Compiled from various sources by Geoffrey T. Falk (gtf @ cirp.org)


What is circumcision?

Circumcision is the surgical removal of the sleeve of skin and
mucosal tissue that normally covers the glans (head) of the penis. This double layer, sometimes called the prepuce, is more commonly known as the foreskin.

Parents are encouraged to read as much as possible about circumcision. They should make themselves aware of the complexities of the circumcision procedure itself. Speak to your doctor about the step-by-step procedure. If possible, ask to observe a circumcision at your hospital, so that you will know fully what is involved.


What is the foreskin there for?

The foreskin serves three functions: protective, sensory, and sexual.

In most cases, the foreskin is still fused to the glans at birth and
will separate over a variable period of time over the first few years.
During the diaper period, the foreskin protects against abrasion from
diapers and feces. Throughout life, the foreskin keeps the glans soft
and moist and protects it from trauma and injury.

Parts of the foreskin, such as the mucosa (inner foreskin) and frenulum,
are particularly sensitive and contribute to sexual pleasure. Specialized
nerve endings enhance sexual pleasure and control [19].

- The inner foreskin (mucosa) is the skin directly against the glans.
   Like the lining of the mouth, this tissue is thinner and of a different
   texture and color than the remainder of the skin covering the penis
   (shaft skin).

- The frenulum is a particularly sensitive narrow membrane that runs
   down the ventral groove of the glans and attaches to the inner
   foreskin.

- The frenar band is the interface between the inner foreskin (mucosa)
   and the shaft skin. It often "puckers" past the tip of the glans.
   The band contains whorled smooth muscle fibers, giving it pronounced
   elastic properties that allow the foreskin to be retracted. The
   frenar band has a tactile sensitivity equivalent to that of the lips.

The foreskin provides ample loose skin for the penis to occupy when
erect. It is a movable skin sheath for the penis during intercourse,
reducing chafing and the need for artificial lubricants, and allowing
the glans and foreskin to naturally stimulate each other.
Warren and Bigelow described some of the physiological
functions of the foreskin in sexual activity. [1]


What are some reasons that circumcision is performed?

Circumcision is primarily performed for cultural or religious reasons.

Because a large number of men in English-speaking Western countries
are circumcised, many think of the foreskin as an unnecessary part of
the penis. Many circumcisions are performed because a circumcised
father often does not want to feel that he is different from his son.

It is often said that a circumcised penis is cleaner, or easier to
keep clean, than an intact penis. Smegma (a natural substance
composed of dead skin cells, normal flora, and secretions containing
the natural antibacterial agent lysozyme) is more likely to accumulate
when the foreskin is present.

Medical grounds for circumcision that are most commonly cited are:
Reduced risk of urinary tract infections (UTI); reduced risk of
penile cancer; reduced risk of cervical cancer in partners of intact
males; reduced risk of sexually transmitted disease (STD).

There is contradictory evidence in the research literature as to
whether circumcision reduces UTI [16,17], but this seems to be
the strongest of all medical claims in favour of circumcision,
because UTI can have serious consequences. These infections can,
however, in most cases be treated by antibiotics. The frequency of
UTI in US male infants is approximately 1%, but is higher for
females. There is evidence that babies who are breastfed have a
lower incidence of UTI. [8]

Penile cancer is an extremely rare form of cancer. It occurs mostly
in older men, and most doctors will not recommend infant circumcision
as a preventative measure. Penile cancer can occur in both circumcised
and intact men: The Maden study (an ongoing study of penile cancer
at Fred Hutchinson Cancer Research Center in Seattle) observed that
37% of penile cancer cases occurred in circumcised men. [2]

The theory that wives of men with intact foreskins are more prone
to cervical cancer has been disproven [12]. The theory that the
presence of a foreskin may cause an increased risk of sexually
transmitted diseases was disproved by a new study [22]. The question
of HIV warrants further study [20], [7]. Although there is an
apparent geographical correlation between male non-circumcision
and HIV infection on the African continent, this is not true
globally, and the pattern seen in Africa could easily be due to
other factors. The only known effective means of preventing HIV
infection are fidelity, condom use and abstinence.


Hygiene

The foreskin is easy to care for and the intact penis is easy to
keep clean. The foreskin usually does not fully retract for several
years and should never be forced. When the foreskin is fully
retractable, boys should be taught the importance of washing
underneath the foreskin every day.

Gently rinsing the genital area while bathing is sufficient. Harsh
soap and excessive washing can irritate the penis, which can lead to
inflammation of the glans (balanitis). [24]

Smegma is a white waxy substance that can appear under the foreskin.
It consists of natural secretions and shed skin cells. In the past
it was feared that smegma might be carcinogenic, but this has been
disproven. Good general hygiene and common sense are key to preventing
infection and disease.


If my son isn't circumcised, won't it have to be done later?

Abnormalities or diseases of the foreskin can be treated conservatively,
if and when they occur, on a case-by-case basis.

