Friday, April 12, 2013

Circumcision is harmful, but what would be sufficient evidence?

In June of 2006 the British Medical Association wrote:

"If it was shown that circumcision where there is no clinical need is prejudicial to a child’s health and wellbeing, it is likely that a legal challenge on human rights grounds would be successful. Indeed, if damage to health were proven, there may be obligations on the state to proscribe it. The UN Convention on the Rights of the Child, which has been ratified by the UK, requires ratifying states to “take all effective and appropriate measures with a view to abolishing traditional practices prejudicial to the health of children”. At present, however, the medical evidence is inconclusive." 1

There is no doubt in my mind that circumcision of infants is harmful, not only in the high incidence of "negative events", but also in the guaranteed effects over male sexuality. And many of those harms have been clearly documented. My concern is, what would constitute sufficient evidence for these institutions to act on?

For example: in the 1st century C.E. it was known that circumcision affected male sexuality, as evidenced in the writings of Philo of Alexandria 2. Not only that, but circa 175 B.E. some Jews under the influence of Rome and Greece had work weights (the Judaeum Pondum) to stretch their foreskins, and Celsius had described a surgical procedure to recreate the foreskin (επισπασμοσ, epispasmos, epispasm). 3

In the 12th Century it was still known that circumcision diminished the pleasure of sexuality, as evidenced in the writings of Moses Maimonides 4. And in the XIX century it was still known, when figures such as J.H. Kellogg promoted circumcision (and female circumcision and other forms of genital mutilation of males and females) to cure masturbation.

In the early 20th century it was still known that circumcision was harmful for sexuality as evidenced in writings by R.W. Cockshut in 1935, referring to the leathery texture of the glans of the circumcised penis. 6

In 1950 circumcision was deleted from the covered procedures of the British NHS leading to an immediate decrease on the incidence of circumcision.

It is known that complications of circumcision can cause deaths, and England has had its share of dead babies due to these complications. Babies Goodluck Caubergs (2010), Boma Oruitemeka (1990), Raju Miah (1991) and Angelo Ofori-Minhah (2012) are just some of the victims 7. However, it has been acknowledged that every surgery has risks, and that on its own is not an argument not to perform them -although it would seem unfair that a non-necessary surgery on a non-consenting individual could result in the death of the patient. 

Many circumcised men have grown with aesthetic defects from their circumcisions, such as skin bridges (sometimes called adhesions), skin tags, excessive scarring, or suffered complications such as meatal stenosis, scars in the glans due to injuries, partial or total amputation of the glans, and in extreme cases total loss of the penis 8. The real incidence of these complications is unknown 9, but most of these complications can be traumatic for the individuals suffering them.

But what I find more troublesome is the sexual effects of circumcision, which are not the result of a complication but part of the intended result of the procedure. These effects include the loss of mobility of the skin of the penis (which creates mechanical and functional changes, changing the penis from a dynamically self-stimulating system, into a passive receptor dependent on external stimulation), the keratinization of the glans (due to the loss of the subpreputial space that helps maintain the moisture on the mucosal surface of the glans) which gradually desensitizes the penis, the damage to the frenulum and the loss of the nerve endings existing in the ridged band of the foreskin 10.

This loss of tissue has been documented by John Taylor in 1996-1999. Yet the medical community so far denies that this loss of tissue on its own alters the form or function of the penis or has any effect on sexual satisfaction.

In 2007 two studies attempted to measure the sensitivity of different parts of the penis comparing the circumcised and uncircumcised penis. While Payne's study 11 concluded that there was no significant difference in sensitivity between the glans of the circumcised and uncircumcised, Sorrells 12 concluded that the foreskin is more sensitive than any other part of the penis. The difference between these two studies was that Payne took no data for the foreskin, under the assumption that the foreskin has no sexual function once it retreats behind the glans, in a case of researcher bias, where an assumption on part of the researcher leads to ignoring data that could be relevant or not.

In 2010 the Royal Dutch Medical Association expressed that circumcision had a very real potential for complications and that there would be valid reasons for a legal ban, but recommended against a ban for fear of creating an underground market 13. The Royal Australasian College of Physicians recognized the existence of high-impact low-frequency complications such as death, permanent damage or loss of the penis 14.

