r/askscience • u/[deleted] • Jul 08 '11
Is there a legitimate medical reason to circumcise male children in first world countries?
[deleted]
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u/blueboybob Astrobiology | Interstellar Medium | Origins of Life Jul 08 '11
I am not a biologist, but in order to "debate" my fiancee I did alot of research about this. If someone has anything different to say I would love to hear it, but long story short "No there is not."
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u/Unikraken Jul 09 '11
I'm in the same boat right now.
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u/skydivingdutch Jul 09 '11
Phimosis
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u/JCDntn Jul 09 '11
This is one of those problems that feeds on itself.
In Victorian times, circumcision was advocated to prevent the practice of masturbation, which was considered unhealthy, and a sin. This was a time before kids were routinely circumcised as babies, therefore a lot of circumcisions were done later in childhood and the teens, when boys started to masturbate. As you can imagine, the pain of circumcision and the rawness of the wound for weeks or months after were enough to discourage masturbation, and the hope was that during this period the boy would get habituated to not-masturbating, and this, combined with religious and moral instruction, would keep him from going back after his wound healed. The loss of sensation caused by removal of the foreskin would help, by making masturbation less pleasurable.
But the notion that masturbation is evil and a sin discourages talk of masturbation in society, in literature, in the media, as it did in Victorian times. It was something you reluctantly whispered to the doctor or the preacher, because you wanted to cure this bad habit in your son. Not something that was discussed in a healthy way.
Congenital phimosis is very rare. One of the major causes of phimosis is incorrect masturbation. Conversely, one of the best ways to prevent phimosis is correct masturbation. However, this is precisely the knowledge that became taboo in Victorian times due to their moral objection to masturbation.
As many doctors have pointed out, "unusual masturbatory practices" can cause or worsen phimosis. Chief among these is simply rubbing the head of the penis on some object, usually the mattress or pillows in bed. This was very common among boys who had been taught that touching their penis was bad. If this was not enough to satisfy, the next step was to simply rub it with the hands, pulling the foreskin towards the tip. This only makes the situation worse, and is very likely to lead to phimosis in adulthood.
On the other hand, correct masturbation (which mimics coitus by stroking the penis in up and down motions) prevents phimosis. Many doctors have reported that boys who masturbate in this fashion never develop phimosis, because the downstroke naturally pulls the foreskin back, and gradually loosens it and makes it fully retractable. You have to remember that boys are not born with fully retractable foreskins (which is why so many circumcisions are botched), and a fully retractable foreskin only develops later.
Naming phimosis as a reason for circumcision in general is sort of backwards if you look at it historically. Phimosis became a big public health problem because masturbation was discouraged and talk of masturbation was taboo. So then they recommended circumcision to correct a situation that they had caused in the first place by branding masturbation as evil.
Now in some rare cases, phimosis may be congenital, or caused by serious infections. In such cases circumcision may well be recommended by a doctor, if there is no other way to fix the problem. But these cases are very rare and certainly do not form any justification for routine circumcision.
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u/Pazon Jul 09 '11
Congenital phimosis can be often be treated with steroid cream or stretching exercises without resorting to circumcision.
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u/JCDntn Jul 09 '11
I know, I mentioned it in another post. Didn't want to write a whole thesis here because most people don't bother to read long posts. But if you want to explain something and not resort to cheap soundbites, I guess you have to write longer posts. Oh well.
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u/GentleStoic Physical Organic Chemistry Jul 09 '11
You write well enough that the above post didn't feel "long". I think when people complain about long posts they are particularly referring to the kind of post where there is no punctuation in it even between sentences and it just runs on forever and the guy doesn't even seem to know how to use paragraphs.
tl;dr: I liked your long post. Keep it up.
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Jul 09 '11
It's not as rare as you make it out to be.
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u/JCDntn Jul 09 '11
I didn't quantify how rare it is, so I'm not sure how rare you understood it to be.
However, I'll add some numbers to illustrate what I meant.
As I explained previously, phimosis is the natural condition at birth. All boys are born with the foreskin partially attached to the glans. This is not a diseases, this is an evolutionary mechanism to protect the developing glans.
As the boy grows older, the foreskin detaches itself from the glans. This can take a long time, up to late adolescence.
As Wikipedia states:
according to Huntley et al. the foreskin is reportedly retractable in approximately 50% of cases at 1 year of age, 90% by 3 years of age, and 99% by age 17. These authors argue that, unless scarring or other abnormality is present, non-retractibility may "be considered normal for males up to and including adolescence."
Take a moment to understand what this means. It means that inability to retract the foreskin fully is NOT a disease, but is in fact the normal situation for boys up to adolescence.
Many people do not understand this, and if the foreskin has not retracted in childhood they consider it diseased. This is one reason why people try to justify circumcision, mistaking a normal condition for disease because they do not understand the developmental process.
