Foreskin Decisions

If you want to piss off some of your readers, write about politics or sex. Well, I’ve never worried too much about rejection on this blog, so here I go with another controversial subject: circumcision.
Do me a favor, BEFORE reading this post take the poll to the right.  Then, after reading this post, take the other two polls at the end — no peaking, wait until you read the post.

This is the first post of a series.  Your comments and these polls’ results will assist in the coming content.  Thank you for participating.

I have worked in medicine for a few decades. For the last three years I have worked in Urology where I have seen more foreskin problems then I knew existed — some are even life threatening. Circumcision avoids these problems.

I believe circumcision evolved as a life-saving technique, not as a mere rite-of-passage ritual.  Instead, it was probably used preventatively and then evolved into a ritual.   But I am only making a wild guess.  I have not studied the issue of circumcision deeply and am instead, just sharing my biased opinions, experiences and choices.

Letting a child decide about circumcision when they get older seems a good option. But without working as a Urologist, and hearing of all the problems, I can’t imagine a person ever wanting to electively remove their foreskin. Why?  Because men don’t share their penis-problem stories with other men.  Even if a person would desire a circumcision as an adult, they would be very hesitant because of the anticipated pain, necessary healing time and the worry of explaining the change to others. So even leaving the choice to adults has its drawbacks.

Mind you, I see a disproportionate number of foreskin problems because (1) I work in urology and (2) because I work with a large number of elderly ex-coal miners whose families were poor and their births took place at home where circumcisions were not performed.

Here are some of the conditions we have treated with circumcision in adult men:

Since I do not work with pediatric patients, I have not seen horribly botched-up circumcisions which would probably alter my opinion. But I knew of botching dangers when my son was born and that is why I assisted in my own son’s circumcision 12 years ago.   Prior to that, when our ultrasound confirmed our first child to be a male, my wife asked me, “What do you feel about circumcision?” (as she was leaning away from it) and I said, “My son will be circumcised.” To which she replied, “It doesn’t sound like you’ll be compromising on that opinion.” And I said, “No.”  And she let me have my way on that issue.

I’ve discussed my son’s circumcision with him several times since. Part of our discussion surrounds stories from my clinic of  horrible foreskin problems. I hope in this way, when he is an adult and thinks how horrible I was to rob him of a foreskin at least he may think, “I resent my Dad’s barbaric decision, but in his own stupid ways he thought he was doing good.”

Questions for Readers:

There are many good arguments for not doing circumcisions, but there are bad ones too. Being “unnatural” is one of the bad arguments — medicine has taught me that nature does not care for our happiness or comfort.

  • Given the above potential problems with foreskins, what do you think are the best anti-circumcision arguments aside from botched circumcisions?
  • How will / did you decide about circumcision for your male child?

Closing polls:

After reading this post has your opinion changed toward:
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58 Comments

Filed under Philosophy & Religion

58 responses to “Foreskin Decisions

  1. Brandon

    My answers were : “I am undecided.” “Yes, a lot.” “And not at all.”

    If you turned out to be the anti-Christ, my opinion wouldn’t change about you. If you somehow managed to walk on water while healing leprosy with your tears, my opinion wouldn’t change.

    The notion that an adult makes this decision before a person consciously would makes sense. Sometimes people just can’t make the decisions that would best benefit them. You once told me that in order for you to really cure my fear of snakes, you’d have to physically force me into a car trunk full of snakes with a light and listen to me scream until I was exhausted. Remember that conversation?

    I love the title of this post, by the way. Great to read first thing in the morning.

    -Brandon

  2. @ Brandon
    Ah, does my anti-Christ spirit shine through so easily?
    Yes, I still think a trunk full of snakes or foreskins would be therapeutic for you.
    So, how did this wonderful, up-lifting morning read change your view toward circumcision — if I may ask?

  3. banzaibob

    All I can say is, after years of pain due to phimosis, I finally got the courage to go to a doctor and get circumcised at the age of 33. It hurt like hell, but I haven’t looked back, and finally being “comfortable” made it more than worth it.

    I wish it’d been done much sooner, however if my folks had had the procedure done when I was a baby – how would I have known that it was a good option for me? So I guess you’d need to be at an age where you can understand the consequences and reasons behind getting “cut” and decide for yourself.

  4. @ BanZai Bob,
    Thanks for sharing !

  5. Brandon

    Only in that a lot of the medical complications you’ve listed make sense to avoid. “Botching it up” is a one-off, ripping the band-aid fear, and I can seriously empathize with it. But in the comfort of my arm-chair, I can say “I agree”.
    Arm-chair thoughts and beliefs are very easy to defend, I find. ; )

  6. DaCheese

    As you’re probably aware, the internet is full of guys decrying the “terrible, awful” practice of circumcision. Most of the concerns center around chafing and (especially) loss of sensation.

    I think the main problem with childhood circumcision is that you don’t know what you’ve missed, so it can easily become mythologized as some huge difference or lack. In some cases people will use anecdotes from someone who had it done as an adult, focusing only on the negative changes and not on the presumably significant reasons why that person had it done in the first place. In that regard, it’s nice to hear the other side of the story from folks like BanZai Bob.

    I was already aware of some of the potential problems with foreskins, but I didn’t think they were that serious or common. My dad supposedly had his cut as an adult, which is one reason why I’m not too bitter about having been snipped as a child. I know that it was done for a valid medical reason (increased risk of similar problems) and not just by default or for cultural reasons.

  7. Best anti-circ. arguments? I’d heard about chafing and the loss of sensitivity which DaCheese mentions, but when porn shops sell cremes which are designed specifically to decrease male sensitivity, you get the impression that loss of some sensitivity may be a good thing if it were to happen. ;-) And there is the one-off botched job. And the chance for infection after the procedure. The best defense I could offer up is the old adage: “If it ain’t broke, don’t fix it.”

