Introduction

Circumcision, in the simplest terms, is “… the removal of the prepuce of a male.” Beyond this basic definition nearly every aspect of circumcision from its origin to its indications, and with whom the responsibility for consent for this operation truly lays, contains some aspect of controversy.

Most newborns in this country are circumcised and there is little disagreement about the technical aspects of this common procedure. There have been volumes written on the potential harms and benefits of circumcision. The American Academy of Pediatrics, to whom many look to for guidance in the treatment of children, have traditionally taken a noncommittal stance on this matter. In the modern political environment in the United States, the newest controversies surrounding circumcision exist in the legal and socioeconomic arenas.

Although sober proponents and detractors of circumcision agree that there is no overwhelming medical evidence to support either side, there is considerable disagreement regarding parents consenting to a nonemergency prophylactic procedure in their minor children. Also, at a time when the cost of health care has become a national issue, many question the government funding for these procedures because there is no overwhelming proof that they are beneficial, necessary, or the only method to achieve the desired goals.

Although there are accepted reasons for circumcision in adults, in the United States, most circumcisions are done on neonates, which is the most discussed and controversial procedure. This article examines neonatal circumcision and the difficult problems surrounding this seemingly simple procedure.

History

Adequate knowledge of all aspects of the procedure is essential for the health care providers who advise parents about their child’s potential circumcision so they can provide comprehensive information to help with this important decision. Circumcision is one of the oldest and one of the most commonly performed operations, even in contemporary medicine. The origin of this procedure dates back millennia and there is some controversy, along with a fascination, as to where and how it actually began.

Although most are familiar with the Jewish and Muslim traditions, circumcision is practiced in many societies from all over the globe. Throughout history, men in societies in Africa, Australia, the Americas, and other parts of the world have been circumcised with no connection to a Muslim or Jewish faith. Much research has gone into the origins of these rituals and how they evolved, but in most cases no written history can pinpoint the origin or reason for these often elaborate rituals.

There are some historical records of circumcision. The first recorded history of circumcision is from ancient Egypt, where wall paintings in Egyptian tombs depict the operation. Also, studies of mummies from nearly 4000 years ago show that they were circumcised. Researchers have surmised that circumcisions may have been performed to help break a young child’s bond with his mother or, in older boys, to initiate the young men fully into the tribe. Circumcision has been used as a less lethal and morbid way for oppressors to mark and humiliate enslaved men. Also, from antiquity to the nineteenth century, circumcision was thought of as a way to stanch the emerging sexual desires of young men. The existence of so many rites in so many places proves that circumcision has no single origin.

The Jewish tradition of circumcision is the most familiar, iconic, and well documented. Although it is hypothesized that the practice may have originated with the mutilation of Jewish slaves to demonstrate the hegemony of their masters, the tradition begins with Abraham in the Old Testament (Genesis 17:23). Within Judaism, there has always been some minor controversy as to the necessity of circumcision; however, more recently, there have been external forces attempting to limit the Jewish practice. For example, in San Francisco, there was a resolution entertained to ban circumcision, even for religious reasons, within the city limits.

Muslims, too, have a long tradition of circumcision also dating from the same covenant between God and Abraham. Muhammad, the Muslim prophet, was circumcised. Unlike the Jewish tradition, which requires circumcision for inclusion in the faith, circumcision is not necessary to be a Muslim because it is never mentioned in the Qur’an. Although circumcision is considered a strong tradition ( sunnah) for men, circumcision in women, practiced by Muslims in some parts of the world, is considered less of a tradition ( makrumah ) in the Muslim faith but has engendered great concern in the West. The United States government enacted The Female Genital Mutilation act to criminalize the practice.

For Christians, who make up the majority of Americans, circumcision holds no particular religious significance. Christians were excused from the circumcision covenant in many New Testament verses; Romans (2: 28–29) and Galatians (5:6) among them. Despite this exclusion, more than 1.2 million circumcisions were performed in the United States in 2005, indicating that religious tradition is not the biggest driver in a family’s decision.