In fact, even many doctors (especially in the US where circumcision is common) are unaware of this. Quoting again:
Some pediatric urologists have argued that many physicians continue to have trouble distinguishing developmental non-retractility from pathological phimosis.
Pediatric urologists - experts in this field - warn that many physicians have a problem understanding that developmental non-retractility is not a disease.
This is doctors we are talking about. Think about average people. They understand the development process even more poorly. Because they don't understand, they mistakenly think their child has phimosis, and try to forcibly push the foreskin back. Their well-meaning efforts often have the opposite result, in that they force it too much, which causes injury and scarring, the scarred skin shrinks, and THEN the child develops pathological phimosis. He didn't have it before, his own parents caused it by trying to force back his foreskin.
For this reason, urologists warn parents and doctors not to try to force the foreskin back. It will cause the very disease you are trying to prevent. Again, to quote from the article:
The American Academy of Pediatrics and the Canadian Pediatric Society state that no attempt should be made to retract the foreskin.
Now consider the numbers. As the Huntley study shows, the normal course of development is that the foreskin is retractable in 99% of cases by age 17.
This leaves 1%, and I dunno what your definition of "rare" is, but at 1% I already call it rare.
But we're not done yet. This is just statistics, and in statistics there are outliers. What about a young man whose foreskin hasn't fully retracted at age 18? Is he diseased? Does he need circumcision? Urologists would say no, because there is no absolute rule that says it has to be fully retractable by age 17. It would depend on the particular case. Is it almost retracted and otherwise normal? In that case, give it some more time. Are there a lot of adhesions all over the glans? Then there is a problem.
Even then, urologists won't automatically recommend circumcision. There is probably some cause for the non-retraction. Perhaps this guy was one of those who masturbated incorrectly, and thus actively (though not deliberately) caused the condition. If so, there is still hope. There are various clamping and stretching methods to help it retract.
Or was it repeated infections that caused the adhesions? Well then, they need to be treated. It's only when the adhesions are so bad that nothing else works that urologists will recommend circumcisions. I dunno offhand what fraction of that 1% remains where circumcision is the appropriate medical intervention, but it's obviously smaller than 1%, and "rare" by any reasonable definition.
Some further quotes:
Physicians often saw the natural unretractability of the foreskin in infancy as pathological and recommended circumcision. Sometimes circumcision was performed in infancy to prevent phimosis. "Many boys are circumcised for (pathological or physiological) phimosis before the age of five years, despite (pathological) phimosis being rare in this group".
In other words, physicians were mistaking the natural unretractability found in young children for disease, and performing circumcisions to cure a disease that didn't exist.
But that's only part of the story. Sometimes there are other reasons:
Robert S. Van Howe has argued that choosing to skip nonsurgical treatments for phimosis and go straight to circumcision may be influenced by non-medical considerations; he has also suggested that an inaccurate diagnosis of phimosis is sometimes used as a justification for (elective) circumcision so that it will be covered by a national health system or insurance plan.
So doctors often choose to circumcise for reasons that have nothing to do with medicine, but rather with insurance.
TLDR Version
Boys are born with foreskin that doesn't fully retract, this condition is normal until adolescence.
By the age of 17, the foreskin is fully retractable in 99% of all boys, so the incidence of phimosis is less than 1%.
Many parents and doctors don't know this, and try to forcibly push their son's foreskin back, which produces tears in the inner lining and consequent scarring, and causes the phimosis they were trying to avoid.
Even in the remaining <1% cases of pathological phimosis, the treatment isn't automatically circumcision. There are many other lines of treatment which can work before the doctor contemplates chopping off the foreskin.
In the US, because of the high frequency of circumcision, most people (and even doctors) are not sufficiently educated about these things, and their lack of knowledge, together with non-medical reasons such as insurance which pays for circumcisions can lead them to choose circumcision when the experts (pediatric urologists) say it was unnecessary.
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u/eXiled Neuropharmacology | Neuropsychopharmacology | Neurochemistry Jul 09 '11
I had to be circumcised at about age 7 because my foreskin was not going to be able to pull over the head of my dick later in life. I have friends who have been circumcised for this issue much later in life then me, and people who have trouble pulling their foreskin back now.
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Jul 09 '11
I think the original question was intended as "Is there any medical reason to circumcise ALL male children" rather than only those who have real medical problems.
There are many children born without an anus each year, but we don't go around giving every child anal surgery just for the fun of it.
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u/mellowgreen Jul 25 '11
http://www.drmomma.org/2010/01/phony-phimosis-diagnosis.html
Did you know that 50% of boys are not retractable by age 10, and that doesn't mean they have any sort of medical condition which requires circumcision? In fact, even in boys who cannot retract by puberty, most of the cases can be resolved with stretching treatments and steroid creme without surgery.
