Harvard's Highly biased Page on Circumcision

Prestige is no protection against prejudice

Harvard Men's Health Watch
October 2001

It’s one of the oldest surgical procedures, dating back more than 4,000 years to the ancient Egyptians and the biblical Jews. [Articles on circumcision that stress its antiquity are usually biased in its favour.] It’s one of the most common operations in the United States, where it is performed more than 1.2 million times each year. It’s one of the fastest operations, taking just 3–5 minutes from start to finish. [A car crash is quick, too.] But it has also become one of the most controversial procedures, stimulating debate among physicians and sparking emotional arguments between nonmedical advocacy groups [Note the contrast between "debate" among prestigious "physicians" vs "emotional arguments" by lowly "nonmedical advocacy groups". In fact the physicians are not as rational nor the laypeople as irrational as this implies.] on both sides of the question. It’s circumcision, an operation that all parents should understand before deciding if it’s right for their sons.

[Among issues they need to consider are

Anatomical Considerations
The tissues of the penis begin to develop during the second month of fetal life. The urethra develops first, but is soon surrounded by the tissue that becomes the shaft of the penis. The shaft ends in a rounded structure called the glans; the skin of the penis gradually grows forward until the glans is covered by a thin layer of skin, called the foreskin or prepuce. Later in embryonic development, the foreskin separates from the glans beneath it.

In most newborns, the foreskin still adheres tightly to the glans. During the first years of life, however, these tissues continue to separate; by the age of 5, the foreskin can be retracted away from the glans in more than 90% of boys. In adolescents and adults, the foreskin covers the glans when the penis is flaccid, but it retracts when the penis becomes erect, leaving the glans exposed. [...as though the glans were the important part. Clearly, the author of this has no notion of the action or function of the foreskin during sex - or even that it has one.]

Newborn Circumcision: Surgical Technique
[More detailed colour photographs of a neonatal circumcision show that the foreskin is not just "loosened" from the glans, but has to be torn away.]
Surgical Considerations
Circumcision is the surgical removal of the foreskin; afterward, the glans is exposed when the penis is flaccid as well as erect. Today surgeons use a clamp to protect the glans during the operation; doctors generally prefer the Gomco clamp, but many of those who practice ritual Jewish circumcision use the Mogen clamp. In either case, a scalpel is used to remove the foreskin after the protective clamp is in place (see figure below). Although newborn circumcision has been performed without anesthesia for centuries, there is no reason to continue that practice. Effective pain control can be accomplished by injecting a local anesthetic into the penis; an anesthetic cream, EMLA, is also helpful but appears somewhat less effective. A sugar-coated pacifier can also reduce discomfort, as can acetaminophen (Tylenol and other brands); however, these techniques should be used only to supplement anesthetic injections or creams. [This only reduces pain, it does not eliminate it, and only operative, not post-operative pain.] In older boys and adults, circumcision often requires general anesthesia and somewhat more complicated surgical techniques, which include stitching the skin’s edges together. ["Hurry, hurry! Offer ends soon!" Infant circumcision has the great disadvantage that by adulthood the penis will have grown substantially, magnifying all surgical irregularities..]

Female Circumcision
Male circumcision has generated more than enough controversy [no, not nearly enough] on its own, but the debate becomes even more emotional when the question of female circumcision or genital cutting is raised. In fact, the two are entirely different. [As a human rights issue, they are just the same.] Although both originated long ago in cultural and religious traditions, male circumcision has potential medical benefits and is safe when performed properly. In contrast, female circumcision — which can be performed in many ways, some of them quite drastic — has no known medical benefits and many potential complications, ranging from sexual and reproductive dysfunction to urinary problems, bleeding, infections, and even death. [Medical benefits are also claimed for FGM, and male circumcision can also result in death. The complication rate for FGM is mainly because of the unsanitary conditions it is performed under - and when it is not "performed properly". Circumcision would be as risky, FGM as safe, if they were carried out under comparable conditions - but this is no recommendation for either.] Although female circumcision has been outlawed in the United States and many other countries, it is still performed illicitly in some societies.

