By Tracy G. Cassels
Adult versus Child or Neonate Circumcision
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% 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. [1] 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. [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. [3] 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. [4] Krieger JN, Bailey RC, Opeya J, et al. Adult male circumcision outcomes: Experience in a developing country setting. Urologia Internationalis 2007; 78: 235-240. [5] http://www.whattoexpect.com/first-year/ask-heidi/newborn-circumcision-care.aspx [6] 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. [7] 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.
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[5]. 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[6]. 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[7]. 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[2]. 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[4]. 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.
And Finally… Religion
Conclusions
I thought this was a good series, although from a strictly written sense it never really felt liked you really had a a strong wrap-up ‘point’, even given the above. But I expect that has more to do with length of time between when I read the first part and this part and how tired I am this morning
Personally I feel the level of ‘modification’ in circumcision is well within the realm of ‘normal’, so I no objection to people who do it for religious reasons. My objection come to those who do it ‘just because’. Perhaps it’s another ‘up there/down here’ thing, but I find it odd that you end focusing on how to convince religious people to give up the right, when the majority of infant circumcisions (in the U.S. at least) are done by people with no religious reasons. It seems like chasing the golden stag instead of worrying about the herd of deer in the grain field. The Torah/Old Testament says ‘cut’, so even if the practice was outlawed I don’t see much likelihood that a large segment of practicing Jews would be willing to accept a ritualized pin prick as acceptable. But the hordes of non-Jews who circumcisize ‘because it was hospital policy’, ‘the doctor said it was standard’, ‘they just brought me the forms to sign’, ‘so he looks like his dad’, etc, etc, etc, seem to be those who we both can and should try to convince to avoid what it, realistically, a religious rite that was spread under a false guise of science. I think, down here at least, we’d see a huge drop in neonatal circumcision if hospitals/doctors were not allowed to bring it up as a ‘standard’ portion of their care and only discuss it (baring the rare medical need) if parents brought it up first. That and I don’t feel that the majority of basic insurance, especially state sponsored insurance, should pay for elective care. I think if 1) the doctors wouldn’t bring it up and 2) if the parents brought it up the doctors inforemed them that it was a purely elective procedure that their insurance was unlikely to cover we’d see the rates of neonatal circumcision drop like a rock. It wouldn’t stop those with convictions for the procedure, but it would likely stop the ‘well, he’s male, that’s what you do, right?’ Which is what I see as the problem.
I think you’re right on the weak round up and I do need to focus more on routine circumcision. To be honest, I finished it in a rush to get it up with Maddy on my case to leave the house to go out, but think I’ll go back and tweak it now to handle that. Thank you 🙂
I have to say, you are probably the most constructive criticism friendly person I’ve run across in a goodly while. It makes it really easy to have a discusion, in general, on your pieces, because you actually listen to what I say (or rather read what I write) as opposed to just immediately getting defensive. It makes for a very good overall blog (and facebook) experience. And given that I’m a Biblical Christian blunt conservative it’s nice not to just get yelled at every once in a while. 😉
Why thank you 🙂 It’s something I’ve learned during graduate school – I wasn’t always this way. But I did learn that listening to others tends to give me better ideas than being too defensive and since I acknowledge that I certainly don’t know everything (or even most things), it stands to reason that others have valuable input too 🙂
Btw, I will get to changing that post, but it may be after the weekend 🙂
Made some changes – what do you think?
Much better, your added stance makes sense of your focus on the religious aspects because you’ve stated it’s the area you feel has some debate/give and take to be done, while the non-regilious just plain *shouldn’t happen*. Which I more or less agree with. Non religious people circumcising always struck me like a white family in Kansas practicing sacrification rituals from some Amazon tribe. It’s not that I feel scarification is, in and of itself, an abusive practice that should be banned, but it sure is questionable at best if there isn’t a compelling cultural/religious reason behind it.