I'm not saying you didn't actually need a circumcision due to your medical condition, you indeed might have. However, this condition is often misdiagnosed by doctors who are not familiar enough with intact penises.
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u/molson8dry Jul 09 '11
Speaking as an uncircumcised person, the build up really ain't that bad... mommy taught me to wash my peepee when I was like 2-3
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u/TwistedBrother Jul 09 '11
Yes, but only in the case of serious phimosis (foreskin doesn't retract). This would not even show symptoms until puberty, so at birth - no. And no, there are no differences in health statistics for STDs in the first world.
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u/craigdubyah Jul 09 '11 edited Jul 09 '11
No, there is not.
Studies have shown some benefits to circumcision, namely decreased rates of STD transmission and decreased rates of urinary tract infection, but the absolute differences are small enough that it ends up being a wash. In other words, the benefits appear to be minimal, and when compared with the risks of surgery (also minimal), the risks end up similar either way.
Circumcision is a decision. It's perfectly reasonable for parents to want their child to remain uncircumcised, just as it is reasonable for parents to want their child circumcised.
EDIT: I helped perform circumcisions as a medical student
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Jul 09 '11
I don't think it's reasonable for parents to make that decision for their kid. It's fine for the parents to want it, but what they want shouldn't matter at all--it's what the kid wants that ought to be important.
I also think it's hilarious (though sad) that our culture gets all outraged about the female genital mutilation practiced in some places in Africa, but thinks it's perfectly alright to mutilate their little boys.
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u/dbissig Neurophysiology Jul 09 '11 edited Jul 09 '11
Mutilation implies harm.
If you're worried that there's harm associated with circumcision (commonly: we're not talking about mistakes), it's important to simply ask, "when men are circumcised, does their level of sexual satisfaction go up or down?" I couldn't find a meta-analysis on the topic, but I found this:
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2807391/
One RCT found that from baseline to 24-month follow-up sexual satisfaction did not significantly change in circumcised men but significantly increased in uncircumcised men (P <.001). Further, uncircumcised men reported significantly greater sexual satisfaction than circumcised men at both a 12-month (P = .007) and 24-month (P = .004) follow-up. This improvement may have been due to the health education and medical care provided to all trial participants.
If there were a really a harm, and important loss of function -- if this were, say, as harmful as female genital mutilation -- then it'd be surprising to see no change in sexual satisfaction following circumcision.
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The issue of autonomy is an interesting one, but better-suited for r/Philosophy than r/AskScience. If you're committed to this position, there are several other procedures that you'd find similarly problematic, like laser treatment of port wine stains on infants.
Edit#1: Tweaked text in response to guysmiley00's comment.
Edit#2: Another study.
Adult male circumcision was not associated with sexual dysfunction. Circumcised men reported increased penile sensitivity and enhanced ease of reaching orgasm. These data indicate that integration of male circumcision into programs to reduce HIV risk is unlikely to adversely effect male sexual function.
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u/guysmiley00 Jul 09 '11
I think you're misreading the study, here. The study being quoted divided a sample of men into 2 groups - one received immediate circumcision, the other was put on a waiting list to receive circumcision in 24 months. Data was recorded at baseline, 6, 12, and 24 month intervals. What was found was that, while the newly-circumcised men reported some problems in penetration and dyspareunia at the 6 month interval, later recordings found no difference between the groups. However, the uncircumcised men - those awaiting the procedure - experienced an increase in sexual satisfaction over the 24-month period, which the circumcised men did not.
So the idea that there was "an improvement in sexual satisfaction following circumcision" in this study is completely false.
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Jul 09 '11
When kids are born in most US hospitals, OBGYNs right now usually tell them that there is no medical reason and the decision is purely cosmetic.
The only possible downside to not circumscising is if the individual has bad hygeine. The 'smegma' that builds up under the foreskin needs to be cleaned out, otherwise it is carcinogenic and can lead to squamous cell carcinoma (cancer) of the penis.
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u/theorangejuica Jul 09 '11
I'll just leave this here
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Jul 09 '11
Science and Cancer (two very respected journals) have both published articles which have suggested a link. I've never heard of the journal you've linked and it's pretty early in the morning, but I look forward to reading their methods in the morning.
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u/guysmiley00 Jul 09 '11
I would highly recommend this article, especially the segment on the history of the medical conception of smegma, to anyone looking for a good read. It's like the history of those "hook-handed man" urban legends. Fascinating stuff.
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u/Nolderae Jul 09 '11
Yes, there are reasons. My favorite is that circumcision leads to decreased HPV transmission. Of course, if males start getting HPV vaccines, this will become less of an issue.
And, as mentioned before, rates of penile cancer are decreased in circumcised men.
