The Controversial Practice Of Circumcision

We talk to experts about the pros and cons.

06/09/2016 3:38 PM AEST | Updated 07/09/2016 5:57 AM AEST
P Deliss
A little boy prior to being circumcised.

What is essentially a little snip can certainly amount to a big debate. Without a doubt, this is the case when it comes to the practice of routine circumcision in infant males, not only in Australia but world-wide.

While the attitudes toward circumcision differ country to country, in Australia, non-therapeutic circumcision has been found to be too risky to warrant the associated health benefits.

"The level of protection offered by circumcision and the complication rates of circumcision do not warrant routine infant circumcision in Australia and New Zealand."

- Circumcision of Male Infants. Sydney: Royal Australasian College of Physicians, 2010.

Yet according to Circumcision Information Australia, the incidence of circumcision in Australian infants is still about 13 percent in the first year of life, making it a fairly common procedure.

And according to the American Academy of Pediatrics, the health benefits of newborn male circumcision actually outweigh the risks (though admittedly not enough to recommend universal newborn circumcision.)

So what's the deal? Is routine circumcision actually risky, or are the health benefits worth it?


The controversy

"Circumcision is controversial for a number of reasons, some of which all come together to form one," Brian Morris, Professor Emeritus in the School of Medical Sciences at the University of Sydney told The Huffington Post Australia.

"It involves surgery, which is always emotional, babies, which is obviously another emotional thing, and religion. Some of these overlap, some of them come as a package all in one. Either way it's not difficult to see why it's such a controversial subject."

It's worthwhile noting this controversy generally does not apply to circumcision when it is felt there is a medical reason to perform the surgery.

According to Dr Grahame Smith, spokesperson for the Urological Society of Australia and New Zealand, these could include lichen sclerosus (which he describes as "a type of dermatitis which affects the foreskin"), boys who have recurrent urinary tract infections or foreskin infections (recurrent being three to four episodes a year) and foreskin which is too tight to be pulled over the head of the penis.

"All of these are good medical reasons to perform a circumcision," Smith told The Huffington Post Australia.

Getty Images/iStockphoto
A baby boy in hospital being circumcised.

Circumcision is also often performed for cultural or religious reasons (Jewish and Muslim religions being the most common examples), but is not the focus of this particular article.

What the debate really boils down to, medically, is whether or not routine circumcision should be performed in male infants as a preventative measure against certain health conditions.

The benefits

According to Morris, a known supporter of circumcision, the benefits associated with the practice are practically endless.

"The benefits start in early infancy in protecting against urinary tract infections," Morris told The Huffington Post Australia. "These affect one to two percent of infant males... but only about 0.1 to 0.2 percent of circumcised males, meaning there's a tenfold protective effect.

"But the protection doesn't suddenly end at the end of year one. It continues over a lifetime."

Morris also says circumcision helps to protect against inflammatory skin conditions such as balanitis (swelling of the foreskin), STDs, penile cancer and genital herpes.

"In terms of genital herpes, protection is about a third. That's not huge, but it's significant. But genital herpes is very common so getting that down by 30 percent is a good thing," Morris said.

Never has so much been written about such a small piece of skin. Dr. Grahame Smith

He also states circumcised penises tend to be more hygienic.

"Circumcised men have better hygiene -- it's quite common to hear that," Morris said. "Because with uncircumcised men, even if they wash, the bacteria returns within hours. It's quite an issue."

Smith, however, dismisses this notion as a common misconception.

"If you live in a desert and can't shower every day, that might be true," Smith told HuffPost Australia. "But in our society we have fantastic access to hygiene, so I don't see it as being relevant."

But in spite of the alleged benefits (many of which the Royal Australasian College of Physicians freely acknowledge in their 2010 circumcision policy statement) it was still found that risks and potential complications proved to be a weightier concern.

