Against the routine infant circumcision

The purpose of this paper is to refute the legal, religious, social and other arguments listed in favour of the routine infant circumcision and show that there are only some rare medical cases in which it could be justified (although even in these cases – like phimosis - probably avoidable).

Routine circumcision of girls (usually between the age of 4 and 8 years) is still present mainly in some Muslim states in Africa and parts of Arabia and Asia (together in 28 states) and is usually performed in unhygenic environment and often without anesthesia. It is considered to be a traditional cultural rite of passage. 10 years ago Amnesty International estimated that 135 million girls have undergone various forms of genital mutilation, which ranges from a clitoridectomy (removal of the clitoris) to stitching the entire vaginal area closed except for a small opening for urination. According to the new information 2 million girls are at risk of female genital mutilation each year. Only 9 countries have specific legislation outlawing female genital mutilation, not long ago Eritrea joined the list, the country in which 89 % of all women are circumcised. [2]

 

Elder women usually cut out the genitalia of a small girl sometimes even with a direct intent to enhance the sexual pleasure of her future male partners. This cruel and brutal custom resulting in significant mutilation, reproductive problems and sometimes death has been criticized for years by the Western countries, in which it is forbidden. But these same countries allow routine circumcision of boys despite of the lack of arguments in its favour (male prepuce is identical to the female prepuce in its embryological development, cell structure, and nerve and blood supply). [3] Routine circumcision of boys is a bloody and a very painful procedure, in which the prepuce is cut from infant's/boy's penis (in case of adults 5-8 cm of prepuce in length is cut away). [4]

Not long ago, the entire world population was 5 Billion, 700 Million. Out of those, 2 Billion, 647 Million were males. 18% of them (487 million) were circumcised and 2 billion 160 million were intact (the newest numbers are 665 millions of circumcised men or 30 % of the male population). Of the world's male population, the circumcised were: 79 million American infants, 9 million American children or adults, 13 million infants in Canada, UK, New Zealand & Australia, 27 million infants in the rest of the world, 44 million children or adults in other parts of world, 315 (?!) million Muslim children/adolescents. Out of the Worldwide Total of 487 million Circumcised Men: 65% occured as Muslim cultural circumcisions, 15% occured in other countries, 3% occured in other English speaking countries, 17% occured in the U.S.

 

Just 30 years ago, as many as 90% of boys in the United States, 70% of those in Australia, 48% in Canada and 24% in the United Kingdom were circumcised (often without any anesthesia). [5] The practice was introduced to the U.S. through England, but they abandoned it nearly 50 years ago, practicing it now at the rate of only 1%. The rate is 3% in New Zealand, 10% in Australia and 20% to 25% in Canada. [6] The decrease in numbers is also due to the raise of the awareness of the doctors asked to perform the circumcision.

Male circumcision is depicted in Egyptian tombs 5,000 years ago. [7] It seems to have its origin in snake worship. The Egyptians believed that when the snake shed its skin, and emerged shiny and new again, it was undergoing rebirth. They reasoned that if, by shedding skin, the snake could become apparently immortal, then humans should follow suit. They made the simple equation: snake skin = foreskin, and the operation began. From there it spread to many Semetic peoples, both Arabs and Jews adopting it and converting it into an act of religious faith. As the centuries passed, it became popular in other regions of the world for other reasons such as moral, medical, or hygenic. [8]

 

Non-religious circumcision began in England in the late 1800s and it became extremely popular in English-speaking countries between 1920 and 1950. England introduced the practice to the U.S. At the time, it was believed that masturbation caused a host of different illnesses. Masturbation was considered extremely immoral and many children, both male and female, have been circumcised throught the years because parents discovered them "in the act." To this day, who doesn't remember the threat associated with masturbation that "you'll go blind?" [9]

The question of circumcision of children poses a legal dilemma – i.e. a collision between two rights: on the one hand the right of a child as a unique human being to make essential decisions regarding his own body and on the other hand the right of the parents (or guardians) to bring up their child as they want. The right of the parents is here a bit different than in the case of education – here a body of a child is in question and a change of it that the circumcision causes can be only partially »repared« in the future (as it is explained below under medical reasons), while doctrines and beliefs can be changed much more easily once a childs matures. Also, in most of the cases there is no valid medical reason to hurry with such a delicate operation, while education is a non-stop on-going process, which cannot be “frozen”.

 

In legal theory and practice two main approaches developed with regard to the collision between the right of a child and the right of his parents (guardians). One sees a child as a sort of extension of the identity of his parents (guardians), giving them virtually unabridged right (control) to treat the child as they think best (here it is worth noting that the most common social reason for circumcision is the wish of the parents to make the sons look like the father). The other one sees a child as an individual in charge of his own life, who makes his own decisions, but is cared for by the parents, who can direct him (yet not force him) along the line they find appropriate.