Btw, the point to entering your children into a covenant with God is, for both Jews and Muslims (Christian too but different covenant) it is a requirement of raising your children properly to see them entered into that and grown up within the beliefs of the religion. Think of the secular equivalent being the argument that you should teach your kids to read, yes, they *could* make that choice themselves at a later date, but it’s part of your job as a parent to make sure they become literate. Asking an observant Jew to wait until their child is an adult would be a similiar parenting fail as asking a dedicated English teacher or writer to wait until their kid was an adult to decide for themselves if they want to learn to read. You, as parent, *know* that *this* is the best course for them and will do everything in your power to make sure they follow that course. Asking Jews to wait until their kids are ‘old enough’ to decide for themselves is, ultimately, to ask them to believe and behave in a manner that shows their religion is not the best choice. And I don’t care if you’re a Biblical Christian or a Druidic Shaman, why would you hold to and practice a religious belief if you didn’t believe it was the best path to be on? I think asking religious people not to ‘indoctrinate’ their children (which they *are* asked, even commanded to do all the time all over the world) is telling them they are not actually allowed to practice their beliefs. It’s like society saying “you’re insane, and we’ll let you proclaim your belief in your insanity, but you can’t drag anyone else into it” which, regardless of how I, we, society feels about any specific religion, is a very dangerious road to go down.
Do you mind if I post your last bit to the Mayim interview comments? Someone wrote about it and I really like your answer. It’s hard being non-religious to think in that way.
I guess there are too many replies there, won’t let me ‘reply’ to your last remark. Sure, of course. I didn’t actually read the interview yet (been busy), so I have no idea the context (and I don’t know who Mayim is), but if you find it appropriate feel free.
Totally appropriate 🙂 And shared 🙂 Mayim Bialik is an actress who’s actively involved in the AP movement and she just wrote a book about it all. It was my first “official” interview which was weird, but I enjoyed the experience.
Another argument I’ve heard is simply “so he looks like dad”.
The idea of going with surgery as the default is distressing, but the chief rebuttal to this one is simply that a 3-year-old boy’s genitalia simply does not look much like a 30-year-old man’s genitalia, circumcision or no — and by the time the boy has passed puberty and has a more adult appearance, he’s far past the age where he’s likely to be seeing his father naked much.
Thanks for this series!
Thank you! And yes, so true – why would we compare a newborn anything to an adults? But even then when people speak of locker room embarrassment, perhaps I’m naive, but wouldn’t this disappear if all boys aren’t circumcised unless medically necessary or for religious purposes? Then they have a reason and otherwise, there’s no embarrassment!
I come to this discussion a bit late, ha! It was almost by complete accident we didn’t get my 7mo old son circumcised. The ped in the hospital kept pushing the issue and we eventually said yes, as long as we were both there for it. Got to the nursery early– they do it in an adjacent room– right as the previous boy was being circ-ed. He screamed absolutely bloody murder and apparently there was some complication. DH and I looked at each other, backed out of the nursery with our son, and withdrew our consent to have him circumcised. I can’t say I fully respect people’s decisions to do it for religious reasons, because I just don’t “get” being religious, but the non-Jewish/Muslims who have it done because “it’s what’s done” should watch one happen before just passing their infant to a nurse to take away and never realizing what their child went through. Beautifully well-written piece. I read through the series fast so if I just missed it, you can ignore me, but I think it’s worth discussing the effects of male circumcision on the infants’ ability to effectively breastfeed in the immediate post-partum period, too,
Ashley – I fully agree that people should have to see a circ before they consent. And that they should have to witness something going wrong too. I should discuss circ and breastfeeding – a new post 🙂 Thank you!
