Critics
According to a comprehensive study, newborn responses to pain are "similar to but greater than those observed in adult subjects" (p. 1326) [2]. Circumcision is overwhelmingly painful and traumatic [3, 4]. Some infants do not cry because they go into traumatic shock from the overwhelming pain of the surgery [5]. No experimental anesthetic has been found to be safe and effective in preventing circumcision pain in infants [3]. Changes in pain response due to newborn circumcision have been demonstrated at six months of age, suggesting lasting neurological effects and a symptom of post-traumatic stress disorder [4].

COMPLICATIONS
Advocates
Circumcision has low risk, less than 1% [6]. Most complications are bleeding and infection.

Critics
The true incidence of complications is unknown [7]. The rate of surgical complications was reported to be from 0.2 to 38 percent [6, 8]. (The higher rate included complications reported during the infants' first year.) Realistic short-term complication rates are between 2-10% [9]. There are over 20 known short-term complications, including bleeding, infection, surgical injury, and in rare cases, death [8]. This does not include complications discovered later in life, problems caused by circumcision but not attributed to circumcision, or unrecognized harm.

INFANT BEHAVIORAL RESPONSE
Advocates
This aspect of circumcision is not discussed by advocates.

Critics
Various studies have found that short-term effects of circumcision include changed sleep patterns, activity level, and mother-infant interaction, more irritability, and disruptions in feeding and bonding [2].

URINARY TRACT INFECTION (UTI)
Advocates
According to a meta-analysis, circumcision reduced the risk of developing UTI in the first year of life by a factor of 12, and the absolute risk of a genitally intact boy developing UTI was approximately 1 in 100 [10].

Critics
The methodology for studies claiming that circumcision reduces the risk of UTI complicates making any conclusion [11]. They do not account for confounding variables such as breastfeeding [12], urine collection method [13], definition of UTI [14], and rooming in [15]. For a rate of 1%, 100 boys would have to be circumcised to prevent one UTI, which might be prevented by breastfeeding or rooming in. A Japanese study of 603 boys who were not circumcised did not find one case of UTI [16]. This further suggests methodological problems with attempts to claim a strong association. UTI is easily treatable with antibiotics [17].

PENILE CANCER
Advocates
Reports of several case series noted a strong association between lack of circumcision and penile cancer [18]. Advocates believe that "invasive penile cancer could be virtually eliminated in the United States by routine newborn circumcision" (p. 621) [19].

Critics
There are no American studies of the incidence of penile cancer and its association with circumcision status. Penile cancer is rare, and the estimated American incidence is about 1 per 100,000 [20]. In other developed countries where circumcision is rare, such as Denmark and Norway, the incidence of penile cancer is lower than the estimated American rate [21, 22]. Penile cancer occurs generally in elderly men [20]. Therefore, a male may make a decision to be circumcised when he is older without losing this claimed benefit.

SEXUALLY TRANSMITTED DISEASES
Advocates
Based on a meta-analysis of published studies, genitally intact men had approximately 3 times the relative risk for HIV infection and increased risk for genital ulcer disease [23]. (Many HIV studies were done in Africa.) A review article concluded that genitally intact men were 2 to 8 times more likely to become infected with HIV [24]. Circumcision reduced the risk of genital ulcer disease, including syphilis and chancroid [23].

Critics
Studies are conflicting for each sexually transmitted disease [25]. Sexually transmitted diseases and circumcision involve behavior, hygiene practices, culture, and religion, and it is impossible to control all the confounding variables that affect sexual behavior and circumcision status. Circumcision may increase the risk of developing gonorrhea and chlamydia. "Based on the studies published to date, recommending routine circumcision as a prophylactic measure to prevent HIV infection in Africa or elsewhere, is scientifically unfounded" (p. 16) [26]. In a study on transmission rates of HIV from infected males to uninfected females and from infected females to uninfected males in Uganda, the authors found that circumcision status was not a significant factor in the risk of transmission [27]. Sexually transmitted diseases obviously cannot be transmitted until an individual engages in sexual activity. Therefore, a male may make a decision to be circumcised when he is older without losing this claimed benefit.

