The Circumcision Decision
BY Luz Martin
I’ve been studying the issue of circumcision for over six years and speaking out about it for over three years. Time and time again, I hear phrases like, “it hurts more as an adult,” “babies can’t feel pain,” “he won’t remember it,” and “it’s just extra skin.” Today, I’m going to challenge these statements in the hope that you will consider the immediate trauma and long-term effects that men experience from genital cutting.
First, let’s talk about the development of the foreskin so you can understand what an infant or adult circumcision entails. At birth, the foreskin (prepuce) is fused to the head (glans) with the balano-preputial membrane. This membrane is very similar to that which adheres your nails to your fingertips. Additionally, there’s a “ridged band” at the tip of the foreskin that functions like a sphincter to protect the urinary opening, allowing urine to flow out but nothing to come in. During childhood, the membrane breaks down and the opening stretches by way of manual tugging done by the boy himself. Once the process is complete, the foreskin will be retractable. The average age of complete physiological retraction is 10 but it can take through the end of puberty, or longer, and may never become fully retractable.
During an infant’s circumcision, because the foreskin isn’t yet retractable, the prepuce must be separated from the glans before the amputation can begin. This involves first ripping the foreskin free with a blunt probe. Then, a slit is made to widen the opening so that a bell (either metal or plastic) can be inserted and placed over the glans to protect it from accidental amputation. Then, depending on the method, a clamp is placed or a string is tied and the foreskin is either immediately cut off or the skin is crushed and left to die. (There is a less popular method using the mogen clamp. This clamp is usually used by mohels and does not include a bell to protect the glans). After an infant circumcision, the entire glans is an open wound at the level of a third-degree burn and there is a circumferential scar resulting from the foreskin amputation.
In contrast, an adult circumcision only requires placement of a clamp (as the foreskin has likely already separated from the glans) and the wound is only a scar around the circumference of the penis. A study published in the journal of urology supports these claims that adults suffer less discomfort than younger patients following circumcision (1). Adults also have the benefit of full anesthesia and are able to take narcotic pain relief after the surgery, if necessary. Another benefit of waiting until adulthood is that the penis is fully grown. The surgeon can accurately determine how much tissue to remove and can leave structures, like the highly sensitive frenulum, untouched. Infant circumcisions have the additional risk of removing too much or too little tissue. Too much removed can lead to painful erections and other complications and side effects as an adult. Too little removed puts the infant at risk of developing adhesions (which occur in roughly 30% of circumcised boys) where the remaining foreskin re-adheres to the glans, attempting to recover it, as it had been at birth (2).
For many years, doctors have believed that infants cannot feel pain. In fact, up until recently, doctors were even performing operations like open heart surgery with no anesthesia at all. Many doctors are still performing circumcisions without anesthesia, despite the fact that “appropriate analgesia” is recommended for circumcision by the American Academy of Pediatrics. There have been many studies about anesthesia for circumcision. None of the methods of anesthesia ever studied have ever been shown to fully eliminate pain. All babies who undergo circumcision experience pain and stress. The most effective anesthesia studied is the dorsal penile nerve block (DPNB)(3). A study of infants who received no anesthesia compared to infants who received the DPNB showed no significant difference in blood cortisol levels; (cortisol is produced during times of extreme stress). This indicates that the infants were still experiencing distress even with the most effective form of anesthesia. Another study showed that an injection alone did not raise cortisol (4). Furthermore, use of the DPNB puts babies at risk of deep internal bruising and, in extreme cases, gangrene. Recent studies are indicating that infants actually experience pain more acutely than adults. There are still doctors who will perform circumcision with only a sugar water pacifier to quiet the baby. This method of “anesthesia” does reduce crying and facial grimacing so some believe that it is as effective as anesthesia. Newer studies have shown that this is false and sugar water is not effective in reducing circumcision pain. (5)
There have also been numerous studies on painful experiences in infancy and future effects on the brain. Additional studies in humans have supported the suggestion that tissue injury at a young age may have long-lasting somatosensory sequelae. First, Andrews and Fitzgerald (1999) showed that the indicator of the excitability of the neonatal spinal cord—a mechanically evoked flexion reflex threshold to stimuli applied to the foot and leg—increased with age in normal comparison infants of PCA 28–42 weeks. However, similar infants with a substantial leg injury did not exhibit the normal age-related increase in threshold, even when the noninjured leg was tested. This absent development of normally increasing thresholds contralateral to the injury reflects substantial ‘secondary’ changes in the spinal cord itself and not merely to the injured leg.” (6)
Studies of circumcised infants have shown that infants who are circumcised without anesthesia have higher pain responses to vaccines at 4 and 6 months of age than infants who had at least a topical anesthesia. Both groups of circumcised infants had higher pain scores than infants who were not circumcised at all. (7) Another study took MRI images of an infant’s brain before circumcision. After circumcision, the MRI showed that the brain was permanently changed. “A neurologist who saw the results postulated that the data indicated that circumcision affected most intensely the portions of the victim’s brain associated with reasoning, perception, and emotions. Follow up tests on the infant one day, one week, and one month after the surgery indicated that the child’s brain never returned to its baseline configuration. In other words, the evidence generated by this research indicated that the brain of the circumcised infant was permanently changed by the surgery.”(8)
A study of injury to rat pups indicates that early injury causes more nerves to grow in the area. “Mary Ann Ruda and colleagues simulated surgery on newborn rats by injecting an inflammatory agent into a hind paw. When the rats reached adulthood, they withdrew the test paw from a hot bulb much faster than rats that had been injected with saline as newborns (Science, vol 289, p628). They also had more nerves in the region.”(9)
Doctors and parents have questioned how early memories are formed. It’s often believed that pre-verbal children cannot form long term memories. Some doctors and parents are starting to question this. There is strong evidence to suggest that all experiences are catalogued in the body. Dr. Alexandra Murray Harrison had this to say after attending a conference about early trauma: “What was remarkable about the cases was the inescapable awareness that children under the age of 1 year can “remember” trauma, although they usually at least at first remember it in their bodies instead of in their minds.” (10) Other doctors, like Dr. David B. Chamberlain, have shown that humans can remember their births. (11) Is it such a stretch to believe that an extremely painful experience like circumcision would be remembered?