Probably the most common abnormality of the penis is "phimosis",
or tight foreskin. (This is not the same as the natural attachment
of the foreskin to the glans in very young children, which is
completely normal.) The foreskin can normally be retracted by
adolescence.

If retraction is not possible, a number of newer treatments are
available which do not involve circumcision: Steroid creams,
stretching, and preputioplasty. Some of these treatments have only
been published recently, and not all doctors are aware of them.

If your son has a serious problem with his foreskin, such as a
severe infection (balanitis xerotica obliterans) or gangrene,
perhaps related to diabetes, removal of the affected area may be
a medically advisable option.


If my son isn't circumcised, won't he be teased?

Children can be cruel, and will find things to pick on another
child about, whether it be his chubbiness, glasses, or freckles.
Some parents think that their son should be circumcised so that he
will "match" his father, brothers, or friends. As parents, we can
help our children to feel good about their bodies and to respect
individual differences.

Parents often express a fear that their son will "feel different
in the locker room" if he is intact. There is good evidence that
proper education is the answer. Boys who are taught from an early
age that they are normal, whole and healthy will have a lesser
chance of suffering embarrassment in the locker room, especially
if some of the other boys are also intact.

Nonreligious infant circumcision is not an issue in European, Asian
or South American countries. In Canada the average rate of infant
circumcision for boys is roughly 25%, with large regional variations.
The rate in the United States has dropped to less than 60%, and
will drop below 50% in a few years if present trends continue. This
is already true in the Western US (35% in 1993).


What are some reasons not to have my son circumcised?

Your son's foreskin is a healthy, natural part of his body. It is
possible, though very unlikely, that it will cause serious problems
during his life. When he becomes an adult, he may prefer not to be
circumcised. Leaving your baby's foreskin alone preserves his right
to a whole and intact body.

Circumcision will be painful for the baby (see below).

The medical evidence in favor of routine circumcision of healthy
babies is not persuasive. If your son has a problem with his
foreskin, such as a severe infection (balanitis xerotica obliterans)
or gangrene, perhaps related to diabetes, your doctor may recommend
partial or complete circumcision or removal of the affected area.
Phimosis (nonretractable foreskin, if it persists much longer than
normal) can usually be treated by gentle stretching and/or steroid
creams. The vast majority of boys will never have any foreskin problems
that necessitate surgery. [18]


Is circumcision painful?

The often repeated statement that babies can't feel pain is not
true. It is documented in the medical literature that babies are
as sensitive to pain as anyone else, and perhaps more so. [13,14]

Most circumcisions are performed without anaesthetic, because there
are risks involved with using anaesthetics on babies. Sometimes
local injections are used, but this does not eliminate pain. Most
babies will show signs of pain during the procedure and in the week
or ten days following circumcision. Recent studies have shown that
the pain is remembered long beyond the time of the procedure itself.
[23]

While pain may help parents decide against circumcision, parents
should look at the long term effects of their decision first, not
only during infanthood, but all the way to adulthood. Your decision
will affect your son for the duration of his life.


Does infant circumcision have risks?

Infant circumcision is surgery, and like all surgery it has risks.
These include:

# Excessive bleeding
# Injury to the glans
# Infection (raw wound is exposed to feces and urine in diaper)
# Complications from anaesthesia, if used
# Surgical error, including removal of too much skin
# In rare cases, complications can be life-threatening.

Up to 20% of males circumcised in infancy will suffer from one or more
of the following complications, to some degree:

# Meatal stenosis (narrowing of the urethral opening due to
   infection and subsequent scarring), occurs almost exclusively
   in circumcised boys [15]
# Extensive scarring of the penile shaft
# Skin tags and skin bridges
# Bleeding of the circumcision scar
# Curvature of the penis
# Tight, painful erections
# Psychological and psychosexual problems [21]

The surface of the glans becomes dry if not protected by the
foreskin. It is believed that dryness and abrasion may cause
progressive loss of sensation in the glans, especially in later
life. Circumcised men on the whole do enjoy sex and are able to
orgasm.


What if we want to have our son circumcised?

Circumcision does not need to be done right away. There is no need
to feel pressured by your doctor. Take your time.

If you intend to ask your doctor to have your son circumcised,
ensure that the procedure is carried out by an experienced surgeon.
Sometimes circumcision is considered "minor surgery" and inexperienced
residents are given the task of performing it. This leads to a
higher rate of serious errors and complications.

You may desire that your son will retain some inner foreskin, and
especially the frenulum, to preserve as much sexual sensitivity and
function as possible. Another method is the dorsal slit. This method
does not involve the removal of tissue, but allows the glans to be
exposed.

Your doctor can help you decide how much skin will be removed and
how much of the glans should remain covered if desired. However, in most
cases, once your signature is on the consent form, the physician has
absolute license to execute the circumcision as he/she sees fit. You must
ensure that your intentions are in writing before the operation occurs.

To lessen the pain, speak to your doctor about the use of an
anaesthetic for your baby.


When and why was routine neonatal circumcision introduced in
  English-speaking Western countries?