Cultural and Religious Considerations
The Egyptians were probably the first people to perform circumcisions. The ancient Jews may have learned the practice from them, but the Old Testament ascribes the ritual to a command from God (And ye shall circumcise the flesh of your foreskin; and it shall be a token of the covenant betwixt me and you, Genesis 17). For more than 4,000 years, traditional Jewish circumcisions have been performed on the eighth day of an infant boy’s life by trained practitioners called mohels. Muslims also perform circumcision; although the timing is less strict, the ritual usually occurs early in life. A few groups of Native Americans, Australians, and Africans have also practiced circumcision for cultural or ceremonial purposes [a "few groups" comprising some millions of people, some of whose "circumcision" makes most female genital mutilation look tame by comparison, but this article is trying to play down the "primitive" aspect], but the operation is not common in Asia, northern Europe, and South America. [Nor in Southern Europe, Scandinavia, Central America or the rest of the English-speaking world. See map. ]

Although circumcision began as a religious rite, it became a routine medical practice in the U.S. about 100 years ago, when it was thought to improve hygiene and prevent disease; in some circles, circumcision was even believed to promote sexual morality [by preventing masturbation. This was the main reason for doing it]. By the 1950s, about 90% of American males underwent newborn circumcision. Since then, medical research has questioned its value, and the operation has become less popular. At present, about 60% of American boys are circumcised shortly after birth, but the rate is much lower in Canada and England.

Potential Benefits
Although doctors are still debating the pros and cons, the American Academy of Pediatrics (AAP) has recently issued a position paper that summarizes the benefits and risks of circumcision. The potential benefits fall into several categories.

Urinary tract infections. The most important benefit is a reduced risk of urinary tract infections during infancy. [This "most important benefit" was unknown before 1982 - long after circumcision had become routine.] Early studies reported that uncircumcised male infants were 10–20 times more likely to get urinary tract infections than were circumcised babies; although recent studies found less benefit, they still report that uncircumcised male infants are 3–9 times more likely to develop urinary tract infections. Critics point to the flaws and limitations in various studies, but the AAP Task Force on Circumcision concludes that the protection is real. Still, it’s a small advantage, since urinary tract infections are not common even in uncircumcised male infants, and most respond well to antibiotic therapy. All in all, 7–18 of every 1,000 uncircumcised male infants will develop a urinary tract infection during the first year of life compared with 1–2 of every 1,000 circumcised male infants. [To et al. calculate that 195 babies must be circumcised to prevent one UTI.]

Cancer of the penis. In the U.S., uncircumcised men are about three times more likely to develop cancer of the penis than are circumcised men. It’s a statistical plus for circumcision [or would be if it were true, but the American Cancer Society doesn't think so], but it’s less important than it seems. That’s because cancer of the penis is rare in America, developing annually in fewer than 10 of every one million men [usually in old age]. Good hygiene also appears to reduce the risk of penile cancer.

Disorders of the penis. Phimosis is the inability to retract the foreskin, usually because of inflammation or infection [or because it's the natural configuration of that penis: many men are perfectly happy never to retract their foreskins.]. The condition is usually mild, but it can produce painful erections and other symptoms. Because circumcision removes the foreskin, it prevents phimosis. But good hygiene is also protective, and when the disorder is treated promptly it usually improves rapidly; some men, though, require circumcision as adults to correct unusually severe cases of phimosis. Circumcision also prevents posthitis, inflammation of the foreskin [Duh!], and it appears to reduce the risk of balanitis, inflammation of the glans. Still, these generally mild conditions respond well to simple treatment.

Sexually transmitted diseases (STDs). New studies demonstrate that circumcision reduces a man’s risk of being infected by HIV, the virus that causes AIDS. [No, they seem to show a correlation in different populations, when factors such as religion and sexual practice are neglected.] Unfortunately, though, the protection is far from complete, and circumcision does not provide any protection against other STDs for a man or his partner. [On the contrary, one study indicated it may even increase the risk of the commonest STD, chlamydia.] Safe sexual practices are the only effective way to prevent STDs.

Potential Risks
If the benefits of circumcision have been overstated by its advocates, its risks have also been exaggerated by its critics. Still, there are possible risks. [The risks are not just "possible", but actual.]

Operative complications. All operations carry risks, and circumcision is no exception. In trained hands, however, complications are uncommon, occurring in between 2 and 6 of every 1,000 newborn circumcisions. [Some researchers rate the risk as much higher.] When complications occur, they are usually mild, with temporary bleeding and mild infections leading the list. In very rare cases, however, complications can be severe or even fatal. [As well as thse risks, there are inevitable disadvantages.]

