MEDICAL SELF-CARE: ALL ABOUT CIRCUMCISION

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This issue's column was guest-written — for Dr. Tom Ferguson — by contributors to Medical Self-Care magazine.

by Mike Samuels, M.D., and Nancy Samuels

After the birth of a boy, one of the first and most difficult decisions faced by the parents is often the question of circumcision: the surgical removal of the foreskin that covers the head of the penis. Although few parents have given a lot of thought to the procedure in the past (many expectant couples routinely sign a consent form for the operation when they check into the hospital), the subject is becoming increasingly controversial as new findings contradict long-established medical beliefs.

6,000-YEAR HISTORY

One of the most ancient of surgical procedures, circumcision is pictured in Egyptian bas-reliefs dating back to 4000 B.C. Tribal cultures around the world — including the Australian aborigines and many African and South Pacific people — circumcise their boys shortly after birth, or as part of later initiation rites. And, of course, Jews have a very long history of the practice . . . in the Old Testament, God commands Jews to circumcise boys eight days after birth as a sign of His covenant with Abraham.

In this country, however, circumcision has spread far beyond those groups who connect it with religious or cultural beliefs: It has become a common medical procedure. Before the 1870's, very few non-Jewish American males were circumcised . . . but by 1910, 56% were. And today, about 85% of the boys born in the United States are circumcised. In fact, we're the only Western nation (besides Israel) that still practices circumcision on a large scale. (For example, in England the percentage used to be quite high, but has now dropped to less than one percent.)

MEDICAL FACTS AND FALLACIES

The foreskin, or prepuce, is a double layer of skin — similar to a lined sleeve — that fits snugly over the tip (glans) of the penis. The outer layer is continuous with the outer layer of the penis, and protects the glans (and the urinary opening in particular). The inner layer is more like a mucous membrane . . . it secretes smegma, a lubricating substance that allows the foreskin to slide back and forth easily over the head of the penis. Since the inner layer houses many nerve endings, it is highly sensitive and enhances sexual pleasure.

The foreskin starts developing during the third month of gestation, and by the fifth month is fused to the tip of the penis. By birth, it has usually begun to separate from the glans . . . a process that continues during the first years of life. By puberty, the foreskin should be fully retractable.

Doctors once thought that circumcision should be used to "correct" a foreskin that could not be retracted at birth . .. and some physicians believed that the foreskins of uncircumcised boys had to be forced back to break what were thought to be adhesions, which are membranes connecting tissues that should be separate. But now, medical science generally understands that both the fusion of the foreskin to the glans and their eventual, gradual separation are normal.

Today, an infant's foreskin is considered too tight only if it impedes the child's ability to urinate normally.

Physicians also once believed that circumcision prevented cancer of the penis and cervix. The theory was that these diseases were caused by smegma, since epidemiological studies showed lower rates of such cancers in circumcised men and their spouses. Recently, however, these studies have fallen into disrepute as being too simplistic . . . with careful foreskin hygiene, uncircumcised men and their lovers show no greater risk of disease than do other couples. Circumcision was also thought to prevent infections of the foreskin, but we know now that these problems, too, can be avoided with basic personal care. Young boys should simply be taught to cleanse the inner layer regularly by retracting the foreskin as far as it will go (without forcing it!) and washing with mild soap and water.

A study in Scandinavia, where circumcision is rare, showed that only two-tenths of one percent of older boys and men had to be circumcised for medical reasons. The current position of the American Academy of Pediatrics Ad Hoc Task Force on Circumcision is that there are "no valid medical indications for circumcision in the neonatal period".

THREE TECHNIQUES

Circumcision is one of only a few surgical procedures still routinely performed without anesthesia. The infant is simply restrained (either held or strapped to a table) . . . the penis is washed with an antiseptic . . . and then a surgical probe is used to separate the foreskin from the glans. To remove the foreskin, one of three methods is used. The least common involves cutting with surgical scissors from bottom to top, and then around in a circle. Another method uses a metal clamp. The foreskin is slit vertically, and a metal cone is placed between it and the tip. The prepuce is then stretched over the cone, a clamp is attached to squeeze blood out of the area, and the foreskin is removed with a scalpel. The third method is similar to the second, but employs a plastic cone. After the foreskin is stretched over the device, the base of the prepuce is tied tightly with a string that acts like a tourniquet. The end of the foreskin is then cut off, and the rest withers and falls away within ten days.

Until recently, doctors were unconcerned about the pain of circumcision, apparently because of the traditional medical belief that newborns are insensitive to pain. However, now we know that babies are highly developed at birth. They can see, hear, smell, feel, and learn remarkably well . . . even during the first few days after birth. Newborns certainly can experience pain, as their reaction during circumcision demonstrates. All babies scream, tremble, and cry . . . many hold their breath or vomit.

Furthermore, infants often continue to be irritable for days after being circumcised. Research has shown that blood levels of adrenal hormones involved in stress reactions rise after the procedure. Another study indicated that circumcision decreased the rapid-eye-movement (REM) sleep involved in dreaming. A third report showed that recently circumcised boys react to noise differently than do their uncircumcised counterparts.

Neonatal researcher Yvonne Brackbill writes: "From all three studies, we may conclude that circumcision does affect infant behavior and psychophysiology. In view of all the evidence showing long-term behavioral, physiological, anatomical, and even neuropharmacological effects of 'minor' events in early development, we would be unwise to assume without empirical demonstration that the effects of circumcision are short-lived."

POSSIBLE COMPLICATIONS

Like any surgical procedure, circumcision may cause complications . . . a fact that, until recently, has not received, proper attention. The most frquent problems are excessive bleeding (requiring sutures or chemical cauterization) . . . infection (requiring post-operative care and possibly antibiotics) . . . urinary obstruction due to contraction of the skin at the base of the foreskin (requiring repeat surgery for correction) . . . and surgically caused problems resulting from improper technique.

The complication rate among circumcisions is not high, and the problems that do occur are rarely life-threatening or permanent. However, the rate is much higher than the rates of the infections and cancers that circumcision was once thought to prevent. An article in Pediatrics states, "Before undertaking circumcision, the physician should be aware that significant complications may occur in one newborn in 500."

A PERSONAL DECISION

Today, with the medical justifications for circumcision largely abandoned, the question has become primarily one of religious or cultural tradition. To many people, these beliefs are very important and should be carefully weighed. In any event, however, expectant parents should at least consider the issue — and make a conscious decision about it, one way or the other — before the baby arrives.

EDITOR'S NOTE: Mike and Nancy Samuels are the authorsof The Well Baby Book (Summit Books, 1979, $11.50), an excellent guide that's available in most libraries and bookstores.