    How would I decide? I would probably be as resolute as you were. There is no enduring pain. There is no inherent problem. It is more hygienic and lower maintenance. Plus, there is the cultural norm, which still favors the circumcised here.

  8. exrelayman

    I start with frivolity. The topic called into my mind a line from the play Julius Caesar, ‘…the most unkindest cut of all…’.

    I started undecided and ended yes a lot. The only reason I started undecided was that I had been exposed to some against writing, but knew that I had not yet heard from the other side. My opinion of you was unaltered. You are a thoughtful person who has seen a lot more of the world than I have. Whether we agree or not, you bring an interesting perspective that I lack. I am glad to have discovered your blog.

    Your enumeration of problems foreskins can cause wins against the lack of particularly cogent reasons (admittedly – in my estimation) for keeping foreskins.

  9. Well, being a scientist I have to choose whatever a child’s doctor decides is healthiest long-term. If short-term problems are considered rare and minor, well, again, it’s up to the doctor. And I’d hope the parents listened carefully and maybe did some of their own research.

  10. a smaller brain

    Despite my circumcision as a child, I still had a lot of problems with my penis. I suffered through years of inflammation of the exposed frenular delta and severed frenulum when I was a child (it kept adhering to other tissue as I grew), chronically painful erections for years during puberty (there just wasn’t enough skin when I started growing rapidly), and yeast infections (a few during late adolescence when I became sexually active). I experience constant awareness of my inner foreskin rubbing against my clothes, and minor, but annoying problems with sensitivity and mild discomfort during sex.

    A lot of these issues are common to many circumcised men, and as a result I don’t think it’s fair to classify my circumcision as “botched.” In many ways I can’t imagine it could have been done better and still have been a circumcision. The best part about my circumcision is that it left me with more of my inner foreskin and frenulum than many others I’ve seen!

    If I could convince myself that things would have been 10x as bad if I had been left as I was born, I might feel OK. Do you really believe that, among healthy males the rates of foreskin problems are high enough that everyone would unconditionally be better off without their foreskin? Not one intact man I know feels this way, and I know them as friends, not through appointments for urological problems.

    The mere fact that there are whole communities of men who are devoting years to re-growing their foreskins suggests that that the foreskin is an important, functional part of our anatomy, and its loss through amputation can cause permanent psychological and physiological discomfort for many people. These men continue in this apparently bizzarre and time-consuming practice because their regrown foreskins alleviate more problems than they create. The magnitude of effort suggests that these men derive real benefit from their foreskins.

    I would give anything to not be circumcised. It has affected my entire life by imbuing this most sensitive piece of myself with discomfort.

  11. Whoops, looks like the anti-circ folks are already hacking your polls. But don’t think your polls are special, this SOP for the insecure & those desperate for acceptance.

    Circumcision is a safe, popular, healthy & beneficial procedure for individuals & parents to choose. It provides benefits such as 12x less likely for UTI, +22x less likely for cancer, decreases HIV acquisition by 53% to 60%, herpes acquisition by 28% to 34%, and HPV prevalence by 32% to 35 % in men. The risks are about 0.2% and are typically minor & easily corrected.

    Parents should research circumcision and make an informed decision for the health & well-being of their son.

  12. Smile101

    @circumcision_Info

    If that were the case why not cut off parts of the female genitals like the clitoral hood or outer labia to also aid in the decrease of HPV, HIV, other STIs, UTIs, etc. Clearly it would be a more dry environment and would build some nice scar tissue to help prevent such diseases.

    You know there is a vaccine for both young girls and boys now to take to fight strains of HPV. Girls also get UTI’s… yet they are simply treated with antibiotics. HIV infections is actually growing amongst the black community here in the U.S. and clearly the rate of black male circumcision is well over 50%. Safe sex and sexual education can help prevent the spread of STD’s…. circumcision provides a false sense of being safe from any of this (which clearly circumcised males still get STI’s). Honestly if you really look at it… circumcision rates are relatively high among U.S. males… and compared to their European men who are mostly intact, HIV rates are much higher here in the States.

    But who listens to logical reasoning? Haha, as a circumcised male myself (at a later age) I can vouch that sensitivity is dramatically decreased. I also have a semi botched circumcision… which could of been prevented by not even going though with the procedure. What is done is done though. I honestly have no idea why parents would want to put their child through so much pain. Isn’t it the parents duty to protect their child from pain and harm?

  13. “cosmetic concerns due to culture pressures” – this is one argument for circumcision that I’ve never really understood, and maybe due to my own view of things. I guess I never really stared at other guys’ junk in the locker room, so I never took the time to compare fish tales. It was a thought that never crossed my mind, and it seems like people that want to make their son “look like dad” are just performing unnecessary permanent cosmetic surgery, which seems like a really weird thing to do to an infant.

    For the record, I was circ’d but I don’t harbor any ill feelings towards my parents about it. I know they did it because it was just one of those things you did back then. No biggie really. But we didn’t circ our son. I just couldn’t come up with any reason to do it that was more compelling than the reasons not to do it. And after watching a few, I couldn’t put my son through that since it wasn’t necessary.

    As for STD risks that the circ troll listed, it has always seemed to me like condoms, monogamy and other safe sex practices would be a saner solution than (albeit minor) surgery.

  14. ~DN

    After 5 years of chronic erection pain that stemmed from a complication of a circumcision that did not heal well due to poor outpatient care from my parents, and having to have a surgical revision while still conscious a few months ago, I think I can say quite concretely that I am against infant genital cutting. I now have more scars than anyone could ever want on their genitals. All for what? I certainly have not reaped anything from this experience except my insomnia.

