The Final Cut
Back when Jenny and Bill Moore of Providence, Rhode Island, were dating, they liked to take long drives in the country and talk about their future together. Eventually, the talk turned to children, and before the pair married, they had already agreed upon names for both a son and a daughter, decided what sort of parental discipline they would mete out, and determined that Jenny would stay home for a few years after having children. Jenny and Bill were pleased that they seemed to be in sync on all of the most important issues involved in raising a family. But several years later, they found themselves blindsided by one very small detail: their newborn son's penis.
"We argued about circumcision from the day my pregnancy test turned up positive until the day we came home from the hospital with the baby," says Jenny Moore. "I told Bill that he would cut off the end of Sam's penis over my dead body. And he told me that no son of his would go around with a 'strange'-looking penis. Eventually I won, because he would have had to literally rip the baby out of my arms to have it done. I also wouldn't have signed a consent form. Really, he is still very annoyed with me about it. It caused the biggest disagreement we have ever had in ten years together. We were both relieved when our next baby was a girl."
The Moores are not alone in their turmoil over the issue of male infant circumcision, one of the most hotly debated of all contemporary American parenting issues. Circumcision--the surgical removal of the "prepuce" or foreskin, the sleeve of skin and tissue that covers the head of a healthy penis, engenders passionate opinion by those both in favor of and opposed to it.
On the surface, the issue of circumcision seems deceptively simple. Why in the world would modern American parents choose to medically or ritually slice off a part of their child's body that science has revealed to house three feet of veins, arteries, and capillaries, 240 feet of nerves, and twenty thousand nerve endings, as well as muscles, glands, and epithelial tissue? As Jewish anti-circumcision writer Debra S. Ollivier has written in Salon magazine: "It doesn't take much to realize that nature didn't intend the foreskin and the penis to be separated at birth. Try retracting the foreskin of a newborn's penis and you are struck by the steadfast, tenacious grip it has on the glans, or head....But it's far more than just a sheath. The foreskin contains thousands of highly sensitive sensory receptors called Meissner corpuscles, which are more abundant than in any other part of the penis. Richly endowed with a profusion of blood vessels, it also has a ridged band of peripenic muscles that protect the urinary tract from contaminants, and an undersurface lined with mucocutaneous tissue found nowhere else on the body....With its frenar ridges and thousands of nerve endings, the foreskin...accounts for roughly one-third of the penis' sexual perceptivity."
Opponents of circumcision claim that the practice constitutes a painful and unnecessary violation of a boy's human rights, in which a significant body part is removed without consent, leading to potential complications and lifelong alteration of his sexual functioning. Proponents, on the other hand, claim that circumcision is a minor, relatively painless procedure, akin to piercing a baby girl's ears. American parents who choose circumcision cite their desire to provide their son with a "cleaner," "more attractive" penis, one with the same look as circumcised fathers. Additionally, for the majority of Jewish and Muslim Americans who circumcise their sons, the practice is viewed as an integral part of their right to freely raise their children according to the tenets of their religious faiths.
Although the percentage of American parents choosing to circumcise their sons has dropped from a high of ninety percent over the past three decades, the operation remains the most common surgical procedure performed on American children, with well over half of all families still choosing to have their son's penis altered at birth. Internationally, however, circumcision is comparatively rare, with only twenty percent of all boys around the world circumcised. Of this number, the great majority are from Jewish or Muslim families.
Despite the continuing American popular support for circumcision, however, major Western medical organizations are increasingly taking a vocal stance in opposition to the practice. In 1996, the Australian College of Paediatrics stated that "Neonatal male circumcision has no medical indication. It is a traumatic procedure performed without anesthesia to remove a normal, functional, and protective prepuce [foreskin]." In the same year, the Canadian Paediatric Society's Fetus and Newborn Committee announced that "[The Committee] does not support recommending circumcision as a routine procedure for newborns." And in 1999, the American Academy of Pediatrics released an exhaustively researched and strongly worded new policy statement on circumcision, stating: "After analysis of almost 40 years of available medical research on circumcision, the American Academy of Pediatrics (AAP) has issued new recommendations stating that the benefits are not significant enough for the AAP to recommend circumcision as a routine procedure.... The new policy recommendations are based on analysis of all available medical literature on circumcision currently available, including new studies published in the last 10 years."