 

Historically, legal solutions transcended the reactionary view of a child as an extension of the parents' identity. If even the right of ownership (over a thing not a living being!) cannot be abused nowadays, how much more this can be asserted in the case of a child. Convention on the Rights of the Child – entry into force 2. 9. 1990 (Act on ratification of the Convention of the United Nations on the Rights of the Child; Official Gazette of SFRJ, n. 15/1990 – International Treaties, Official Gazette of RS, n. 9/1992 – International Treaties, – from now on: convention), which is being used directly in Slovenia, is apparently »on the side of a child«. Regarding child’s religious freedom it determines that parents provide direction to the child in the exercise of his or her right in a manner consistent with the evolving capacities of the child. Freedom to manifest one's religion or beliefs may be subject only to such limitations as are prescribed by law and are necessary to protect public safety, order, health or morals, or the fundamental rights and freedoms of others (second and third paragraph of the 14th article). Furthermore, the convention says that: »States Parties recognize the right of the child to the enjoyment of the highest attainable standard of health« (first paragraph of the 24th article), and that: »States Parties shall take all effective and appropriate measures with a view to abolishing traditional practices prejudicial to the health of children« (third paragraph of the 24th article). The convention sets “the best interest of the child” as a primary consideration for the state parties in all their activities concerning children (first paragraph of the 3rd article).

 

Constitution of the Republic of Slovenia (Official Gazette of RS, n. 33/91, 42/97, 66/00, 24/03, 69/04, 68/06 – from now on: constitution) also speaks about the fact that: »The religious and moral guidance given to children must be appropriate to their age and maturity, and be consistent with their free conscience and religious and other beliefs or convictions” (3rd paragraph of the 41st article). No one may be subjected to torture, inhuman or degrading punishment or treatment. The conducting of medical or other scientific experiments on any person without his free consent is prohibited (18th article).

 

Circumcision of children opens also other legal and ethical questions: is a child later on entitled to a money compensation because of the suffering caused without his consent? Aren’t doctors suppose to heal medical disorders, sicknesses etc. instead of performing operations, which don't benefit individual's health, can circumcision be performed by others than doctors – like e.g. so-called mohels in the Jewish community etc.? Some have called for the legal responsibility of the medical organizations (like national organizations of doctors) supporting circumcision or not warning against its dangers (for details see the chapter 4.a - Opinion of the Medical organizations).

Perhaps the most »progressive« countries on the field of the legal regulation of the circumcision of male infants are the Scandinavian ones. Sweden was heavily criticized by some groups of Jews and Muslims after it enforced a law restricting medically unnecessary circumcision on the 1st of October 2001. The law was accepted with a vast majority in the parliament after a Muslim boy died while being circumcised. Jewish community claimed that in the mentioned case the circumcision was performed by a registered physician and that the reason of death was an overdose of the anaesthetic. Every year about 3,000 Jewish and Muslim boys are circumcised in Sweden for religious reasons.

 

Unfortunately, the law was greatly watered-down from when it was first introduced, despite the protest from Swedish pediatricians, who claimed that circumcision of boys is an abuse which contravenes the UN Convention on the Rights of the Child and should be abolished. The initial text said that no one could be circumcised before the age of 18 and then only with full disclosure. Following negotiations with the Jewish community, the act made Jews exempt for the first two months, during which time a mohel can obtain a license from the government to circumcise a baby. Perhaps this was done with an (un)conscious traditional and (untrue) belief that small children don’t suffer any long-term consequences from this kind of procedure. A mohel living in Sweden even stated publicly that a week old baby doesn’t feel any pain during the circumcision. [10]

 

Swedish Circumcision Act determines that a boy under the age of two months old may be circumcised by a person who is not a registered physician provided that person has obtained special authorization from the National Board of Health and Welfare. No boy may be circumcised without an anaesthetic, which must be administered either by a registered physician or by a registered nurse. Jewish community fears that it will not be able to find nurses or doctors to help them perform the ceremony because many health professionals in Sweden view circumcision as a form of mutilation.

In Judeo-Christian tradition the reason for circumcision is mainly derived from this excerpt from the Old Testament: “Then God said to Abraham, thou too Shalt observe this covenant of Mine, Thou and the race that shall follow thee, Generation after generation. That is the covenant you shall keep with Me, Thou and thine; every male child Of yours shall be circumcised (Genesis 17: 9-11).” There are many other parts in the Bible referring to the circumcision (including Jesus’ - St. Luke, 2:21) some in favour of it, others not (also from Jesus Himself – “If a man can be circumcised on the sabbath to prevent a violation of Mosaic law, how is it you are angry with me for curing a whole man on the sabbath? Stop judging by appearances and make an honest judgment” - John 7: 23-24). Some people say: didn’t God stop the sacrifice of Abraham’s son (Genesis 22)? So why would he demand circumcision of the believers’s sons? The main objection of the circumcision is supposed to be the sacrifice given to the God – renouncing the flesh (body) with its sins, Augustine thought that circumcision signified cleansing even in infants of the original sin, just like baptism (On Marriage and Concupiscence, II, 24, p.292.) The others argue that Jesus got circumcized so that the Christians would no longer needs circumcision, as a sort of redemption. Paul rejected circumcision probably because of pragmatical reasons, since it could impede spreading of christianity (especially among the Greeks and Romans); see Romans 2:25-28 and Galitians.

 

Quite some (Christians and Jews) list many arguments against circumcision [11] : e.g. why hurry with the procedure and not wait until the adulthood; didn’t God create the man by his own image – Genesis 1:26 (meaning that God is not circumcised? Doesn’t circumcision therefore represent the violation of the integrity of what the God has created?) Historically, the circumcision originates in snake worship in the ancient Egypt (animals represented Egyptian gods and godesses) and the Jews and Arabs only transferred this ritual to their own god etc. In fact, theological debate on the subject seems to be never-ending.

