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Routine Male Infant Circumcision?

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I have heard a lot of debate recently about circumcision of infants, both for and against. As someone training to be a physician, I would like to develop as an informed an opinion on the topic as possible. I tried to think about it a bit, based on reading and comments posted on the interwebs by many different people. I’ve tried to identify some of the issues. 

Sexuality: There seem to be some real, although perhaps slight advantages for maintaining the foreskin for the boy and his future partner(s) for sexual pleasure. However, so much of sexuality is psychological, the predominant social norms probably play a big role here too. Being the only circumsized or uncircumsized person in your milieu probably has its own negative impact, but that’s not an argument against changing practice as a whole, just something to note.

Infectious disease: There is risk of infection with a surgical procedure, but the protection from HIV (and perhaps other viruses) seems to be pretty strongly established. The general arguments about other kinds of infections are little less striking. It’s also unclear when measures to prevent STD’s should best be instituted. The Gardasil vaccine controversy is an example of the difficulties in identifying an appropriate time. In general, since it is a disease prevention measure, erring on the side of being earlier seems like a good thing. Certainly teenagers are often (typically?) sexually active before 18, regardless of what society or their parents want for them. 

Pain & trauma: I think the procedure can be done in a manner with minimal pain and discomfort by a trained professional using analgesia. The arguments for doing circumcision without analgesia seems spurious and frankly barbaric. There seem to be little long term effects psychologically for people who do or do not get circumsized by the process itself (i.e. people don’t end up schizophrenic or homeless in the gutter because of circumcision) even if it was done in a relatively painful manner. Again, not an argument in support of the procedure, but worth noting.

Best outcome of procedure: Most urologists seem to agree that the results of infant circumcision are much better than when done in an adult. The recovery times are much shorter at least. I’m not entirely sure the risk of complications is any better though, just different. It seems that if you are going to have it done, infancy is maybe a better time.  That is probably true of lots of surgical procedures though, as a young child is more robust with significant physical plasticity.

Sanctity of the body: There is an argument that can be made on the sanctity of the body of a child. This is a lot less clear to me, and is a bit of a slippery slope, and where people seem to differ. For example, I know that female infants in Brazil and India commonly have their ears pierced, but I have also seen some people react very strongly against that. Surgical procedures are done to “correct” children of ambiguous gender, which basically means forcing them to biologically conform to a social construct of gender identity. Children are given cochlear implants, even though many in the deaf community are actually opposed to this. The same is true of exogenous growth hormone for a perceived deficiency. Some “little people” protest this as it is a kind of disease-mongering and making being extremely short into an illness instead of just a range of normal human variation. Still, it is all a lot less clear, and I have to reason by analogy to other things done to children without their consent (like vaccines). The human body is something arrived at through a long evolutionary history of modifications piled on top of past design “decisions”. Much of human medicine is about trying to compensate for aspects that might have been designed a better way (e.g. the bipedal spine, the pharynx, the retina, the birth canal, etc.). Biomedical technology development is about finding ways to alter things when we want to do it, then it becomes a ethical or values decision about what modifications and changes we want to make.

One way ticket without consent: Circumcisions are basically permanent. Should such a strong decision be made on an individual’s behalf without their consent? Lots of decisions are made by parents on behalf of their children which are one time, one way choice without consent. Where they will live as children, where they will go to school, what will be in the home, whether or not they will play sports or do other activities. All things that will affect them in the long term, and there is no going back to the past to completely redo them. Children, particularly infants, do have some civil and human rights, but they are definitely not free to make their own medical decisions; society has determined that that is best left to the parents. It has been argued that parents should only be able to make “therapeutic” medical decisions for their children. This is not tenable for a few reasons, the first is that parents inherently make all sorts of decisions about “elective” parts of medicine for their children, and when it comes down to very serious “therapeutic” decisions, such as whether or not to receive life saving therapy, we actually often take decision making capacity away from the parents. For example, a child in need of a transfusion but whose parents refuse blood products or a child whose parents attempt to refuse surgery for appendicitis. 

