The psychological impact of circumcision

easier to dismiss their pain [7]. Some doctors minimize Introduction circumcision pain by calling it ‘discomfort’ or comparing it to the pain of an injection, although these opinions have From a global perspective, most of the world does not practise circumcision; over 80% of the world’s males are been refuted by empirical studies [8]. Anatomical, neurochemical, physiological and behavintact (not circumcised) [1]. Most circumcised men are Muslim or Jewish; the USA is the only country in the ioural studies confirm that newborn responses to pain are ‘similar to but greater than those in adult subjects’ world that circumcises most (60%) of its male infants for non-religious reasons. Other countries that circumcise a [8]. Infants circumcised with no anaesthesia (reflecting common practice) experience not only severe pain, but significant minority of male infants for non-religious reasons include Canada and Australia. This article refers also an increased risk of choking and diBculty in breathing [9]. Increases in heart rate of 55 bpm have been mostly to the American practice, because the USA has the highest rate of non-religious circumcision and the recorded, i.e. #1.5 times the baseline rate [10]. After circumcision, the level of blood cortisol increased by a most contentious debate about circumcision. Discussion about the advisability of circumcision in factor of 3–4 times the level before circumcision [11]. As a surgical procedure, circumcision has been described English-speaking countries that practise circumcision typically has focused on supposed health factors. as ‘among the most painful performed in neonatal medicine’ [12]. Investigators reported, ‘This level of pain However, recent information about circumcision often disagrees with previous long-held beliefs about the health would not be tolerated by older patients’ [13]. Using a pacifier during circumcision reduced crying but did not benefits of circumcision. The conflicting conclusions, beliefs and opinions surrounding circumcision, together aCect the hormonal pain response [14]. An infant may also go into a state of shock to escape the overwhelming with the tenacity with which advocates and opponents of circumcision maintain their viewpoints, suggest that pain [15]. Therefore, while crying may be absent, other body signals show that severe pain is always present deep psychological factors are involved. The strong motivation to circumcise male infants is shown by the during circumcision. There is disagreement among physicians about using fact that the practice continues even though no national medical organization in the world recommends it. anaesthesia during circumcisions. Before the mid-1980s, anaesthesia was not used because infant pain was denied Questions concerning the psychological motivation to circumcise and the long-term psychological eCects of by the medical community. That belief has changed among many physicians, but an anaesthetic (local injecmale circumcision have rarely been studied; this lack of studies on the long-term eCects was noted in the literation, the best option tested) still is not typically administered, because of a lack of familiarity with its use, as ture about 20 years ago [2,3], and little has changed since then. well as the belief that it introduces additional risk [12]. Although there is an indication that the risk is minimal, most physicians who perform circumcisions do not use Infant pain and behavioural response to anaesthetics. When an anaesthetic is used, it relieves circumcision only some but not all of the pain, and its eCect wanes before the postoperative pain does [16]. To understand the long-term eCects of circumcision, it is important to review the eCects on the infant. The question Behavioural changes in infants resulting from circumcision are very common, and can interfere with parentof infant pain is often raised in debates about circumcision. Some physicians believe early work claiming that the infant bonding and feeding [3,8]. The American Academy of Pediatrics Task Force on Circumcision notes newborn nervous system is not suBciently developed to register or transmit pain impulses [4,5]. According to more increased irritability, varying sleep patterns and changes in infant–maternal interaction after circumcision [17]. recent work, this belief is ‘the major myth’ of physicians regarding infant pain [6]. That babies cannot physically Canadian investigators report that during vaccinations at age 4–6 months, circumcised boys had an increased resist and stop the circumcision procedure also makes it