Ryan McAllister, Ph.D., Executive Director of NotJustSkin.org and others.
One of NotJustSkin's primary missions is to educate the public about violations of informed consent or bodily integrity. In the U.S., male genital cutting, more often called circumcision, is commonly practiced even though parents rarely receive the information that would be required to give informed consent to any other procedure. Circumcision is the only procedure where a doctor can legally amputate part of a nonconsenting child without any medical reason.
You can watch our lecture on circumcision, Child Circumcision: an Elephant in the Hospital. Note that this presentation includes graphic material to convey more complete information about the topic.
Child Circumcision: an Elephant in the Hospital from Ryan McAllister on Vimeo.
The following are answers to some commonly asked questions about circumcision. Further questions and suggestions can be directed to Ryan, above.
- Isn't circumcision just a little snip?
In a typical infant boy, the foreskin is a double-sided sleeve of skin and soft mucosal tissue that completely encloses the glans (the head of the penis). It is actually physically bonded to the infant's glans. This skin contains thousands of blood vessels and specialized nerves. In an adult, it would grow to cover 12-15 square inches. Circumcision removes this part of the penis. The operator forces a metal clamp inside the foreskin, and tears the skin away from the glans. The operator then slices the foreskin down past the glans and cuts the foreskin off. The entire procedure is excruciatingly painful. Infant circumcision is performed without adequate anesthesia, since anesthetizing such a young infant can be very dangerous. Partial or complete amputation of the penis sometimes occurs. Some children even die from the trauma, hemorrhage, or other complications.
- What problems can occur after the initial surgery? Are there complications?
Immediately after circumcision, a child is at risk for infection and hemorrhage. The loss of the protective foreskin places him at risk for complications including meatitis (inflammation and ulceration of the urinary meatus), meatal stenosis (constriction of the meatus, resulting in blocked urinary flow and potential infection), preputial stenosis (scarring that constricts the glans), and buried penis (entrapment of the penis by scar tissue). Together, these conditions, which are almost unheard of in non-circumcised males, affect up to 20% of circumcised males and may require additional surgery.
A circumcised male may also experience chafing and abrasion of the exposed glans against clothing, painful erections due to the tightened skin, scarring, and desensitization that can severely reduce enjoyment of sexual activity. A circumcised penis may be significantly smaller than it would otherwise have been. For more information, see the Circumcision Information Resource Center, under "Complications of circumcision."
- What is the value of the foreskin?
The foreskin has protective, sensory, biomechanical, and immunological functions. Throughout life, the outer part of the foreskin protects the sensitive inner part of the foreskin and the glans from injury, abrasion, chafing, and infection. The foreskin keeps its mucosal tissue and the glans soft and moist so that it maintains sensitivity. During sexual activity, the foreskin glides up and down over the glans, providing sensation from thousands of specialized nerve endings in the inner foreskin. Parts of the foreskin, including the frenulum (a narrow membrane on the underside of the foreskin) and the ridged band (the edge of the foreskin, between the inner and outer skin), are particularly important in sexual function. See the Circumcision Information Resource Center, under "Foreskin sexual function." Circumcision removes most of the inner and outer foreskin, and destroys these functions.
The foreskin secretes immunological substances that fight infection, called lysozymes, and also produces natural lubricants, reducing the need for artificial lubricants during sex. The presence of the foreskin can enhance the sexual experience for both partners. Polls of women who had experienced both circumcised and uncircumcised partners indicated a strong preference for the latter, with longer duration of coitus and higher rate of orgasm cited as the main reasons (for example, see "The effect of male circumcision on the sexual enjoyment of the female partner").
- Isn't female circumcision worse than male circumcision?
Female circumcision is typically viewed by people in the U.S. as more horrific than male circumcision because it is usually done under unhygienic conditions rather than in a hospital, and because one form of female circumcision, infibulation, is particularly severe. However, both male and female circumcisions remove functional, normal tissue, cause extreme pain, permanently disfigure the genitals, and permanently damage the sexual response. And in most cultures where female circumcision is performed, male circumcision is also performed with equally unhygienic instruments. Regardless of the child's gender, when done to infants or children, unnecessary genital surgeries violate human rights because they are amputations performed without medical need, and thus cannot have legitimate proxy consent.
