This piece was originally published in the Spring 2013, Issue 06 of Nurture Magazine and the original (in pdf) can be seen here.

By Tracy G. Cassels

I used to be one of those people who thought that routine infant circumcision was a personal decision.  And by personal, I mean parental.  Yeah, I personally would never do it because there was just no point to it in my mind.  But to be honest I also never really thought it was “an issue”.  I knew wonderful, loving parents who circumcised their little boys.  I also knew wonderful, loving parents who didn’t.  I knew the stance in Canada (where I’m from) was that there was no reason to do it and officially there was a statement suggesting it best not to, but that it was still left up to the parent.

Then I learned.

I learned that what most of the Western world considers barbaric for females is actually acceptable for our male boys.  Before you tell me that they are two totally different procedures, let me explain what female circumcision entails around the world[1]… There are four different types, only one of which is actually far worse than male circumcision.  It is this type – infibulation – which involves removal of all or part of the inner and outer labia, the clitoris, and the wound is then fused, leaving open only a small hole for urine and menstrual blood.  Of those who undergo female circumcision, 15% will endure this type.  The other 85% will endure either the partial or full removal of the clitoral hood or the partial or full removal of the clitoral hood and part or all of the inner or outer labia (more akin to male circumcision in Western countries).  A fourth type includes all other types of procedures, which may include simply pricking the clitoris in a ceremonial way (the most common form of female circumcision in Indonesia), and which is still illegal in Western countries.

I’m not saying any of these should be legal at all and in fact I am thrilled they’re illegal as the lack of medical care during the procedure is highly dangerous for females; however, the idea that even the more benign prick of Indonesia is illegal but our boys can have their entire foreskin removed is ridiculous to me.  I would hope we value both our boys and our girls equally.

I learned that the so-called medical benefits to male circumcision don’t really exist in the research and certainly not in a way that justifies the procedure.  Three main areas are often brought up with respect to medical “benefits”: HIV/STIs, penile cancer, and urinary tract infections (UTIs).  Though there is some research suggesting that rates of HIV in high-infection areas can be lowered with a combination of circumcision and sex education[2][3][4], much of the research is flawed and the trials that aren’t provide mixed results to efficacy[5].  Similarly, attempts to replicate findings for HIV or STIs in developed nations have failed far more than they have succeeded[6].  Penile cancer is an area in which there are consistent findings that infant circumcision is correlated with lower or non-existent rates of penile cancer[7].  However, further examination of the findings shows that it only holds for individuals with a history of phimosis (a condition in which the foreskin cannot fully retract over the penis after the age of adolescence – it is completely normal not to retract in childhood)[8].  Thus if phimosis is diagnosed early (i.e., in adolescence) it may be a medical reason for later circumcision.  Finally, UTIs are brought up regularly in North America as circumcision is linked with lower rates of UTIs in Western samples and circumcision in childhood for children with recurrent UTIs seems to offer a type of cure[9][10].  However, this latter case would be a medical indication for circumcision.

In all of these cases, however, the cost-benefit ratio is miniscule or even in the negative.  For example, the base rates of STIs or HIV and the amount of protection that can be conferred is similar to or less than the risks of real complications from circumcision[11][12][13].  With penile cancer and UTIs, the risks of complications from circumcision actually outweigh the risks of either penile cancer or getting a UTI (for a discussion of this with UTIs, see [10]).  This means that you are putting your child at a heightened risk of a medical complication instead of conferring a benefit from it.

I learned that the pain from circumcision can send a baby into shock, that pain relief is only partial, and that there are practitioners who don’t use any pain relief at all on their newborn patients.  Parents may tell you their child didn’t cry much.  Doctors or nurses may tell you that your child is just in a deep sleep after undergoing a circumcision.  It’s not that.  It’s shock.  Infants undergoing circumcision without pain relief (something that is sadly too common given that 26% of training programs in the United States don’t even teach pain relief for circumcision under the misguided notion that it’s not needed[14]) have their cortisol raised three to four TIMES their baseline levels[15].  In one study examining pain relief methods versus a placebo, the researchers had to end the trials early due to the extreme responses of the infants in the placebo group[16].  Ethically they could not continue.  Even when there is pain relief used it’s not 100%, with the best relief options offering only partial relief[17].