Despite the fact that uncircumcised adult men swear that the foreskin is one of the most sensitive areas of their body ("Think how much men complain if it gets caught in their zipper!" remarked one), the vast majority of circumcised infants are given no pain relief at all before, during, or after their surgery. Parents, religious leaders, and medical personnel who attend circumcisions have long observed that some infants cry loudly after a circumcision, while others retreat into a deep sleep, which can indicate a type of mild shock. A number of medical personnel have noted that many newly circumcised babies have trouble sleeping and eating for hours and even days afterward. Although for many years parents were told that circumcision--whether done for secular or religious reasons--did not cause significant pain to a baby, this belief has now been conclusively debunked by modern scientific inquiry. The AAP's 1999 Policy Statement on Circumcision takes note of the pain involved in this procedure: "For the first time in AAP circumcision policy history, the new recommendations...indicate that if parents decide to circumcise their infant, it is essential that pain relief be provided....Considerable new evidence shows that newborns circumcised without analgesia experience pain and stress measured by changes in heart rate, blood pressure, oxygen saturation and cortisol levels. Other studies suggest that the circumcision experience may cause infants to respond more strongly to pain of future immunization than those who are uncircumcised.
Many parents who have their sons' foreskins altered for religious reasons are adamant that ritual circumcision--as opposed to routine medical circumcision--is less painful, citing the skill of the mohel (the person who performs the circumcision), the fact that ritual circumcision sometimes removes less of the foreskin than a medical circumcision, that a ritually circumcised baby is often held and comforted during the procedure, or even that the baby is allowed to suck a drop of wine from the finger of an adult while the actual cut is made.
Lara Pappas (a pseudonym) is a thirty-year-old lawyer in New York City. Although Pappas is not Muslim, her husband is, and together, they decided that their son--now two--would be raised a Muslim, including having him circumcised. Pappas does not believe that circumcision is particularly painful or traumatic for a child. "My husband wasn't circumcised until he was about seven," explains Pappas. "Perhaps one of the reasons I am not queasy about my decision to have my son circ'ed is that I believe my husband when he says that it was not very painful for him at the time (and he remembers it) and that it causes him no pain now and never did after the fact."
Leah Cohen, a Jewish parent from Clarksville, Tennessee, says that she is certain that neither of her infant sons experienced any "real pain" during their circumcision ceremonies eight days after birth. "Jewish circumcision is fundamentally different from medical circumcision. At eight days of age, there is less chance of complications than on the first or second day. Both of my sons smiled and laughed immediately after their circumcisions and never seemed to experience a moment's discomfort," says Cohen.
However, based on research into the pain of the procedure, the AAP now unequivocally recommends pain relief for all circumcisions, stating that "analgesia has been found to be safe and effective in reducing the pain associated with circumcision, and should be provided if the procedure is performed. Analgesic methods include EMLA cream (a topical mixture of local anesthetics), the dorsal penile nerve block and the subcutaneous ring block."
Given the growing medical evidence against circumcision, it seems odd that the procedure continues to be a topic for debate. But the complex and multifaceted history of male circumcision reveals why parents today continue--and continue to be empowered by society at large--to subject their baby boys to this surgery.
Circumcision's roots can be traced at least 3,000 years to ancient Egypt, where it was performed as both as a ritualistic practice and as a hallmark of slavery. Jews and Muslims who even today continue to circumcise their baby boys believe that they have been commanded by God to circumcise in memory of Abraham, their shared ancestor. Circumcision is addressed in the Torah in Genesis 17:10-11: "Such shall be the covenant between Me and you and your offspring to follow which you shall keep: Every male among you shall be circumcised. You shall circumcise the flesh of your foreskin, and that shall be the sign of the covenant between Me and you."
For contemporary Jewish and Muslim families who circumcise, the practice--performed as a significant religious rite--irrevocably commits their sons to their cultural and religious heritage and indeed, to God himself. Jewish families generally circumcise their sons in the second week after birth, while many Muslim families wait until well past babyhood.
Until the late nineteenth century, male circumcision in the United States was virtually unknown outside the (at that time) relatively small Jewish and Muslim communities. In 1870, however, an American physician named Lewis Sayre began publicizing his views linking the intact male foreskin to a wide variety of medical maladies, including gout, asthma, curvature of the spine, and tuberculosis. Universal infant circumcision, claimed Sayre, could prevent such diseases. Although Sayre's views gained a wide audience, the pseudo-scientific hypothesis that most significantly fueled the secular-medical circumcision craze in the United States was the growing belief during the Victorian era that circumcision would "cure" masturbation, a practice believed by most Americans of the era to be both sinful and dangerous. Physicians frightened concerned parents into circumcising their babies by threatening that masturbation could send a boy to jail, the insane asylum...or straight to hell.
