THE CIRCUMCISION REFERENCE LIBRARY


SEXUALLY TRANSMITTED INFECTIONS, Volume 79: Pages 427-428,
November 2003.



Issues associated with the introduction of circumcision
into a non-circumcising society

A team lead by Kebaabetswe propose the introduction of infant circumcision in Botswana, based on:

There are several medical, psychological, sexual, social, ethical, and legal problems with this proposal.

Medical effects
Male neonatal circumcision is not an innocuous procedure. There are many complications ranging from trivial to life threatening. Complications generally include bleeding, infection, and surgical accident, including penile necrosis and penile amputations.2 Bleeding or infection can progress to death.3 4 It is difficult to control complications with mass circumcisions.5 Circumcision excises significant amounts of nerve bearing penile skin and mucosa, especially the ridged band structure near the mucocutaneous boundary.6 The protective effects of circumcision against HIV remain controversial.7 UNAIDS has not accepted circumcision as a useful public health measure.

In neighbouring South Africa, many children are infected with HIV.8 This is attributed to unsafe health care.

Circumcision creates an open wound through which infection may proceed.9 It is not clear that safe aseptic circumcisions can be delivered in Botswana. It is possible that mass circumcision may worsen the epidemic.

Psychological effects
Psychological manifestations of circumcision have been an area of study at Bond University.

Neonatal circumcision is an intensely painful, traumatic, and stressful operation.10 General anaesthesia is unsafe in the new-born. Available methods of anaesthesia are only partially effective.10 Circumcised infants show hypersensitivity to pain suggestive of post-traumatic stress disorder (PTSD).11 Our study of the incidence of PTSD in the Philippines found extensive PTSD in circumcised boys.12 PTSD secondary to neonatal circumcision has been documented in adult males.13 Victims of trauma tend to re-enact their trauma either on themselves or others in a cycle of violence.14 Circumcised males may rely on psychological defence mechanisms such as rationalisation and denial, and strongly avoid thoughts, feelings, or conversations about circumcision.15

There are additional concerns. The state of the phallus is closely related to a man’s sense of wellbeing.16 Men who were circumcised neonatally may feel unhappy about being circumcised, experience significant anger, sadness, feeling incomplete, cheated, hurt, concerned, frustrated, abnormal, and vio-lated. In addition, circumcised men may suffer from resultant low self esteem,16 which frequently can result in a host of disordered behaviours.

Circumcision may be difficult to eradicate from a society once it is introduced. In addition, to the re-enactment described above,16 Goldman reports that circumcised men tend to defend the practice.16 Circumcised doctors tend to develop intellectual arguments to support genital cutting.17 Fathers who are circumcised may adamantly insist on a son’s circumcision in an emotional defence against their own painful feelings of grief for a lost body part and reduced sexual function.18 Kebaabetswe et al (p 217) reported that, ‘‘Being circumcised was the only significant predictor for a man who would definitely or probably circumcise a male child.’’

Sexual effects
As noted above, circumcision excises large amounts of skin and mucosa from the penis. The removal of the prepuce tightens the remaining skin and makes it relatively immobile. Since stimulation of the sex nerves normally occurs by movement of the mobile skin, this further desensitises the penis,17 perhaps even more than the removal of the ridged band of erogenous nerves noted by Taylor.6 Excision of sexual nerve endings necessarily reduces sensory input. A decrease in sensation may therefore decrease the sexual response.19 20

Male circumcision also may adversely affect female sexual response. A survey of women found that they were markedly less likely to have an orgasm with a circumcised partner.21

Social effects
There has been little study of social problems that may occur when entire cohorts of males are circumcised and consequently most of the men in a society bear physical and psychological wounds associated with circumcision. We might expect more dependence on alcohol to relieve the symptoms of PTSD. Low self esteem may generate a feeling of shame. Shame may generate problems with relationship dissatisfaction, poorer health, depression, drug use, and loneliness. In-creased sexual incompatibility and marital problems in circumcised societies might be expected as a result of reduced penile sensory input, increased sexual dysfunction, PTSD, and low self esteem among circumcised men.22 Increased antisocial behaviour may also be expected. Thus, we might expect to see higher levels of domestic violence, rape, child sexual abuse, suicide, and theft.22

Human rights
The fight against HIV-AIDS requires the careful protection of human rights.23 Among these human rights one finds the rights to security of the person and protection from degrading treatment. The unnecessary excision of normal human tissue6 from unconsenting minor children is an obvious violation of the security of the person.

Through amputation of erogenous tissue, circumcision necessarily diminishes sexual sensation and function as described above and may constitute degrading treatment.

Ethics
Doctors have a duty of care to behave in an ethical fashion. Among other requirements, they are expected to respect the human rights of their child patients.24 Circumcision has been shown to be a violation of the child’s human rights and, clearly, many ethical doctors are unwilling to carry out destructive circumcisions on normal, healthy boys. The British Medical Association recognises the right to conscientious objection to the performance of circumcision.24

Law
Male circumcision is not unlawful, but valid consent must be obtained. This may be a problem in the case of circumcision per-formed on unconsenting minors, in the absence of any medical indication. Cases involving the right of parents to consent to the non-therapeutic surgical ster-ilisation of a child have been heard in several nations.25 26 The cases agree that, in the absence of any medical indication, parents are not empowered to consent to the non-therapeutic, irreversible, surgical alteration of their child’s genitals. In the absence of a valid consent, a circumcision may constitute an assault.27

Conclusion
The value of male circumcision in preventing HIV infection remains unclear. Non-sterile circumcisions may increase the risk. The proposal by Kebaabetswe and colleagues for the introduction of circumcision into Botswana is seriously flawed, and is irresponsible in failing to place the emphasis on safe sex practices. As described here, there are many medical, sexual, psychological, social, human rights, ethical, and legal aspects that must be considered. Reliance on circumcision to prevent HIV transmission is wishful fantasy, and can only result in a calamitous worsening of the HIV-AIDS epidemic.

