Circumcision

We haven’t had Elliot circumcised yet.  I always assumed that we would, mainly because I am.  But I haven't thought too much about it, and every time I look at his little wiener while changing his diaper it feels strange to think about cutting it.  I realized that I need to examine this question a little more closely, so I did a little early Sunday morning web review. 

The arguments for circumcision are hygeine issues (phimosis is not a fun thing; don't click that link if you're squeamish) and lower rates of STD infection. 

The arguments against circumcision are that it hurts, it reduces sexual pleasure, and simple principle: the foreskin is a normal human body part, why should we cut it off?

"Circumcision is not an ethical medical procedure," said Georganne Chapin, executive director of Intact America, a Tarrytown, N.Y., advocacy group. "You are removing a perfectly normal body part. We don't allow people to do that to their daughters. We should not let them do it to their sons."

On the topic of sexual pleasure, here’s a paragraph from another anti-circumcision website:

One must also consider that the foreskin contains 50% of the surface area of the penis. Each circumcision cuts off what would grow to be 6 inches of tissue, laden with 240 feet of nerves and 1,000 nerve endings Removal of it can only lead to a drastic loss of sensation during sexual activity.

These people seem to be saying that size matters.  If a penis was four times normal size, would the pleasure be four times as much?  The argument seems bogus. To quote the esteemed philosopher Raquel Welch, the brain is the biggest erogenous zone.  And the brain wires itself to the organ its connected to.

But that's just my gut feeling, I could be wrong.  So I looked for some data, and sure enough there's plenty.  Here's a study done a few years ago:

Objectives: Currently no consensus exists about the role of the foreskin or the effect circumcision has on penile sensitivity and overall sexual satisfaction. Our study assesses the effect of circumcision on sexually active men and the relative impact this may have on informed consent prior to surgery.  Materials and Methods: One hundred and fifty men between the ages of 18 and 60 years were identified as being circumcised for benign disease between 1999 and 2002. Patients with erectile dysfunction were excluded from the study. The data was assessed using the abridged, 5-item version of the International Index of Erectile Function (IIEF-5). Questions were also asked about libido, penile sensitivity, premature ejaculation, pain during intercourse and appearance before and after circumcision. Results: Fifty-nine percent of patients (88/150) responded. The total mean IIEF-5 score was 22.41 8 0.94 and 21.13 8 3.17 before and after circumcision, respectively (p = 0.4). Seventy-four percent of patients had no change in their libido levels, 69% noticed less pain during intercourse (p ! 0.05), and 44% of the patients (p = 0.04) and 38% of the partners (p = 0.02) thought the penis appearance improved after circumcision. Penile sensation improved after circumcision in 38% (p = 0.01) but got worse in 18%, with the remainder having no change. Overall satisfaction was 61%. Conclusions: Penile sensitivity had variable outcomes after circumcision. 

That's just one study.  Nine have been done --- three showed more penile sensation, one showed less, and five showed no change.  Here's the creepily comprehensive wikipedia page on the topic of penile sensation after circumcision. Of course, all these studies are done in adults, so it's impossible to know what might be different in an infant.  But

Now, what about infections?  Three large studies, involving almost 10,000 men, showed massive decreases in the number of HIV infections.  Here are the result of the biggest study:

 A total of 3,274 uncircumcised men, aged 18-24 y, were randomized to a control or an intervention group with follow-up visits at months 3, 12, and 21. Male circumcision was offered to the intervention group immediately after randomization and to the control group at the end of the follow-up.  The trial was stopped at the interim analysis, and the mean (interquartile range) follow-up was 18.1 mo (13.0-21.0) when the data were analyzed. There were 20 HIV infections (incidence rate = 0.85 per 100 person-years) in the intervention group [i.e. circumcised] and 49 (2.1 per 100 person-years) in the control group [uncircumcised], corresponding to an RR of 0.40 (95% CI: 0.24%-0.68%; p < 0.001). This RR corresponds to a protection of 60% (95% CI: 32%-76%). When controlling for behavioural factors, including sexual behaviour that increased slightly in the intervention group, condom use, and health-seeking behaviour, the protection was of 61% (95% CI: 34%-77%).

Until just this year, it had been a mystery why circumcision lowered the rate of HIV infection.  Now there's some actual data.  Sampling bacteria from the penises of men before and after circumcision and found that

there are gross changes in the penis's microbiome following circumcision, suggesting that shifts in the bacterial environment could account, in part, for the differences in HIV infection. Families of anaerobic bacteria, which are unable to grow in the presence of oxygen, are abundant before circumcision but nearly disappear after the procedure. The researchers suspect that in uncircumcised men, these bacteria may provoke inflammation in the genitalia, thereby improving the chances that immune cells will be in the vicinity for HIV viruses to infect.

There was an interesting article in New York magazine last year, in which the author examined the pros and cons and decided to circumcise her son.  She notes that

the foreskin is pretty much like the appendix or the wisdom tooth—it is an evolutionary footnote that serves no purpose other than to incubate infections. There’s no single overwhelming health reason to remove it, but there are a lot of smaller health reasons that add up.

Also, there are apparently thousands of men who are very angry about having been circumcised.

After all this reading, I'm pretty much where I started: not deeply committed to circumcision, but still leaning toward it. Then I came across this:

A picture is worth a thousand words....