An Epidemic of Circumcision

George Denniston, M.D.

Presented at
The Third International Symposium on Circumcision,
University of Maryland, College Park, Maryland
May 22-25, 1994.

Introduction

       Circumcision in the United States is an epidemic caused by doctors, in other words, an iatrogenic epidemic. Iatrogenic comes from the Greek and simply means "caused by doctors." Many people think doctors use obscure words to try to avoid having other people not know what is going on. I am inclined to concur with them.

       Circumcision is another example of clouding the truth with a seemingly benign word. Circumcision means 'cutting around,' which is correct as far as it goes, but this is hardly an adequate definition of the modern procedure. Some people have replaced the word circumcision with 'male genital mutilation' to distinguish it from the religious ritual. The definition of mutilation is to remove a material part of so as to render imperfect. Although calling circumcision a mutilation may sound harsh to some, that is precisely what it is.

       Circumcision is a massive epidemic, putting at risk every individual American male from birth to death and harming more than half of the males in the United States. I have heard of men in their eighties being circumcised for no determinable medical reason whatsoever. Also at risk are all males delivered by U. S. trained doctors anywhere in the world.

       Circumcision is a recent epidemic in America. This strange practice was unknown during the first century after American independence. Doctors began to perform it around the turn of the 20th Century and it became a major epidemic only after 1950. In the 1930s many doctors never offered it and never performed it. By the 1950s some doctors were doing it routinely, without parental consent. Even today it is rarely, if ever, performed with fully informed consent, which is the standard of care for all other procedures in this country for medicine.

       In the 19th century, another iatrogenic epidemic was puerperal fever, or childbed fever. Everyone agreed that childbed fever was harmful. It killed women during and right after childbirth. What had to be proven was that doctors caused it. Most doctors then could not, and would not, believe that they were causing this epidemic. A number of doctors, most notably Semmelweis of Austria and Oliver Wendell Holmes in America, demonstrated that childbed fever was transmitted from victim to victim by the very doctors who were supposed to be helping these women have their children safely. Despite the compelling nature of the data collected, it took some years before all doctors accepted the horrifying truth and before steps were taken to eradicate the disease. One of the facts that the researchers demonstrated was that the transmission of childbed fever was easily stopped. The doctors involved simply had to wash their hands in a caustic solution. We now know that this would kill germs, but germs at that time were unknown. This exciting fact provided much hope that the terrible epidemic could be stopped. Once it was understood and accepted that doctors caused the fatal illness, it did stop fairly quickly.

       In the case of circumcision, there is no denying that it is caused by doctors. In America virtually all the circumcisions not done for religious reasons are performed by doctors. In order to prove that circumcision is an iatrogenic epidemic, we must now demonstrate that it is harmful.

Harm of Circumcision

Lack of necessity

       We know that circumcision is unnecessary. This is proven by the example of the vast majority of men who have ever lived in the world, who for millennia have led their entire lives happily intact. Additionally, there are now living in Europe 250 million men happily intact and free from all of the diseases and discomforts alleged by American advocates of circumcision.

Excuses for circumcision

       The alleged medical reasons for circumcision are simply excuses - there are no valid medical reasons. The arguments for doing circumcisions have centered on alleged medical reasons.

       It began in the late 1800s with a few doctors claiming that circumcision prevented masturbation, which in turn prevented insanity. When that absurd idea was discredited other excuses were invented to replace it. Circumcision was next touted as a cure for epilepsy, then hernia, tuberculosis, syphilis, and even cancer. All of these excuses have in time been disproven. Recently, the excuse has been the alleged prevention of urinary tract infections. A Dr. Wiswell has claimed that 1.4% of uncircumcised boys get urinary tract infections. Even if we grant Wiswell his facts, which wiser doctors disagree with, only one percent of intact infants get these urinary tract infections. No sane person could justify mutilating a hundred infants to possibly protect one of them from an infection that can easily be treated with antibiotics. Altschul1 has not found significant excess morbidity due to urinary tract infection.

