Sunday, July 19, 2015

Circumcision and the Risks for Infants When Used as a Cosmetic Procedure

Cassie Rhodes, Valarie Violette

Circumcision is too much of a risk to be done for strictly cosmetic or preventative reasons.




Circumcision and the risks for infants when used as a cosmetic procedure
Research suggests that circumcision can have negative consequences when done as a cosmetic procedure during infancy, such as risk of severe bleeding, risk of infection, and accidental removal of the glans of the penis. Other risks include blood poisoning, decreased feeling in the penis, erectile dysfunction, and damage to the urethra. This is not an exhaustive list of complications. More complications can be found here

Circumcision is the removal of the prepuce of the penis, typically done in infant males. The procedure can be performed using multiple methods. Anesthesia is not always used when a circumcision is performed. Though sometimes performed for religious reasons, historically, circumcision is not a tradition in Western cultures. Routine circumcision is a modern practice that started in the Victorian era. Circumcision was first introduced as a method to prevent masturbation as it reduces nerve endings in the penis. The procedure of circumcision is generally considered to be a preventative measure to reduce the risk of many diseases. Though this procedure is common, it is damaging to the infants it is performed on.

Circumcision has been shown to be damaging to the infants brain.
Fleiss explained, that “Recent studies published in leading medical journals have reported that circumcision has long-lasting detrimental effects on the developing brain, adversely altering the brain's perception centers. Circumcised boys have a lower pain threshold than girls or intact boys.” (Fleiss, n.d.). Circumcision is unsanitary when performed on children who are still in diapers. Circumcising an infant means that the wound will be sitting in urine and feces. Even if the care giver changes diapers quickly, the wound is exposed to germs that should not be purposefully be introduced to a surgical wound site.

The majority of issues said to be prevented by circumcision are preventable in other, non-surgical ways. In the instance of phimosis (tightening of the foreskin), the vast majority of cases can be resolved by using a topical steroid (Van Howe, R. S. 2009). If circumcision is meant to be a procedure to prevent disease and reduce risk, it should not involve risks such as it has been shown to have. The breastfeeding relationship is at risk when babies are circumcised. The benefits of breastfeeding outweigh the possible benefits of routine infant circumcision. Circumcision should not be a routine cosmetic procedure, and should only be used as a last resort after exhausting other methods of treatment.

The foreskin is a functional organ that is there for many reasons. The primary function of the foreskin in infants is to protect the urethra from feces, germs, and potential forms of infection. When a circumcision is performed, the wound must sit in a diaper, exposed to feces and urine. The foreskin also protects the glans of the penis from thickening. This is true in both the infant and adult penis. (DOC, 2013) “The foreskin is a uniquely specialized, sensitive, functional organ of touch. No other part of the body serves the same purpose. As a modified extension of the penile shaft skin, the foreskin covers and usually extends beyond the glans before folding under itself and finding its circumferential point of attachment just behind the corona (the rim of the glans). The foreskin is, therefore, a double-layered organ. Its true length is twice the length of its external fold and comprises as much as 80 percent or more of the penile skin covering.” (Fleiss, n.d.) This is a lot of tissue to remove for a procedure that is cosmetic.

Another argument for circumcision is that it is considered to be a tradition. Many decide to circumcise so the child will look similar to the father as to not cause confusion. It is easy for a parent to explain that it was believed that it was better to circumcise when daddy was younger, but evidence shows that it isn't needed. Circumcision rates in the United States are dropping. The intact penis is slowly going back to being considered to be the average, normal penis. Circumcision is a fairly recent commonality in Western culture, influenced by religion and false belief that it is a preventative measure against many diseases and conditions. MacNielly points out that “Social, cultural, aesthetic and religious pressures form the most common reasons for non-therapeutic circumcision.” (MacNielly, 2007) Even though it is considered socially acceptable, that does not mean it is right. Female genital mutilation is considered culturally acceptable in some areas of the globe and causes many documented issues, including difficulty with childbirth and reduction in pleasure or feeling. Female genital mutilation has many of the same claims for its benefits that are similar to those made for circumcision. A couple of these claims are reduction of masturbation and cleanliness. Female genital mutilation is not an acceptable practice, and is considered to be a humans rights violation.

Circumcision influences the future sexual enjoyment of those on which it was preformed, and the enjoyment of their partner. Masturbation was seen as unsafe and unnatural in that time circumcision became popular during the Victorian era. It was beneficial for there to be methods to prevent what was considered an unnatural thing. We now know that masturbation is a perfectly normal activity. There is no need to prevent masturbation in adolescent boys. The foreskin contains numerous nerve endings that make masturbation and sexual intercourse more pleasurable. Per DOC, “Some twenty small concentric, circumferential ridges, collectively called the frenar band, carry specialized nerve endings back and forth across the corona of the glans, producing pleasure.” (DOC, 2013) Reducing the pleasure receptors can lead to issues with sexual health later in life, including difficulty maintaining an erection. Making the decision to reduce future pleasure should not be done on the slight chance that the procedure may prevent an issue that is treatable with other, less invasive, methods.

