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Audience: Those people who are undecided about circumcision Routine neonatal circumcision is the subject of many debates in the United States. The practice has attracted passionate advocates and critics. From a global perspective, most of the world does not practice circumcision; over 80 % of the world's males are intact (not circumcised). Most circumcised men are Muslim or Jewish; the USA is the only country in the world that circumcises most of its male infants for non-religious reasons. This article refers mostly to the American practice, because the USA has the highest rate of non-religious circumcision and the most contentious debate about circumcision. The analysis presented here examines the available medical evidence relating to routine neonatal circumcision in order to weigh its risks, costs, and benefits.
Discussion about the advisability of circumcision in English-speaking countries that practice circumcision typically has focused on long-held beliefs about the health benefits of circumcision. The conflicting conclusions, beliefs and opinions surrounding circumcision, together with the tenacity with which advocates and opponents of circumcision maintain their viewpoints, suggest that deep psychological factors are involved. The strong motivation to circumcise male infants is shown by the fact that the practice continues even though no national medical organization in the world recommends it [ 1 ]. Infant pain and behavioral response to circumcision To understand the long-term effects of circumcision, it is necessary to review the effects on the infant. The question of infant pain is often raised in debates about circumcision. Some physicians believe early work claiming that the newborn nervous system is not sufficiently developed to register or transmit pain impulses [ 1 ].
According to more recent work, this belief is 'the major myth' of physicians regarding infant pain; that babies cannot physically resist and stop the circumcision procedure also makes it easier to dismiss their pain [ 1 ]. Some doctors minimize circumcision pain by calling it "discomfort" or comparing it to the pain of an injection, although these studies have been refuted by empirical studies [ 2 ]. Anatomical, neuro chemical, physiological and behavioral studies confirm that newborn responses to pain are 'similar to but greater than those in adult subjects' [ 2 ]. Infants circumcised with no anesthesia, reflecting the common practice, experience not only great pain, but also an increased risk of choking and difficulty in breathing [ 3 ]. Increases in heart rate of 55 bpm have been recorded at 1. 5 times the baseline rate [ 4 ]. After circumcision, the level of blood cortisol increased by a factor of 3 - 4 times the level before circumcision [ 4 ].
As a surgical procedure, circumcision has been described as 'among the most painful performed in neonatal medicine. ' Using a pacifier during circumcision reduced crying but did not affect the hormonal pain response [ 4 ]. An infant may also go into a state of shock to escape the overwhelming pain. Therefore, while crying may be absent, other body signals show that severe pain is always present during circumcision. There is disagreement among physicians about using anesthesia during circumcision. Before the mid- 1980 s, anesthesia was not used because the medical community denied infant pain. That belief has changed among many physicians, but an anesthetic (local injection, the best option tested) still is not typically administered, because of a lack of familiarity with its use, as well as the belief that in introduces additional risk [ 4 ].
Although there is an indication that the risk is minimal, most physicians who perform circumcisions do not use anesthetics. When an anaesthetic is used, it relieves only some but not all of the pain, and its effect ashen before the postoperative pain does [ 5 ]. Behavioral changes in infants resulting from circumcision are very common, and can interfere with parent-infant bonding and feeding [ 6 ]. The American Academy of Pediatrics Task Force on Circumcision notes increased irritability, varying sleep patterns and changes in infant-maternal interaction after circumcision [ 6 ]. Canadian investigators report that during vaccinations at age 4 - 6 months, circumcised boys had an increased behavioral pain response and cried for significantly longer periods than did intact boys.
The authors believe that 'circumcision may produce long-lasting changes in infant pain behavior' [ 6 ]. That study suggests that circumcision may permanently alter the structure and function of developing neural pathways. The severe pain of circumcision and the changes to infant-maternal interaction observed after circumcision raise the question of the effects on the mother. The typical hospital circumcision is performed out of view of the parents, in a separate room.
However, a few are observed by parents, and many Jewish ritual circumcisions are carried out in the homes of the parents. There are no studies of how these parents respond to observing their son's circumcision. Some parents regret their son's circumcision and report that they wish they had known more about circumcision before they consented to it. Margaret Pollack submitted the following comments in her letter to a magazine: 'My tiny son and I sobbed our hearts out. After everything I'd worked for, carrying and nurturing Joseph in the womb, having him at home against no small odds, keeping him by my side constantly since birth, nursing him whenever he needed closeness and nourishment -- the circumcision was a horrible violation of all I felt we had shared.
I cried for days afterward' [ 6 ]. Other mothers have reported that watching their son's circumcision was the 'the worst day of my life. 's ome mothers clearly remember their son's circumcision after many years; Pollack reported 15 years after the event. 'The screams of my baby remain embedded in my bones and haunt my mind. His cry sounded like he was being butchered' [ 6 ]. Parents may not express strong adverse reactions to a son's circumcision for two possible reasons. First, because the feelings engendered by circumcision are so painful and are not generally supported by the community, they may be suppressed [ 6 ].