       Wiswell and his colleagues may be responsible for causing a ten-fold increase in urinary tract infections among intact infants born in military hospitals by advising parents incorrectly about the care of the intact penis. The military doctors recommended partial retraction of the foreskin during cleansing. This unnecessary and harmful practice would easily introduce germs into the urethra, causing many infections. In an ignoble attempt at semantic self-defense, they denied forceful retraction, but they definitely did recommend retracting while cleaning. European medical experts agree that retraction of the child's foreskin is harmful and can lead to infection.

       Cancer of the penis occurs in one in 100,000 men. If cancer is to be prevented by removing healthy, normal tissue, it would make far more sense to remove all female breasts at puberty, for the risk of breast cancer is now about one in nine. Since breast removal, fortunately, is not being recommended on an across-the-board basis, it is clearly unethical for anyone to even suggest that circumcision be done to prevent cancer of the penis.

       Death from circumcision

       Based on data presented in Gairdner's 1949 study in England, which was instrumental in stopping circumcision in Great Britain, there would be 15 infant deaths from circumcision each year in the effort to possibly prevent one cancer of the penis in one older man. This data could well apply today. Finally, even if a significant protective effect against cancers of the penis were to exist, each man should still have a right to decide whether or not he wishes to live his life with an intact foreskin and take whatever small risk there might be. Should not each man have a right to choose?

       Similar arguments are used by people in Africa to justify female genital mutilation, yet no one in America would suggest that any of these arguments justify the performance of this barbaric act. Hanny Lightfoot-Klein's book, "Prisoners of Ritual" documents this in full. Today, in America, circumcision is widely used as a treatment for conditions that do not require it. I am frankly shocked by the doctors I have encountered who are desperately searching for excuses to continue carrying out this harmful procedure. I recently met a doctor and his wife, who had a four-year-old son who was having two minor problems with his prepuce. The parents did not think he needed to be circumcised. However, he ended up being circumcised because three doctors insisted that he needed it and overrode them. Now, if they could override a doctor and his wife, pity the poor lay person.

Foreskin Physiological Function

       Now let's take a look at the usefulness of the male foreskin.

       First, the amount of skin that is removed from the newborn may seem small, but if left in place the foreskin does grow and in the adult becomes quite large. The adult foreskin has been measured. It has the same surface area as a 3 by 5 card, i.e., 15 square inches.

       The foreskin has several useful functions. It serves to protect the infant glans from feces and other sources of infection. In the infant, and the adult as well, the protecting foreskin prevents the surface of the glans from thickening. Without protection, the glans adds many cell layers with subsequent loss of sensitivity - as many as 14 and 15 cell layers over the one that is present when the prepuce is present.

       Over time the foreskin separates from the glans penis, and it does so by a very fascinating process. In the area where the preputial space will form, cells begin to form up into whirls. As these whirls increase in the number of layers that they have, the cells in the center are cut off from the nutrients that normally go to cells and they die, that is, they desquamate. As these whirls coalesce, the preputial space is formed. This process goes on from the 17th week of intrauterine life until 17 years of age, within normal limits. You can have a 17-year-old boy who is still waiting for his prepuce to separate from the glans penis. It takes many years. It is a perfectly natural developmental process.

       The desquamated cellular material combines with glandular secretions to form smegma, which is the natural penile lubricant and moisturizer. Why does the foreskin separate from the surface of the glans over time? Why is there this large loose fold of skin? The answer is that the foreskin is designed to cover the shaft of an erect, enlarged penis. During erection the penile shaft elongates becoming about 50 percent longer. The foreskin covers this lengthened shaft. It is specifically designed to accommodate an organ that is capable of a marked increase in diameter and length.

       Another function of the foreskin is that it makes manual stimulation of the penis, or masturbation - now recognized as a normal activity - easier and much more pleasurable. The foreskin makes it easier for the male to enter the female. It slides back during entry. This function may be compared with rolling on a sock as contrasted with trying to pull it on. It may be even more relevant to compare it with rolling on a condom. No one tries to pull an unrolled condom on. The friction would be too great. Because there is more friction when circumcised males have intercourse with females, circumcision may be the cause of a variety of gynecological conditions such as dryness and pain during intercourse.