Perhaps most importantly, pain relief or not, infant circumcision is linked with heightened pain responses to other stimuli months later[18].  This means that the experience of circumcision is altering our boys’ physiology in a way that we can actually measure.  The degree of change is dependent on the degree of pain relief received, but even those boys with the best pain relief available show significant increases in pain to later stimuli.  Thus I have to ask, is a cosmetic procedure worth altering our children’s physiological reactions to pain?  And can we say we’re doing no long-term harm when we can measure this long-term effect?

I learned that male circumcision may have negative effects on a man’s sexual functioning.  Though you may not hear many adult males complain about their sex lives, you will hear some given that the foreskin contains some of the largest numbers of sensitive nerve endings in the penis.  We know that a circumcised penis is far less sensitive to stimulation than the uncircumcised penis[19] (though the pleasure of sex involves so many other factors that it would be unfair to say that sex was less pleasurable and research on adults who have been circumcised shows no difference in subjective pleasure despite decreased sensitivity).  Often though, men who are studied are those who underwent adult circumcision for specific problems[20], a factor that might influence sexual pleasure prior to circumcision.

However, there is one study that has looked at non-adult circumcision and found that sexual satisfaction for both men and women was decreased when the men had been circumcised[21].  This is hypothesized to be due to the loss of sensitivity for men and the loss of lubrication for women as lubrication is a natural effect for an uncircumcised penis.  A second potential problem that comes from the loss of sensitivity is that it may be linked with riskier sexual practices.  One longitudinal study out of New Zealand[22] found that circumcised men were far more likely to engage in unprotected sex.  This shouldn’t be too surprising given the further loss of sensitivity that can come from wearing a condom.  Personally I hope my children would be careful regardless, but why would I want to stack the deck against them being careful?

I learned that to value the male infant means to value him as a whole, with a right to bodily integrity.  Unfortunately the idea that children have rights to their body is something we may give lip service to but rarely do we encourage it in practice.  From physically forcing children into seats they are screaming to get out of, to forcing hugs to others they don’t want to touch, to the most invasive—cutting off a piece of a child’s body for cosmetic purposes.  Children should have the right to bodily integrity and to take that away from them is to assume that somehow our child is born wrong.  That we can’t value the intact child as much as we value the altered child because if we did, we would not see the value in changing his body.

*****

I learned all these things and as soon as I did I could no longer say that routine infant circumcision was something parents should decide.  It should not be a parental choice.  When we make it such we are saying that boys are allowed to be born imperfect and that they should undergo a procedure no adult would want to endure.  And to endure it without full pain relief (if they are provided any at all).  Our boys deserve better than that.

And yet, despite our growing awareness of complications and pain responses due to circumcision, the American Academy of Pediatrics changed their stance on circumcision[23].  Whereas it was once discouraged, the stance now more neutral but bordering on support, though the real focus is making sure it’s paid for by insurance companies.  It’s not too surprising given the financial motivation doctors have but this change has wide-reaching implications.  Already the Canadian Pediatric Society is revising their stance[24] to be more in line with the AAP[25].  Who knows if other countries will also follow suit.  Remember, when you know more, you do better.  And our boys need us to know everything there is.



[1] World Health Organization.  Eliminating Female Genital Mutilation: An Interagency Statement.  WHO Library Cataloguing-in-Publication Data (2008).

[2] Gray RH, Kigozi G, Serwadda D, et al.   Male circumcision for HIV prevention in men in Rakai, Uganda: a randomized trial.  The Lancet 2007; 369: 657-666.