After reviewing the currently available evidence, the RACP believes that the frequency of diseases modifiable by circumcision, the level of protection offered by circumcision and the complication rates of circumcision do not warrant routine infant circumcision in Australia and New Zealand. However it is reasonable for parents to weigh the benefits and risks of circumcision and to make the decision whether or not to circumcise their sons.

- Circumcision of Male Infants. Sydney: Royal Australasian College of Physicians, 2010.

The risks

"When we talk about the benefits of any surgery, it's also important to talk about the risks," Smith told HuffPost Australia. "And it has been found, in Australia, that the risks of routine circumcision outweigh the benefits."

The first risk, of course, is if the medical professional tasked with performing the procedure somehow botches the job.

"I have seen first-hand the complications of circumcisions that haven't gone well," Smith said. "People ask what the incidence of that is, and it's probably in the order of half a percent, but the damage to the end of the penis can be considerable, depending on whether too much or not enough skin has been removed."

There are also concerns regarding the rates of haemorrhage, which the RACP states "may indicate an underlying vitamin K deficiency or haemophilia.

"The risk of postoperative bleeding after Plastibell circumcision is reported to be as high as 3 percent, but is generally thought to occur at a rate of about 0.8 percent."

Getty Images
One of the concerns surrounding circumcision is whether it has an adverse effect on sexual function and pleasure.

The RACP also outlines other risks to include infection, meatal stenosis (a narrowing of the opening of the urethra), secondary phimosis, secondary chordee, cutaneous tags, poor cosmetic appearance and psychological trauma.

Then there is the matter of sex and whether circumcision has an adverse affect on sexual function or pleasure.

"The actual function of the foreskin is for sexual intercourse. It assists with the penis moving in and out. That's why it's there," Smith said.

Morris told The Huffington Post Australia that while he acknowledged "the adverse effect on sexual function, penile sensitivity and sexual pleasure is a big concern" among those against circumcision, he also claimed this viewpoint was largely formed due to a reliance on anecdotes rather than any large studies.

Ethical concerns

"When it comes to the ethical issues [surrounding routine circumcision], there is not a right or wrong answer," Smith said. "Though you could argue that as it's not a 'medically necessary' procedure -- in that you're not treating an actual illness -- parents therefore cannot consent on behalf of the child."

"Part of the argument surrounding circumcision is when it should happen," Smith continued. "As parents may not be able to give permission on behalf of their child at such a young age.

"Should circumcision should be left to the children to decide? After all, one of the benefits of circumcision is that it reduces the instance of STDs slightly. Obviously a boy is not going to be sexually active at the time most circumcisions are performed.

"There is no harm in waiting for the boy to be older and make his own decision."

The public system won't do request circumcisions as the procedure is not thought to be cost effective, and bearing in mind, the risks outweigh the benefits.

(In a somewhat similar vein, in 2012, a court in Germany ruled circumcising young boys for religious reasons amounted to bodily harm, as it contravened the "interests of the child to decide later in life on his religious beliefs".)

Yet it is widely agreed that if circumcision is to be performed, during infancy is the best time to do it.

"Serious risks are very rare especially if its done during infancy," Morris stated. "The first week of life is the best time because the foreskin is very thin and pain is minimum. In fact, pain studies show it's virtually painless.

"By about one month to three months of age, there is considerable growth of the foreskin and a lot of vascularisation. The risks are therefore higher as there is more of a likelihood of bleeding and the pain is greater."

Where we're at

As previously discussed, the official viewpoint of medical professionals in Australia is that boys should not be routinely circumcised as a health precaution.

"In the public hospital system, we won't do routine circumcisions," Smith told HuffPost Australia. "We won't do them as a request.

"The public system won't do request circumcisions as the procedure is not thought to be cost effective, and bearing in mind, the risks outweigh the benefits."

Morris, on the other hand, is hopeful the policy will change.

"There is a lot of talk about how a new policy is way overdue," he said. "Though so far, there have been noises but no traction."

How and where this debate will end up remains yet to be seen, but perhaps in the meantime, Smith sums it up best.

"Never has so much been written about such a small piece of skin."

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