 

Apparently a significant part of the “sacrifice in the form of the circumcision” is the shedding of the blood and circumcision is a notoriously bloody operation; even in modern surgical conditions hemorrhage (big loss of blood) can be a problem. A rate of up to 2% is supposedly requiring blood transfusion. [12]

 

It is often argued that the real reason behind the listed religious arguments in favour of the circumcision is the attempt to establish the control over the (male) sexuality and consequently over the human race. One of the direct consequences of the circumcision is a greatly reduced possibility of pleasurable sensations of a circumcized man during the sexual intercourse. [13] This should in a way “raise the value of the sacrifice to god”, since the prepuce is by itself just “a piece of skin”. It should also help stop masturbation, since it was believed in the past that masturbation caused blindness, mental illness, alcoholism, epilepsy and a host of other ills. It therefore made sense to some physicians that genital surgery would stop masturbation and prevent the onset of these illnesses. [14] Again this argument could be interpreted as an ideological disguise covering the real reason: the control over male’s sexuality (human race).

 

In Jewish tradition the child is usually circumcised at the age of 8 days. Although circumcision is considered to be a tradition, many Jews argue that there are other “traditions” according to Torah (holy book of Judaism), which are not followed nowadays (e.g. a death penalty for the following deeds: cheating on the husband, fornication – for women, homosexuality, blasphemy, insulting one’s parents, disobeying one’s parents), also other practices have been abandoned despite being recognized by Judaism in the past (slavery, animal and human sacrifices, divorce for men only, female subservience to men including obedience to every order and no right to refuse sexual intercourse). [15]

 

Circumcision is not mentioned in Koran, yet the divine law of sharia is not based only on Koran but also on the hadith (the sayings of the Prophet Mohammed) and the sunnah (Prophets’ tradition – prophet’s teachings and acts). Circumcision has the status of sunnah. Only the Shafiite school of law regards circumcision as obligatory, while others regard it as only recommended. Even those who consider circumcision an obligatory duty for themselves do not see it as an essential requirement for others to become a Muslim. Yet, the procedure is very commonly practiced and is seen as an important external symbol of submission to god’s will. [16] The usual age for circumcision of a Muslim is 7 years, but in practice it could be performed from few days after the birth all the way up to the puberty. Adult converts to Islam have traditionally been required to undergo the operation, but this practice is not universally considered to be essential, especially if there is a health risk. [17]

 

The circumcision is also a business: doctors, mohels and others live off its performance, and there are quite some medical, religious and tribal instruments that are used during the procedure and can be bought. There is even talk of the “circumcision industry”. It is estimated that 1.2 million newborn males are circumcised in the United States annually at a cost of between $150 and $270 million. [18] In the West, biotissue companies use amputated newborn foreskins to create profitable artificial skin products. [19] So, religious reasons are sometimes viewed as an ideological excuse supporting the survival of the “circumcision industry”.

Medical aspects of the circumcision are most often listed in the pro & con debate about the procedure. Yet, they seem to speak much more against it than in favour of it. No National medical organization in the world recommends routine circumcision of the male infants. And lots of them are quite critical about the procedure (to name but a few from the English speaking countries): 2003 British Medical Association, 2002 Royal Australasian College of Physicians, 2002 Canadian Paediatric Society (reaffirmed 1996 position), 2000 American Medical Association, 1999 American Academy of Pediatrics, 1996 Australian College of Paediatrics, 1996 Australasian Association of Paediatric Surgeons. [20]

 

The Canadian Pediatric Society e.g. concluded that: “The overall evidence of the benefits and harms of circumcision is so evenly balanced that it does not support recommending circumcision as a routine procedure for newborns.” [21] American Academy of Pediatrics (AAP) issued a more reserved policy statement in 1999, especially compared to some of its previous statements in which it e.g. claimed that: “There are no valid medical indications for circumcision in the neonatal period (1971).” [22] In its 1999 opinion AAP wrote that: ”Existing scientific evidence demonstrates potential medical benefits of newborn male circumcision; however, these data are not sufficient to recommend routine neonatal circumcision. In circumstances in which there are potential benefits and risks, yet the procedure is not essential to the child's current well-being, parents should determine what is in the best interest of the child. To make an informed choice, parents of all male infants should be given accurate and unbiased information and be provided the opportunity to discuss this decision. If a decision for circumcision is made, procedural analgesia should be provided.” [23]

 

The AAP policy statement might be revisited in the future since it has been heavily criticized. Some even suggested that AAP didn’t quote all of the necessary researches and that some of the listed researches were misquoted: “The 1999 Task Force on Circumcision policy statement also has flaws and may likewise be culpable for failing to adhere to the generally accepted scientific and professional preference for valuing methodology in assessing the soundness of existing information. The responsible course of action for the AAP would be to admit that the evidence does not now support, and never has supported the continued routine performing of circumcision on infant males. … In the alternative, assuming that the AAP, ACOG (The American College of Obstetricians and Gynecologists), and individual physicians can reasonably hypothesize beneficial utility that a century of research has failed to prove, circumcision should be reclassified as experimental and/or cosmetic surgery and thus be subject to all the laws governing such therapies. Parents who still choose this surgery for their baby boys should do so only after a much more rigorous informed consent process. All infants who then undergo this surgery should be made part of nationwide prospective research studies into the complication rates and health results, pro and con, that this surgery holds for men. In any future brochures or publications on the subject, the AAP and ACOG should fully disclose the medical profession's succession of erroneous rationalizations used to justify circumcision for more than a century. Additionally, the AAP should disclose alternative sources of information, so that it does not convey to parents the false impression that there are no medical professionals who oppose, or who have opposed, routine circumcision of infants.