       The foreskin has complex nerve endings which give a degree of sexual pleasure not experienced without it. As one man who had been circumcised after he had become sexually active said: "Stimuli that had previously aroused ecstasy now have relatively little effect." By destroying the important sexual nerve endings of the foreskin, circumcision permanently desensitizes the penis.

Harm From Circumcision

       Now let us examine the harm of circumcision. Even the way that circumcision is performed in the modern hospital contributes significantly to the harm done. In the Barzel shield method of circumcision, the prepuce is caught between two blunt metal shields and is instantly cuts it off. The result of using this shield, is that a significant amount of the inner prepuce is preserved, having been everted by the shield. The shaft skin of the penis is amputated, and the inner prepuce is now turned inside out and forms the new covering of the penile shaft.

       The method that was used in biblical times cut off only the very tip of the foreskin. There is a big debate about why the famous statute of David by Michelangelo looks like he is not circumcised. Michelangelo knew what he was doing. David is circumcised, but by the biblical method. In addition to preserving lots more foreskin, the traditional religious techniques are vastly quicker. They can permit a straighter cut and they do not crush to the extent of the Gomco Clamp. For these reasons some might suggest there is less pain during the religious circumcision.

Pain.

       It is impossible to deny excruciating pain with the Gomco Clamp, which crushes the foreskin before the doctor cuts if off with a scalpel. The Gomco Clamp was invented in 1934 by Hiram Yellin, M.D. an obstetrician, and Aaron Goldberg from Buffalo, New York. A friend of Dr. Yellin's told me the story of its invention. He was placing a hose clamp on his automobile radiator when he was paged to see a bleeding circumcision wound. On the way to the hospital he decided that some sort of clamp might help alleviate the bleeding, which was so frequent. Thus, the Gomco Clamp was born. The wide use of the Gomco Clamp has resulted in a change in technique that has affected several generations adversely. It would be appear that few doctors using the Gomco Clamp would bother to recognize the terrible difference.

       The Gomco and the Plastibell method, which performs the amputation similarly, are responsible for an entirely different outcome, a far more significant mutilation. As a result very little of the inner prepuce is preserved in so-called modern medical circumcision. In the unwitting attempt to protect the glans from being cut off, which even today occasionally happens in a freehand circumcision, the point of removal of the foreskin at the base of the glans, not at the tip of the glans or at the tip of the foreskin, but at the base of the glans.

       Lest I be accused of being anti-Semitic by presenting these facts, let me say that I can conceive of nothing more likely to promote prejudice than the recognition that Moslem and Jewish physicians are making several hundred dollars for each Christian infant they mutilate.

       Before 1987, when the New England Journal of Medicine published Anand and Hickey's study2 proving the severe pain caused by circumcision, most doctors actually tried to deny that circumcision hurt. Now this can no longer be denied. What we have in this country is a small group of doctors, a very small group of doctors, torturing male infants.

Complications

       One in 500 circumcised boys has a significant complication, according to Dr. Julian Ansell, who favors the procedure.3 This means that at the very least, 2,000 significant medical complications from circumcision occur each year in America. The mortality resulting from circumcision in newborns is not available. The relationship between circumcision and infant death is usually obscured by the reporting of the immediate cause of death, like infection, and omitting the precipitating cause - the circumcision wound. Deaths associated with circumcision are rarely reported. They should be.

Psychological Effects

Psychologic Trauma

       The complications say nothing about the millions of men who would prefer to have their foreskins and are now beginning to say so. Tim Hammond has been collecting statements from men who tell that they have been harmed by male genital mutilation. Looking at what happens after a procedure is done is in the best tradition of medicine, which is right now just beginning to take a hard look at the outcomes of many of the procedures that it offers. Since it is perfectly clearly that circumcision is unnecessary, a single individual harmed is one too many. Men are finally getting in touch with their feelings on the subject. Frankly, I cannot blame any man for not wanting to get in touch with his feelings about so traumatic an event right after his birth. One cannot help but wonder to what extent this profound trauma keeps men from getting in touch with any of their feelings - a deficiency that women are constantly accusing them of.

