Circumcision can be a touchy subject. Parents are in the unenviable position of having to make this important and permanent decision for their sons with a lot of conflicting information. Those who choose to fully investigate the issue find an overwhelming spectrum of opinions amidst the facts, and most will encounter heated debate in the media, their social circles, or even within their own families. They hear from staunch defenders on medical, cultural, or religious grounds. They hear from others who consider the procedure unnecessary but relatively benign. They hear from those who see it as a human rights violation, ethically no different from female circumcision common to other cultures.
As you may have guessed, I am among those who hopes cultural change will make circumcision a distant memory. In the future, I suspect we will all be scratching our heads in disbelief that this is what we used to do to almost all our baby boys.
How do parents make this decision? For many, it is taken for granted as “just something you do.” Others do ask the question, “Should we or shouldn’t we?” and when their health care providers emphasize the touted health benefits of circumcision, they understandably take that at face value and proceed without further investigation. Then there are those who do more research and have more discussions and agonize over it. Of those, some come to an informed decision they feel good about and go ahead with the procedure, confident that this is the best decision for their child. Others who learn about the function of the foreskin, the reality of the procedure, and the gaping holes in the arguments in favor of it come away from their inquiries determined and empowered to leave their sons intact.
Sometimes, the decision to have it done has nothing to do with any health care professional’s recommendation or parental conviction about the procedure’s benefits. I have seen mothers sobbing as they send their babies to be circumcised, saying they do not want to do it and wish they didn’t “have to.” I have seen them do it anyway, even as the doctor who is about to take the baby assures them that it is an elective procedure they are free to decline, and that many parents are doing just that. These parents seem to be unable to let their own intuition and parental authority trump the enormous internal and external pressure they feel to follow this deeply ingrained cultural practice.
So what are the medical arguments in favor or circumcision, anyway? Whereas previously the American Academy of Pediatrics and Centers for Disease Control were relatively neutral on the subject, their latest guidelines lean more toward recommending the procedure. Briefly, the benefits cited are a decrease in the incidence of treatable urinary tract infections in the first year of life (with the risk of UTI’s still being low for babies with intact penises); reduction in risk of penile cancer (already very rare), and reduction in risk of HIV and other sexually transmitted infections, based on studies of adult men in Africa undergoing circumcisions. Ease of hygiene is often cited as a benefit as well. In a recent Huffington Post article, Dr. Morten Frisch did a fine job of addressing the newer guidelines, explaining all the reasons why newborn baby boys’ genitals ought to be left intact, and pointing out the problems with the arguments in favor of routine infant circumcision. Click here to read the article.
This is the first in a series of stories about circumcision from various perspectives–parents who had it done (those with and without regrets), parents who didn’t, adult men who had the procedure and those who didn’t, nurses and nursing assistants who assist with the procedure, and doctors who perform it.
I’ll start with my story.
My first exposure to circumcision was 20 years ago, as a nursing student doing my maternal-child health rotation on the postpartum unit. It was my day to be in the nursery and I was told I would observe a circumcision. Up to that point, I hadn’t given circumcision any real consideration. If I thought about it at all, I viewed it as “just something we do.” I can tell you I thought about it a lot afterward, because it made quite an impression on me.
First, the nurse strapped the baby to the “circ board.” I could see that alone was very distressing to the baby. I wondered what he was thinking. I was shocked, horrified and heartbroken by what followed. The baby screamed hysterically in pain throughout. Afterward, he looked glassy-eyed and shell-shocked. The procedure I witnessed was pretty much identical to the one in this video:
I was flabbergasted that this whole set-up could be treated as a normal and routine happening—that it seemed to be OK with everyone present. I was struck by the obvious desensitization of everyone involved, how oblivious everyone seemed to the baby’s suffering. (I don’t blame them—no doubt, this is a natural adaptation to be able to do the job day in and day out.) I wondered if the parents knew what was really going on here. In that moment, I decided that if I should ever have a son, circumcision was not going to be part of his experience. At the time, I had no knowledge of all the other reasons to leave newborns’ penises intact—I made that decision based on the procedure alone, and the fact that it is an elective surgery. In the weeks that followed, I did a lot of reading about the history of circumcision and the nature of the foreskin, all of which reinforced my resolve.
To be fair, most providers use anesthesia now, and a typical circumcision looks more like the one in this video:
It’s an improvement, but the use of anesthesia does not make it painless. The local anesthetic injections obviously hurt. It doesn’t always appear to take away all the pain of the procedure, although sometimes there is less crying than what you see here, and some babies don’t cry at all after the initial injections. In either case, there is post-op pain. And there is still a minority of providers who inexplicably do not use anesthesia.
What about the health care providers who perform the procedure? Most circumcisions are done by obstetricians, with fewer being done by pediatricians, family physicians, and midwives. There are of course those (most?) who believe it to be either benign or beneficial. How many see it as a heartbreaking yet unavoidable part of their profession? I often wonder what that spectrum looks like. What percentage of providers performing circumcision feel deeply conflicted about it and would prefer never to do the procedure again?
I don’t believe I would ever choose do the procedure with my own hands. That said, I can see how a provider could do them even if he or she objects to the practice (and for reasons beyond needing the job for which it’s a requirement). I can relate, because I often went out of my way to assist with them when I worked as an assistant nurse manager on a postpartum unit, even though it wasn’t part of my regular responsibilities. Some of the staff who assisted with circumcisions actively comforted the babies and were clearly very much aware of their suffering, while others seemed to approach it as a purely clinical event of little significance. As painful as I found it to witness, part of me wanted to be there, just in case the baby could feel the loving presence of someone who appreciated the magnitude of his experience. Just in case that made a difference somehow. I could see reluctant providers extending that mindset to actually performing the procedure—perhaps some feel that since the baby will be circumcised one way or another by someone, they will do it with as much care and compassion as they can muster. On the other hand, if there were an increase in providers unwilling to perform routine circumcision, that might spur more parents who take it as a given to consider the decision more carefully.