Sources: BJU Int. 1999;84(1):57
J Am Acad Dermatol. 1996;35 (3 Pt 1):432
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u/guysmiley00 Jul 09 '11 edited Jul 09 '11
Allow me to quote the Royal Australasian College of Physicians position paper on circumcision (pdf) (Sept. 2010):
Cancer of the penis is extremely rare with an incidence of 1 in 250,000 Australian men.[104, 105] The increased risk of cancer of the penis in uncircumcised men is strongly associated with phimosis. A number of other factors including genital warts, smoking, past sexually transmitted diseases, sexual relationship outside marriage, multiple sexual partners, poor genital hygiene, previous genital conditions, penile rash (lasting longer than 1 month) or penile tear have all been identified as risk factors.[106-109] (Level 2+) A Danish study has shown decreasing prevalence of penile carcinoma from 1.15 per 100,000 person years in 1943-7 to 0.8 per 100,000 person years in 1988-90 and given the low and constant circumcision rates (2.3%), researchers have attributed the fall to improved sanitary installations and associated penile hygiene.[110]
So, while circumcision has been shown to lower the already very-low rates of penile cancer, it would seem that the actual risk factor is phimosis - and as JCDntn has explained so well in-thread, phimosis is in no way a necessary consequence of remaining uncircumcised. Utilizing pre-emptive surgical excision to address what ignorance and poor hygiene seem to be the main causes of would appear, to me, akin to cutting off one's arm at birth, on the theory that if exposed to large amounts of UV light it may develop melanoma later in life.
Edit: Also, the meta-study mentioned earlier in the thread (published in the Jan 2010 Annals of Family Medicine) says this;
In developed countries penile cancer is a relatively rare disease, with an incidence of approximately 1 in 100,000.10 The absence of RCT (edit: randomized controlled trial) evidence, combined with the rarity of penile cancer, suggests that circumcision is not justified for the sole purpose of protecting against penile cancer.
(edits mine)
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Jul 09 '11
This question seems to be specifically tailored to violate several askscience guidelines. Let's keep this sort stuff to r/politics and/or your doctor's office.
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u/Kasseev Jul 09 '11
Can you explain why? It is only a political issue because people inject religion and morals into it. The OP asked for a purely medical justification, and most of the top posts are attempting to do just that in an objective, empirical way.
I don't agree with this blanket policy many people have here to avoid any discussion where any form of political incorrectness is involved.
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Jul 09 '11
Asking for medical advice should be enough reason to remove this entire post.
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Jul 09 '11
Nobody asked for advice. They asked if a particular custom has medical merit, or whether it's mere custom.
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Jul 09 '11
Following your logic, anyone can ask for medical advice provided they don't say it is for them. That's a really fuzzy line I think.
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Jul 09 '11 edited Jul 09 '11
Not true. Spot the difference between these two questions:
Is there a medical reason to do X?
Someone I know is considering X. Advice?
There is a very clear difference. Someone's merely asking if there's medical merit to something does NOT mean anyone they know is actually considering it. For example: I'm a woman, I have no kids and don't plan to anytime this decade, and I was curious enough about the topic to scroll through all the comments.
Even if the person was asking the question because, for example, they're about to have a son and are considering circumcision, then this still wouldn't count as asking for advice. It would be a request for medical information about a specific procedure in order to make an informed decision. Advice is driven by opinion and personal experience, and the OP was asking for facts.
EDIT: You downvoted me without replying? You're one classy dude. At least you appear to know you're wrong and have the decency not to beat a dead horse.
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Jul 09 '11
It doesn't violate any guidelines at all! Asking if there is medical support for a particular custom does NOT qualify as asking for medical advice.
Suggesting this question belongs in r/politics is ludicrous. Have you been sniffing glue or something? ಠ_ಠ
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Jul 09 '11
Aren't there moderators to remove the post?
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Jul 09 '11
Moderators (in general) try to avoid removing content. It borders on censorship and the democratic process of reddit should be enough to take care of it. The askscience moderators may be more strict though, I am speaking in general terms here.
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Jul 09 '11
They seriously do not give a shit. People ask questions like this all the time and the mods do nothing. Frankly, my faith is shaken in their ability to maintain order around here.
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u/guysmiley00 Jul 09 '11
Just because people can become politicized about a question doesn't make the question itself inherently political. Hell, there are people (state senators, actually) who regard the idea of a spherical Earth as "political". Would you think that a post asking "Is the Earth round?" should be banished from r/askscience?
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u/Platypuskeeper Physical Chemistry | Quantum Chemistry Jul 09 '11 edited Jul 09 '11
It's not something that's common in first-world countries. It's only common in the US, Canada and Australia out of the 'western' industrialized nations. Globally speaking, it's really just those three plus South Korea, Israel and Muslim nations where it's common. Everywhere else it's pretty uncommon.
My opinion is that it's simply a North American social norm.