Many people mistakenly believe that because their infants didn’t cry, they didn’t experience distress. Dr. Berry Brazelton is a pediatrician who developed the newborn assessment. Dr. Brazelton observed that infants have different coping mechanisms, even at birth. Some infants will cry when stressed or startled. Other infants will go to sleep or shut down in the face of stress. (12) Infants who are experiencing pain do not always cry hysterically. Many infants will appear to be in a quiet state. Physiological studies of these infants will show that they are in fact in a state of distress. Additionally, many mothers report that their sons would not readily breastfeed post-op. Other mothers report that their son would not make eye contact immediately following the procedure.
Not only is circumcision painful and traumatic, it also causes permanent damage to the penis and nerves of the lower body. The penilo cavernosus reflex was tested on men. The reflex is present in 92% of intact (uncircumcised) men, 36% of men with foreskin retracted, and 27% of circumcised men. (13) This is also evidence that the glans of the penis is not as sensitive as the foreskin. The foreskin has many important nerves and structures not found anywhere else on the penis. A study using the filament pressure test showed that there are no areas on the circumcised penis that are as sensitive as areas of the foreskin. The glans of circumcised men had significantly higher pressure thresholds than the glans of intact men, showing that much higher pressures were required to obtain a response (less sensitivity). Additionally, the study revealed that there were five areas on an intact penis that were more sensitive than any of the areas on a circumcised penis. (14) Not only does the foreskin provide protection of the glans, it also serves important sexual functions for both partners during intercourse. You can see an example of how the skin moves by rubbing the top of your knuckle. The skin bunches and shifts as the top finger glides back and forth over the bottom finger. Now rub the underside of your finger. The lack of movement on the underside demonstrates the loss of shaft skin mobility that circumcised men have. This can result in pain during intercourse due to increased friction for either partner, especially if the skin is very tight.(15)
I hope that this article has given you something to think about today. I urge you to check out some of the references and links I have provided, and perhaps share what you have learned. You can do further research at drmomma.org or savingsons.org. As you can see, evidence has overwhelmingly shown that babies do experience pain and stress during circumcision. They also experience pain and stress during the time they are healing from this surgery. This experience can cause profound changes in behavior. It also causes damage to the nervous system. As I’ve shown, circumcision of adults is less painful and less risky than the circumcision of infants. Adults also have the benefit of understanding what is happening to them, and giving fully informed consent to having it done.
Whose body–whose choice?
I say it is HIS body and HIS choice.
1. How painful is adult circumcision? A prospective, observational cohort study. http://www.jurology.com/article/S0022-5347%2812%2906003-X/abstract
2. Variabililty in penile appearance and penile findings: a prospective study. http://www.ncbi.nlm.nih.gov/m/pubmed/9393302/
3. Pain relief for neonatal circumcision. http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0012623
4. Neonatal cortisol response to circumcision with anesthesia.http://m.cpj.sagepub.com/content/25/8/412.abstract
5. Oral sucrose as an analgesic drug for procedural pain in newborn infants: a randomised controlled trial
6. Are there long term consequences of pain in newborn or very young infants. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1595204
7. Effect of neonatal circumcision on pain response during subsequent routine vaccination http://www.ncbi.nlm.nih.gov/m/pubmed/9057731
8. MRI studies: The brain permanently altered from infant circumcision http://www.whale.to/a/mri_studies.html
9. Circumcision and pain http://www.circumstitions.com/Pain.html
10. Do babies remember trauma? The psychology and neurobiology of early trauma
12. Understanding the language of children’s behavior: Lessons from the research of Berry Brazelton http://m.huffpost.com/us/entry/1764381
13. Clinical elicitation of the penilo-cavernosus reflex in circumcised men http://www.ncbi.nlm.nih.gov/m/pubmed/21883821
14. Fine-touch pressure thresholds in the adult penis http://www.ncbi.nlm.nih.gov/m/pubmed/17378847