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Harvard Commentaries
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Harvard Commentaries
Reviewed by the Faculty of Harvard Medical School


Medical Myths Medical Myths
 

Circumspection for Circumcision


February 27, 2013

By Robert H. Shmerling M.D.

Beth Israel Deaconess Medical Center


Last reviewed and revised February 27, 2013

Consider this apparent contradiction: Most American boys are circumcised. Yet  the American Academy of Pediatrics (and other health organizations)  does not specifically recommend it. So it must be religious reasons that lead so many parents to have their sons circumcised, right? 

 Not so, according to studies and authorities on the subject. In fact, the United States is the only developed country in the world where so many male infants are circumcised without religious justification.

Then why do so many boys have circumcision? The answers probably include some myth and misconceptions about the medical risks and benefits of the procedure as well as some degree of cultural peer pressure — for example, so that a son looks like his peers or like his father. Keeping the emotional, religious and cultural justifications that promote circumcision separate from the medical justifications is not easy and has not always happened in discussions about the merits of circumcision.

There are multiple studies demonstrating health advantages to circumcision, ranging from a reduced incidence of penile cancer to a lower incidence of HIV infection. Yet, most experts have concluded that routine circumcision of all boys is not medically justified. The reason for this paradox lies in a closer look at the balance between specific medical benefits and risks.

What Is Circumcision?

Circumcision is a procedure in which the prepuce (more commonly known as the foreskin), a mobile flap of skin and tissue surrounding the tip (or glans) of the penis, is surgically removed. It may be performed at the hospital before going home for the first time, as is true for about 60% of newborn boys in the United States, or as part of a religious ceremony outside of the hospital (as is commonly practiced in Judaism). In some cultures, circumcision is performed much later, when a boy is considered at the threshold of "manhood."

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Medical Reasons To Perform Circumcision

It is important to distinguish routine circumcision for healthy, normal boys from that performed for a specific medical problem. There are only a few conditions that warrant circumcision as a treatment in children or adults. For example, sometimes the foreskin cannot be adequately pulled back, or retracted, a condition called phimosis. Because it may be difficult to clean under the foreskin when it cannot be retracted, there may be inflammation or infection under the foreskin, difficulty with urination, or problems with sexual function.

In children under age 4, the foreskin is often not completely retractable; this "normal phimosis" typically resolves on its own by early childhood. If irritation or infection occurs, it usually can be readily treated with ointments or creams. However, in older boys or men, recurrent infection or irritation related to phimosis that does not respond to simple measures (such as good hygiene or topical therapies) may lead to a recommendation for circumcision.

Paraphimosis, in which a tight, retracted foreskin becomes stuck, may impair the blood supply to the tip of the penis. Severe pain, pressure and a purple discoloration may follow. This requires immediate medical attention, including possible emergency circumcision.

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Routine Circumcision, Hygiene and Health

Surgical removal of the foreskin has been performed for centuries for a variety of reasons, including religious practice, cultural identity or even punishment. The notion that it had health advantages is a relatively new one, attributed to Victorian-era physicians. They believed that circumcision would prevent masturbation (untrue, of course) because the foreskin is the most moveable and erogenous part of the penis. Masturbation, in turn, was erroneously considered to be the cause of a host of medical problems, including paralysis, epilepsy, fever, tuberculosis, syphilis and insanity. This sequence of faulty assumptions led to the widespread notion that circumcision contributed to moral and medical health.

Confusion abounds regarding the health implications of circumcision. What are the medical benefits and risks of circumcision? Why has it become such a routine procedure for so many? Studies during the last 15 years have provided some answers that may be important to consider when making the decision for your son (or for yourself).

Some have suggested that the circumcised penis is easier to keep clean. In fact, no special treatment or care is recommended for those who are uncircumcised. Another possible benefit is that newborn circumcision will eliminate the potential necessity of circumcision as an adult; in fact, the incidence of adults requiring circumcision for medical reasons is quite small.

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The Advantages

For healthy, normal newborn sons, medical studies suggest that circumcision might decrease the risk of some health problems, including:

  • Urinary tract infections in the first year of life
  • Penile cancer
  • Sexually transmitted diseases
  • Cervical cancer among female partners
  • Contracting HIV infection

However, for each of these, the overall impact of circumcision is small, and there are much better ways to prevent these problems than by circumcisions. Perhaps this is why the popularity of circumcision is falling in the United States. And it may explain why health experts have stopped short of recommending it for all boys.

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The Risks

The most obvious and immediate risk of circumcision is pain. While there has been debate in past years about the capacity of the newborn to appreciate pain, research during the last decade has provided compelling evidence that the perception of pain is well developed even among newborns. Anyone who has been present at a circumcision performed without anesthesia can tell that newborns readily express displeasure once the procedure begins.

The safety of anesthetic agents for newborns has also been uncertain, but in recent years, guidelines recommend that all male infants undergoing circumcision receive anesthetic, generally in the form of a numbing ointment or an injection of novocaine-type medication.

Estimates regarding the rate of complications of circumcision range from 0.2% to 10%, depending on the quality of the reporting and how a complication is defined. These include scarring, laceration of the penis, bleeding, and inflammation of the urinary opening, and infection. Most are minor and self-limited. However, very rarely, more serious problems follow circumcision, including serious infection, gangrene, partial or total penile loss and even death. Other factors that one might consider as problems or risks associated with circumcision include the concern that there is lack of informed consent — at the time of most circumcisions, boys cannot themselves weigh its risks and benefits. Some have raised the concern that there may also be emotional trauma for the parents; in fact, many cannot bear to watch.

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The Bottom Line

In most cases, the decision to have a boy circumcised is made by his parents. That decision must be individualized and based on a host of factors. From my reading of the medical evidence, there are medical reasons to consider routine circumcision, but for many boys, the impact on health is small.  Where circumcision remains popular, including the United States, most circumcisions are done for nonmedical reasons (including religious and cultural ones).

It is worth asking yourself whether, if 90% of the boys and men in your town or community were not circumcised, would you recommend it for your son? Conversely, if you were inclined not to have your son circumcised, would it matter to you if he were the only one in the locker room with an intact foreskin?

Circumcision is a topic that has long been surrounded by myth. Much of the myth has been exposed for what it is, although defining the precise balance of risks and benefits is still not simple. Many questions remain unanswered.

Regardless of the decision parents make about circumcision, they should feel they have made the right one for them and their sons. They may have compelling religious or cultural reasons to have their sons circumcised.

However, if circumcision is based primarily on an assumption of large medical benefits, it may be time to rethink the issue. As with any other decision about the health or well-being of children, it is important that parents understand the risks, benefits and unknowns regarding routine circumcision.

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Robert H. Shmerling, M.D., is associate physician at Beth Israel Deaconess Medical Center and associate professor at Harvard Medical School. He has been a practicing rheumatologist for over 20 years at Beth Israel Deaconess Medical Center. He is an active teacher in the Internal Medicine Residency Program, serving as the Robinson Firm Chief. He is also a teacher in the Rheumatology Fellowship Program.

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