Dr. John Harvey Kellogg, an American physician and medical reformer (as well as the inventor of corn flakes), wrote in his 1888 popular health manual, Plain Facts for Old and Young, of the "Secret Vice [Solitary or Self-Abuse]. Kellogg advised that "A remedy for masturbation which is almost always successful in small boys is circumcision. The operation should be performed by a surgeon without administering an anesthetic, as the brief pain attending the operation will have a salutary effect upon the mind, especially if it be connected with the idea of punishment." For baby girls, Kellogg noted that the application of pure carbolic acid to the clitoris provided "an excellent means of allaying the abnormal excitement."
Few parents today are aware that this was the original justification for widespread popular adoption of circumcision. Instead, modern families are likely to explain their choice to have their sons' foreskins removed by saying that they prefer the "look" of a cut penis and that they understand that intact penises are more likely to be "dirty" and prone to infection and disease. Each of these beliefs regarding circumcision is deeply rooted in issues of class and culture that also date back to the late nineteenth century. At a time when United States society was being shaken up from top to bottom by an influx of vast numbers of immigrants from all over the world, circumcision became a way to mark one's son as a "native" American. Additionally, circumcision increasingly became a sign of class status, with middle- and upper-class Americans adopting the practice in much greater numbers than the underclass. Even today, many older Americans think of an intact penis as a sign of low status and poor hygiene, much the way they think of breastfeeding. Among younger parents, these class biases have morphed into a desire to see their son "fit in" among his peers and the men in his family. While mothers and fathers are no longer concerned with their sons being mistaken for recent immigrants, they do worry that leaving him uncircumcised will subject him to "teasing in the locker room" or "problems attracting women."
Although few Americans accept it as so, the parallels between our beliefs and practices regarding male circumcision and the now widely reviled, mostly African practice of female circumcision (often called "female genital mutilation" by human rights groups) are clear and compelling. According to the World Health Organization, female circumcision is routinely practiced in approximately twenty-eight countries, with about 130 million African women circumcised. African women are circumcised at some point between infancy and puberty, either by clitoridectomy, the partial or complete removal of the clitoris, or, in most cases, infibulation. With this latter method, the inner and outer lips of the vagina and the clitoris are completely removed. The wound is then sewn shut, leaving only a small hole for urine and blood to pass through. Later, on a girl's wedding night, another ritual takes place in which the girl is cut open again so that her groom can penetrate her during intercourse.
Clearly, infibulation is a much more radical and dangerous procedure than male circumcision. With all that is now known about the extreme sexual sensitivity of the male foreskin, however, the argument can be made that clitoridectomy and the removal of the foreskin are similar in more ways than parents might like to believe. In both cases, the affected individual is left with the ability to have sexual intercourse...but with reduced sensation. As one circumcised Senegalese woman said to writer Vivienne Walt, "I feel I have full sexual pleasure with my husband, but then I wouldn't know what it is to be uncircumcised."
The parallels between male and female circumcision aren't particularly surprising, since the roots of both spring from the desire to lessen interest in sexual habits thought by various cultures to be sinful and undesirable. In the case of female circumcision, the practice originated in an attempt to prevent women from engaging in sex before or outside of marriage. Uncircumcised women are also thought to be more likely to engage in lesbianism. Similarly, and as was previously noted, American medical circumcision can be traced to the desire to prevent men from engaging in masturbation.
In the case of both male and female genital alteration, however, the practice has become something much more than simply an attempt to control sexuality. In African cultures where female circumcision is the norm, girls who are left with their genitals intact are considered highly unattractive, of low caste, and "dirty." Mothers and grandmothers insist that their daughters be circumcised so that they will "fit in" with other women and not risk being ridiculed by the circumcised majority. Uncircumcised girls are also believed to be at greater risk for disease. In the United States, parents who circumcise their sons often do so for exactly the same reasons.
Although the risks of medical complications from female circumcision are obvious and have been well publicized by the international press, complications caused by male circumcision in the United States have received little attention. They are not common, but they can include excessive bleeding, serious infection, and surgical mistakes, including loss of glans and, in a few extremely rare instances, loss of the entire penis.