That was absolutely fantastic. I found that you touched base on everything – including some positives about circumcision, but then weighed them to the negatives of routine infant circumcision. Fantastic overall … I am very impressed
[…] and that number has been on a steady decline. Here’s a great look at the entire issue: from religion to culture to the physical procedure (I recommend reading all four […]
What do you know about specific medical need for circumcision in some males? Numerous males on both my husband’s and my extended families have had teen/adult circumcision due to enormous pain during erection/masturbation/intercourse caused by overly tight foreskin. As the mother of a son it makes me nervous that he may have inherited an especially tight foreskin that will cause him the problems that his relatives from great grandfathers to uncles have had. I know you have argued that it’s best to let men decide for themselves when they are older but you haven’t taken into account the psychological impact that can go with being a teenage boy who experiences pain when erect or masturbating. Pain that he will most likely keep to himself for months, maybe years as he doesn’t want to discuss the details of his masturbation with his parents. And the embarrassment he will endure if the pain is so great that he must tell his parents about it in order for them to consent to medical treatment. That might sound hyperbolic but it’s exactly what my BIL went through as a teenager, waiting until he was 17 and had experienced years of pain before going to the doctor, having circumcision recommended and then being faced with the choice of waiting until after his birthday to book the surgery himself or tell his parents something he had kept from them for years. At this point the pain was so great he had to tell them so they would agree to the surgery and he describes it all as completely nightmarish. I would hate for my son to experience something similar in the future. I am a very different type of parent to my in laws, who are lovely but religious and old fashioned, but I still suspect that I’m the last person my son will want to discuss his masturbation with when he is a teenager. Is there a way of telling in infancy if the foreskin is very tight? And if it is are there exercise he can do as he matures that will help the skin stretch? I’d rather not circumcise him but I feel to ignore a problem that many of his male relatives have had would be worse.
That’s a tough one. I can only say that I would personally focus on making sure my child IS comfortable talking about erections and masturbation by having it be an open, nothing-to-fear topic in the house. And if you know this is coming up, talking to your child ahead of time and explaining why can be helpful as well. Starting when they are a bit younger, telling them that if their penis ever hurts a lot, that’s something to come to you about and that it can happen and has happened to x, y, and z in the family so they don’t feel alone or that no one will understand. In fact, even let him go to a person in the family who experienced it if he’s more comfortable talking to them.
I just see that there’s no reason a child by definition HAS to be embarrassed about these things. We simply provide a culture and environment that makes them shameful. But likewise, we can create a environment that is not like this.
An important thing to consider in this issue of phimosis [tight foreskin] is forced retraction in infancy/childhood, which is both harmful to the child and common in areas like the U.S. where so many people are ignorant of the proper care of intact boys. Forced retraction can cause phimosis [secondary phimosis is what I’ve heard it called] and phimosis that is not caused by forced retraction, etc. [primary phimosis] is not common and is usually easily resolved with less invasive treatment, like stretching exercises!
I’m sorry that I don’t have the time to give any specific citations [feverish baby needs my attention] but the WHOLE network [facebook and web page] has a library where you can look up more info 🙂 http://www.thewholenetwork.org/the-foreskin-and-penis.html#retraction and http://www.thewholenetwork.org/the-foreskin-and-penis.html#confusion
Thank you for this write-up. My wife and I recently chose not to circumcise our first son (first child). We both recently deconverted from Evangelical Christianity.
Though we haven’t “come out” to our families yet, the choice not to circumcise (and not to go to church currently or dedicate our child) has caused some conversation.
I wish I had read your research first, as I was actually a bit too aggressive in claiming that there are NO medical benefits to circumcision. My aim is to be factual in conversation, so as not to discredit myself!
I am relieved that we made a very good choice, as it seems that the primary benefits from circumcision come later in life and that the need for it becomes apparent later too.
My wife and I have held the somewhat bold view that circumcision is basically mutilation and therefor child abuse. Because we saw no compelling necessity, we decided against it. I also appreciate your perspective that we need to be respectful of religious folks. I can empathize, after all. I believed (or tried to believe) some crazy crap for many years!
Anyway, thank you!