 

If the preceding actions are not undertaken voluntarily, the AAP and ACOG should be named as co-defendants in legal actions involving circumcisions that have resulted in serious injury or death.” [24]

Defenders of the circumcision claim that a circumcisized penis is cleaner. But as all men know hygiene of the private parts is simpler and less time taking than brushing or flossing the teeth. So this argument hardly calls for the routine circumcision of the infants. [26]

Circumcision is extremely painful and bloody. Excessive bleeding can require a blood transfusion with the attendant blood supply risks for HIV and other disease organisms. Also, pain can be experienced in the days after operation and even later in the case of complications.

Modern psychology knows much more about child’s abilility to feel the pain and remember the traumatic experiences, than it used to. Here we list only a few examples: [27]

An experiment designed to measure fetal and neonatal memory for speech sounds proved that in utero subjects, who were read a target story twice daily by their mothers, would later as neonates respond preferentially to their target story as opposed to similar sounding stories, regardless of who recited it to them.

 

Researchers also found out a significantly higher percentage of adolescent suicides among subjects that had experienced respiratory distress at birth, compared to adolescents who experienced no problems at birth. A pattern of distressed behaviors, similar to those of "infants born at risk," occurs during the trauma of circumcision. In another retrospective epidemiological study conducted in Sweden, researchers also found a significant correlation between the type of suicide method chosen by suicide victims and the type of complications they experienced at birth. Researchers of both studies dealing with adolescent suicide carefully pointed out the correlational, rather than causal, certainty of their findings.

 

One study demonstrated that three-month-old infants can remember a picture for weeks after a brief exposure. A researcher, who electronically recorded brain activity in infants during memory experiments came to the conclusion that infants have "covert" long-term memory, even if there no overt evidence of such memory.

 

Researchers Anna Taddio et al., demonstrated that neonatal circumcision increased the pain exposure of infants to vaccination at four and six months. This result held even for those boys given EMLA cream (a topical anesthetic that numbs the skin and decreases the sensation of pain) as a pain prevention measure during their neonatal circumcisions. This article soundly proved that neonatal circumcision does have long-term behavioral aspects. [28]

 

Many parents believe their child can be anesthetized during circumcision, but this is very risky. Anesthesia can lead to complications and the question arises, why should a child undergo such a traumatic experience, if the procedure is not necessary. In a known Canadian case (in August 1994) a few hours after his circumcision, a baby developed significant Methaemo-globinaemia (a blood disorder where the blood is unable to carry oxygen to cells in the body. Normal haemoglobin, which is found inside the red blood cells, is changed to abnormal haemoglobin, called methaemoglobin. This can cause brain damage and death in small infants). Two other cases of Methaemo-globinaemia due to Prilocaine have occurred in British Columbia. Lidocaine has been known to cause the same results. [29]

The injection of local anesthesia into the penis has risks as well. It can cause permanent vascular and nerve damage. The shot itself can be very painful.

 

Even when anesthesia is attempted, it is not always effective.

 

Some children later on regret the circumcision and take on the foreskin restoration process. This can be achieved surgically, with a number of operations. Foreskin restoration can also be achieved by non-surgical tissue expansion techniques. The unique structure of the inner lining of the prepuce can never be recreated, although most men seem to be satisfied with the results of the foreskin restoration. [30]

A study found that 29.7 % of circumcised boys under three years of age have adhesions (scar tissue) or skin bridges. [31] They are complication of circumcision. They form when the raw remnant where the foreskin was cut attaches to the raw surface of the glans and heals that way. These tend to interfere with hygiene (it is difficult to clean the penis under the skin bridge).

According to the study balanitis (inflammation of the glans) is more common in circumcised boys. Perhaps some parents mistakenly believe that the circumcised penis is maintenance free and do not attend to penile hygiene when their son is circumcised. The foreskin has protective functions that are not available when the boy is circumcised.

 

The circumcised boy needs to have any skin overlaying the glans pulled back and cleaned regularly until 15-18 months of age to prevent adhesions from reforming and debris from accumulating. The debris consists of "lint, dirt, talc, stool and detritus." There is strong association between coronal adhesions and the presence of subpreputial debris. Most preputial adhesions in circumcised boys resolve by 24 months after parents were instructed to apply gentle retraction on the adhesion. The circumcised penis actually requires more care than the intact normal penis which is protected by the preputial spincter and is cleaned by the swirling urine, and thus requires no special care. [32]

 

Infection occurs after circumcision in up to 10% of patients. [33] Repeated infections can result in meatal stenosis (a narrowing of the urinary opening) which may require surgery.