    I don’t imagine that there are many of you who can fathom this, but having a stranger take a knife to your genitals while you are still conscious is not fun, I will tell you from experience, and I would never wish this on an infant.

    If an adult should want it done and feels that strongly about it, then at the very least they can reap the benefits of general anesthesia, and have adequate pain control–neither of which can be offered to babies without fatalities due to the inability of the neonatal physiology to cope with such things.

    When it comes down to it, I now know that when my future sons (God willing these newer scars ever stop hurting) are born that the first gift I will ever be able to give them is to love them enough to think they are perfect just the way they are–no genital dissassembly required.

    My common sense tells me “if it isn’t broken, don’t fix it.”

    Circumcision is erroneous prophylaxis, with parents assuming something WILL go wrong and it will HAVE to happen later, but looking at the demographics of the world’s male population (the large portion of which who are intact, and the vast majority of which never having a problem with it), the overwhelming odds are that it won’t.

    Urology offices are not places where one can make good, random inferences of the population at large. It IS a select clientele of only those who do have problems, and I would not equate them with the population of the US at large.

  15. ~DN

    I should have specified earler, and I apologize for the comment spam.

    “After 5 years of chronic erection pain that stemmed from a complication of a[n infant] circumcision…”

  16. @ Readers,
    Yep, I got discovered by Anti-Circ Folks.
    This post got immediately listed on one of their forums:
    Foreskin-Restoration and Intactivist Network
    Under the heading “Biased Sample” by a senior member named, interestingly, “Peter Pink”. Where they encourage their crew to rush to my post.
    So which of my regular readers is the informant? :-)

    Of course Polls on a website like this are horrible for real data both because, like mine, they aren’t constructed carefully and because you have no control of the population — they are self-selecting. But I have ideas about how to use the polled information in a coming post, so they won’t go to waste. Thank you for participating.

    But even with the flood of enthusiasts, I am happy. Let me touch on a few points.

    (1) Data
    Anecdotal data from these three folks is very important! ~DN makes reinforces a point I made in my post by saying:

    “Urology offices are not places where one can make good, random inferences of the population at large. It IS a select clientele of only those who do have problems, and I would not equate them with the population of the US at large.”

    I can not understate how very important this point is!!

    (2) Common Sense
    A couple folks used the argument of:

    My common sense tells me “if it isn’t broken, don’t fix it.”

    First, common sense is useful but a bad guide when it comes to science without checks of data when possible and objective measure. And as I said in my post, “Nature does not care for our well being as some would imagine.” So even if they are right that circumcision is a bad choice, this is a bad reason to put as an ally.

    (3) STD risks
    Adam, a thoughtful regular reader, said:

    As for STD risks that the circ troll listed, it has always seemed to me like condoms, monogamy and other safe sex practices would be a saner solution than (albeit minor) surgery.

    First, I don’t see the pro-circ guy as a troll, nor do I see the anti-circ folks as trolls. They are all being very civil and offering arguments.
    Smile101, a welcomed new guest, used the same argument:

    Safe sex and sexual education can help prevent the spread of STD’s….

    I found Adam’s & Smile101’s argument oddly similar to the Catholic Church about why condoms should be forbidden — after all, abstinence is a good choice. So, I don’t think this argument should be weighed heavily. But it does offer support if the stats (the data of number one above) show significant harm vs benefit — and we all know how hard cost benefit analysis is.

    Meanwhile here is an article from the Archives of Pediatrics and Adolescent Medicine in 2010: “Male Circumcision for the Prevention of Acquisition and Transmission of Sexually Transmitted Infections: The Case for Neonatal Circumcision

    BTW, Adam, the cosmetic requests were concerned about how women viewed their penises. I think it is very odd too.

  17. As with most things there are no absolutes. I am not circumcised. I was taught to pull back the foreskin and keep it clean. I’m fifty seven and I’ve never had a problem. But that is certainly not true for everyone. Personally, as the old saying goes, if the shoe fits the foot is forgotten. The only time that I ever give my penis any thought is when I pee or have sex. For someone who experiences the penis like glass in the pants, I can see that it would be a big problem. By all means, cut the damned tipper off!

  18. D

    @Sabio Lantz

    It’s worth mentioning that the AMA is citing an HIV study that was fundamentally flawed- one such error was that after their clock was started, men who were circumcised had to abstain from sexual activity for a period of six weeks, meaning that the men who were not circumcised had a six week head start.

    I think it’s telling that the Royal Dutch Medical Association and the Royal Australasian College of Physicians see little credence in that particular study, as they say that the supposed protection against HIV is still insufficient to recommend circumcision and that circumcision itself is a violation of bodily autonomy.

    Call me a “nut” if you like(and being that I’m an American who holds this view I get this sort of treatment constantly), but that’s how I feel.

  19. chris

    I know I’m late to the fight but here is a great vid on this very topic http://www.youtube.com/user/C0nc0rdance#p/search/0/i2gloq-prkA. It’s 20min long but chock full of good info.

  20. @ D,
    OK, “You are a nut!” There, I said it. smile!

    I can’t be sure if you are a nut or not, but your comment seems very reasonable. Do you have links to support it, for anyone interested in checking out the facts. Also, HIV is not the only infection claimed to have been reduced in circumcised men, right? Would you claim those other studies are also faulty?

    “Violation of Bodily Autonomy” : what does that mean. I don’t want to guess.

    Also, may I ask how you found this post?

    Thanx

  21. Smile101

    @Sabio

    Oh by no means do I want to bring in religion. That in itself is another topic a lot of people can be debated about (probably with no end =P). But what you said about the Catholic church….. forbidding condom use, well you do know that safe sex entails the use of condoms. Not to say that I am trying to impose on Catholic beliefs, but just wanted to point out the difference between a religious belief and one that is something completely different because condom use = safer sex.

