for the argument that routine infant circumcision is harmful. As such, the argument AGAINST circumcision in the U.S. can’t be made on the basis of scientific evidence, and must instead be made on the basis of values and beliefs.
What do you think about the risks of circumcision?
References:
AAP. Circumcision policy statement. American Academy of Pediatrics. Task Force on Circumcision. Pediatrics. 1999 Mar;103(3):686-93.
AAP. American Academy of Pediatrics: Report of the Task Force on Circumcision. Pediatrics 1989 Nov;84(5):761.
Anand et al. Can Adverse Neonatal Experiences Alter Brain Development and Subsequent Behavior? Biol Neonate. 2000 Feb;77(2):69-82.
Bailey et al. Acceptability of male circumcision as a strategy to reduce HIV infection in Uganda. AIDS Care. 2002 Feb;14(1):27-40.
Brady-Fryer et al. Pain relief for neonatal circumcision. Cochrane Database Syst Rev. 2004 Oct 18;(4):CD004217.
Burger et al. Why circumcision? Pediatrics. 1974 Sep;54(3):362-4.
Calnan et al. Tonsillectomy and circumcision: comparison of two cohorts. Int J Epidemiol. 1978 Mar;7(1):79-85.
Fabrizi et al. Electrophysiological Measurements and Analysis of Nociception in Human Infants. J Vis Exp. 2011 Dec 20;(58). pii: 3118. doi: 10.3791/3118.
Fink et al. Adult circumcision outcomes study: effect on erectile function, penile sensitivity, sexual activity and satisfaction. J Urol. 2002 May;167(5):2113-6.
Goldman, R. The psychological impact of circumcision. BJU Int. 1999 Jan;83 Suppl 1:93-102.
Hammond et al. A preliminary poll of men circumcised in infancy or childhood. BJU Int. 1999 Jan;83 Suppl 1:85-92.
Lander et al. Comparison of Ring Block, Dorsal Penile Nerve Block, and Topical Anesthesia for Neonatal Circumcision. JAMA. 1997 Dec 24-31;278(24):2157-62.
Moses et al. Male circumcision: assessment of health benefits and risks. Sex Transm Infect. 1998 Oct;74(5):368-73.
Razmus et al. Pain management for newborn circumcision. Pediatr Nurs. 2004 Sep-Oct;30(5):414-7, 427.
Shockley et al. Clinical inquiries. What’s the best way to control circumcision pain in newborns? J Fam Pract. 2011 Apr;60(4):233a-b.
Taddio et al. Effect of neonatal circumcision on pain response during subsequent routine vaccination. Lancet. 1997 Mar 1;349(9052):599-603
Taylor et al. The prepuce: specialized mucosa of the penis and its loss to circumcision. Br J Urol. 1996 Feb;77(2):291-5.
Williamson et al. Women’s preferences for penile circumcision in sexual partners. J Sex Educ Ther. 1988; 14: 8.