The World Health Organization recognizes three types of female circumcision. Type I removes the clitoral hood and/or the clitoral tip. Type II removes the clitoral hood, clitoris, and part or all of the labia. Type III, also known as infibulation or pharaonic circumcision, involves removal of all external female genitalia and suturing of the vaginal opening.
Male circumcision can be compared to type I or II female circumcision. Although the glans is not harmed at the time of circumcision, the loss of protective structures causes it to dry out and lose sensitivity over time. It is also important to note that most of the nerves and pleasure receptors present in the clitoris are, in the male, present in the foreskin and its associated structure, the frenulum. Removal of these nerves constitutes a loss that can be most adequately compared to a partial clitoridectomy.
- If circumcision were really harmful, wouldn't a lot of men be talking about it?
A lot of men are. National organizations such as NOCIRC (National Organization of Circumcision Information Resource Centers) and NORM (National Organization for Restoring Men) testify to the existence of millions of men who have lost sensitivity and function due to circumcision. Married, single, heterosexual, homosexual, and bisexual men of all ages are finding that their adult sexuality has been compromised by the loss of their foreskins in infancy.
Because our culture discourages men from admitting feelings of inadequacy or discussing health problems, particularly those of a sexual nature, many men have felt unable to describe their problems or have not found a receptive audience to their concerns. Many are also unaware of how much feeling they have lost; it is impossible for a circumcised man to know what his experience of sexuality would have been, had he not been circumcised. There is medical literature suggesting that circumcision causes sexual dysfunction later in life, as well as anecdotal evidence from circumcised men who experienced problems with chafing or lack of pleasure from sex (see Personal Stories).
Circumcision affects each man differently. During the healing process, some may be able to reroute more or fewer of the severed nerves and blood vessels and may retain more or less ability too feel. Some men feel numb during sexual activity and are unable to feel any pleasure. One man who was circumcised as an adult compared his sexual experiences before and after to the difference between seeing in color, and seeing in black and white.
- If circumcision doesn't provide any health benefits, then why do doctors still do it?
The primary reason in the United States is cosmetic. The image of the circumcised penis has become so much a part of our cultural consciousness that most people do not know what a non-circumcised penis looks like. They may feel that the natural look is ugly or may think it is unhygienic. Discomfort with the natural appearance of the penis is a learned response.
Tradition is powerful. Many parents cite their desire to have their son look like his father, or like his friends. As the circumcision rate in the U.S. falls (it is now around 60%), the intact penis will become the norm instead.
Some parents ask for circumcision because they believe that it will save their sons from having health problems later in life. In fact, circumcision does not provide any protection against infection, penile cancer, or sexually-transmitted diseases (including HIV/AIDS), and does not reduce the rate of cervical cancer in female partners. (See the Circumcision Information Resource Center, under "The role of the prepuce in prevention of disease and infections.") Myths about circumcision are slow to die and are still used to justify many surgeries.
Another reason doctors continue to perform circumcisions is that they, like the general public, are unaware of the value of the foreskin. The standard medical education in the United States includes the technique of circumcision but lacks a description of normal penile anatomy or function. Around the turn of the previous century, medical textbooks began printing images of circumcised penises instead of intact ones, so most medical students do not even have the opportunity to learn what a normal adult penis looks like.
Many doctors and medical students are not aware that infant circumcision is not recommended by any national medical organization in the world.
Circumcision is also a procedure that doctors can perform in just a few minutes. The cost of an infant circumcision is a few hundred dollars. Amputated foreskins can be sold later to pharmaceutical and medical companies for use in research and in the production of shampoos, emollients, and skin for burn therapy. These financial incentives may complicate the issue.
- Isn't circumcision part of Jewish religious heritage? Is circumcision part of other faiths?