Some people complain that not enough skin was removed during their son’s circumcision. They fear he looks uncircumcised. Children are often subjected to circumcisions being ‘redone.’ [34] Sometimes, a circumcision may only appear to be incomplete when actually it is not. There may be fat pads in the pubic area. “When the child grows and the fat pad disappears,” it will likely have the look of an ordinary circumcised penis. Often too much tissue is removed, although this is not become obvious until later. This can cause painful erections and curvature of the penis.

Many parents are led to believe that circumcision is safer than leaving the penis in its natural form. “Your Child’s Health” by Barton Schmitt reports one out of every 500 circumcisions results in a serious complication. [35] Paediatrician Dr. George Williams says that three out of every 100 cases of circumcision have complications. [36] One study was conducted that followed circumcised boys beyond the immediate post-operative period. It concluded that complications occurred at an alarming rate of 55 %. [37] Some say realistic rate of complications is between 2 and 10 %, [38] other speak about the 4% immediate complication rate and the 13 % late complication rate. [39] Many things can go wrong including hemorrhage (big loss of blood), infections and damage to the penis. Much of the harm of circumcision does not become apparent until adulthood.

The assumption that circumcision is inevitable at some later time is a myth. There is a less than 1% chance that circumcision will ever be medically necessary.

Parents who choose circumcision for cosmetic reasons do not realize that it cannot be accurately described as truly cosmetic. When it is presented so lightly, people naturally assume the effects of circumcision are minimal - even insignificant. The word is misleading. Cosmetic surgery is performed to improve physical appearance without affecting function. The foreskin, commonly believed to have no purpose, actually has numerous functions and all of them are eliminated when the foreskin is removed.

The prepuce has more functions.

 

Firstly, it is itself sensitive due to the nerve endings on its inner surface, which become exposed during sexual arousal.

 

Secondly, it protects the glans. The protected glans remains soft, moist and sensitive throughout life, but the exposed glans of the circumcised male becomes increasingly thickened and desensitized. If this would not be so it would be impossible for a circumcised man to tolerate the abrasion of clothing on the exposed glans.

 

Thirdly, the mobile sheath of skin on the intact penis allows the prepuce to slide back and forth over.

 

Fourthly, slack skin on the shaft of the erect penis allows it to glide within its own sheath of skin.

 

These caracteristics facilitate an intercourse and help avoiding problems with vaginal dryness. [40]

 

It is strange that doctors in Western countries will not permit female circumcision, which involves removal of some or all of the erogenous tissue from the vulva for reasons other than major pathology such as malignancy, but will permit, and in some cases encourage, the removal of the male prepuce, which is identical to the female prepuce in its embryological development, cell structure, and nerve and blood supply. [41]

Avoidance of penile problems is sometimes listed as a reason in favour of routine circumcision of infants. However, the incidence of bleeding, erosion of the glans and stenosis of the ureteral meatus has been reported to be higher in male infants who have been circumcised than in those who have not been circumcised. Meatitis and meatal ulcers occur almost exclusively in circumcised boys. [42]

The results of a study published in the New England Journal of Medicine show that women have an increased risk of cervical cancer if their partners are not circumcised. Why? It seems uncircumcised men are more likely to transmit human papilloma virus (HPV) and, worldwide, HPV could be the cause of 99 % of cervical cancers in women. [43] Yet, another study shows no correlation between uncircumcised sexual partner and cervical cancer. [44] A good screening program and a vaccine seem to be a far better weapon against cervical cancer than circumcision. [45]

Penile cancer is extremely rare. An incidence rate of penile carcinoma is of two cases per 100 000 men annually and the condition almost never presents before 50 years of age, so there have been calculations according to which the cost of circumcising 100 000 male infants is 3.8 million $ and that this manoeuvre would prevent only two cases of cancer of the penis, [46] as it came out the neonatally circumcised men were not immune to penile cancer, at least some cases of cancer occur in circumcised men as well. [47] Also, hygiene seems to lower the risk of penile cancer.

Some claim that there is also evidence that circumcision results in a reduction in the incidence of HIV transmission. However, there is inadequate information to recommend circumcision as a public health measure to prevent it. [48] Some studies made in Africa suggested that circumcision could prevent spreading of HIV and other sexually transmitted diseases. [49] A study made in the West (among heterosexual men) showed that circumcision had no significant effect on the incidence of common sexually transmitted diseases. [50] The older studies made in Africa were supposedly conducted in a methodologically wrong way and using the outdated data. Also, one study found a higher rate of chlamydia among circumcised men, while no higher sexual transmitted diseases rates occurred in intact men. [51] The newer studies about Africa and HIV are more accurate, their authors claim. The reason for the increased risk of infection is supposedly because the foreskin of the penis is susceptible to scratches and tears during the intercourse. In addition, the foreskin contains a high density of Langerhans cells, which are especially vulnerable to HIV.

Yet, health experts warn that men might think circumcision will completely protect them from AIDS, causing them to take increased risks in their sex lives. [52] Also, circumcision brings other problems (especially when it is not performed in the hospital and by a doctor), beside that religious and cultural norms are difficult to change and there are many other ways to prevent spreading of AIDS, like usage of condoms, which is more secure and less painful than the circumcision. Health experts warn that nothing can substitute prevention, the results of which clearly show in the medically more developed countries.