Second, as described earlier, if the infant goes into traumatic shock, he does not cry, and parents tend to interpret lack of crying as a sign that circumcision is not painful. Studies investigating circumcision al pain have referred to circumcision as traumatic [ 4 ]. The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) published by the American Psychiatric Association [ 4 ] is helpful in discussing the question of trauma as it relates to circumcision. Its description of a traumatic event includes an event that is beyond human experience, such as assault (sexual or physical), torture, and a threat to one's physical integrity. An assault is a physical attack; torture is severe pain or anguish. It does not necessarily take account of intent or purpose, but focuses on the act itself and the experience of the victim.
From the perspective of the infant, all the elements in the DSM-IV description of traumatic events apply to circumcision; the procedure involves being forcibly restrained, having part of the penis cut off, and experiencing extreme pain. Based on the nature of the experience and considering the extreme physiological and behavioral responses, circumcision traumatizes the infant [ 6 ]. The question of an infant's capacity to experience trauma needs to be emphasized. Wilson, an author with a national reputation for trauma research, supports the idea that trauma can occur 'at any point in the life cycle, from infancy to the waning years of life' [ 7 ]. In addition, the DSM-IV states that traumatic effects 'can occur at any age' [ 6 ]. Clinicians have documented that children are particularly vulnerable to trauma [ 7 ].
Psychic trauma seems to have a permanent effect on children, no matter how young they are when they are traumatized. The possibility of circumcision resulting in traumatic effects on older children can be better explored because of the easier access to memory and the child's ability to talk. Two reports have studied the ritual as practiced without anesthesia on children in Turkey. In the first report, testing subjects 4 - 7 years old shortly before and after the ritual yielded this result: 'Circumcision is perceived by the child as an aggressive attack on his body, which damaged, humiliated and, in some cases totally destroyed him' [ 7 ]. According to this study, circumcision resulted in increased aggressiveness and weakened the ego, causing withdrawl and reduced functioning and adaptation.
Withdrawal is a defensive response that individuals use to protect themselves against further attack. In the second study, children were observed to be 'terribly frightened' during the procedure, and 'each child looked at his penis immediately after the circumcision as if to make sure that all was not cut off' [ 7 ]. One 8 -year-old boy fell 'unconscious' during the cutting and subsequently developed a stuttering problem. A few weeks later, parents being interviewed reported that their children exhibited increased aggressive behavior and experienced nightmares. In the same report, adults who were interviewed and recalled castration anxiety and other serious fears connected with their childhood circumcision, particularly if they had been deceived or forced by parents to undergo the procedure. Freud, who had a strongly critical view of circumcision, believed that it was a 'substitute for castration' [ 7 ].
Castration anxiety resulting from circumcision may be related to the finding that symptoms from personal injury trauma often include fear of repetition of the trauma [ 7 ]. Without published studies, current knowledge of men's feelings about their circumcision is generally based on reports from self-selected men who have contacted the Circumcision Resource Center (CRC) and other circumcision information organizations [ 8 ]. The feelings reported generally include anger, sense of loss, shame, and sense of having been victimized and violated, fear, distrust, grief, and jealousy of intact men. The overwhelming majority of these men were circumcised as newborn infants.
The memory of this event is not in their conscious awareness. Consequently, the connection between present feelings and circumcision may not be clear. However, some men attribute many negative feelings to their circumcision. Based on the responses of men who contacted the CRC, the origin of this attribution is in the impact of discovering one's circumcision as a child. If a child grows in a community that has children who are not circumcised, it is probable that someday the circumcised boy will notice the difference. Under certain circumstances the realization that part of the penis was cut off can have trauma-like consequences, such as recurrent unwelcome thoughts and images.
Attitudes about people, life and the future, may also be affected. Lack of awareness and understanding of circumcision, emotional repression, fear of disclosure, and non-verbal expression help keep circumcision feelings a secret [ 8 ]. Although men may be unaware of the effects of circumcision, the fear that their penis is somehow deficient is reported to be widespread in American culture [ 8 ]. Commercial interests have responded to this fear by advertising various methods of penile enlargement in men's magazines. Male preoccupation with the penis is also reflected in a survey of what men think women find attractive in men. The data showed that men greatly exaggerated the importance of penis size as a physical attribute that attracts women [ 8 ].
The effect of circumcision on this result is now known. Negative feelings about the penis are related to the idea of body image; this includes value judgements about how the body is thought to appear to others, and can have a great impact on how men live their lives are conducted [ 8 ]. In addition, the concepts of self and body image are interconnected and affect personal psychology. A diminished body image can diminish a person's social and sexual life. Those who have a bodily loss fear the judgement of others and the weakening of personal relationships. The feelin...
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