    Its also noted that the Christian belief doesn’t allow people to eat shellfish for example. I don’t think many people strictly follow some beliefs to that extent.

    Again if circumcision is a profound in its effects as many claim, then HIV rates in the United States should be lowest among the entire world, but it is clear that this is not true.

    Though I am for circumcision for male or female if medically necessary. If some things cannot be treated by medication or other means then it may be needed if the male or female has some extreme infection of some sort that can save the individual’s life (or other medical care that can not be rid of my other ways).

  22. @ Chris,
    Thanx, your YouTube channel looks interesting — I will have to check it out later. May I ask, “How did you find this post?”

    @ Smile101,
    BTW, I love your handle.
    Thanx for the further input.

  23. Pat

    I don’t think anyone here has yet addressed the concern that in most cases when doctors do it to children, and pretty much 100% of the time they do it to babies, circumcision is medically unnecessary. In my view, this brings up a serious ethical problem: isn’t it essentially unnecessary surgery? And done to a minor, no less, who is incapable of giving any sort of informed consent.

    @ Sabio – the concept of patient autonomy, as referenced by the poster D above (incorrectly as “bodily autonomy”), is an important consideration in medical ethics these days. Perhaps it was not as commonly discussed back at the time of your medical schooling; as far as I’m aware, that’s changed over the course of the last few decades.

    I’ve chatted with several people at anti-circumcision sites like the one that posted a link to this blog, and most often people are angry that such a thing could have happened to them at a time when they were powerless to do anything about it (or even know what was happening to them, in many cases). Some of them are able to let go of their anger, and there are some who aren’t – and sites like this Foreskin Restoration Intactivism one may contain more of the latter than the former. While I myself agree with their opposition to the practice of unnecessary surgery, I think sometimes their anger can be counterproductive to getting their message across effectively. Then again, anger can be a powerful motivator for change – if enough people complain loudly about an injustice, others will listen.

  24. I say “troll” simply because that person trolled me on twitter and I’ve seen them on just about every damn circumcision post on the interwebs.

  25. @ Adam,
    Pray tell, what are you doing at all those circumcision posts on the web? :-)

    @ Pat,
    Lots of things are done electively: removing wisdom teeth, braces, vaccines (well before needed), antibiotics in they new born eyes before infected. All these have some risk, but the benefits are considered much higher than the risk. So “medically unnecessary” also does not seem a strong argument except in the cost-benefit arena discussed prior.

    Actually, Pat, I taught medical ethics at a graduate level for a few years. “Autonomy” is an important topic, of course — I just wasn’t sure of “D’s” use of “body autonomy” and didn’t want to guess.

    We do all sorts of things to kids well before they know what is happening: teach them religion, give vaccinations, pierce their ears (in some cultures), have various corrective surgeries, give them various diets (many unhealthy), raise them with emotional habits. Kids don’t have autonomy. The debates about how much autonomy is difficult. But I agree, I think this one is rather big — so the benefit of doing it young would have to be large. Some would argue that getting it done latter is a much bigger memory and infants won’t remember — I agree. And as I said earlier, many people may want it but put it off when they should have it done. I don’t think these are strong arguments, but they are the ones out there.

    I totally agree that angry people can have good effects or than can turn others off. Influence is complicated.

    Thanks for your note.

  26. As it used to be done, with stone tools and no asepsis, male genital cutting probably killed far more babies than it ever protected. Rabbis used to earnestly discuss how many brothers might be allowed to die of circumciion before one might be excused. Before it was religious, the origins of circumcision were probably magical, a blood/sex ritual to ensure fertility and/or potency or some such. Circimcision has always been a “cure” looking for a disease, an intervention looking for an excuse.

    “Bodily autonomy” is simply the right to decide for yourself what (normal, healthy, integral, functional, non-renewing) parts of your body you want, or don’t want, to have cut off. In the US Constitution it comes – or should come – under the Fourth Amendment, security of the person against unreasonable seizures. The only reason the male foreskin isn’t already protected by it automatically, is that a custom has arisen that it need not be.

    Since you taught medical ethics, you’ll be familiar with the Bioethics Committee of the American Academy of Pediatrics’ statement:

    “…[P]roviders have legal and ethical duties to their child patients to render competent medical care based on what the patient needs, not what someone else expresses. … The pediatrician’s responsibilities to his or her patient exist independent of parental desires or proxy consent.” (American Academy of Pediatrics Committee on Bioethics. Informed consent, parental permission, and assent in pediatric practice. Pediatrics 1995;95(2):3 14-7.)

    – So why is the decision left to the parents?

    @circinfo gives a lot of Relative Risk Reductions (RRRs) which make any reduction in rare diseases look big. Look rather at how very many circumcisions you’d have to do to prevent any of those diseases.

    Now lets have a look at your reasons for doing it:

    chronically infected (balanoposthitis) (often due to poor hygiene)
    So tell them to wash it.

    painful on erections due to short frenulum (frenulum breve)
    Frenuloplasty – a big word for a little nick, removing no tissue.

    narrowed down tip which restricts or stops urine (phimosis)
    swollen from not being reduced (paraphimosis)
    Both can be treated non-surgically or by other surgery (postheplasty, Z-plasty)

    foreskin cancer
    Yes, you’ve got us there, foreskin cancer is an indication for circumcision. And foreskin cancer is a fraction of penile cancer, which is rarer than male breast cancer. You’d have do to THOUSANDS of circumcisions to prevent one foreskin cancer.

    prophylaxis for balanitis xerotica obliterans
    There are other treatments, with steroids, etc.

    cosmetic concerns due to culture pressures
    When an adult wants to have part of his (or her) thang cut off, that’s his (or her) right, but no reason to do it to babies.