 

There are some medical cases in which circumcision of infants is more acceptable, like true phimosis. Yet, quite a few medical experts think that is is avoidable even in that case. [53]

Phimosis usually means any condition in which the foreskin of the penis cannot be retracted. Most infants are born with a foreskin that does not retract and this is normal. The “true phimosis” is "preputial stenosis", which occurs in less than 2% of intact males. Of these 2%, 85–95% will respond to topical steroids. Of those who fail this, at least 75% will respond to stretching under local anesthesia, either manually or with a balloon. The arithmetic is simple: At the very most 7 boys in 10,000 may need surgery for preputial stenosis.

 

The prepuce of boys may be tight until after puberty. This is an entirely normal condition and it is not phimosis. According to the experience in cultures where circumcision is uncommon, this tightness rarely requires treatment. Spontaneous loosening usually occurs with increasing maturity. One may expect 50 percent of ten-year-old boys; 90 percent of 16-year-old boys; and 98-99 percent of 18 year-old males to have full retractable foreskin. Some claim that up to 90 % of uncircumcised infants have a fully retractable foreskin by the age of 5. [54] If treatment should be necessary, it should not be done until after puberty and the male can weigh the therapeutic options and give informed consent.

 

It is important to note that the immature foreskin of a child must not be forced back for "cleaning" or for any other reason, because this will cause damage to the developing tissues. The child should be instructed that his foreskin will eventually retract. The first person to retract the foreskin should be the child himself.

 

A number of reports indicate that medical doctors are not trained to distinguish between normal developmental tight prepuce in boys and pathological phimosis. This results in cases of misdiagnosis of normal developmental preputial tightness as pathological phimosis. [55]

 

The 1990s have seen the advent of the use of topical steroidal and nonsteroidal medication for the treatment of narrow foreskins (phimosis) in boys. Topical steroid ointment is now the treatment of choice for phimosis, due to low morbidity, lack of pain or trauma, and low cost. It is considered to be the most cost effective, while the circumcision is deemed to be the least cost effective. [56] The application of steroid ointment to the foreskin has the effect of accelerating the normal growth and expansion of the foreskin that occurs over several years and which usually results in the spontaneous relief of the non-retractile condition. Narrow foreskins usually eventually widen without treatment.

 

The treatment is non-surgical. There is no trauma and no surgical risk. The treatment is inexpensive.

 

Skin that is under tension expands by growing additional cells. A permanent increase in size occurs by gentle stretching over a period of time. The treatment is non-traumatic and non-destructive. If needed it can be combined with the topical steroid onintment treatment.

 

Preputioplasty is the medical term for plastic surgery of the prepuce or foreskin. It is a more conservative alternative to the traditional circumcision or dorsal slit for the treatment of preputial stenosis or phimosis. Many doctors have proposed surgical alternatives to circumcision because of the many problems, risk, complications, and disadvantages inherent in circumcision.

 

Advantages claimed for preputioplasty are more rapid, less painful recovery, significantly less morbidity, and preservation of the foreskin and its various protective, erogenous, and sexual physiologic functions. [57]

This paper shows that there are virtually no valid reasons for the routine circumcision (cutting of the prepuce) of the boys. Religious reasons are either superstitious (redemption for the original sin), either incoherent in the frame of the very religious tradition from which they originate (if God created humans by its image, why violate the integrity of His creation etc.) or just ideological excuses used to establish control over male sexuality (and subsequently over human race), since (involuntary) circumcision of boys decreases possibility of male pleasurable sensations of sexual nature.

 

UN Convention on The Rights of The Child demands from the State Parties to abolish traditional practices prejudicial to the health of the children and to always act in the best interest of the child. The mentioned document transcends the old view according to which children were only an extension of their parents’ identity. Instead it sees a child as a unique human individual, who takes major decisions in his/her own life for himself/herself (even though only when he/she is mature enough), while the role of his/her parents is restricted to a sort of guidance/counseling. Therefore the wish of the parents to make the child look like a father cannot represent a reason justifying circumcision.

 

Slovenia should follow the initial text of the Swedish act on circumcision, in which medically unnecessary circumcision was allowed only to the adults. In that way the professional opinion of the many medical organizations speaking against the routine circumcision of infants would be legalized; none of the national medical organizations recommends the controversial procedure.

 

Faculty of Slovene doctors should take a firm stand against the circumcision of children or otherwise carry the risk of being sued sometime in the future, in case some complications arises during a concrete case of infant circumcision.

 

There are many serious medical and psychological reasons against the circumcision of children, while there are virtually none in favour. Even those claiming that there are some benefits from the circumcision (less risk for penile problems, sexually transmitted diseases, urinary tract infections, penile cancer, cervical cancer) admit that the circumcision is not the best solution for the listed health problems and that these problems can be avoided in other ways. They even admit that studies showing correlation between circumcision and less risk for the mentioned health problems are methodologically and otherwise dubious and that there exist other studies proving the opposite.

 

Even phimosis, or precisely preputial stenosis (the state, in which the foreskin of the penis cannot be retracted) can be successfully cured with other less painful means (topical steroids, stretching or preputioplasty).

 

Given the listed arguments one can only conclude that a clear stand against routine infant circumcision is needed on the state level and also on the wider international level.

 

---

 

[1] Sometimes referred to also as Male (or Female) Genital Mutilation.