[3] Bailey RC, Moses S, Parker CB, et al.  Male circumcision for HIV prevention in young men in Kisumu, Kenya: a randomized control trial.  The Lancet 2007; 369: 643-656.

[4] Auvert B, Taljaard D, Lagarde E, et al.  Randomized, controlled intervention trial of male circumcision for reduction of HIV infection risk: the ANRS 1265 trial.  PLoS Med 2005; 2: e298.

[5] Van Howe RS, Storms MR.  How the circumcision solution in Africa will increase HIV infections.  Journal of Public Health in Africa 2011; 2: e4.

[6] Dave SS, Johnson AM, Fenton KA, Mercer CH, Erens B, Wellings K.  Male circumcision in Britain: findings from a national probability sample survey.  Sex Transm Infect 2003; 79: 499-500.

[7] Schoen EJ, Oehrli M, Colby CJ, Machin G. The highly protective effect of newborn circumcision against invasive penile cancer.  Pediatrics 2000; 105: e36.

[8] Tseng H-F, Morgenstern H, Mack T, Peters RK. Risk factors for penile cancer: Results of a population-based case-control study in Los Angeles County (United States). Cancer Causes and Control 2001; 12: 267-277.

[9] Wiswell TE, Smith FR, Bass JW. Decreased incidence of urinary tract infections in circumcised male infants. Pediatrics 1985; 75: 901-903.

[10] Singh-Grewal D, Macdessi J, Craig J. Circumcision for the prevention of urinary tract infection in boys: A systematic review of randomized trials and observational studies. Archives of Disease in Childhood 2005; 90: 853-858.

[11] 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.

[12] Ceylan K, Burhan K, Yilmaz Y, Can S, Kus A, Mustafa G. Severe complications of circumcision: An analysis of 48 cases. Journal of Pediatric Urology 2007; 3: 32-35.

[13] Bocquet N, Chappuy H, Lortat-Jacob S, Cheron G. Bleeding complications after ritual circumcision: About six children. European Journal of Pediatrics 2009; 169: 359-362.

[14] Howard CR, Howard FM, Garfunkel LC, de Blieck EA, Weitzman M. Neonatal circumcision and pain relief: Current training practices. Pediatrics 1998; 101: 423-8.

[15] Gunnar MR, Malone S, Vance G, Fisch RO. Coping with aversive stimulation in the neonatal period: quiet sleep and plasma cortisol levels during recovery from circumcision. Child Development 1985; 56: 824-34.

[16] Lander J, Brady-Fryer B, Metcalfe JB, Nazarali S, Muttitt S. Comparison of a ring block, dorsal penile nerve block, and topical anesthesia for neonatal circumcision. JAMA 1997; 278: 2157-2162.

[17] Razmus IS, Dalton ME, Wilson D. Pain management for newborn circumcision. Pediatric Nursing 2004; 30: 414-7.

[18] Taddio A, Katz J, Ilersich AL, Koren G.  Effect of neonatal circumcision on pain response during subsequent routine vaccination.  The Lancet 1997; 349: 599-603.

[19] Sorrells ML, Snyder JL, Reiss MD, Eden C, Milos MF, Wilcox N, Van Howe RS.  Fine-touch pressure thresholds in the adult penis.  BJU International 2007; 99: 864-9.

[20] Senol MG, Sen B, Karademir K, Sen H, Saracoglu M. The effect of male circumcision on pudental evoked potentials and sexual satisfaction. Acta Neurol. Belg. 2008; 108: 90-93.

[21] Frisch M, Lindholm M, Gronbaek M. Male circumcision and sexual function in men and women: A survey-based, cross-sectional study in Denmark. International Journal of Epidemiology 2011; 40: 1367-81.

[22] Fergusson DM, Boden JM, Horwood J.  Circumcision status and risk of sexually transmitted infection in young adult males: an analysis of a longitudinal birth cohort.  Pediatrics 2006; 118: 1971-7.