Circumcision

We’re expecting a boy in a couple of weeks—our first child. I was circumcised when I was a baby and want him to be too. My wife’s not sure. Her sister has told her “no way,” that it’s barbaric. What should we do?

The decision as to whether or not to have your son circumcised entails several important factors. The preferences of you—the parents—is a significant one, influenced by the father’s own circumcision status. Then there are the opinions of other family members and even friends, plus a desire for conformity, to “fit in”—or maybe more importantly, to not “stand out.” And of course, there’s the centuries of religious tradition. Sorting out all of these is going to be your work. Our job is to present you with the current medical facts—for and against—and to help you assess the risks and benefits for your son.

Before we do that, it might be interesting to know what other people are doing. It turns out that the United States is the only country in the developed world where the majority of male infants are circumcised for nonreligious reasons. An estimate of the overall prevalence is somewhere around 80% of U.S. males. This is least common in our Western states (only about 30%) and most common in the Midwest (more than 75%). The South and Northeast fall somewhere in between. The great majority of these procedures are done when the child is a newborn, but a substantial number are performed at an older age—older children, teenagers, and even young adults. In fact, of those not circumcised as a newborn, as many as 1 in 5 will elect to have it done later. These are the guys who walk funny for a couple of days and wish they had had the procedure while they were a few days old.

The benefits of circumcision are important and well-established. Significantly, urinary tract infections (UTI) are reduced by as much as 90%. That’s a big number, and this is the major medical benefit during infancy. UTI is uncommon in males at any age, but is more prevalent in infants, when it can lead to life-threatening complications. This reduction in UTI extends beyond infancy and through a man’s entire life.

Circumcision has also been found to reduce the risk of some forms of cancer. There’s a reduction in the incidence of penile cancer. This is a rare problem (the incidence is estimated to be less than 1 in 100,000 males) but studies demonstrate a protective effect of circumcision. Cervical cancer is more common in the sexual partners of uncircumcised men. The reason may be because uncircumcised men have a higher incidence of human papilloma virus infection (HPV). With the widespread use of the HPV vaccine in women and men, this may become less of a factor.

Easier cleansing and improved hygiene leads to a reduction in the inflammatory problems that are more common in uncircumcised males. These include infections of the foreskin and glans itself, sometimes leading to scarring and the need for corrective surgery. While we’re talking about proper cleaning of your infant’s penis, it’s important to know how to do this. The foreskin needs to be completely retracted and the glans gently cleaned with soap and water. Look carefully for the presence of a hair encircling the glans. It can be hard to see. The two of us have observed multiple instances of this, usually when an anxious parent brings their child to the office or ER with “something wrong with his parts.” The hair can act as a tourniquet, causing swelling and infection. In the extreme, it can cut off blood flood to the glans and result in amputation. Not good.

Interestingly, circumcision has been proven to protect against the spread of HIV and herpes simplex virus type 2. Maybe even trichomonas, but not gonorrhea, chlamydia, or syphilis. The evidence for HIV is such that the World Health Organization (WHO) has recommended that male circumcision be a part of an HIV preventive plan in areas of the world where the infection is very common.

What about the pain? I’ve read that my newborn will experience a lot of pain and that it might interfere with his breastfeeding. I also read that when he’s older, he’ll have less sensitivity and less, you know, satisfaction.

One question at a time. Yes, there are some complications associated with this procedure, but the risk is less than 0.2% (2 in 1,000). These include:

• This is usually mild and controlled with local pressure. Very rarely, it can be severe and require surgical treatment.
• If the person doing the procedure is experienced and uses a sterile technique, this shouldn’t happen. If it does, the infection is usually mild and needs only a topical antibiotic.
• Inadequate skin removal. Shouldn’t happen with an experienced provider, but can lead to a poor cosmetic appearance, resulting in a corrective operation at some point in the future.
• Removal of too much skin. Again, mainly a cosmetic problem.
• Scarring and adhesions. Rare, but when significant, might lead to another procedure.

All of these complications are more common among premature newborns, those with congenital anomalies, those performed after the newborn period, and those performed by poorly trained providers. In a large teaching hospital, a first-year resident possessing little experience will sometimes be relegated to this task. Ask your obstetrician who is going to be doing it, what’s their level of experience, and maybe even ask to meet them. Don’t assume anything. This is a simple and safe procedure, but one with life-long consequences.

About your “pain” question. This is a “surgical procedure” and some degree pain will be a reality. The good news is that this can be safely controlled with a couple of local anesthetic options. Not too long ago, this wasn’t considered to be of great importance, but now every infant should be afforded relief of the anticipated discomfort. Another question to ask the person who’s going to do the procedure. Insist on it.

Regarding your concern about breastfeeding, with adequate pain management this should not be a problem. Any behavioral changes noted in your newborn, if any, shouldn’t last more than 24 hours. And concerning your “sensitivity” issue, there is no evidence in the medical literature that finds this to be a problem.

On balance, most experts agree that the medical benefits of circumcision outweigh the risks. The American Academy of Pediatrics has developed a policy statement on this issue. We’ve included it here because we believe it presents an accurate and objective presentation of the current data and provides solid guidance for soon-to-be parents of male children.

“Systematic evaluation of English-language peer-reviewed literature from 1995 through 2010 indicates that preventive health benefits of elective circumcision of male newborns outweigh the risks of the procedure. Benefits include significant reduction in the risk of urinary tract infection in the first year of life, and subsequently, in the risk of heterosexual acquisition of HIV and the transmission of other sexually transmitted infections.

The procedure is well tolerated when performed by trained professionals under sterile conditions with appropriate pain management. Complications are infrequent; most are minor, and severe complications are rare. Male circumcision performed during the newborn period has considerably lower complication rates than when performed later in life.

Although health benefits are not great enough to recommend routine circumcision for all male newborns, the benefits of circumcision are sufficient to justify access to this procedure for families choosing it and to warrant third-party payment for circumcision of male newborns. It is important that clinicians routinely inform parents of the health benefits and risks of male newborn circumcision in an unbiased and accurate manner.

Parents ultimately should decide whether circumcision is in the best interests of their male child. They will need to weigh medical information in the contest of their own religious, ethical, and cultural beliefs and practices. The medical benefits alone may not outweigh these other considerations for individual families.

The American College of Obstetricians and Gynecologists has endorsed this statement.”

In the end, it’s all about making a thoughtful and informed decision. This information informs us. Now we can give it some thought.

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This is an excerpt from the new book I’m writing with pediatrician Dr. Robert Alexander. The book will address 100 questions from parents regarding their children’s health. Feel free to email us with questions: askthedox@yahoo.com