 

[2] For more on the subject see e.g.: Desiree Cooper, Circumcision traditions challenged, Detroit Free Press, March 8, 1999 http://www.infocirc.org/dcooper.htm; Isabel Mbugua, Ending the Mutilation, People & the Planet, Vol.6, No.1, 1997 http://www.womenaid.org/press/info/fgm/fgm-kenya.htm; Facts and Figures Report 2006, The state of the world's human rights, press release, 23. 5. 2006, http://news.amnesty.org/index/ENGPOL100232006; Eritrea bans female circumcision, 4. 4. 2007. http://news.bbc.co.uk/2/hi/africa/6527619.stm, Eritreja prepovedala obrezovanje žensk, 5. 4. 2007, http://www.rtvslo.si/modload.php?&c_mod=rnews&op=sections&func=read&c_menu=2&c_id=138359.

 

[3] Wallerstein E. Circumcision: an American Health Fallacy. New York. Springer Publishing Company, 1980.

 

[4] John P. Warren, Jim Bigelow, The Case against Circumcision, British Journal of Sexual Medicine: Pages 6-8, September/October 1994, http://www.cirp.org/library/general/warren2/.

 

[5] Neonatal circumcision revisited, Canadian Medical Association Journal 1996; 154(6): 769-780, Reference No. FN96-01, http://www.cps.ca/english/statements/FN/fn96-01.htm , see also: The growing consensus against circumcision, Jackie Smith, National Post, August 30, 2002, http://www.canadiancrc.com/articles/Nat_Post_growing_consensus_against_circumcision_30AUG02.htm in WHO and UNAIDS announce recommendations from expert meeting on male circumcision for HIV prevention, Paris 28. 3. 2007, http://data.unaids.org/pub/PressRelease/2007/20070328_pr_mc_recommendations_en.pdf.

 

[6] Mary G. Ray, 1997, http://www.mothersagainstcirc.org/.

 

[7] Supra note n. 4.

 

[8] From the book, Babywatching by Desmond Morris, quoted from the source listed in the note n. 6.

 

[9] Ibidem.

 

[10] For Swedish regulation see e.g. Sweden restricts circumcisions, BBC News, Monday, 1st of October 2001. http://www.cirp.org/news/bbc10-01-01/ and Circumcision in Sweden and its regulation http://www.circumstitions.com/Sweden.html.

 

[11] See e.g. http://www.catholicsagainstcircumcision.org/, http://www.jewsagainstcircumcision.org/,

 

[12] Supra note n. 4.

 

[13] Ibidem.

 

[14] Supra note n. 6.

 

[15] Supra note n. 11.

 

[16] See e.g. Dr. John Dean, Circumcision, last updated on 12. 9. 2005 http://www.netdoctor.co.uk/menshealth/facts/circumcision.htm.

 

[17] See e.g. Traditional Muslim Male Circumcision on http://www.circlist.com/rites/moslem.html.

 

[18] American Academy of Pediatrics, Task Force on Circumcision, Circumcision Policy Statement, Pediatrics, Volume 103, Number 3, Pages 686-693, March 1, 1999, http://www.cirp.org/library/statements/aap1999/.

 

[19] Instruments Used in the Circumcision Industry - http://www.noharmm.org/instruments.htm.

 

[20] Position Statements of Medical Societies in English-Speaking Countries - http://www.circumcision.org/position.htm. For the extensive list of statements see Circumcision: Medical Organization Official Policy Statements, last updated 20. 2. 2007, http://www.cirp.org/library/statements/. Many organizations dealing with the protection of the rights of the children also decisively object to the circumcision of boys, e.g. Canadian Children’s Rights Council, http://www.canadiancrc.com/circumcision/circumcision.htm.

 

[21] Supra note n. 5.

 

[22] American Academy of Pediatrics, Committee on Fetus and Newborn. Standards and Recommendation for Hospital Care of Newborn infants. 5th ed. Evanston, IL: American Academy of Pediatrics: 1971, http://www.cirp.org/library/statements/aap/#a1971.

 

[23] Supra note n. 18.

 

[24] Matthew R. Giannetti, Circumcision and the American Academy of Pediatrics: Should Scientific Misconduct Result in Trade Association Liability. Iowa Law Review, Volume 85, Number 4, Pages 1507-1568, May 2000, http://www.cirp.org/library/legal/giannetti/.

 

[25] Mostly derived from supra note n. 6.

 

[26] Circumcision can hardly be called “a routine procedure” from the point of view of the stress experienced on the behalf of the child, see e.g. the photos (last updated 7. 10. 1998): http://www.mothersagainstcirc.org/plastibell.htm.

 

[27] Quoted from the article supra note n. 24.