  27. mirica

    My husband and I were both raised Jewish and identify as Jewish, though we are not very observant and each have our own complicated histories and ambivalent feelings about the religion and tradition. When we were expecting our first child 7 years ago, we did not find out the sex before the birth. Although it was assumed by our families that we would have a “Bris” if we had a boy, we questioned the practice and and did some research into the whole circumcision debate. On an emotional level, we didn’t like the idea of causing our newborn pain and altering his body in such a fairly dramatic way just for the sake of “tradition” if we couldn’t find any evidence of benefit.

    We were on the fence about it for a while (circumcision, not just the ceremony), because it did seem that there were some valid medical/physical arguments for and against, though none of them struck as as particularly strong one way or another. I guess the “loss of sensitivity” issue jumped out at us in the anti column and the “easier to keep clean, lowered risk of std, hiv” argument seemed strongest in the pro. I don’t really remember hearing too much of the risks of “botched” circumcisions and complications. The cost/benefit analysis we were trying to do just didn’t seem to sway us strongly in one direction or another. I think my husband thought the evidence of lower HIV risk looked very strong. And I think we both recognized that it was something that was extremely important and meaningful to our families and though they would have respected our decision not to do it, I think it would have been very hard for them.

    So 8 days after the birth of our son, we had a bris at our house, complete with oohhing and ahhing relatives and bagels and lox. I refused to serve coffee because I wanted everyone out as soon as possible! I know not all new moms react this way, but I was sobbing uncontrollably in another room as my father-in-law held him down and the “mohel” did the deed. Now, I do feel very comfortable with the decision we made and needless to say, when his little brother was born, it was much easier on me emotionally than the first time.

    A couple of other observations/thoughts:

    1. I found it interesting that most Jews, even those with very little to no connection with their heritage, regard the “bris” as almost sacrosanct and would not even consider not doing it for their sons. I think, even if not consciously for some, the issue of the Holocaust comes up. A circumcised penis was an easy identifier in Nazi Germany.

    2. After we had the bris, I heard that 8 days is actually a better time to do it, than 1-2 days as they do in the hospital, because by that time blood-clotting mechanisms are more mature and there is less pain/easier healing. Also that mohels (those trained to do ritual circumcisions in the Jewish tradition) are generally more skilled than those that perform them in hospitals. I don’t know if this is true. Also, at home the baby can be held and nursed immediately for comfort, whereas in the hospital he is sometimes left clamped and crying for a period before brought back to the mom. All of this of course made me feel better. Also our mohel was also an ob/gyn physician.

    Sorry for the long post. I’ve really been enjoying your blog since I came across it a couple of months ago and truly appreciate what you’re doing here.

  28. D

    @Sabio

    I’ll return with the proper documents I cited in my next comment, but I would just like to give some background on where I’m coming from with this just so I don’t seem like another faceless anti-circumcision fanatic: I found your post through that foreskin restoration forum you linked(I’ll admit, I probably would have never seen it otherwise), and that brings me to my next point- like many men here, I was circumcised as an infant. Later in life, when I began to engage in sexual activity, I always found myself uncomfortable and, more often than not, dissatisfied by my sexual experiences.

    Mind you, this was all well before I even knew what circumcision was. Even then, I could tell that there was something missing, and often I would wonder if there was something wrong with my “technique”- I never imagined that my problems stemmed from the fact that an important sexual mechanism had been removed from my body around the time of my birth, but when this finally did come to my attention I was distraught, to say the very least. I would come to find out that the reason for my sexual problems was multi-layered: not only had a sensitive part of my body been removed by circumcision but in my case the procedure had taken away so much tissue that erections caused me discomfort and there was no skin mobility on my penis, which naturally put a damper on my capacity to experience sexual pleasure.

    When I finally got fed up with it and confronted my parents about the trouble they had caused me(and continue to cause me), they literally laughed in my face and dismissed all of my problems as being strictly mental. My friends weren’t much better in this regard, and also dismissed my grievances as being “all in my head”. I was in pain in more ways than one because of a bodily alteration that was imposed upon me before I could do and/or say anything about it, and not even the people who I thought cared about me would show me any sympathy. At the risk of getting overly emotional, I’ll just summarize by saying that this was a very dark period in my life, and I still bear the ill physical effects of this procedure to this very day.

    With all that being said, I hope you can understand that while I appreciate your civil manner when dealing with a topic that is not often given such respect, I cannot help but hold a grudge against you for trying to find justification in imposing this operation on your own son. I think it is ethically wrong to take away a boy’s right to his foreskin because issues may or may not occur with it in the future, and that such a mindset would be considered outrageous if it were applied to any other part of the human body or to the genitals of women.

    Thank you for your time.

  29. Pat

    @Sabio, your reply seems to avoid addressing my contention that this is unnecessary surgery. Surely you’re aware of the difference between it and the other sorts of medical procedures you’ve referenced. Corrective surgery is therapeutic in nature. Elective surgery is done at the explicit request of the patient. Circumcision, except in the rare cases mentioned in your original post, fits neither of the above two definitions.

    Isn’t one of the purposes of medical ethics is to protect those who, for whatever reason, are unable to exercise or understand their own personal autonomy? You say kids don’t have any, but I somehow doubt everyone would agree with you. If a patient is unable to speak, is he not still afforded certain rights to his own body?

    On an unrelated note, for your future blog posts in the series you’re doing, I’d suggest doing some research the history of circumcision in this country. Specifically, look into the fact that 19th century doctors originally did this for the sole purpose of preventing boys from masturbating. The idea that the operation could have any other practical value seems to have been invented later on, possibly to hide that original purpose.