In 2011 a Danish survey 15 showed that circumcised men and their partners were more likely to have difficulties during sex and less satisfaction. A 2011 preliminary investigation 16 suggested a link between circumcision, alexythimia and erectile dysfunction. In 2012, a Global Survey of Circumcision Harm 17 collected case studies of mild to severe circumcision complications of over 900 respondents, including photos and video testimonies. In 2013 a Belgian survey also indicated less sexual satisfaction and more frequency of pain during sex for circumcised men. 18

It is known that more men are expressing dissatisfaction over their circumcision at birth, and wish they had been left intact. The 1999 preliminary survey of men circumcised in infancy and childhood 19, while not an unbiased survey, evidenced the existence of these men who are unhappy that their genitals were altered and that they didn't have a choice over the procedure. The reason why more men are not expressing similar dissatisfaction could be because many of them feel that there is nothing that can be done and feel alone on their coping with the surgical alteration, or because they simply have no awareness of what they lost.

But as this list implies, there are harms that are the result of complications and also harms that are the natural result of the procedure. Those harms have been documented, and yet these documentation continues to be neglected and ignored by the medical community.

Gladly men themselves are creating awareness of this problem, as evidenced in a recent survey that shows that Britons support a ban on medically unnecessary circumcision. 20

How much evidence will be necessary for the medical community to react? How much evidence constitutes sufficient evidence, for the BMA and the government to make good on those words: "if damage to health were proven, there may be obligations on the state to proscribe it." 1



1. BMA. The law and ethics of male circumcision Guidance for doctors 2006

2. A Treatise On Circumcision. Philo Judaeus

3. Schultheiss D, Truss MC, Stief CG, Jonas U. Uncircumcision: a historical review of preputial restorationPlast Reconstr Surg 1998;101(7): 1990-1998.

4. The Guide for the Perplexed, Part III, Chapter 49. Moses Maimonides

5. J. H. Kellogg. Plain Facts for Old and Young

6. R.W. Cockshut. Circumcision. British Medical Journal, Vol.2 (1935): p.764

7. http://www.cirp.org/library/death/

8. http://www.circumstitions.com/Botched1.html

9. AAP Technical Report on Circumcision. 2012. Pediatrics.

10. J.R. Taylor, A.P. Lockwood, and A.J. Taylor The prepuce: specialized mucosa of the penis and its loss to circumcision

11. Payne K, Thaler L, Kukkonen T, Carrier S, Binik Y. Sensation and sexual arousal in circumcised and uncircumcised men. J Sex Med. 2007 May;4(3):667-74. Epub 2007 Apr 6.

12. Sorrells ML, Snyder JL, Reiss MD, Eden C, Milos MF, Wilcox N, Van Howe RS. Fine-touch pressure thresholds in the adult penis. BJU Int. 2007 Apr;99(4):864-9.

13. Royal Dutch Medical Association. Viewpoint on circumcision. 2010

14. Royal Australasian College of Physicians. Policy on Circumcision.

15. Frisch M, Lindholm M, Grønbæk M. Male circumcision and sexual function in men and women: a survey-based, cross-sectional study in Denmark. Int J Epidemiol. 2011 Oct;40(5):1367-81. doi: 10.1093/ije/dyr104. Epub 2011 Jun 14.

16. Dan Bollinger, Robert S. Van Howe Alexithymia and Circumcision Trauma: A Preliminary Investigation International Journal of Men's Health Volume 10, Number 2 / July 2011

17. http://www.circumcisionharm.org/

18. Guy A. Bronselaer1, Justine M. Schober2,3, Heino F.L. Meyer-Bahlburg4, Guy T'Sjoen5, Robert Vlietinck6, Piet B. Hoebeke1,* Male circumcision decreases penile sensitivity as measured in a large cohort. BJU 4 FEB 2013 DOI: 10.1111/j.1464-410X.2012.11761.x

19. T. Hammond. A Preliminary Poll of Men Circumcised in Infancy or Childhood . BJU International (83, Suppl. 1),  p. 85-92, January, 1999 (British Journal of Urology)

20. http://helpingmenblog.blogspot.com/2013/03/banning-circumcision-in-uk-more-popular.html


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