Cultural/cosmetic artifact: The fact that it may be primarily motivated by the inertia of prior cultural practices and may be largely “cosmetic” in nature is often raised as a criticism. However, again, this needs to be put into a larger context and isn’t necessarily an argument against. An analogy can be drawn with dental braces. Many children receive them against their wishes, they can be extremely painful (and that pain can be spread out over many months), and then have associated risks (irritation and cuts inside the mouth, infection, hidden tooth decay) and perhaps very modest longer term health benefits (maybe easier to clean the teeth if they are more aligned). It is essentially a one way procedure, particularly if any of the back teeth are extracted to make room in the mouth as is often done. However, there are strong cultural pressures to have aligned teeth, and it will probably have longer term sociocultural impacts and about conforming to a social norm.  Parents often make the decision for their children because the outcomes of braces are much better if done at a young age (perhaps shared with circumcision). The widespread application of circumcision in the US may be a holdover from a mix of Victorian era feelings on sexuality and the medicalization of birth, but that’s not entirely an argument against either, just historical context. Many people consider attempts to ban or limit circumcision as religious intolerance as it is an important religious rite in Judaism and Islam; however, I’m going to ignore that issue as it is not really as important to me who is making an argument and why, just what the facts are for and against. Because something is tied to “religion” does not protect it from my mind any more than any other practice which might be deemed more generally “cultural norm”. Religious arguments have been made for all many of activity, so I don’t think it’s really relevant.  At the same time, I’m not interested in stereotyping the advocates of one opinion or another into different categories.  That seems counterproductive.

Overall, I think if you live in a place with a very high rate of HIV infection, more routine circumcision seems to make a bit more sense, given that it is done by a trained health professional with anesthesia. In the modern US, it seems like a more cosmetic effect, with some non-negligible risks associated with the procedure. However, both the risks and benefits seem very modest, and the sociocultural and psychological impact seem to be the largest. I also don’t see why a parent should feel particularly bad about having the procedure done or not done. Both circumcised and uncircumcised men go on to lead successful and healthy lives. It seems like because a large segment of people strongly want to have it done, they should have the option as it doesn’t strike me as dramatically worse than a lot of life decisions parents make for their children.  On the other hand, there doesn’t seem like any super strong medical reason in support of circumcision.

I probably should have put in some citations, as I read several articles on the issues, but a good place to start is, as usual, Wikipedia, there are lots of links and references:
http://en.wikipedia.org/wiki/Ethics_of_circumcision
http://en.wikipedia.org/wiki/Medical_analysis_of_circumcision

I like to take an approach that tries to use science to help inform my ethical thinking, and there is a book discussing the evolutionary “origins” of many of the things we think about as human illness:
http://www.amazon.com/Why-We-Get-Sick-Darwinian/dp/0679746749

Finally, there is a lot of strong rhetoric with people using terms like “mutilate” or “anti-Semitic” in their discussion and attempts to sway other’s opinions.  These are heavily loaded words being used for rhetorical effect.  I’ve tried to avoid them, and I would encourage others to do the same.  For reasons I’ve mentioned, I don’t think it is productive to use powerfully negative language as it is not helpful when it makes people feel bad or defensive.  It’s impossible for me to regulate language usage of other people (unless I guess, it is a journal article I am editing or reviewing), but it doesn’t seem helpful to make parents feel guilty about one decision or another, to make circumcized or uncircumsized individuals feel better or worse about themselves, or accuse those opposed to the practice of religious intolerance.  There are medical and cultural opinions on both sides of the issue, and it looks like the long term outcomes are not that different.  That being said, I am somewhat saddened then that people end up making themselves (and others) so upset over the issue, particularly expectant mothers, an already emotionally and physically difficult time. Parents, particularly new parents need all the support they can get.  Lets all send them as much love as possible, not stress.  Things will work out fine, whatever they decide.

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