 

[28] Another, a bit controversial research showed that the children, who were circumcised without anaesthesia suffered “extreme distress during and following circumcision”. Beside that researchers also tested three different forms of anaesthesia (ring block, EMLA cream and dorsal penile nerve block). Ring block is a form of a local anaesthesia, at which the anaesthetic is injected in a circle surrounding the surgical site, by which the surgeons avoid having to inject into specific area of the operation. Dorsal penile nerve block is a form of the local anaesthesia, at which the injection of the anaesthetic numbs the dorsal penile nerves. The ring block was equally effective through all stages of the circumcision, whereas the dorsal penile nerve block and EMLA cream were not effective during foreskin separation and incision. Reserachers claim that the most effective anesthetic is the ring block, while EMLA cream is the least effective. Lander J, Brady-Freyer B, Metcalfe JB, et al. Comparison of ring block, dorsal penile nerve block, and topical anesthesia for neonatal circumcision. JAMA 1997; 278:2158-2162, http://www.canadiancrc.com/circumcision/AMA_journal_circumcision_1997.htm. Some researchers believe that it is possible to get better results at decreasing distress and pain, if the dorsal penile nerve block is combined with the pacifier dipped in 24% sucrose and a more comfortable, padded, and chair, to which the baby is restrained during the circumcision. Howard J. Stang et al, Beyond Dorsal Penile Nerve Block: A More Humane Circumcision, Pediatrics Vol. 100 No. 2 August 1997, p. e3, http://pediatrics.aappublications.org/cgi/content/full/100/2/e3.

 

[29] Warning from the Canadian hospital against the use of Prilocaine and EMLA cream upon newborns:http://www.cirp.org/CIRP/library/complications/EMLA/ (last updated 7. 2. 2007). Canadian Nurse, August 1994, pp. 5-6.

 

[30] Supra note n. 4.

 

[31] For the photos of the skin bridges see e.g. A Gallery of Circumcisions, http://www.circumstitions.com/Restric/Botched1sb.html.

 

[32] Dr. Robert Van Howe, British Journal of Urology, Volume 80: pages 776-782. (November 1997).

 

[33] Williams and Kapila, Complications of Circumcision, Brit J Surg v80, Oct 1993, pages 1231-1236.

 

[34] Botched jobs often call for additional surgeries as well. Although seriously botched jobs are rare, most malpractice suits are settled. In exchange for the financial compensation, the malpractice charges against the doctor must be dropped. As a result, statistics on this type of incident are under-reported. Supra note n. 6.

 

[35] Schmitt, Barton D., Your Child’s Health, Bantam Books, Revised Ed. 1991.

 

[36] Circumcision, reporter: Jonica Newby, 20. 6. 2005, http://www.abc.net.au/catalyst/stories/s586954.htm.

 

[37] Patel, H., The Problem of Routine Circumcision, Can Med Assn J 95; 576-81, 1966.

 

[38] Supra note n. 5.

 

[39] Supra note n. 24.

 

[40] Supra, note n. 4.

 

[41] Supra notes n. 3 and 4.

 

[42] Supra note n. 5.

 

[43] Supra note n. 36.

 

[44] Kessler II: Etiological concepts in cervical carcinogenesis. Gynecol Oncol 1981; 12 (suppl 2): S7-S24.

 

[45] Supra note n. 35. For the information on the cervical cancer vaccine see e.g. Gostout Bobbie, M.D., Cervical cancer vaccine: Who needs it, how it works, 22. 1. 2007, http://www.mayoclinic.com/health/cervical-cancer-vaccine/WO00120.

 

[46] Hartunian NS, Smart CN, Thompson MS: The incidence and economic costs of cancer, motor vehicle injuries, coronary heart disease and stroke: a comparative analysis. Am J Public Health 1980; 70: 1249-1260.

 

[47] Supra note n. 24.

 

[48] Supra note n. 5.

 

[49] See e.g. Lovrgen Stefan, Circumcision Can Reduce AIDS Risk, Study Says, 27. 7. 2005, http://news.nationalgeographic.com/news/2005/07/0726_050726_circumcision.html. Some of the new researches made in South Africa, Uganda and Kenya supposedly show that the probability of circumcised men to pick up the virus is on average 60 per cent smaller than that of uncircumcised men (New Scientist, 25 November 2006, p 8). On the basis of these researches WHO and UNAIDS (United Nations programme to fight AIDS) recently recommended male (not infant!) circumcision as a mean to fight spreading AIDS, stressing that circumcision does not provide complete protection against infection and that men and women must continue using other forms of protection (e.g. condoms and reducing the number of sexual partners) and that further researches about the influence of circumcision on the spreading of sexually transmitted diseases are needed, see supra note n. 5. The excitement melt down a bit, when the newest (albeit not finished) research showed that women can get infected with HIV virus more easily through sexual relations with circumcised men than through sexual relations with uncircumcised men, while some claim that the reason is the fact that some of the circumcised men had sexual relations soon after the operation, before their wounds healed, Male circumcision to fight HIV poses risk to women, 7. 3. 2007, http://www.newscientist.com/channel/health/dn11327-male-circumcision-to-fight-hiv-poses-risk-to-women.html.

 

[50] Donovan B, Bassett I, Bodsworth NJ: Male circumcision and common sexually transmissible diseases in a developed nation. Genitourin Med 1994; 70: 317-320.

 

[51] Supra note n. 24.

 

[52] Supra note n. 49.

 

[53] See e.g. Conservative Contemporary Treatmeant of Phimosis: Alternatives to Radical Circumcision, last updated 12. 7. 2006, http://www.cirp.org/library/treatment/phimosis/.

 

[54] Supra note n. 18.

 

[55] See e.g. supra note n. 5.

 

[56] See supra note n. 24.

 

[57] Supra note n. 53.