The Problem of Circumcision in America

James L. Snyder, M.D.
The Truth Seeker, pp 39-42, July/August 1989
Presented in 1989 at the First International Symposium on Circumcision

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In the matter of circumcision of newborn males, it must be recognized that the child is normal as born, and that circumcision inflicts loss of a normal body part and leaves a scar. This is contrary to the motto of medicine which is "First, do no harm. "

"There is no absolute medical indication for routine circumcision of the newborn."

In the United States, alone among industrialized societies, and in the two generations born since about 1940, routine newborn circumcision has become such an accepted routine in the process of birth and delivery that for some people it is a surprise to discover that there is controversy over the desirability of the procedure. In 1975, The American Academy of Pediatrics (AAP) published the report of a committee formed to study circumcision, whose opinion was that "There is no absolute medical indication for routine circumcision of the newborn." This statement is contained in the body of the Report of the Ad Hoc Task Force on Circumcision from the Committee on Fetus and Newborn of the AAP (Pediatrics, Vol. 56 No. 4, October 1975, and modified in March 1989). The body of the report addresses most of the commonly voiced concerns, such as phimosis, hygiene, care of the penis, cancer, balanitis and venereal disease, surgical risks, and contraindications to circumcision. The Report also called for "true informed consent " and a "...program of education leading to continuing good personal hygiene (which) would offer all the advantages of routine circumcision without the attendant surgical risk. " And finally stated, "Therefore, circumcision of the male neonate cannot be considered an essential component of adequate total health care."

"Circumcision of the male neonate cannot be considered an essential component
of adequate total health care."

Almost immediately the American College of Obstetricians and Gynecologists and the American Urological Association - medical specialty societies with an immediate interest in the question - published positions which in very nearly the same words supported the position of the AAP. The expected result should have been an immediate drop in the number of newborns subjected to routine circumcision. The procedure would have been discarded or, at least, physicians who continued to perform significant numbers of circumcisions would have been under the same critical review as those who continued to perform large numbers of unnecessary tonsillectomies when that operation fell into disrepute. Curiously and, in some instances, tragically, no such thing occurred. Even today, more than thirteen years after the AAP made its findings known, the Report, only slightly modified in March 1989 to emphasize balance of risks versus benefits, continues to be ignored by physicians and to be unknown to the lay public. As a result, and contrary to the recommendations of the American Academy of Pediatrics, circumcision continues to be performed in rates varying from 50% to 90% of newborns in various parts of the country. Just why this is tragic is what I propose to show. Initially, it must be recognized that the statement of the AAP, "There is no absolute medical indication for routine circumcision of the newborn," has been perceived to mean that, while circumcision is not necessary, it is perfectly all right to continue to do it. Therefore, physicians who would refuse to give a child an unnecessary shot of penicillin, simply because it was requested by parents, are continuing to perform an operation on the request or by the compliance of parents.

Sadly, there have even been instances when a child was circumcised
without the parents' wishes or consent.

It must be acknowledged that there are numerous reasons why circumcision continues to be performed upon children. Some parents request the operation because of the influence of family or friends and find that their physician will comply. Some physicians continue to insist that the operation be performed on children in their care and persuade young and impressionable parents that they have no choice, or that it is in the child's best interest. Sadly, there have even been instances when a child was circumcised without the parents' wishes or consent.

The fact is that circumcision confers no immunity to any of these diseases.

The proponents of circumcision in recent years have published articles which are claimed to show as a scientific fact that uncircumcised males are at greater risk of acquiring a number of benign diseases and one rare malignancy. It has been stated, for instance, that circumcision would reduce the opportunity to acquire syphilis, gonorrhea, herpes, venereal warts, urinary infections, and other benign conditions. The fact is that circumcision confers no immunity to any of these diseases, which any physician treating large numbers of circumcised American men - as in the military services - can readily observe. If all men were circumcised, only circumcised men would contract these diseases, for most of which there are satisfactory antibiotic treatments. Most recently, there has been speculation that circumcision would offer protection from infection by Human Immunodeficiency Virus, the suspected causative agent of the disease AIDS. The stated basis for this is the observation of the AIDS infection pattern in a small number of African men who frequented AIDS infected prostitutes. The proponents of this speculation choose to ignore the obvious fact that AIDS infections were first recognized in American homosexual men who were overwhelmingly Caucasian, middle class, and circumcised. Thousands of men with AIDS fill the hospital beds of our major cities and are testimony to the failure of circumcision to offer any degree of immunity to AIDS infections.