There are risks of surgical complications with circumcision that make it contraindicated for cosmetic and routine use. If done as a cosmetic procedure, circumcision exposes the infant to many risks. Fleiss indicates that “[t]hese complications include uncontrollable bleeding and fatal infections. There are many published case reports of gangrene following circumcision. Pathogenic bacteria such as staphylococcus, Proteus, Pseudomonas, other coliforms, and even tuberculosis can cause infections leading to death. (Fleiss, n.d.)”. It is understandable that there is a high risk of infection related to circumcision, as the wound is exposed to urine and fecal matter while healing. Even if the caregiver changes the baby immediately upon soiling their diaper, the wound is still in contact with fecal bacteria that can cause wound infection. The rate of complications with circumcision is high. As Fleiss reports, “Its surgical complication rate is one in 500.48” (Fleiss, n.d.). For something that is meant to prevent medical issues, the rate of complication is very high. The rate of complications caused by circumcision is greater than the risk of being uncircumcised (intact). “In Finland, where the circumcision rate is zero at birth, the risk of needing the foreskin removed later is one in sixteen thousand, six hundred sixty seven (16,667)” (DOC, 2013). With a complication rate of one in 500, circumcision itself becomes too risky to justify regular use. The complication rate should not be higher than the rate of prevention.

There is a large amount of pain that comes with circumcising an infant. Though pain relief may be offered or used, it is not always effective. “The analgesics used for circumcision only decrease pain; they do not eliminate it. Further, the open wound left by the removal of the foreskin will continue to cause the baby pain and discomfort for the 7-10 days it takes to heal.” (Intact America, 2013) Pain relief is more complete when the circumcision is done on an adolescent or adult as they can convey the amount of pain that they are in. Anesthetic is not always used when performing infant circumcisions. JAMA concluded during their study regarding the types of anesthesia used during circumcisions that “It is our recommendation that an anesthetic should be administered to newborns prior to undergoing circumcision. '(JAMA, 1997) Even though this is the recommendation suggested by this study, it is not always the case that pain relief is provided during the procedure. The wound is easier to keep clean when the person that has had the circumcision is able to care for it themselves. It is not typically considered safe to give over the counter pain relief to newborns, so the babies must suffer without relief for those 7-10 days.

The effects of the pain of circumcision without adequate pain control doesn't only last for 10 days. Research shows that pain that occurred during the neonatal period influences how the children feel pain during routine vaccinations. “Circumcised infants showed a stronger pain response to subsequent routine vaccination than uncircumcised infants.”( Lancet, 1997) This research shows that it is very important to have sufficient pain control during circumcision. Adequate pain control is frequently not provided for circumcision procedures. Due to the amount of pain shown during vaccinations in the circumcised children that had not received adequate pain control, the study authors make the statement: “Circumcised infants showed a stronger pain response to subsequent routine vaccination than uncircumcised infants. Among the circumcised group, preoperative treatment with Emla attenuated the pain response to vaccination. We recommend treatment to prevent neonatal circumcision pain. “ (Lancet, 1997) It is important that infants are provided sufficient pain relief if they do require a circumcision. This pain relief is not always used during the procedure. There is the chance that the only pain relief provided to the infant is a pacifier dipped in sugar water. Adequate pain relief should be a legal requirement when circumcisions are performed.

Some people would argue that babies cannot feel pain as acutely as adults do. This is a false assumption that happens because babies cannot articulate pain in the way that adults do. Chamberlain states, “in a thorough study of cries during circumcision, acoustic features precisely reflected the degree of invasiveness of the surgery.” (Peaceful Parenting, 2010) In the early 20th century, it was believed that crying was not an indication of pain. Since crying was not seen as an indication that babies were in pain, newborns were deemed to not feel pain early in their lives. This led to the false belief that infants do not require pain relief during painful procedures. More recent research has shown that babies do in fact feel pain, and different degrees of pain are met with different responses that can be anticipated. “In response to pain, babies jerk, pull back, try to escape, swing their arms, use their hands to push away, and frantically scrape one leg against the other to dislodge an offending stimulus in that area. They strike out with their upper extremities and kick with the lower.” (Peaceful Parenting, 2010). Not understanding the ways that babies express pain has caused it to be considered acceptable to not anesthetize the babies undergoing these painful procedures.

