By Tracy G. Cassels
One of the factors that routinely comes up in questions surrounding neonate circumcision is the idea that the pain and healing associated with adult or even child circumcision are far greater, thus if one is to circumcise, infancy is the period of time in which to do it. The problem with this view is that it originated when individuals thought infants could not perceive pain in the way older children and adults do. Remember there was a time doctors thought it was fine to operate on an infant with no anesthesia. We now know that to be unassailably wrong. Unfortunately, though, there are no studies directly comparing infant and adult pain during the procedure, but I will add my own thoughts here. First, even if the pain is slightly more in adulthood, we have the cognitive capacity to handle that pain – to understand it and contextualize it – making the issue of quantity of pain potentially moot. Second, there are far more anesthetics available to adults than there are children. We have to be highly restrictive in what is given to an infant to reduce pain which is most likely why most of the measures to block pain in infants are not drug-based and not as effective as we would like.
What we do have as evidence, though, is the rate of complications which do seem to increase with age. Even the difference in complications between the neonatal period and childhood circumcision is linked with a rise in complications (1.5% to 6%). However, one thing that we must be cognizant of is that the older a child is, the more invasive some forms of circumcision are. And of course there is a large relationship between the severity of the procedure and the risk of complications. We can see this when we examine complication rates in adults receiving the “Westernized” form of circumcision as adults to reduce the risk of HIV – studies have found complication rates that are lower than that for childhood circumcision (e.g., 3.5%, 1.8%, 3.1%) and the vast majority of these complications were bleeding and infections, similar to in infancy. Notably, the rates of complications were higher in those who resumed sexual relations prior to the recommended time frame, suggesting the rates could be lower if proper protocol is followed.
The other concern raised has to do with healing time, specifically the question of whether the healing time is significantly longer in adult circumcision. Because an infant is incapable of fully expressing himself after circumcision, we are left to try and deduce what the healing time is based on imperfect measures. Thus a comparison to adult circumcision is going to be inherently flawed, but let’s do our best here. With respect to neonatal circumcision, the general consensus is that it will take 7 to 10 days to fully heal and this is providing that the utmost care is taken to avoid infection or other problems. That’s the physical healing, however, there is evidence of longer-term effects with respect to the infant’s response to pain. In the short term, though, infants circumcised without anesthetic showed behavioural problems linked to the pain response a day after the circumcision. More notably, researchers have found that infants who undergo painful procedures as neonates show a heightened response to pain years later and that this effect is linked to the strength of the pain reaction as a neonate. In adults, in one study it was found that 91% of men returned to work within a week after the procedure, 97% within two weeks; furthermore, 96% reported resuming normal activities within one week and 99% within two weeks. In another study, the median time after surgery to return to normal activities was 1 days, with 93% resuming all normal activities within one week. These are quite in line with what was reported for infants, suggesting no extra time is needed for adults. The only difference is that adult males must abstain from sex for a longer period, something neonates need not worry about, and resuming sexual activities too soon can lead to further complications, as previously mentioned.
What does this mean? The way I read it, it means that there is not a significant difference between the complications or healing time for neonatal or adult circumcision. The largest difference, and potential cause for further complications, is sex and frankly, if people want to claim it’s too difficult to abstain, then that is their problem. As far as I can see based on the research, there is no reason to be concerned over the complication rate or healing time of adult circumcision as opposed to neonatal circumcision.
Two religions worldwide account for the majority of religious circumcisions – Judaism and Muslim faiths. In Judaism, the infant male is to be circumcised on the 8th day post-birth, but for Muslim boys, the circumcision typically takes place later in childhood, though can take place from infancy into adolescence. Because of this difference, when we discuss the pros and cons of neonatal circumcision, we tend to be discussion a predominantly Jewish practice and as such, I will focus on what I have learned about that particular rite.
First I must state again that I am not Jewish. I am basing this section on readings and personal discussions and am therefore very happy to be corrected or to add anything that I may have missed. I welcome any and all information regarding this section. Given my lack of expertise, why put this in at all? Because religion is one of the dominant reasons for circumcision and as such it must be discussed and it must be discussed respectfully. Name-calling and a complete disregard for religious-based beliefs (especially when the individuals are not attempting to get everyone circumcised) will lead us nowhere because it will simple stop all dialogue, ending any chance of initiating real, honest change.
Why circumcise? Well, from what I can gather, the act of circumcision serves as a physical manifestation of the covenant with God. Thus, the failure to have this done can be seen as not having that full covenant with God, a very serious thing for those who believe. One of the issues that comes up is the question of why God would want Jewish men to circumcise themselves, and the answer seems to be an issue of submitting to God’s will. This is not something that is unique to Judaism, as many religions have certain rituals that are there to serve as evidence of giving in to God’s will so hopefully people can understand that aspect of it. Another reason is the “like father, like son” argument. That is, that circumcision is a sign of Jewishness – a marker both for others, and within the family. However, this last point loses traction when one considers that circumcision was done en masse for many years for non-religious reasons, but could have significance again as the rates decrease. (There are other reasons, such as the view that it “completes” man, but they are called out less than the aforementioned ones, so far as I can tell.)