  30. MrBBQ

    I don’t suppose that losing 50%+ of their erogenous zone skin, plus their frenulum, plus losing the lubricating benefit of mechanical foreskin motion is a “penis problem” that needs addressing, does it? It happens in 100% of circumcised men.

    By the way, circumcision unambiguously violates medical ethics. AAP’s own bio-ethics committee position papers:
    “A patient’s reluctance or refusal to assent should also carry considerable weight when the proposed intervention is not essential to his or her welfare and/or can be deferred without substantial risk.”

    [This means that unnecessary surgery without consent of the patient is unethical.]

    “Such providers have legal and ethical duties to their child patients to render competent medical care based on what the patient needs, not what someone else expresses. […] the pediatrician’s responsibilities to his or her patient exist independent of parental desires or proxy consent.”

    [This means that the child is your patient, and only his best interests matter. The parent has no right to elect unnecessary surgery for their child.]

    You are in violation of basic bio-ethics. Some doctor you are. But hey, you’re in good company in the USA.

  31. @ Hugh Intactive :
    (1) That seems highly reasonable that circumcision done with primitive tools was probably a clearly bad choice in terms of cost and benefit. Makes you wonder why it persisted — and clearly religion (‘sanctification’) is one way to make unreasonable things persist.

    (2) Interestingly, the AAP has changed its positions on circumcision.

    (3) Government vs Parent Decision
    This, is a drastically important, complex and controversial question. You apparently the government should legislate this issue. Do you feel the government should legislate discipline methods, foods allowed for children, vaccines, type of clothing, ear rings…? Just curious where you draw the line.

    (4) Tx of Urology issues with Foreskin
    Good analysis.
    I haven’t studied the issue of balanitis xerotica obliterans but I have seen cases respond very poorly to steroids. But most people , due to embarrasment don’t come in until it is rather advanced.

    @ D :
    Thank you for your personal sharing. I am sorry for your suffering. I understand your grudge with my post, given your experiences. Hang in there for future posts and tell me what you think.

    @ Pat :
    Autonomy with children is a thorny issue. I think I understand your anger with me on this issue. I must daily make decisions for elderly people who can talk or express themselves or at least help their relatives make that decision. Too bad kids can’t come with their preferences in hand.
    You bring up important issues.
    May I suggest that you start a blog, and you do post on the history of circumcision in this country. You are right, the rhetoric behind it has often been reprehensible.

    @ MrBBQ :
    I am not sure that the percent of erogenous zone is directly proportional to the experience.

    Interestingly, when the AAP was for circumcision, anti-circ folks told us why we should ignore them, now when AAP discusses the down sides, anti-circ folks run to them as evidence.

    Curious how we use evidence, isn’t it?

    You said:

    You are in violation of basic bio-ethics. Some doctor you are. But hey, you’re in good company in the USA.

    That rhetoric won’t get you far on this blog.

  32. @ Mirica :

    Wow, that was an amazingly wonderful, refreshing comment!!!

    You shared the complexity of your personal decision process in all its fullness. This is exactly what I hope to be getting to in coming posts. If you have read me for a while, you realize that I am often shooting for meta-conversations and not necessarily the apparent details.

    BTW, I assisted in my son’s circ so I could watch that is was done with care, so I was assured of good anesthesia and so I could hold him and return him to his loving mother immediately. And no coffee was served there either. :-)

    Again, I loved your comment — thank you kindly. (wish you had a blog)

  33. MrBBQ

    Primum non necere

  34. mirica

    @ Sabio

    “I am often shooting for meta-conversations and not necessarily the apparent details.”

    This is one of the things I appreciate most about your blog. The circumcision issue does raise really interesting questions and insights about how people make personal decisions, justify them, interpret available evidence. So many things. I’m really glad you felt my story contributed to the discussion and I look forward to reading your future posts on the topic.

    Reading the comments of those who have suffered both physically and emotionally makes me wonder how I would feel about my decision if either of my sons grew to have similar problems that were attributed to their circumcision. I think I would regret the decision deeply, but I hope I would forgive myself and that my son would forgive me too and understand that his dad and I did the best we could. Also we would not know what the outcome would have been if he had not been circumcised. Maybe he would have adverse effects attributed to NOT being circumcised. There are so many decisions we make as parents and nobody can predict the future and anticipate all the consequences perfectly.

    Although, as I responded in the poll, my opinion of you didn’t change after reading your post, I do wonder why you were so adamant and uncompromising with your wife when she raised the issue. Your unwillingness to even discuss it with her seems surprising to me.

  35. @ Mirica,
    Great question. The downside of my personality trait that I am not really too concerned about what others think of me, is that I can be careless in telling a story and make myself sound much more harsh than I am.

    When I originally wrote this post, I said something like, “Out of character, my wife let me have my way.”
    I let my wife read the post to see if she agreed with the story and she said, “Why are you saying it like that, they will think I am stubborn.” To which I replied, “Ahh, I didn’t want them to think you were a push over and to realize that if you have a strong opinion about things, you’ll say so.” She replied, “Well, I still think that is a bad way to say it.” So I changed it, and she like the new way much better — cause, I guess, it makes me look bad!

    Well, actually, we had talked about it a lot. I had looked into the issue a bit and thought about it. I am in medicine and she is not and she trusted my decision. It was a fun moment and no real comment. When I told the story, I had a smile on my face because I remembered the humor of her comment that: “Sounds like you aren’t going to compromise on that.” She was smiling then.

    Oh well, so much for telling a story, but as you can see, that would have made the story too long all to avoid people thinking I am a male chauvenist pig or my wife as subservient and weak willed. Neither of which are true– though my wife may think I am a bit of a pig! Smile.