Many of the risks associated with the intact penis would be reduced with education on proper care. Certain infections of the foreskin are caused by improper care of the intact penis, and would have a much smaller risk of occurring if caregivers and healthcare workers were properly informed on how to care for a non-circumcised penis. Forced retraction is a great risk to uncircumcised prepubescent males. “While it remains attached, the foreskin is the skin of the glans. It is there to protect the glans. Retraction can tear the attachment, producing pain, scarring, and disfigurement.” (DOC, 2013) Inability to retract the foreskin at puberty is still not a indication that circumcision is necessary.

An intact penis is not unhygienic. The intact penis requires the same amount of care and cleaning as a circumcised penis. As circumcision rates rose due to routine circumcision, Americans became less familiar with the intact penis and how to care for it. Once retraction has naturally occurred, all that is required to clean the penis is to pull the foreskin back and rinse with water. It is not necessary to retract the foreskin for cleaning while it is still attached to the glans. “[I]t is more usual for the tip of the foreskin to gradually enlarge, and for the remaining attachment points between the foreskin and the glans to dissolve. By puberty, many boys have a fully retractable foreskin, which can easily be pulled back so the glans is fully exposed. There is no constriction, because the foreskin is now a wide channel. (DOC, 2013) Care of the uncircumcised penis is just as easy as care for a circumcised penis. Hygiene concerns are not an indication that circumcision is needed.

It is know that human breast milk gives babies the best possible start in life, and can prevent many diseases in both mother and baby. Circumcision has a negative influence on the breastfeeding relationship. “Babies who are breastfed are more likely to experience optimum health and well-being throughout life than babies who are given a substitute for mother's milk.” (NOCIRC, 2002) Circumcisions that are performed before the breastfeeding relationship is established can prevent breastfeeding from being successful. “Post-operatively, the circumcised infant is in pain and is in an exhausted, weakened, and debilitated condition. Most importantly, the circumcision procedure frequently causes the newborn to withdraw from his environment, thus interfering with his process of bonding and breastfeeding.” (NOCIRC, 2002) Procedures that interfere with breastfeeding should be avoided until breastfeeding is well established and the mothers supply is established. This means that circumcision or any other avoidable procedure should not be done in the first six weeks of life while the mothers supply is being regulated. Do the known and proven benefits of breastfeeding outweigh the alleged benefits of circumcision? Research would suggest yes, breastfeeding is more important to an infants long term well being than any benefit derived from circumcision. Breastfeeding reduces the risk of urinary tract infections in intact males. “After Wiswell's studies were published, Coppa et al. discovered that human milk contains oligosaccharides that are excreted in infant urine and inhibit the adhesion of E. coli to the tissue of the urinary tract. This protective effect was quickly confirmed in a preliminary report in 1990 by another group of Italian scientists, headed by Pisacane, and further confirmed by Swedish researchers. The Pisacane group then produced a prospective case-control study, published in 1992, that found breastfed infants have only 38% as many urinary tract infections as non-breastfed infants.” (NOCIRC, 2002) It is clear that nature has ways of protecting the breastfed, intact male, including preventing the urinary tract infections that circumcision is supposed to prevent. Urinary tract infections are also treatable by antibiotics.

Behavioral development and bonding with the mother are disrupted when a baby is circumcised. “Studies performed at the University of Colorado School of Medicine showed that circumcision is followed by prolonged, unrestful non-REM (rapid-eye-movement) sleep.65 In response to the lengthy bombardment of their neural pathways with unbearable pain, the circumcised babies withdrew into a kind of semicoma that lasted days or even weeks. Numerous other studies have proven that circumcision disrupts the mother-infant bond during the crucial period after birth. Research has also shown that circumcision disrupts feeding patterns. In a study at the Washington University School of Medicine, most babies would not nurse right after they were circumcised, and those who did would not look into their mothers' eyes.” (Fleiss, n.d.) While it is hard to say that the infants trust has been violated by this procedure, something changes in the behavior of the infant when it is performed. The lack of eye contact and disruption of nursing, even for comfort, implies that the bond has been negatively influenced by circumcision.

Circumcision is a risky surgical procedure that does not have as many benefits as most people believe. It is possible to treat the majority of the issues that circumcision is supposed to solve non-surgically. Circumcision should be used after all alternative methods of treatment have been followed and are not successful, not as a preventative method. Circumcision can be a useful tool in the treatment of certain conditions, but it is not beneficial as a routine procedure. Work should be done to help educate regarding intact care to both caregivers and healthcare workers. Circumcision should be treated with more respect for the risks, and avoided for cosmetic usage.