SEXUAL AND PSYCHOLOGICAL EFFECTS
Advocates
In a national survey, circumcised men reported less sexual dysfunction than genitally intact men [28]. Women prefer circumcised sexual partners [29]. Psychological effects are not recognized.

Critics
The difference in reported sexual dysfunction above is not statistically significant [30]. The Williamson study consists of young, Midwestern, 98% white mothers. They live in an area of the country with the highest circumcision rate, and 78% of the group had no experience with genitally intact men.

In a more recent survey, women with longer dual experience preferred anatomically complete men overwhelmingly to circumcised men [31]. Without the foreskin to provide a movable sleeve of skin, intercourse with a circumcised penis resulted in decreased vaginal secretions, more vaginal discomfort, harder and deeper thrusting of the partner, less chance of having an orgasm, less frequent orgasms, less frequent multiple orgasms, and shorter duration of coitus.

Circumcision results in a significant loss [32]. The foreskin is an integral, normal part of the penis. It protects the head of the penis and is comprised of unique zones with several kinds of specialized nerves that are important to optimum sexual sensitivity. Investigators found that circumcision removes about one-half of the erogenous tissue on the penile shaft. The foreskin on the average adult male is about 12 square inches of highly erogenous tissue [33]. Men circumcised as adults reported a significant loss of sensitivity [34].

A description of the complex nerve structure of the penis explains why anesthetics provide incomplete pain relief during circumcision [35]. Cutting off the foreskin removes many fine-touch receptors from the penis and results in thickening and desensitization of the glans outer layer. The complex anatomy and function of the foreskin dictate that circumcision should be avoided or deferred until the person can make an informed decision as an adult.

In a national survey, circumcised men reported they were more likely to engage in masturbation, heterosexual oral sex, and anal sex than genitally intact men [28]. The result suggests that circumcised men seek alternative forms of stimulation to compensate for reduced sensitivity.

A poll of circumcised men described adverse outcomes on men's health and well-being [36]. Findings showed wide-ranging physical, sexual, and psychological consequences. Some respondents reported prominent scarring and excessive skin loss. Sexual consequences included progressive loss of sensitivity and sexual dysfunction. Emotional distress followed the realization that they were missing a functioning part of their penis. Low-self esteem, resentment, avoidance of intimacy, and depression were also noted. Male satisfaction with circumcision depended on knowledge about circumcision. The more men knew, the more likely they were to be dissatisfied. They wished they had a choice.

Circumcision is traumatic, and the long-term psychological effects of circumcision are similar to the long-term effects of trauma [37]. Using four case examples that were typical among his clients, a practicing psychiatrist presented clinical findings regarding the serious and sometimes disabling long-term somatic, emotional, and psychological consequences of infant circumcision in adult men [38]. These consequences resembled complex post-traumatic stress disorder and emerged during psychotherapy focused on the resolution of perinatal and developmental trauma. Adult symptoms associated with circumcision trauma included shyness, anger, fear, powerlessness, distrust, low self-esteem, relationship difficulties, and sexual shame.

ETHICS
Advocates
Ethical issues are not discussed by advocates.

Critics
When circumcision is performed, it does not treat any disease, injury, or other health problem. Since there is no urgency to do it, it must be delayed until the child is old enough to make the decision for himself [39].

Circumcision violates a major principle of medical practice: First, do no harm. It also violates all seven principles of medical ethics [40]. Some doctors and nurses refuse to perform or assist with circumcisions because of ethical considerations [41, 42]. They have organized to form Doctors Opposing Circumcision and Nurses for the Rights of the Child [43, 44].

The AAP Committee on Bioethics report states, "Pediatric health care providers. . . have legal and ethical duties to their child patients to render competent medical care based on what the patient needs, not what someone else expresses. . . .[T]he pediatrician's responsibilities to his or her patient exist independent of parental desires or proxy consent" (p. 315) [45]. See also   Response to American Academy of Pediatrics Policy Statement .

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