Male Neonatal Circumcision: Ritual or Public-Health Imperative

A sea of change has occurred in the way routine medical procedures are evaluated. The issues surrounding neonatal circumcision bring many of these into focus.

The place of circumcision as "the oldest and most widespread surgical procedure" (Speert 1953) was initially obtained by its inextricable link to religious ritual and cultural custom. This is still a legitimate role for circumcision.

The medical evidence for circumcision as a positive component of preventative care for men is more recent. Penile cancer appears to be a disease of uncircumcised males. While all other factors—such as sexual activity, HIV infection, and smoking—may increase the risk, the incidence of penile cancer in males circumcised at birth is low compared to uncircumcised males (Maden et al. 1993). However, cancer of the penis is a rare disease with annual rates of 0.9 to 1.0%/100,000 men in the United States (American Academy of Pediatrics 1999).¹

Evidence regarding the relationship of circumcision to sexually transmitted diseases (STDs) in general, specifically HIV, is of greater concern. Uncircumcised status appears to be an independent risk factor for HIV infection, according to a review by Moses et al. (1994) of 30 studies, both prospective and cross-sectional. The increased risk ranged from 1.5% to 8.4%. While behavioral factors, such as the number of sexual partners, might be more important risk factors for HIV acquisition, patterns of sexual behavior are more difficult to change. The role of circumcision is not to be underestimated.

Rates of female acquisition of cervical cancer and STDs in populations of uncircumcised versus circumcised males are now attributed to social issues such as the number of sexual partners and the importance of monogamy (Barrasso et al. 1987). If the HIV data is confirmed, however, circumcision might again become a relevant issue in the care of sexually active populations.

The seminal issue of inflicting pain in a newborn is important. The technique of dorsal penile nerve block introduced in 1978 appears to be effective (Arnett, Jones, and Horger 1990). Widespread use seems indicated as a way of reducing pain and physiologic stress during the procedure. Since most nonritualistic circumcisions are performed by obstetrical house staff, instituting a new protocol would quickly initiate the next resident group on this essential component. Years of practice and academic teaching have taught practitioners of male circumcision that it is often duration and associated immobilization of the infant that truly disturbs him during circumcision. The actual cutting of the foreskin with a surgical scalpel produces minimal or no infant response. It is a misconception that amputating the foreskin causes pain.

With regard to different standards for males and females: to equate female circumcision with male circumcision under any guise is ludicrous. The ultimate outcome and purpose of each is quite different. Male circumcision—whether religious, cultural, or cosmetic in purpose—is performed with no intent to inhibit or change sexual or psychological function. Indeed, while there has been commentary, most reports indicate no change in sensation, stimulation, or function. Female circumcision has a different purpose and effect; it is meant to decrease sexual enjoyment and pleasure, ergo the name it has been given in the West: Female Genital Mutilation (FGM). In addition, FGM frequently results in severe vaginal scarring, pain, and dysfunction with vaginal delivery as well as vaginal intercourse. In fact, cesarean section for delivery of a baby is often required as a result of FGM. The two practices are not comparable morally or physically as currently performed, as Slosar and O'Brien (2003) point out. It is of interest that in the Jewish tradition an adopted child, even if previously circumcised, must have a drop of penile blood drawn to complete the ritual conversation (Gold 1988). A similar approach to female circumcision—such as the surgical nictation of the labia suggested by Davis (2003)—seems entirely appropriate (Coleman 1998).

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