Despite these reasons, some of you will probably be aware of movements within Judaism to not circumcise and they do seem to exist, and in fact are growing in number (even within Israel). Some simply do not do it at all, others do a modification – typically a prick to draw blood (akin to the heel prick or vitamin K shots nearly all babies receive) – which serves as a means to signify the covenant with God. If this is a possibility, why is it not widely embraced? Primarily because none of the official movements of Judaism officially support this (though there are individual rabbis who support it). If a modification is not supported by those in a position to make such statements, how are we to expect the followers to change their beliefs accordingly? Particularly if one views the act as central to one’s religion?
It’s very easy to sit on one side and say that you don’t buy religious arguments. But for someone who truly, honestly believes that this is the way for their child to have a covenant with God (and that without it, their child will not have said covenant), it’s a very serious matter. In many instances we value our children’s spiritual life over physical pain. As I have been reminded by individuals, we do not guarantee our children a life without any suffering, and if some suffering, particularly what has been deemed “minor” suffering, has a greater good to it, then do we not have the obligation to do that for our children? If we want to change the practice of circumcision, it seems to me we need to focus on understanding the religious impetus behind it and getting those in a position of authority to accept certain modifications or even simply a later age at which it can be performed (after all, a willing adult seems like a better candidate to have that covenant than a child who wasn’t given a choice). There are options, but none of them will be accepted if we simply refuse to accept the premise by which many Jewish individuals make their decision.
Hopefully this series has provided information on the science behind circumcision and how it’s a bit of a myth to argue that there are scientific benefits to routine circumcision. The pain in which the infant finds himself should be taken far more seriously than it is by many as even anesthesia does not reduce the pain entirely. The complications are real and need to be heeded. Legally we find ourselves in a bit of bind as similar procedures for girls are outlawed while the same does not hold true for boys. One of the things I found most interesting was the similar healing and complication rates between adult and infant circumcision. When the rates are so similar, it becomes impossible to argue that infant circumcision should be preferable. This is why I believe we strongly need to fight routine circumcision. There is absolutely no non-religious reason for circumcising a child who shows no medical need for the procedure, despite the rantings of some doctors who feel that all boys should routinely be put under the knife.
And perhaps that’s where we need to head in the religious debate as well, though the topic of religious circumcision adds a layer of complexity (or two, or five). Should a man not choose to enter a covenant with God as opposed to it being forced upon him? And what of other rites or rituals that may take its place? To change this though would require the support of both individual rabbis (which has begun) and those with the authority to sanction this type of change. That needs to come from respectful discussion and dissent from within (something that has also begun), and as long as those in favour of keeping young men intact use name-calling and are unwilling to engage in honest and open discussion, this won’t happen. So I ask any of you who are fighting religious circumcision to realize that the only way to approach this is to avoid name-calling and engage in open, honest, and respectful discussions.
Does all this make infant circumcision right? Personally I don’t think so. But I don’t think it’s something we can just declare to be wrong and ignore open discussions. I believe there are considerations that need to be made. The closest link to me is vaccinations in which we harm an infant, we inject them with something, all in the name of future benefit. There are many people against routine vaccination as well, but we acknowledge it’s about a parent’s choice. While the medical benefits of circumcision are far more tenuous, the spiritual ones are not. As such I believe we need to focus our efforts on education about the potential harms and alternatives that may satisfy the spiritual needs while refraining from name-calling. However, when there is no spiritual benefit as part of the discussion (and no medical condition that would benefit from the procedure), no infant should be subjected to circumcision. Period. As adults they can choose to be circumcised if they feel the benefits outweigh the risks of the procedure, but no newborn baby is capable of making that decision.
 Weiss HA, Larke N, Halperin D, Schenker I. Complications of circumcision in male neonates, infants and children: A systematic review. BMC Urology 2010; 10: doi:10.1186/1471-2490-10-2.
 Krieger JN, Bailey RC, Opeya J, et al. Adult male circumcision: Results of a standardized procedure in Kisumu District, Kenya. BJUI 2005; 96: 1109-13.
 Kigozi G, Gray RH, Wawer MJ, et al. The safety of adult male circumcision in HIV-infected and uninfected men in Rakai, Uganda. PLoS Medicine 2008; 5: e116.
 Krieger JN, Bailey RC, Opeya J, et al. Adult male circumcision outcomes: Experience in a developing country setting. Urologia Internationalis 2007; 78: 235-240.
 Dixon S, Snyder J, Holve R, Bromberger P. Behavioral effects of circumcision with and without anesthesia. Journal of Developmental and Behavioral Pediatrics 1984; 5: 246-250.
 Taddio A, Katz J. The effects of early pain experience in neonates on pain responses in infancy and childhood. Pediatric Drugs 2005; 7: 245-257.