       We have seen that circumcision is harmful. Since circumcision is harmful to at least some of its victims, we have proven what we set out to prove, that circumcision is a doctor-caused epidemic. Oliver Wendell Holmes had this to say about puerperal fever:

Whatever indulgence may be granted to those who have heretofore been the ignorant causes of so much misery. The time has come when the existence of a private pestilence in the sphere of a single physician should be looked upon not as a misfortune, but a crime.

       Whether or not this applies to circumcision from now on remains to be seen.

Medical Motivations to Circumcise

       Why do doctors mutilate the genital organs of infants they are supposed to be caring for? Clearly, money is involved. If two obstetricians deliver 700 babies each year and one of them circumcises all the males, he makes a cool $35,000 each year on this procedure alone.

       Other doctors do it because they refuse to admit that a huge medical mistake has been made, and others do it out of ignorance, yet this does not explain everything. I know too many otherwise perfectly rational men and women doctors who are unable to be reasonable on this subject. I have seen a lot of bizarre occurrences surrounding this practice. I do not believe that doctors would be doing this unless there is something more, and I believe that something is denial.

Denial of Loss in the Circumcised Male

       Elizabeth Kubler-Ross talks about denial in her book, "On Death and Dying:"

Among the 200 dying patients we have interviewed, most reacted at first to the awareness of a terminal illness with the statement, 'No, not me, it cannot be true.' Denial - at least partial denial - is used by almost all patients. When the first stage of denial cannot be maintained any longer, it is replaced by feelings of anger, rage, envy and resentment. This anger is displaced in all directions and projected onto the environment almost at random.

The fourth stage:

The fourth stage: Depression. When the terminally ill patient can no longer deny his illness, he cannot smile it off anymore, his anger and rage will soon be replaced by a sense of great loss.

The fifth stage:

Acceptance. Acceptance should not be mistaken for a happy stage.

       Many people never make it to the acceptance stage. They die first. This is also true for circumcision. Denial operating with respect to circumcision can be even stronger than the denial associated with death. Because death is universally regarded as being inevitable it is more readily accepted. Circumcision, however, is not inevitable, and this is its great injustice. It did not have to happen.

       Some men who have had this happen to them cannot bear the thought that another man can go through life intact. A Welshman, living in Los Angeles had a minor problem with his foreskin. He was in his 40s. His friends, who happened to be doctors, said that they could fix it. He insisted that they not circumcise him, and they assured him that they would not. But after he was under anesthesia they circumcised him anyway. This betrayal is done each day to newborns.

       This may be the motive of male genital mutilation. It has been called by some "prepuce envy." This may be the motive that has tended to perpetuate circumcision wherever it is found. Men who have had it done to them cannot face the fact that they must go through this life, their one and only life, sexually impaired. So to maintain the denial they insist that their sons be mutilated in the same way.

       This tragic facet of human nature, this denial of the outrage perpetrated on an individual, perpetuates the process. This does not make it right. These concepts should help us better understand the father who insists that this traumatic, unnecessary procedure be performed on his son. They should also help us to understand why this practice has been going on for so long. Denial has begun to operate wherever circumcision has been introduced.

       What are the consequences of this theory? Doctors who have been cut themselves may be unable to stop cutting others. If that is so, then all of us have a solemn responsibility to keep them from harming other people's children.

Pressures on Intact Male Doctors and Women Doctors

       What about the intact male doctors and what about the women doctors who perform circumcisions? Having performed these procedures for some time, they are now defensive and deny it is harmful. It is much easier to accept the status quo than to accept that they are harming newborns. When I was an intern I was told by my chief resident to go and do three circumcisions. As low man on the totem pole, I went and did them. I was given no training. I had to figure out how to work the Gomco Clamp by myself and I remember to this day still figuring it out. I think I did, but it was still not very pleasant. My abiding memory of this miserable experience is of a fellow intern, a brilliant Jewish radiologist, standing next to me doing his quota of circumcisions. He was all thumbs when it came to surgery. As he floundered along he just kept shaking his head.