Beyond the religious history of circumcision, there is a transition, mostly in the late nineteenth and early twentieth century, of this religious practice into a medical procedure. The first serious medical discussions of circumcision were directed toward phimosis and other foreskin problems associated with sexually transmitted diseases. Medicine was a fledgling specialty at this time and medical knowledge was rapidly expanding, although not always in beneficial directions. In America, Dr Lewis Sayer, a nineteenth century orthopedic surgeon, became a strong champion of circumcision after he used either amputation or manipulation of the foreskin to cure young male patients with paralysis. Dr Sayer was an influential physician and his support of circumcision encouraged others to expand the indications for the procedure. On both sides of the Atlantic, circumcision soon became a treatment of impotence, masturbation, bedwetting, night terrors, and even homosexuality.

As medical knowledge advanced, so did surgical technique. Beyond better techniques, 2 developments in the late nineteenth century made newborn circumcision possible. First, better anesthesia and analgesia made procedures on younger patients safer. Second, the acceptance of germ theory prompted physicians to suspect the moist environment under the foreskin as a breeding ground for future pathologic conditions. If the foreskin caused significant problems in adults, the reasoning went, then earlier circumcision would prevent those problems all together. Modern advocates of circumcision continue to use this notion, the prevention of further problems, as their primary argument, although they wish to prevent different pathologies than prior proponents. The central controversy surrounding circumcision is the question as to whether this prevention is medically, financially, or morally justified.

History

Adequate knowledge of all aspects of the procedure is essential for the health care providers who advise parents about their child’s potential circumcision so they can provide comprehensive information to help with this important decision. Circumcision is one of the oldest and one of the most commonly performed operations, even in contemporary medicine. The origin of this procedure dates back millennia and there is some controversy, along with a fascination, as to where and how it actually began.

Although most are familiar with the Jewish and Muslim traditions, circumcision is practiced in many societies from all over the globe. Throughout history, men in societies in Africa, Australia, the Americas, and other parts of the world have been circumcised with no connection to a Muslim or Jewish faith. Much research has gone into the origins of these rituals and how they evolved, but in most cases no written history can pinpoint the origin or reason for these often elaborate rituals.

There are some historical records of circumcision. The first recorded history of circumcision is from ancient Egypt, where wall paintings in Egyptian tombs depict the operation. Also, studies of mummies from nearly 4000 years ago show that they were circumcised. Researchers have surmised that circumcisions may have been performed to help break a young child’s bond with his mother or, in older boys, to initiate the young men fully into the tribe. Circumcision has been used as a less lethal and morbid way for oppressors to mark and humiliate enslaved men. Also, from antiquity to the nineteenth century, circumcision was thought of as a way to stanch the emerging sexual desires of young men. The existence of so many rites in so many places proves that circumcision has no single origin.

The Jewish tradition of circumcision is the most familiar, iconic, and well documented. Although it is hypothesized that the practice may have originated with the mutilation of Jewish slaves to demonstrate the hegemony of their masters, the tradition begins with Abraham in the Old Testament (Genesis 17:23). Within Judaism, there has always been some minor controversy as to the necessity of circumcision; however, more recently, there have been external forces attempting to limit the Jewish practice. For example, in San Francisco, there was a resolution entertained to ban circumcision, even for religious reasons, within the city limits.

Muslims, too, have a long tradition of circumcision also dating from the same covenant between God and Abraham. Muhammad, the Muslim prophet, was circumcised. Unlike the Jewish tradition, which requires circumcision for inclusion in the faith, circumcision is not necessary to be a Muslim because it is never mentioned in the Qur’an. Although circumcision is considered a strong tradition ( sunnah) for men, circumcision in women, practiced by Muslims in some parts of the world, is considered less of a tradition ( makrumah ) in the Muslim faith but has engendered great concern in the West. The United States government enacted The Female Genital Mutilation act to criminalize the practice.