The death rate of circumcision is now reported to be 1 in 500,000. (Fleiss, n.d.) The rate of penile cancer is 1 in 100,000 men. Fleiss states that “Gairdner’s study was instrumental in stopping circumcision in Great Britain during the 1950s. His data showed there would be 15 infant deaths for circumcision per one hundred thousand circumcisions.” (Fleiss, n.d.) this suggests that the risk of penile cancer is lower than the risk of death by circumcision. The death rate of penile cancer is not 100%, so there are more deaths caused by the prevention than the disease.

Circumcision carries the risk that the male genitalia may be damaged or destroyed during the procedure. There are instances where the circumcision goes wrong, and the baby that was born  with male genitalia is given female genitalia because the male genitalia was damaged beyond repair. Fleiss discusses how fully conscious, unanesthetized babies have had their entire penis burned off with an electrocautery gun. The September 1989 Journal of Urology published an account of four such cases. The article described the sex-change operation as "feminizing genitoplasty," performed on these babies in an attempt to make them have female presenting genitalia. The March 1997 Archives of Pediatrics and Adolescent Medicine described one young person's horror on learning that she had been born male, but that a circumcision provider had burned their penis off when they were a baby. Many other similar cases have been documented. (Fleiss, n.d) This has severe emotional repercussions later in life when the child discovers that they were born with male sex organs, but lost their genitalia in a primarily cosmetic procedure that was unnecessary for their well-being. Even if the occurrence is very rare, parents should be made aware of the possibility. More care should be taken when performing circumcisions, and more training provided to the healthcare workers to ensure these things do not happen.

When all of the evidence is examined together, a very good case is made against routine circumcision. The quoted benefits do not outweigh the risks, and make the procedure not worth the possible complications. There are many alternative, less invasive treatment methods that work in the same way circumcision is purported to work. Many of the treatments are very non-invasive, such as an antibiotic for a urinary tract infection. Breastfeeding also lowers the risk of urinary tract infection effectively. There are many well documented benefits associated with long term breastfeeding, and circumcision puts that relationship at risk as the child can withdraw and not be interested in the breast after being circumcised. The reduction in pain threshold in children that are circumcised is a real concern. Circumcision causes babies to feel pain more acutely later in life. Proper intact penis care reduces the risk of adhesions and other issues that would require treatment. Though tightening of the foreskin is a small risk, it is possible to treat topically using cream instead of resorting to circumcision in 85% of cases.(Van Howe, 2009) Tightening will usually resolve with minimal external involvement. It is our social responsibility to ensure that people are informed on the risks and complications of circumcision. There should be an effort made to educate new parents on the dangers of circumcision so that an informed decision can be made based on accurate data. Parents should be made aware that death is a possibility with circumcision due to the potential for extreme blood loss and infection. If parents were informed of the risks carried by circumcision, I believe the circumcision rate would be lower worldwide. 




References

Chamberlain, D. B. (January). peaceful parenting: Babies DO Feel Pain. Retrieved 19, 2013, from http://www.drmomma.org/2010/01/babies-do-feel-pain.html

Doctors Opposing Circumcision (n.d.). Physicians Guide to the Normal (Intact) Penis. Retrieved February 1, 2014, from http://www.doctorsopposingcircumcision.org/info/physiciansguide.html
Intact America (2014). The Myths and Facts of Circumcision | Intact America. Retrieved from http://www.intactamerica.org/learnmore
JAMA (1997, December 24). JAMA Network | JAMA | Comparison of Ring Block, Dorsal Penile Nerve Block, and Topical Anesthesia for Neonatal Circumcision: Â A Randomized Controlled Trial. Retrieved from http://jama.jamanetwork.com/article.aspx?articleid=419531
MacNielly, A. E. (2007, November 14). Routine circumcision: the opposing view. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2422979/

MD Fleiss, P. M. (n.d.). Retrieved from http://www.mothersagainstcirc.org/fleiss.html
Mothering: The Case Against Circumcision. (n.d.). Retrieved from http://www.mothersagainstcirc.org/fleiss.html
peaceful parenting: The Effects of Circumcision on Breastfeeding. (n.d.). Retrieved from http://www.drmomma.org/2009/12/effects-of-circumcision-on.html
Taddio, A., Katz, J., & Koren, G. (n.d.). Effect of neonatal circumcision on pain response duri... [Lancet. 1997] - PubMed - NCBI. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/9057731
Van Howe, R. S. (2009). Medscape: Medscape Access. Retrieved from http://www.medscape.com/viewarticle/589332
Stanford School of Medicine (2015) Complications of Circumcision. Retrieved from:


[Originally written by Cassie Rhodes, collaborated with Valarie Violette to add additional information and sources.] Currently still a work in progress.

Due to the controversial nature of this post, comments have been disallowed. I encourage you to do your own research if you disagree with the things I have brought up here.