       The very idea that a doctor does not approve of circumcision and yet still does it is bizarre. Yet this is part of the picture of this strange epidemic. Of course, many doctors have already looked at the facts, have stopped, and now shun the procedure. I am confident that most future doctors will never start doing circumcisions.

       The fact that circumcision has been going on for centuries in certain cultures, or the fact that circumcision has been going on in American on a massive scale since the 1950s has been used as a reason for continuing it. It is said that the reasons to continue it are 'cultural.' Any mutilative practice that arose in early times under primitive, barbaric conditions has no place in 21st Century America. I suggest that its ancient origins are a good reason for stopping it now.

      

Bioethics

       What about fathers and mothers who "insist" that it be done? First, according to modern ethicists, when parents make decisions regarding their own infant these decisions must be in his best interest. Second, what doctor does an operation because a relatively ignorant lay person tells him to? Doctors virtually always decide for themselves whether and when they shall operate. They must apply this same standard to their decision to circumcise. Doctors who perform male genital mutilations are violating all seven principles of the A.M.A. Code of Ethics. For example, the first, second, third, and fourth principles are:

  1. A physician shall be dedicated to providing competent medical services with compassion and respect for human dignity.

  2. A physician shall deal honestly with patients.

  3. A physician shall respect the law and also recognize a responsibility to seek changes in those requirements which are contrary to the best interests of the patient.

  4. A physician shall respect the rights of patients.

       Applied to circumcision, as we understand it, all of these principles, and more, are flagrantly violated.

       In addition, circumcision lies outside the bounds of accepted surgical practice. As Dr. David Grimes points out in his excellent 1978 paper,4 the principles of surgery as laid down in surgical textbooks by our greatest surgeons have no place for, simply do not include, this type of allegedly preventive surgery.

Conclusion

       Once we recognize why this terrible thing is happening, we can take more meaningful action to stop it. In the fight to control this epidemic everyone, including every doctor who has anything to do with families, must think in terms of saving, one at a time, each individual infant male from this mutilation and thereby making a tremendous contribution to the health and to the life of that individual. A doctor should not only counsel against male genital mutilation, he/she should refuse to perform it.

       If the hypothesis is correct, that men who have been cut are in denial, every doctor who has a responsibility to stop this epidemic. He or she must not only protect children from doctors who perform circumcision, but from their own fathers and mothers who simply do not have the ethical right to do anything to their child that is not in his best interests. Young parents rarely have the facts in their defense and it is clearly the doctor's responsibility to provide the correct ones. Despite the evidence that has been available for the past 20 years, doctors have been irresponsible by failing to protect those whom they are pledged to protect.

       It must simply be made it clear that no one has the right to do this to newborns. Simply let American boys grow up and when they become adult Americans like us, let them decide for themselves whether or not they wish to have part of their penis amputated.

References

  1. Altschul, Martin S. The Circumcision Controversy, American Family Physician, vol. 41, no. 3 (March 1990): pp. 817-820.

  2. Anand, K.J.S., & P.R. Hickey. Pain and its Effects in the Human Neonate and Fetus, The New England Journal of Medicine, vol. 317, no. 21 (November 19, 1987): pp. 1321-1329.

  3. Gee, William F. & Julian S. Ansell. Neonatal Circumcision: A Ten-Year overview: With Comparison of the Gomco Clamp and the Plastibell Device, Pediatrics, vol. 58, no. 6 (December 1976): pp. 824-827.

  4. Grimes, David A. Routine Circumcision of the Newborn Infant: A Reappraisal, American Journal of Obstetrics and Gynecology, vol. 130, no. 2 (January 15, 1978): pp. 125-129.

Biography

George Denniston, M.D., M.P.H., specializes in Preventive Medicine and Gynecology and has published extensively in his specialty. He has produced a number of medical training films and documentaries and has served with many medical and professional organizations. Dr. Denniston was formerly Associate Medical Director of Planned Parenthood Federation of America, New York. He is President and Medical Director of Population Dynamics in Seattle, Washington, and Consultant, to the Alaska Women's Health Services. He serves on the Advisory Council of the International Symposia on Circumcision.

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