For Christians, who make up the majority of Americans, circumcision holds no particular religious significance. Christians were excused from the circumcision covenant in many New Testament verses; Romans (2: 28–29) and Galatians (5:6) among them. Despite this exclusion, more than 1.2 million circumcisions were performed in the United States in 2005, indicating that religious tradition is not the biggest driver in a family’s decision.

Beyond the religious history of circumcision, there is a transition, mostly in the late nineteenth and early twentieth century, of this religious practice into a medical procedure. The first serious medical discussions of circumcision were directed toward phimosis and other foreskin problems associated with sexually transmitted diseases. Medicine was a fledgling specialty at this time and medical knowledge was rapidly expanding, although not always in beneficial directions. In America, Dr Lewis Sayer, a nineteenth century orthopedic surgeon, became a strong champion of circumcision after he used either amputation or manipulation of the foreskin to cure young male patients with paralysis. Dr Sayer was an influential physician and his support of circumcision encouraged others to expand the indications for the procedure. On both sides of the Atlantic, circumcision soon became a treatment of impotence, masturbation, bedwetting, night terrors, and even homosexuality.

As medical knowledge advanced, so did surgical technique. Beyond better techniques, 2 developments in the late nineteenth century made newborn circumcision possible. First, better anesthesia and analgesia made procedures on younger patients safer. Second, the acceptance of germ theory prompted physicians to suspect the moist environment under the foreskin as a breeding ground for future pathologic conditions. If the foreskin caused significant problems in adults, the reasoning went, then earlier circumcision would prevent those problems all together. Modern advocates of circumcision continue to use this notion, the prevention of further problems, as their primary argument, although they wish to prevent different pathologies than prior proponents. The central controversy surrounding circumcision is the question as to whether this prevention is medically, financially, or morally justified.

Indications

Patients with true phimosis, balanitis, noniatrogenic paraphimosis, and localized pathologic conditions of the foreskin (warts for example) are accepted as candidates for circumcision, and it is also accepted that these conditions are not present in the newborn. Rickwood says a generous estimate would be that less than 2.5% of newborns would require circumcision based on these criteria. Newborn circumcision is motivated by the prevention of these problems during a period when the operation is purportedly cheaper, safer, and easier. The counter-argument from a medical standpoint is that operating on many healthy boys to relieve potential problems is not preferable to operating on the few boys who might actually develop those problems when they are adults and have demonstrable improvement from surgery.

Phimosis and urinary tract infection

Phimosis is a pathologic condition in which the patient’s foreskin is not retractable. This condition is painful and can cause the foreskin to balloon during urination, hurt during erection, and lead to urinary tract infection (UTI). In adults, this condition is effectively treated with circumcision. Men are born with a physiologic phimosis in that, in most, the foreskin does not easily retract at birth. This condition is usually asymptomatic and resolves as the boy ages, and most boys by puberty will have a retractable foreskin. If the foreskin does become symptomatic, boys are candidates for circumcision. Topical steroids have also been used in the treatment of pathologic phimosis with success in most patients.

Boys with foreskin, whether or not true phimosis is present, have an increased incidence of UTI, especially in the first months of life. Wiswell followed up a large number of boys born at military hospitals and showed a dramatic difference in the rate of infection between boys who were circumcised and uncircumcised and in the morbidity and mortality between the groups. Wiswell found that the circumcised boys had few complications from the removal of their foreskin, whereas the uncircumcised group had UTI’s, hospitalizations, as well as 2 deaths and concluded that routine circumcision seemed justified and medically prudent. More recently, Spach and colleagues showed that a foreskin may predispose young adults to infection.

Opponents of this approach, correctly point out that most problems Dr Wiswell found were easily treated with antibiotics that death was rare, and that 98 boys would have to undergo circumcision to prevent just 2 urinary infections. They advocate treating only the boys who have demonstrable foreskin-related pathologic conditions.