Circumcision occurs in Jewish, Islamic, and many tribal traditions. In Judaism, the circumcision is performed during a naming ceremony called Brit Milah, and is done by a mohel on the 8th day of life. In many Islamic traditions, circumcision is done near puberty, and the ceremony is called kataan. There are also many other cultures or faiths in which male circumcision, usually done between ages 6 and 12, is important.
The vast majority of infants who are circumcised in the United States do not have parents who belong to a faith or culture in which circumcision is important and are not circumcised for religious reasons. Furthermore, hospital circumcision is not performed as part of a religious ceremony.
Within the Jewish community, there is growing disagreement about circumcision. Some feel that circumcision contradicts other aspects of the Jewish religion. The Torah forbids the torture or causing of pain to any living creature, especially physically assaulting or harming another person (Exodus 21:18-27). Jewish law specifically forbids body modification, including the cutting or marking of the human body (Lev. 19:28). Jews are also required to help those who are helpless, such as newborn infants, and are exempt from performing religious duties that would cause harm to others.
There is an alternative ceremony called a Brit Shalom that incorporates the tradition of the naming ceremony without damaging the foreskin. Ronald Goldman's article, "Circumcision: A Source of Jewish Pain" provides an in-depth discussion of circumcision from a Jewish perspective. There is additional information under the Religious Support section of our site, including contact information for Jews Against Circumcision.
Some ethicists feel that all types of infant and child circumcision, whether done as part of a religious ceremony or not, violate human rights. Female circumcision is seen as a human rights violation even though it occurs in the context of a religious ceremony in many cultures.
- I've heard or seen that some babies don't even cry when they're circumcised, so it must not hurt them. Even if it is painful for them, if they can't remember the pain later, why does it matter?
It's impossible for us to know what kinds of long-term consequences a procedure as traumatic as circumcision might have on the developing mind and senses of a newborn baby. Babies who don't cry during circumcision are so severely traumatized by the pain that they lapse into a state of shock. For all infants, the experience of circumcision is an injury that betrays their early desire to bond with their caregivers. Babies who have been circumcised are significantly more likely to avoid eye contact, to be unresponsive to adults, and to have problems breast-feeding.
Babies may feel pain more intensely than adults. Because the neural pathways that allow "pain-killer" endorphins to be released in response to severe injury are not yet fully developed, babies may experience more intense and unrelenting pain than they would if they were subjected to the same trauma later in life. There is also evidence that the memory of circumcision pain is retained far longer than previously thought. In one study, circumcised male babies reacted more severely to the pain of vaccination months later, than non-circumcised male babies did. See the Circumcision Information Resource Center, under "Pain of circumcision and pain control."
No anesthetic can make circumcision a painless procedure.
- If parents decide not to have their son circumcised, won't he be teased?
Circumcised children are also teased. The body of a non-circumcised boy is normal, healthy, and whole. A proper understanding of his own anatomy and the reasons he was allowed to remain intact, will enable a boy to feel self-confident about his body. Furthermore, circumcision is already uncommon internationally and is becoming less common in the U.S.
- Isn't it more complicated to care for an uncircumcised penis?
An infant's foreskin is non-retractable and should not be forcibly retracted for cleaning. It does not require any particular care. By the age of 18, most men's foreskins will have become retractable, and can be cleaned by sliding the foreskin back, rinsing with warm water, and letting the foreskin slide forward again. It is not necessary to use soap or any harsh cleansers; soap use may even cause problems. The intact penis is a self-cleaning organ that produces smegma (a creamy substance also produced by females, containing dead cells and immunological substances) to combat infection. See the Circumcision Information Resource Center, under "Proper penile hygiene for intact men."
Meanwhile, following circumcision, the injured penis requires careful attention and monitoring. In the absence of complications, the open wound takes about ten days to heal. During this time, the child may have difficulty sleeping and breastfeeding. In addition, there is a risk of infection, adherence of the bandages to the wound, and abnormal healing.
- What if an uncircumcised man has problems with his foreskin later?