Expense. Although the British National Health Service has stopped covering routine newborn circumcision because it could not document a medical benefit, most American insurers pay for the operation. Even so, circumcisions add $150 million–$270 million to America’s annual medical bill.

Pain. Contrary to some cultural beliefs, infant circumcision is painful. However, [fairly] effective pain relief is available, and there is no evidence to support concerns about lasting psychological damage from the "trauma" of circumcision. [Yet when men complain bitterly about having been circumcised, their concerns are dismissed, they are told to "get over it", "get a life" etc. These men have been traumatised by their circumcisions. This also accounts for "emotional" opposition to circumcision.]

Sexual dysfunction. There is no reliable evidence to support the claim that newborn circumcision increases the risk of sexual problems in adulthood or that it impairs sexual satisfaction in either partner. [This is highly debatable. There is considerable anecdotal evidence. The foreskin was considered the centre of sexual pleasure for centuries - by men who had one. The proponents of the opposite view are virtually all themselves circumcised and have no idea what they are missing. It should be self-evident that an intact penis is better for sex than one with part cut off, and the onus is on the circumcisors to prove that it is not.]

Skin Grafts from Foreskin Cells
Circumcision is an ancient custom, but it has a new, high-tech twist. Scientists have learned that foreskin cells can be cultivated in the lab, where they grow into a skin substitute. Several products have been developed and used in treating damage to the urethra, the tube that carries urine or semen through the penis. Because the tissue is pliable and does not grow hair, it has also been used for burns, diabetic foot ulcers, and chronic leg ulcers. The foreskin tissue is voluntarily donated by parents [Spot the obvious fallacy in that statement. Whose penis is it again?]; because the cells divide and grow in the lab, only tiny amounts are needed [Yet it's constantly dragged in to justify circumcision in general, as if your baby's foreskin is certain to be used to save lives.]. It’s an interesting medical development, but it has added fuel to the controversy over circumcision, as opponents have raised ethical questions about the profits generated by these commercially available skin substitutes. [and the ethics of cutting healthy, erogenous tissue off babies unable to give or withhold their consent, to benefit third parties.]

After studying all the data, the AAP Task Force on Circumcision concluded that "existing scientific evidence demonstrates potential medical benefits of newborn male circumcision; however, these data are not sufficient to recommend routine neonatal [newborn] circumcision." It’s a fair statement. [It's not, but it should be enough to make a responsible medical body recommend that elective cosmetic surgery should not be done on a non-consenting third party.] Although the statistics favor circumcision, the margin of benefit is so small that parents may reasonably choose to forgo the operation. [Forgo, or repudiate with horror.]

It’s an individual choice [And the individual most concerned is...?] with no wrong answer. [So you might as well toss a coin? How can the question "Should I have part of my son's penis cut off?" have no wrong answer?] Religious convictions, cultural attitudes, and personal beliefs are usually the determining factors. [And the person most concerned has not yet formulated any religious convictions, cultural attitudes or personal beliefs.] If parents cannot make a decision based on these factors, they may choose to consider the simple advice that a son should look like his father. [No, they should consider the simple advice, "If it's not broke, don't fix it."] But if parents choose circumcision, they should be sure that the procedure is performed by an experienced individual [Studies of complications have shown no correlation with the experience of the operator], that their son is healthy at the time of the operation, and that modern anesthesia is provided. [...which will only alleviate operative pain, not eliminate either that or post-operative pain]

Circumcision has been controversial since its earliest days, and the controversy is not likely to disappear anytime soon. [It has never been controversial in the many parts of the world where it has never been customary.] Doctors will continue to study the pros and cons, but they have already produced enough information to allow parents to make a calm, rational decision. And the best time to make that decision is before birth, when there is time to consider circumcision with circumspection.

[This article mentions the great (stone-age) antiquity of circumcision four times, but makes no mention of ethics, human rights or why God/evolution provided the baby with a foreskin in the first place. No other non-renewable part of the human body is subject to removal at the whim of a third party. The child is under the protection of his parents for less than a quarter of his life, but circumcision is lifelong. Most of the men in the world are intact and very few choose to have themselves circumcised. Why not leave his body alone (it's completely painless) and let him decide if he wants an integral part of his penis cut off?]

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