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CIRCUMCISION

Parents didn’t used to need advice about circumcision. The decision was pretty much made for them in the middle of the 20th century when over 80% of the boys born in the US were routinely circumcised at birth.

Circumcision is the surgical removal of the foreskin of the penis so that the glans (the head of the penis) is permanently exposed. It is the oldest pediatric operation, practiced by the ancient Egyptians at least 6000 years ago though it originated much earlier. Ritual circumcision is practiced by about 20% of the world’s population. America was the first country to introduce nonreligious circumcision in the 1870s and, after aseptic techniques led to an increase in all surgery, circumcision increased in popularity so that by 1910 half of the boys born here were circumcised.

During the 1970s both parents and pediatricians began to question whether newborn circumcision is necessary. Following the publication of two reports by the American Academy of Pediatrics (AAP) which both stated there were no indications for routine circumcision in the newborn, the rate of circumcision in the newborn dropped. In 1989, an AAP report stated, “Newborn circumcision has potential medical benefits and advantages as well as disadvantages and risks. When circumcision is being considered, the benefits and risks should be explained to the parents and informed consent obtained.” A 1999 AAP report stated that circumcision is not recommended and is “not essential to the child’s current well-being.”

Currently, like so many other issues which should be decided by science-based evidence, circumcision has become a political issue. Both the pro’s and the anti’s may use rhetoric, powerful methods of persuasion, and pseudo-science. Although fewer circumcisions are performed, there are those who think the rate is not dropping fast enough and some speak out against circumcision as a violation of the human rights of the male infant. There are also experts who have spoken out against the AAP’s strong anti-circumcision stance based on evidence that circumcision protects against both urinary tract infection and sexually transmitted disease including HIV.

But the decision belongs to the parents not the pediatrician or the AAP. In order for parents to make an informed decision they must look carefully at the SCIENCE behind both the pro’s and the con’s of the procedure.

What are the ADVERSE EFFECTS OF NON-CIRCUMCISION?

Retaining the foreskin can lead to problems in a small percentage of uncircumcised boys. Phimosis, a condition in which the foreskin cannot be retracted over the glans, is one such problem. The foreskin is not usually fully retractable until somewhere between three and five years. In a very small number of boys the foreskin does not become retractable and circumcision will be required with increased risks (general anesthesia will be needed) and cost. Hygiene problems can also occur if the area is not kept clean but, once the foreskin becomes retractable, the boy can be taught to keep the area clean as easily as he is taught to brush his teeth. Balanitis, a painful inflammation of the glans, almost always occurs in uncircumcised males and may require two operations; one to allow the infection to subside, followed by circumcision.

All in all, problems with the penis are more than twice as common in uncircumcised males. Cancer of the penis is found almost exclusively in uncircumcised males. Also among males with a history of multiple sex partners, circumcision reduces the risk of cervical cancer in current sex partners. There is also the issue of infection. Sexually transmitted diseases, including AIDS, is more common in the uncircumcised. Several studies have shown that uncircumcised males were more likely to have a urinary tract infection than circumcised ones.

Finally there is appearance. Because most males have been circumcised, non-circumcision means the boy won’t look like Daddy. (Of course this may not justify surgery–if Daddy has an appendectomy scar, we don’t recommend an operation so father and son will match!)

What are the possible ADVERSE EFFECTS OF CIRCUMCISION?

Surgical complications are very rare but hemorrhage, infection, and other surgical mishaps can occur. A very small proportion of babies will have later complications such as adhesions. The pain of the procedure is a major concern as there is physical evidence of the effects of pain (increase in pulse rate, for example) and irritability may persist for several days. Many circumcisions today are performed using local anesthesia. Meatitis, an ulceration around the opening of the urethra, occurs mainly in circumcised males probably because the foreskin serves a protective function. Fortunately most cases are mild and clear up easily.

How do most parents decide? According to one study looking at reasons parents chose circumcision, hygiene was the reason given in 69%; appearance, 31%; social custom, 21%. Some parents choose a ritual circumcision for religious reasons.

Parents today tell me that they decided on circumcision because of hassle-free hygiene, to avoid the complications of non-circumcision which can be time-consuming to treat, to avoid worry whether circumcision will be required later in childhood with its greater risk, and so the boy would look like his father. All are valid reasons.

On the other hand, no special care of the penis is needed in the young baby and it is easy to teach the older boy how to care for the foreskin. And the incidence of all of the complications of non-circumcision in childhood is relatively small.

The controversy over circumcision has had a positive effect. Circumcision has been forever removed from the category of routine and no invasive procedure should ever be considered routine. The procedure should be explained to the parents. They should receive unbiased, accurate information about the potential complications of circumcision and the consequences of non-circumcision. Then the parents should make up their own minds and decide what they want for their son.

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