The most commonly cited indication for circumcision after infancy is a condition called phimosis, in which the foreskin has scar tissue or inflammation and becomes tight around the glans. In children, this can result from premature, forcible retraction of the foreskin, which causes tearing of the skin and creates a raw wound susceptible to infection. Circumcision is an excessive treatment for phimosis, which can be resolved by steroid creams, and gentle manual loosening and stretching of the foreskin, and in severe cases, moderate preputioplasty. See the Circumcision Information Resource Center, under "Conservative treatment of penile problems."
Like every part of the body, the foreskin has the potential to develop malignancies. Malignancy of the foreskin is extremely rare (approximately 1 in 100,000) and occurs mostly in older men. It is appropriate to treat this cancer by removing the cancerous region of the tissue. The only other medical reasons to amputate foreskin tissue are frostbite and gangrene of the foreskin, also extremely rare.
- How late can parents wait to make the decision about circumcision?
Parents may wait as long as they like to make this life-changing decision; circumcision does not need to be performed at any particular point. Parents are typically asked during pregnancy whether they want a circumcision if the child is a boy. In more rushed scenarios, mothers may be presented with a circumcision consent form while they are in labor or under anesthesia. Doctors usually do not provide comprehensive information about the procedure or its effects, so parents need to take the time to educate themselves about it.
If they decide not to circumcise, they must be prepared to enforce their decision and to not allow the infant to be removed from their sight while they are in the hospital. There are numerous cases of circumcisions being performed on infants whose parents had not given consent, or who had directly indicated that they did not want a circumcision done.
- Are there ethical concerns about circumcision? Can circumcision be viewed as a violation of human rights?
There are two main arguments that performing circumcision upon minors cannot be ethically defensible.
The first argument is based on the child's rights to physical integrity and self-determination. Several United Nations General Assembly Resolutions have established these and related rights for children. (See Attorneys for the Rights of the Child.) The act of performing an unnecessary amputation violates both these rights. Circumcision is not medically necessary, and has no established health benefits; therefore it is an unnecessary amputation.
The second argument is that all human beings have equal rights. Since any unnecessary surgical alteration to female genitals has been condemned by the U.N. and has been illegal in the U.S. since 1997, equal rights dictates that male and intersex children have the right to equal protection from unnecessary genital surgeries.
Further, to be ethically and legally defensible, any elective surgery requires informed consent. Informed consent becomes even more important when the surgery is performed on a minor and/or when the surgery is sexual in nature. The informed part of informed consent requires that the decision-maker (in the case of infant circumcision, this is the guardian) be given complete information about the procedure, including risks, proposed benefits, and alternatives. At the time of this writing, circumcision consent forms used in hospitals and by private practitioners generally lacks this information. Therefore the right parents have to be offered informed consent is also being violated.
- What is foreskin restoration?
Partial, non-surgical restoration of the foreskin is possible. Circumcised men who wish to restore their foreskins can attempt the slow process of non-surgical restoration, which involves gradually stretching the shaft skin over the glans until it grows enough to cover the glans. There are various techniques, including daily manual tugging, taping, or extension devices like weights. The process typically requires several years. Many men who have restored report benefits including reduced chafing, enhanced lubrication and softness, and enhanced pleasure during sex. For more information, visit the National Organization of Restoring Men (NORM).
- I've heard that there are other genital surgeries done to children? What is intersex? What is forced gender assignment surgery?
A small fraction of children (estimates vary, but perhaps around 0.1% of live-births) are born with atypical genitals, meaning genitals that do not look to an observer like most babies' penises or vulvas. Don't panic. Atypical does not mean bad, just unusual. Over a dozen underlying biological conditions can cause result in atypical genitals. In the past, a child born with unusual genitals may commonly have been treated as an emergency requiring surgical alteration to look more like other children. Unfortunately, these forced gender assignment surgeries have resulted in unnecessary traumatization and injury to thousands of persons. These surgeries can also be viewed as a violation of human rights.
When parents become aware that they have a child whose genitals appear unusual, or a person becomes aware that they have an intersex condition, a good next step is to begin learning about intersex. Organizations like the Intersex Society of North America and Bodies Like Ours provide medical and scientific information about intersex conditions and contact with other individuals in similar situation.
This FAQ may be freely distributed without change.