Circumcision in boys and infants
Circumcision is one of the most controversial and emotional topics in urology and andrology. The debate revolves around the removal of the foreskin (“prepuce”), which completely covers the glans of the penis when flaccid and retracts backward during an erection.
This article aims to clarify the subject and distinguish fact from myth to provide a solid foundation for one of the most personal decisions parents can make for their son and men can make for themselves.
Circumcision is one of the most commonly performed surgical procedures worldwide.
For billions of people, it is not primarily a medical procedure, but rather a deeply rooted cultural and religious practice. Today, the Jewish and Muslim traditions are particularly well known:
- Brit Mila (ברית מילה): In Judaism, circumcision is a central religious commandment. It is traditionally performed on the eighth day of a newborn boy’s life by a so-called mohel. This procedure is highly ritualized and symbolizes the covenant between God and the Jewish people for devout Jews.
- Chitan / Khitan (ختان): In many Islamic cultures, circumcision also takes place during childhood – however, the age varies greatly from region to region, ranging from a few days to adolescence. Here, too, religious purity is the main focus, with medical and hygienic reasons often cited as additional factors.
Regardless of the medical debate, these practices are an expression of identity and belief and should be viewed with respect.
In North America, for example, circumcising boys was common because it was considered more hygienic. Over time, the circumcised penis has also become the beauty standard in many Western countries.
False diagnosis of phimosis as the most common “medical” reason for circumcision in boys
Here in Europe, however, the most frequently cited reason for circumcision in childhood is phimosis, or tightness of the foreskin. Many parents become concerned if they are unable to retract their toddler’s foreskin.
However, in most cases this is a completely normal stage of development: in almost all newborn boys, the foreskin is stuck to the glans (conglutination) and the opening of the foreskin is still very narrow, meaning that the foreskin cannot be pulled back.
This physiological phimosis is not a pathological condition, but rather an evolutionary protective mechanism, as the foreskin protects the sensitive glans and the opening of the urethra from friction, dehydration, and infections. In most cases, this adhesion of the foreskin resolves itself completely during the first few years of life.
Important: Never try to pull back your child’s foreskin by force! This can lead to small tears, scarring, and ultimately to pathological phimosis.
For many years, a flawed study by British pediatrician Douglas Gairdner from 1948 was cited, which stated that the foreskin of boys must be retractable by the age of 5 at the latest, leading to numerous misdiagnoses of pathological phimosis in the following decades. More recent studies show that about half of all boys under the age of 10 cannot fully retract their foreskin and that physiological phimosis can actually persist into puberty without being pathological.
When is treatment for phimosis necessary?
Treatment for a tight foreskin is only necessary if the phimosis has not resolved during puberty, if symptoms only appear later in life, and/or if it causes problems.
Such problems include, for example:
- Balanitis and balanoposthitis: Recurrent inflammation of the glans or foreskin.
- Painful erections: When the foreskin does not allow for an erection without causing pain.
- Secondary phimosis: When the foreskin becomes diseased and an inelastic, scarred ring forms.
- Lichen sclerosus: A chronic skin disease, especially in the genital area.
- Pain when urinating: This occurs when painful urine retention causes the foreskin to swell (“ballooning”).
Complete or absolute phimosis occurs when the foreskin cannot be pulled back over the glans, even when the penis is flaccid. In contrast, with incomplete or relative phimosis, pulling back the foreskin is difficult only when the penis is erect.
Conservative treatment or circumcision?
When pathological phimosis is present and requires treatment, surgery has long been the standard therapy. However, circumcision as a treatment for foreskin tightness can often be avoided today. Modern medicine prefers to treat phimosis conservatively.
For example, through:
- Topical ointment therapy: An ointment containing cortisone is applied to the tip of the foreskin over a period of four to eight weeks. This makes the skin more elastic and stretchy.
- Gentle stretching: Accompanying the ointment therapy, the foreskin is carefully and painlessly stretched.
- Loosening adhesions by carefully moving the foreskin.
The success rates of these methods are excellent, at over 80%. It is painless, avoids the risks of surgery, and preserves the foreskin in its entirety.
If the foreskin cannot be pulled back over the glans without pain or if you experience severe pain during an erection, discuss the problem with a urologist.
Surgical treatment by circumcision
At the same time, surgical treatment of phimosis still has its place.
- Circumcision: The classic circumcision, in which the foreskin is completely or partially removed and the glans is then exposed.
- Preputioplasty: As an alternative to conventional circumcision, there are approaches to foreskin-preserving surgery. However, these techniques are quite complex, so they are only performed by very few doctors.
Circumcision can be performed using various techniques: in addition to the classic incision with a scalpel, there are various clamping and ligation techniques (e.g., Gomco or Plastibell) and even circumcision with a medical laser.
The debate: circumcision pros and cons
Apart from medical circumcisions, there is an intense debate surrounding the routine circumcision of infants, toddlers and boys.
Critics argue above all that children are not capable of giving consent, and that circumcision without medical necessity violates the child’s right to physical integrity and is therefore contrary to the child’s welfare.
The most common argument is that removing the foreskin reduces the sensitivity of the glans, making it difficult to have a fulfilling sex life later on. Psychosexual consequences are also sometimes mentioned.
On the one hand, advocates of circumcision cite the cultural and religious traditions mentioned above and the social component of “belonging.” They also argue that circumcision makes intimate hygiene easier, which reduces the risk of certain infections. Various studies do indeed indicate a lower risk of urinary tract infections and some sexually transmitted infections (STIs) such as HIV, HPV, and herpes.
From a technical standpoint, it’s important to note that, in the absence of clear medical indications, the decision to circumcise is a personal one that parents make primarily for social, cultural, and religious reasons.
Late decision to undergo circumcision in adulthood
Of course, it is a completely different matter for men who decide to undergo circumcision as adults. There are many reasons for this: in addition to medical reasons, such as acquired phimosis or recurrent inflammation, personal wishes also play a role here.
Above all, the aesthetic appearance of the penis plays a major role for many men. Partly due to the easy access to pornography, where 99% of male performers are circumcised, some men perceive the circumcised penis as the norm and feel the desire to adapt their own body image to this norm.
A man who decides to undergo circumcision for purely aesthetic reasons, because he feels more comfortable, confident, or “clean” with the appearance, is therefore making an autonomous decision.
Conclusion
Circumcision is sometimes a controversial topic. It touches on religion, culture, ethics, and medicine. While patience and conservative methods should clearly be the focus in cases of physiological phimosis in childhood, the decision is a deeply personal one when there are no medical reasons. In adults, however, circumcision is an act of individual self-determination.
If you have any questions or would like a personal consultation—whether for your son or for yourself—please do not hesitate to make an appointment.
Open and honest information is the key to making a decision that you will feel comfortable with in the long term.
Sources
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- S2k-Leitlinie Phimose und Paraphimose bei Kindern und Jugendlichen, Deutsche Gesellschaft für Kinder- und Jugendchirurgie e.V. (DGKJCH) https://register.awmf.org/de/leitlinien/detail/006-052
- Gairdner D (1949).”The fate of the foreskin.”, Brit Med J2: 1433-7, https://www.cirp.org/library/general/gairdner/.
- Denniston GC, Hill G. Gairdner was wrong. Can Fam Physician. 2010 Oct;56(10):986-7. PMID: 20944034; PMCID: PMC2954072.
https://pmc.ncbi.nlm.nih.gov/articles/PMC2954072/ - Seidenberg M, Nolte J, Azad M, et. al.: Entwicklung der Vorhaut, https://flexikon.doccheck.com/de/Entwicklung_der_Vorhaut