  36. mirica

    @sabio, Thanks for the background story!

  37. Pat

    Oh, I didn’t mean to sound angry with you there – it’s not easy to express a strong disagreement without sounding too abrupt. And I’m not a blogger, but this subject matter has been discussed ad nauseum on the internet; you shouldn’t have trouble finding information elsewhere. You probably have better access to information on the history of medicine than I.

  38. Jessica

    I have worked with very young children (ages 0-3) for several years and I have never seen a case of a botched circumcision, however I have seen case upon case of medical problems that arise from opting out of the procedure within the first three years of life. While my years of experience may not be as vast as many, the statistics for me are startling, considering I typically see anywhere from 10-15 different children per week. At 50 weeks per year the numbers are terrifying. Obviously these experiences have affected my opinions about circumcision and I believe making it illegal would have dire ramifications.

  39. @ Jessica,
    May I ask that you share what sort of cases you’ve seen when you said:
    I have seen case upon case of medical problems that arise from opting out of the procedure[circumcision] within the first three years of life.

  40. DaCheese

    For what it’s worth, I used to worry about problems with sensitivity. But I think that the psychological effect of the worrying and bitterness is greater than people realize; I found that many of the issues that I attributed to my physical status were actually related to my mental attitude and expectations regarding it. (YMMV, of course.)

    @Jessica, I wonder how many of the problems you see arise from ignorance of basic foreskin care, which in turn results from fathers who have no experience with it due to their own infant circumcisions?

  41. D

    Royal Dutch Medical Association:

    http://knmg.artsennet.nl/Publicaties/KNMGpublicatie/Nontherapeutic-circumcision-of-male-minors-2010.htm

    “There is no convincing evidence that circumcision is useful or necessary in terms of prevention or hygiene.”

    Royal Australasian College of Physicians:

    http://www.racp.edu.au/index.cfm?objectid=D7FAA93E-E091-4209-15657544BA419672

    “After reviewing the currently available evidence, the RACP believes that the frequency of diseases modifiable by circumcision, the level of protection offered by circumcision and the complication rates of circumcision do not warrant routine infant circumcision in Australia and New Zealand.”

    I haven’t gotten around to finding the proper documents for the HIV RCTs yet, but I will in due time.

    @DaCheese @Jessica
    I’d be curious, too- premature retraction of the male foreskin can cause serious problems, and considering that Jessica lives in America this is probably what she has been seeing. Most American doctors- and even some parents who have decided against the procedure- understand how the foreskin develops and may try to pull the foreskin back while it is still fused to the head of the penis, which can result in serious damage and infections. What Jessica is talking about is more likely the result of improper care of the penis rather than evidence of an inherent flaw with the foreskin itself.

  42. D

    Correction to the above comment:

    Most American doctors- and even some parents who have decided against the procedure- DON’T understand how the foreskin develops…

  43. @ DaCheese
    Thanx for sharing

    @ D
    Thanx for the articles.

  44. MrBBQ

    @mirica
    I liked your posting up to this point, when you said this:
    “Also we would not know what the outcome would have been if he had not been circumcised. Maybe he would have adverse effects attributed to NOT being circumcised. There are so many decisions we make as parents and nobody can predict the future and anticipate all the consequences perfectly.”

    This is unfortunately perpetuating a paradigm that paints circumcision is too favorable a light. It is also rationalizing after the fact.
    It’s not really a justification for this unnecessary procedure. Ask yourself, what other surgery would be OK because you don’t know whether or not a body part will be defective? (every body part has a defectiveness rate)
    The decision of parents to circumcise children is largely based on fear of what might happen. This includes social consequences of non-conformity, as well as the “future medical problems” boogeyman. By saying, “well you don’t know what might happen if you *don’t* circumcise”, you are really creating a false dilemma of “parent’s choice” in the face of uncertainty, and unintentionally equivocate the two “decisions”. There is no “choice” needed for a baby because there is nothing in the way of amputation an infant needs at that age. The body is just fine as it was born. Standard medical ethics is to leave the patient alone until intervention is needed–the default position is always to do nothing: “first, do no harm”. One does not simply roll the dice and decide what body parts to cut off just because they might give you cancer later in life. You leave people’s bodies alone; this is standard practice. The penis is no different.
    By making this statement, you unintentionally reinforce the idea that the foreskin is somehow this ticking time-bomb, a really problematic myth that abounds in our society, and perpetuates unnecessary circumcisions. It also perpetuates the false paradigm of “choice”. There is no decision that even needs to be made in the first place. We have to recognize circumcision as what it is: a cultural practice, not a medical one, and not paint false pictures of some kind of dilemma that really isn’t there.

  45. Great article. You may be right that circumcision began as a medical procedure not a religious rite but that doesn’t make it effective. Bloodletting was a “medical” procedure. Bear in mind, I’m not a doctor or a parent. There are going to be errors either way but I think we should err on the side of the child’s bodily rights. 70% of men around the world do not circumcise and they get along pretty well.

  46. @ Funston
    Thanks for droppin’ in.

    You say “I think we should err on the side of the child’s bodily rights.” and the next post asks where you go with your thought: Do you enforce your thought and make everyone obey it, or do you try and spread your thought and hope more people agree with you.

    When you say 70% of the uncircumcised men around the world “get along pretty well” — you make an empirical claim with fuzzy terms. That won’t work as an argument, however. But it may be right. :-)

    Interestingly: I have done a bit of blood letting in Japan during my Oriental Medical days. I “saw” it work for certain conditions. I saw it used for asthma and other breathing issues, and for varicose veins and leg pains. But I am not sure how much was placebo, or anecdotal nonsense.

  47. D

    I think what Funston meant, Sabio, is that 70% of the men in the world are not circumcised, not that 70% of men who are not circumcised get along pretty well.