When you look at the medical benefits of circumcision, it all sounds good at first glance, but the practice of performing surgery on all newborns to reduce the risk of these problems borders on ludicrous when you apply the same logic to other situations. Should we start surgically removing baby girls’ labia so they don’t have to learn to clean between the skin folds? If we found that some form of female genital mutilation resulted in a small decrease in risk of urinary tract infection in the first year of life, would we start performing those procedures on all our newborn baby girls? What if we found that the same procedures might decrease the risk of contracting sexually transmitted infections because of the resulting changes in the nature of the post-operative genital skin, decreasing the amount of mucous membrane, which is more permeable to disease-causing organisms? Would we then start performing that procedure on all our newborn baby girls? Or might we refrain from surgically altering their genitals at birth and instead focus on safer sex practices when they are older? While we’re at it, breast cancer is much more common than penile cancer. Should all girls have double mastectomies at puberty?
These examples may seem extreme, but the point is this: we don’t remove healthy, functional body parts on a routine and widespread basis because it’s possible for those body parts to become infected or cancerous. If we started doing so with other body parts, where would that end? This conjures up some absurd images and scenarios. We would not adopt a brand new surgical procedure to be performed on all newborns for the same health reasons used to justify circumcision.
We need to finally admit that in this country, aside from the minority of circumcisions done for religious reasons, the real reason this routine procedure endures and continues to be promoted by health care professionals is due to cultural convention, not health benefits.
Health benefits are touted in the case of routine infant circumcision because we are already doing it and we want to keep doing it. So we use those arguments as justification for continuing a practice that we’re already doing for other, less defensible reasons—cultural convention, conformity, and unwillingness to question “the way we’ve always done it.”
I will admit that at times in the past, I have shied away from a full discussion with expectant parents. I kept it short and watered down, knowing I was unable and unwilling to suspend my bias on this particular topic if I discussed it in any depth. I no longer take that approach. This is the gist of what I now tell parents–to-be who are undecided about circumcision:
- I disclose that my personal bias is pretty strongly against routine infant circumcision. I suggest they also do their own research and have a discussion with their pediatrician, keeping in mind that the pediatrician likely has biases of his or her own.
- The foreskin is sexually functional, highly sensitive erogenous tissue.
- It is extremely straightforward and easy to teach boys with intact penises to clean themselves. Hygiene is simply not a valid reason to have this procedure done.
- There have been some modest health benefits demonstrated in some of the studies, namely in the prevention of urinary tract infection in the first year of life, possibly sexually transmitted infections, and penile cancer. These conditions are, respectively, relatively rare and easily treatable, otherwise preventable, or exceedingly rare. As such, if this were a new procedure, we would certainly not adopt the widespread practice of surgically removing functional genital tissue in healthy infants for these reasons. In light of that, the primary reason this procedure endures seems to be cultural custom. In addition to some possible health benefits, there are risks, as with any surgical procedure. (We give this handout to outline the risks and benefits.)
- Yes, it hurts. There is no way around that. Even when anesthesia is used, that involves several injections of lidocaine into the penis. This causes pain not only due to the needle sticks, but also the significant volume of the anesthetic that must be injected into the tissue to achieve adequate anesthesia. Think of a Novacaine shot you had at the dentist, and imagine a newborn baby experiencing that in his most sensitive area. And it doesn’t always work perfectly. Either way, the baby is strapped to a board with outstretched arms and legs restrained for the procedure, and most babies are clearly distressed by this alone. After the procedure, there is post-op pain. The glans of the penis is red and raw from the adherent tissue between the foreskin and the glans being separated with a surgical tool before removal. (These are the unembellished realities of the procedure. I think it’s important for parents to know exactly what is involved for their babies so an informed decision can be made. I don’t feel it’s responsible or respectful of parents’ intelligence to sugarcoat or gloss over this information.)
- Many parents are understandably concerned about cultural conformity. At this point, less than 60 percent of boys in the U.S. are circumcised. A boy with an intact penis will look like plenty of other boys in the locker room.
- If you have any doubts at all, consider that once it is done, it cannot be undone.
Here are some of the questions I hope to explore through this series:
- If health care providers must routinely, day in and day out, perform or assist with an elective procedure that inflicts pain on newborn babies, to what extent must they desensitize themselves to newborns’ experience in order to cope with this aspect of their work? How might the answer to that question differ depending on whether the provider is in favor of the routine practice, or believes this is unnecessary cosmetic surgery at best? If desensitization is required to be able to do the job, how might that desensitization challenge our ability to provide sensitive and compassionate care in general?
- Questioning the acceptability of this practice as a culture would require many adult men to consider how they feel about having been circumcised themselves. It would also prompt many parents to revisit the decisions they have already made for their children and consider whether or not they would make the same choices today. How much of our unwillingness to question this practice as a culture is due to understandable avoidance of this potentially painful inquiry?
- If a boy’s very first experience of his penis is pain and trauma, what unseen yet profound imprints might that make on him, psychologically and sexually? Good luck studying that. We can only speculate.
What questions come up for you? Please share your questions, thoughts and experiences in the comments.
Part 2: a mother of two boys who had one of her sons circumcised and left the other intact shares her story. (Subscribe using the link at the top left of this page to receive new posts via email.)
© Camille Williams and Wake Up, Mama! 2015