Thousands of men with AIDS...are testimony to the failure of circumcision
to offer any degree of immunity to AIDS infections.

The most significant argument that has been put forth for circumcision is that it prevents cancer of the penis. This may be true, but even proponents of circumcision admit that there have been occurrences of penile cancer in men circumcised as infants. Cancer of the penis occurs, on average, in men aged 55 years, and is one of the least common malignancies in men, representing ½ of 1% of all cancers in men and occurring at a rate of less than one case per 100,000 per year in the United States. This is the same incidence as in the countries of Northern Europe, where infant circumcision is almost unknown. Proponents of circumcision would like to have the public believe that the low incidence of penile cancer in the United States is due to infant circumcision, but they ignore the fact that the population of American men born before 1940, who are now in the over 50 age group at risk for this cancer, is a group of predominantly UNCIRCUMCISED men. It is known that the rate of occurrence of penile cancer in the men of India, China, and the Caribbean areas (where circumcision is not customary and where sanitary facilities are primitive) is 20-30 times more common than in the uncircumcised men of Northern Europe. Therefore it is apparent that the variable of circumcision or non-circumcision is not the primary variable influencing the occurrence of penile cancer. Referring again to the Report of the American Academy of Pediatrics, it must be concluded that "...continuing good personal hygiene..." may be a significant factor protecting the uncircumcised men of Europe and America from penile cancer.

No one seriously advocates removing the breasts of female infants
to prevent this more common malignancy of breast cancer.

Circumcision is the only surgery which is used to prevent disease. In contrast, consider that in absolute numbers over a ten-year period (1943-1953) the Danish Cancer Registry reported 251 cases of penile cancer and for the same period reported 10,000 cases of breast cancer in women. Yet, nobody seriously advocates removing the breasts of female infants to prevent this more common malignancy of breast cancer. Almost certainly such a proposal would be greeted by howls of outrage over such a mutilation of women to prevent breast cancer. Circumcision must be recognized as an equally serious mutilation of men with equally insubstantial justification for continuing the practice.

Circumcision must be recognized as an equally serious mutilation of men
with equally insubstantial justification for continuing the practice.
...Most often a poor surgical result is not recognized until years after the event.

The risks of newborn circumcision are an underreported and ignored factor in this argument. Most often a poor surgical result is not recognized until years after the event. By the time a child reaches the age of maturity and discovers how he has been mistreated, the surgeon cannot be found, and parents may be beyond the age of interest in such matters. The child who simply has been cut too short will then become a sexually dysfunctional adult. Some of the men who have realized that they have been deprived of a normal part of their bodies have sought plastic surgical procedures to reconstruct their bodies with the same motivation as persons who have lost other portions of their bodies by accident or disease, and who have sought to regain normal bodily integrity. The more serious complications of circumcisions are increasingly being reported in the lay press:

On balance, circumcision is an unjustifiable preventive for penile cancer
with an unacceptable number of serious complications.

My own personal experience as a urologist with nearly 25 years of practice has included two children who must be numbered in these tragedies and are likely to be genital cripples. In Florida, in 1976, 1 was called to see a newborn immediately after his circumcision with a Gomco clamp. This child had suffered complete removal of the skin of the penile shaft, but the surgeon had left the foreskin in place. In panic, he had discarded the skin and tried to conceal the mishap. The obviously raw surface of the penile shaft required an urgent surgical procedure to cover its surface by grafting (for a similar child see Figures 1 and 2.) In 1982, I was called to see a Virginia infant who had been circumcised using a Gomco clamp and electrocautery. The result was complete loss of the glans and shaft of the penis due to a full thickness burn. After this child's penis fell off at the level of the scrotum, he underwent a series of surgical procedures at major medical centers which have created a tube for urination through a pedicle skin graft. There is, of course, no tissue to create an erection and no nerves for genital sensation in this graft (see Figure 3). Although this child's tragedy cannot be measured in dollars alone, he will recover $1 million in the out-of-court settlement of a lawsuit. He will never fully recover his sexual functions, which had been destroyed in the circumcision tragedy.