Once started, circumcision tends to persist even when the need is over. Circumcision was introduced more than 100 years ago in Western nations on the grounds than it would prevent masturbation, which would prevent mental and emotional illness. That, of course, is no longer believed, but the practice of circumcision persists and has proved difficult to eradicate although progress is being made. The incidence of circumcision is declining in Western nations. The Department of Health of the Philippines is trying to discourage circumcision (called ‘‘tule’’) in that nation where it has persisted.28 The practice of neonatal circumcision in certain Western countries such as the United States does not constitute a valid reason for introducing neonatal circumcision in Botswana.

Extreme care must be taken in a decision to introduce circumcision into a society.

G J Boyle
Bond University, Gold Coast, Qld 4229, Australia;
gregb@bond.edu.au

Accepted for publication 25 June 2003

References
  1. Kebaabetswe P, Lockman S, Mogwe S, et al. Male circumcision: an acceptable strategy for HIV prevention in Botswana. Sex Transm Infect 2003;79:214–19.
  2. Williams N, Kapila L. Complications of Circumcision. Br J Surg 1993;80:1231–6.
  3. Scurlock JM, Pemberton PJ. Neonatal meningitis and circumcision. Med J Aust 1977;1:332–4.
  4. Proctor P. Totally unexpected death of baby probed. The Province. Thursday, 29 August 2002. Vancouver: British Columbia.
  5. Ozdemir E. Significantly increased complication risks with mass circumcisions. Br J Urol 1997;80:136–9.
  6. Taylor JR, Lockwood AP, Taylor AJ. The prepuce: specialized mucosa of the penis and its loss to circumcision. Br J Urol 1996;77:291–5.
  7. Van Howe RS, Cold C, Storms MR. Some science would not have gone amiss. BMJ 2000;321:1467.
  8. Brody S, Gisselquist D, Potterat JJ, et al. Evidence of iatrogenic HIV transmission in children in South Africa. Br J Obstet Gynaecol 2003;110:450–2.
  9. Committee on Fetus and Newborn. Standards and recommendations for hospital care of newborn infants. 6th ed. Evanston, IL: American Academy of Pediatrics, 1977:121.
  10. Lander J, Brady-Freyer B, Metcalfe JB, et al. Comparison of ring block, dorsal penile nerve block, and topical anesthesia for neonatal circumcision. JAMA 1997;278:2158–62.
  11. Taddio A, Katz J, Ilersich AL, et al. Effect of neonatal circumcision on pain response during subsequent routine vaccination. Lancet 1997;349:599–603.
  12. Ramos S, Boyle GJ. Ritual and medical circumcision among Filipino boys: evidence of post-traumatic stress disorder. In: Denniston GC, Hodges FM, Milos MF, eds. Understanding circumcision: a multi-disciplinary approach to a multi-dimensional problem. New York: Kluwer/Plenum, 2001.
  13. Rhinehart J. Neonatal circumcision reconsidered. Trans Analysis J 1999;29:215–21.
  14. Van der Kolk BA. The compulsion to repeat the trauma: re-enactment, revictimization, and masochism. Psychiatr Clin N Am 1989;12:389–411.
  15. 309.81 Posttraumatic Stress Disorder. In: Diagnostic and statistical manual of mental disorders. 4th ed. Washington: American Psychiatric Association, 1994:424–9.
  16. Goldman R. The psychological impact of circumcision. BJU Int 1999;83(Suppl 1):93–103.
  17. Gemmell T, Boyle GJ. Neonatal circumcision its long-term sexual effects. In: Denniston GC, Hodges FM, Milos MF, eds. Understanding circumcision: a multi-disciplinary approach to a multi-dimensional problem. New York: Kluwer Academic/Plenum, 2001.
  18. Boyle GJ, Goldman R, Svoboda JS, et al. Male circumcision: pain, trauma and psychosexual sequelae. J Health Psychol 2002;7:329–43.
  19. Winkelmann RK. The erogenous zones: their nerve supply and significance. Proc Staff Meetings Mayo Clinic 1959;34:39–47.
  20. Halata Z, Spaethe A. Sensory innervation of the human penis. Adv Exp Med Biol 1997;424:265–6.
  21. O’Hara K, O’Hara J. The effect of male circumcision on the sexual enjoyment of the female partner. BJU Int 1999;83(Suppl 1):79–84.
  22. Goldman R. Circumcision: the hidden trauma. Boston: Vanguard Publications, 1997:139–75.
  23. United Nations High Commissioner for Human Rights. HIV/AIDS and human rights. Geneva: Office of the United Nations High Commissioner for Human Rights, 2002;(available at www.unhchr.ch/hiv/index1.htm.... approach).
  24. Committee on Medical Ethics. The law and ethics of male circumcision—guidance for doctors. London: BMA, 2003;(available at www.bma.org.uk/ap.nsf/Content/ malecircumcision2003)).
  25. E (Mrs) v Eve, 2 SCR 388 (1986), Supreme Court of Canada.
  26. Secretary, Department of Health and Community Services v JWB and SMB. Marion’s Case 1992:175, CLR 218 F.C 92/010, High Court of Australia.
  27. Boyle GJ, Svoboda JS, Price CP, et al. Circumcision of healthy boys: criminal assault? J Law Med 2000:301–10.
  28. Ramos GAS. Circumcision: the uncut version. Healthbeat (Manilla) 2003;(available at www.doh.gov.ph/mmc/issue01/tule.htm).



Citation:
(File revised 11 December 2006)

http://www.cirp.org/library/disease/HIV/boyle-sti/