Doctors in the English-speaking countries started circumcising
babies in the mid-1800s to prevent masturbation, which some doctors
claimed caused many diseases, including epilepsy, tuberculosis and
insanity. Of course, these arguments are not accepted today.


Where can I get more information?

The organization NOCIRC can provide help and advice, as well as
free telephone referral of physicians in your area who are trained
in the proper care of the intact penis. Telephone (415) 488-9883,
or write to: NOCIRC, P.O.Box 2512, San Anselmo CA 94979-2512, USA.
A list of local NOCIRC centers in the USA can be found at the NOCIRC
Website: http://www.nocirc.org/

This FAQ is part of Circumcision Information and Resource Pages.
A vast range of information is available at http://www.cirp.org/CIRP/
This includes pointers to other sources of information on the WWW.


Selected References

1. Warren and Bigelow. British Journal of Sexual Medicine, Sept/Oct
1994.
2. Maden, Christopher, et al., "History of Circumcision, Medical
Conditions, and Sexual Activity and Risk of Penile Cancer," Journal
of the National Cancer Institute 1993;85:19-24.
3. Cook LS, Koutsky LA, Holmes KK. Circumcision and sexually
transmitted diseases. Am J Public Health 1994; 84: 197-201.
4. Cook LS. Koutsky LA. Holmes KK. Clinical presentation of genital
warts among circumcised and uncircumcised heterosexual men attending
an urban STD clinic. Genitourin Med 1993; 69: 262-264.
5. Donovan B, Bassett I, Bodsworth NJ. Male circumcision and common
sexually transmissible diseases in a developed nation setting.
Genitourin Med 1994; 70: 317-20.
6. Smith GL, Greenup R, Takafuji ET. Circumcision as a risk factor
for urethritis in racial groups. Am J Public Health 1987; 77: 452-4.
7. Guimaraes M, Castilho E, Ramos-Filho C, et al. Heterosexual
transmission of HIV-1: a multicenter study in Rio de Janeiro,
Brazil. VII International Conference on AIDS. Florence, June 1991
[abstract MC3098].
8. Piscane, A. Breastfeeding and Urinary Tract Infection. Lancet,
July 7, 1990:50.
9. Marshall RE, Stratton WC, Moore JA, Boxerman SB, Circumcision
I: effects upon newborn behavior. Infant Behav Dev. 1980;3:1-14
10. Marshall RE, Porter FL, Rogers AG, Moore J, Anderson B, Boxerman
SB, Circumcision II: effects upon mother-infant interaction. Early
Human Development 1982;7:367-374
11. Lawler, F. Circumcision: Decision Analysis of its Medical
Value. Family Medicine, 1991;23:587-593.
12. Elizabeth Stern, M.D., Peter Neely, Ph.D., "Cancer of the
Cervix in Reference to Circumcision and Marital History", Journal
of the American Medical Women's Association, Vol. 17, No. 9 (Sept.
1962)
13. Anand and Hickey. Pain and its effects in the human neonate
and fetus. N Engl J Med 1987; 317(21): 1321-9.
14. Dixon S, Snyder J, Holve R, Bromberger P. Behavioral Aspects
of circumcision with and without anesthesia. J Dev Behav Pediatr
1984;5:246-250.
15. Williams N, Kapila L. Complications of circumcision. Br J Surg
1993; 80: 1231-6.
16. Wiswell TE, Routine Neonatal Circumcision: A Reappraisal,
Armed Forces Physician 41(3), Mar 1990, 859-863
17. Altschul, M. Cultural Bias and the UTI/Circumcision Controversy.
The Truth Seeker Jul/Aug 1989, 43-45.
18. Kayaba H. Analysis of shape and retractability of the prepuce
in 603 Japanese boys. Journal of Urology (Nov 1996), 156(5):1813-1815
19. Taylor JR, Lockwood AP, Taylor AJ; The prepuce: specialized
mucosa of the penis and its loss to circumcision. British Journal
of Urology (Feb 1996), 77, 291-295
20. de Vincenzi I, Mertens T. Male circumcision: a role in HIV
prevention? AIDS 1994, 8(2), 153-160.
21. Cansever G. Psychological effects of circumcision. Brit J Med
Psychol (1965), 38, p 321.
22. Laumann E. Circumcision in the United States: Prevalence,
Prophylactic Effects, and Sexual Practice. JAMA 277 No. 13, 1052-1057,
April 2, 1997.
23. Taddio A, Koren G et al. Effect of neonatal circumcision
on pain response during subsequent routine vaccination.
Lancet, Vol. 349: Pages 599-603 (March 1, 1997)
24. Birley HDL et al. Clinical features and management of recurrent
balanitis; Association with atopy and genital washing. Genitourinary
Medicine 1993; 69: 400-403.


The information in this FAQ is not meant to replace the care and advice
of your pediatrician.

Revision: 5.13 $, $Date: 98/02/10

--
Geoffrey T. Falk <gtf(@)cirp.org>      http://www.cirp.org/~gtf/

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