Complications in adult males who were circumcised in infancy are more common, and may include scarring, skin tags and skin bridge, curvature of the penis, tight, painful erections, and difficulty reaching orgasm. According to the anti-circumcision medical group Doctors Opposing Circumcision, many men don't recognize these medical problems as related to the loss of their foreskin.
With the recent publication of the new AAP position statement on circumcision, and as the facts regarding male circumcision become more widely known, it is likely that the number of parents choosing the procedure for their own sons will continue to drop. In the Jewish community, there is a burgeoning movement to develop meaningful ceremonies for infant boys that will provide an acceptable alternative for parents who are not comfortable with ritual circumcision (see sidebar). Perhaps in the next millennium more families will listen to the advice of the pioneering Dr. Benjamin Spock who said, "My own preference, if I had the good fortune to have another son, would be to leave his little penis alone."
Katie Allison Granju lives in Knoxville, Tennessee, with her two uncircumcised sons and one uncircumcised daughter.
Katie Allison Granju is a contributing editor to Minnesota Parent.
Caring for Your Son's Intact Penis
If you choose not to circumcise, your son's intact penis will require no special care (unlike the cut penis, which will need to be treated as a painful and infection-prone wound for several weeks after the procedure). Your baby's whole, healthy penis will also be less inclined to develop diaper rashes and irritation. But one very important thing to know about a baby's intact (uncircumcised) penis is that the foreskin should never be forcibly retracted. According to pediatrician Paul Fleiss, M.D., M.P.H., "Forcibly retracting a baby's foreskin destroys the beneficial bacterial flora that protect the penis from harmful germs and can lead to irritation and infection." Sometime in the first one to five years of your son's life, his foreskin will loosen and begin to retract naturally on its own. If your pediatrician is not familiar with uncircumcised babies, she may try to convince you to force the foreskin back or even retract it herself. This can tear your baby's delicate tissues and cause permanent scarring.
Once your son's foreskin begins to retract on its own, you can teach him to gently wash himself, just as you would teach your daughter of the same age to clean the folds and crevices of her own external genitalia. A child's foreskin, like his eyelids, is self-cleansing. Just as you would never lift the eyelid to "wash" the eyeball, it isn't necessary to pull back the foreskin to wash the glans, which is essentially an internal organ. Rinsing in warm water is all that is needed to keep the intact penis clean. Applying soap to the inner lining of the foreskin or the head of the penis isn't recommended, because it can cause irritation.
The white emollient under the child's foreskin is called smegma. Dr. Fleiss notes that "Smegma is probably the most misunderstood, most unjustifiably maligned substance in nature. Smegma is clean, not dirty, and is beneficial and necessary. It moisturizes the glans and keeps it smooth, soft, and supple. Its antibacterial and antiviral properties keep the penis clean and healthy." The best way to care for a child's intact penis is to leave it alone.
Resources for Learning More
About the Circumcision Issue:
Circumcision Exposed: Rethinking a Medical and Cultural Tradition, by Billy Ray Boyd. (Crossing Press, 1998).
Circumcision: The Hidden Trauma, by Ronald Goldman, Ph.D. 1996. $21.95. Write to: Vanguard Publications, P.O. Box 8055, Boston, MA 02114. Credit card orders: 1-888-445-5199.
Circumcision: The Rest of the Story, Peggy O'Mara, ed. 1993. For information, write to: Mothering, P.O. Box 1690, Santa Fe, NM 87504.
The Joy of Uncircumcising! Exploring Circumcision: History, Myths, Psychology, Restoration, Sexual Pleasure, and Human Rights, by Jim Bigelow and James L. Snyder (Hourglass Books, 1997).
Prisoners of Ritual: An Odyssey into Female Genital Circumcision in Africa, by Hanny Lightfoot-Klein. 1989. Now available in German. $22. Write to: Lightfoot Associates, 4040 Via Del Vireo, Tucson, AZ 85718.
Questioning Circumcision: A Jewish Perspective, by Ronald Goldman, Ph.D. 1997. $14.95. Write to: Circumcision Resource Center, P.O. Box 232, Boston, MA 02133. Credit card orders: 1-888-445-5199.
The Circumcision Information and Referral Pages
National Organization of Circumcision Information and Referral Centers:
Doctors Opposing Circumcision
Circumcision: An online peer-reviewed medical journal
Mothers Against Circumcision
The Female Genital Mutilation Education and Networking page
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