  48. Sabio Lantz

    @ D,
    That is how I understood what he meant. But thanks.

  49. Here’s a bit about a newer study linking circumcision to a reduced risk for prostate cancer: http://www.sciencecodex.com/circumcision_may_help_protect_against_prostate_cancer-87632

    I find it odd that in all of these circ studies where they try and link circumcision to reduced risk of STDs, they always seem to fail to mention things like safe sex practices, monogamy, rates of prophylactic usage etc… which all seem to me like more reliable and better indicators, though I certainly don’t doubt the science behind what they’re proposing here.

  50. Sabio Lantz

    @ Adam
    Great, Adam, thanks. Interesting, if guys come in asking for circs to avoid prostate Ca, I can tell them it only works if they haven’t yet had sex — according to the study.
    But on a serious note, the infection thing is important.
    Should we get Hep B vaccines and Herpes vaccines can be avoided with safe sex practice and monogamy too. So should we forego them?

    I have yet to understand those who try to counter with safe sex and monogamy arguments as you did in 2 of your comments and as smiley101 did. It seems the weakest of arguments, if not faulty.

    Thanx for the article, dude !!

  51. How’s about vaccines + safe sex practices considering all of the non-vaccinatable (that’s a word! right?) outcomes that one could encounter?

  52. Sabio Lantz

    Sorry, Adam, I didn’t follow your question. But then I looked at my comment and realized I left off “when infections” after the phrase “Herpes vaccines”.

    So maybe my comment didn’t make sense. My point was, it seems that your logic could also generate a question like:

    Though the Herpes Vaccine can protect again an infection known to cause cancer, if people are taught to be monogamous and practice safe sex, why get the vaccine since the vaccine does come with some risks, even if minimal?

    I hope that is more clear. But perhaps you won’t see my point if you are against vaccines. Then I will have to think up another example. :-)

  53. Jessica

    @ Sabio (apologies for the lateness of the answer)
    My personal view of the medical issues I have encountered is that they result due to laziness and blatant disregard of the parents for the general care of their children rather than being a result of poor education about health and hygiene of being uncircumcised. To me this is much worse than being completely ignorant.

    Having an uncircumcised child to many of the parents I have worked with seems to be a “fun trend” and many parents don’t really have a reason as to why they opted out of the circumcision procedure. Most of them fully understand that opting out of circumcision will result in having to provide more careful attention to the care of their son’s penis (i.e. having to pay more attention to hygiene, educating other caregivers about how to care for your child’s cleanliness, and for goodness sake, keeping your child out of public fountains and changing diapers consistently and often), but they just end up finding it too tedious and think, “It will take care of itself.” Please let me know when a penis grows appendages and the common sense to bathe itself, because I’m sure I can make a lot of money by publicizing such a finding. (I apologize for the sarcasm. I get hot under the collar about issues of neglect.)
    I find that circumcision is less a health issue and more of a cultural issue of laziness. I have seen so many parents who think children are like puppies. They tend to want to sport them around for show and pat them when they feel like it, but when it comes to providing adequate care for daily needs like clothing, food, and shelter; they would rather be able to leave some food and water in a bowl with some newspaper out for accidents. With attitudes like that, not having their children circumcised is a huge mistake. For this reason, I think that making circumcision illegal would significantly increase an already-existing problem. At least now if parents have enough insight to realize that they will not pay attention to the finer details, it will save the child pain, increased urinary tract infections, kidney infections, phimosis, etc. (all conditions I have seen in my clients and conditions which their doctors have attributed to improper hygiene/supervision/training). Unfortunately, this will not address those parents who have stated great reasons (or not-so-great reasons) for wanting to leave the foreskin intact, but who are unwilling to provide proper care. I can’t recall a single client who had medical issues with their son’s uncircumcised penis who stated that they had not been informed of proper hygienic procedures.

    I would be interested to know if this is a big problem in other countries. I have a feeling that, like so many other issues, this is mostly an American problem.

  54. Jessica

    @ DaCheese: You have something there, but (see my post previous to this) I don’t think it’s ignorance of how to care for it, but laziness.

  55. @ Jessica,
    Fantastic points – thank you. Indeed, I too see parents who treat their kids like puppies — they love the puppies, but hate the dogs. Arghhh!

  56. D

    Sorry I’m so comically late with this(it’s been a very hectic couple of months), but here is a rebuttal the recent HIV studies:

    http://www.futuremedicine.com/doi/full/10.2217/17469600.2.3.193

    In any case, you’ve earned a new reader in me.

  57. D

    @ Jessica I don’t mean to sound aggressive but your suggestion that parents should be allowed to circumcise their male children because it supposedly takes a tremendous amount of effort to care for the penis in its normal state is upsetting to me, considering that no such “luxury” is afforded to parents of female children; any alteration of the female genitalia is forbidden by law, at least in the United States. While I don’t speak for you and I don’t claim to, I assume that you wouldn’t appreciate it if your genitals were legally allowed to be functionally altered because your parents thought it would be too much of a hassle to care for your genital area as it was.

    Maybe you think this is comical, but I am deeply hurt by the fact that this was carried out on me and the fact that there is no way to undo what was done means that, frankly, there is no end to my pain.

    I hope I haven’t misunderstood you.

  58. Here’s a good reason to not circumcise, science cannot be done and/or the information channel connecting good science with public information is unsettled. Whether there is a sound basis for the decision or not, the information must be admitted as apocryphal, baring knowledge and qualifications of the decision maker of course. Consider defective HIV studies. Yes, lives were saved. But what if one group had circumcision and the other control group got a painful tattoo? If you know that both groups would get exactly the same benefit, would you be in favor of circumcision?

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