To Circumcise
or Not to Circumcise?
By Elizabeth Pantley
For some parents, circumcision
has a deep religious significance; the procedure is central to
establishing a newborn boy's identity. But for many other parents,
the circumcision decision has become increasingly difficult.
Thirty years ago, up to 90% of
American newborn baby boys were circumcised; currently, around
60% are circumcised. On the west coast, this figure has gone as
low as 40%, and in parts of Canada, 25% and less. Worldwide, the
uncircumcised penis is clearly the norm: 85% of the world's male
population has "intact" (uncircumcised) penises.
The medical perspective
Traditionally, many parents turn to the medical profession for
advice, but the American Academy of Pediatrics has made it clear
that there is no right or wrong decision on the circumcision issue.
According to their Task Force on Circumcision (1999):
Existing scientific evidence
demonstrates potential medical benefits of newborn male circumcision;
however, these data are not sufficient to recommend routine
neonatal circumcision. In the case of circumcision, in which
there are potential benefits and risks, yet the procedure is
not essential to the child's current well being, parents should
determine what is in the best interest of the child. To make
an informed choice, parents of all male infants should be given
accurate and unbiased information and be provided the opportunity
to discuss this decision.
The changing circumcision statistics
and new information leave many parents in a quandary. This is
a decision that cannot be made overnight, and you are right to
think about, research and discuss the pros and cons of circumcision
well before your baby is born. While this issue occasionally is
highly sensationalized and passionately debated in the media,
be sure to look as objectively as possible at the procedure, its
history and its potential benefits and risks. In the end, you
are the only ones who can make the decision about what is best
for your child.
What exactly is circumcision?
Every physically normal male is born with a foreskin, or prepuce,
that covers the glans (tip) of the penis. The inside of this foreskin
is a mucous membrane similar to the inside of the cheek, with
numerous nerve endings. The foreskin is thought to protect the
glans and to keep it moist and clean.
During a circumcision, the physician
removes the foreskin surrounding the glans. The procedure is normally
performed within the first two weeks of life, because the risks
of a circumcision are greater if the baby is more than two months
old.
There are several different surgical
approaches, but the following is typical: The baby is put on his
back, and his legs and feet are restrained. Then the foreskin
is separated from the glans with a type of forceps (necessary
because tight adhesions connect a baby's foreskin with his glans).
Clamps hold the foreskin in place, a protective cover is put over
the glans, the foreskin is pulled over the cover, and then about
one-third to one half of the skin is cut off using a clamp. Antiseptic
petroleum jelly may then be put on the penis to prevent irritation
and infection. Complications are rare.
Where did circumcision
start?
So how did circumcision become such a routine procedure in the
United States? And why are opinions changing?
Circumcision has existed for thousands
of years, going back to Egyptian times; it is typically an intricate
part of religious faith for Jewish and Muslim families. In the
United States, circumcision was not practiced widely, however,
until the late 19th century. Around the beginning of the 20th
century, cleanliness became associated with wealth, and a circumcised
penis was thought to be cleaner; about 25% of men were circumcised
at that point. In the 1930s, the military began requiring circumcisions
because soldiers in the field had little access to water, and
maintaining adequate personal cleanliness was difficult. Studies
in the 1940s and 1950s (some of them questionable) showed medical
advantages for circumcised men and their partners and circumcision
became almost universal within the United States.
Circumcision has always carried
an element of tradition: When the father is circumcised, the parents
want their son to "be like the father” (or the brother,
or the other boys in the locker room). This is probably a key
reason for the relatively high rates of circumcision in the United
States.
Opinion has started to change,
however, and the rate of routine circumcision is decreasing. Recent
studies have shown benefits of circumcision as well as risks,
and the decision falls fully into the hands of parents. Below
are two tables looking at arguments for and against circumcision.
| Reason |
Supporting
evidence |
Arguments
against |
|
| Lower chance
of urinary tract infection (UTI) in first year of life |
Studies show
that circumcised boys have a 1 in 1000 chance of UTI,
vs. 1 in 100 chance for uncircumcised boys. |
UTIs are rare
in boys and are easily treated. |
|
| Penile cancer
prevention |
Cancer of
the penis is three times more common among uncircumcised
men than circumcised men, among whom the disease is virtually
nonexistent. |
Penile cancer
affects only one in 100,000 older men and is related to
sexual behavior. |
|
| Lower risk
of sexually transmitted diseases (STDs) |
Some studies
have shown that the risk of STDs, vaginal disorders in
partners, and HIV are lower for circumcised men. |
Risk is only
slightly lower, and sexual behavior is a much better predictor
of sexually transmitted disease frequency and type. |
|
| Cleanliness |
Uncircumcised
males risk infection of the foreskin. |
Simple education
about good hygiene virtually eliminates this risk. |
|
| Prevention
of a more complicated circumcision later in life |
There are
sometimes medical reasons for circumcision, such as phimosis
(a condition in which foreskin retraction is impossible);
post-infancy circumcisions are painful and carry a higher
risk of complications. |
Phimosis and
other penile conditions requiring circumcision are not
very common and not generally considered a valid reason
for routine circumcision. |
|
| A son should
"look like" his father |
Some people
worry that there may be confusion or even psychological
problems if the father's penis is circumcised and the
son's is not. |
Boys won't
necessarily "look like" their fathers in all
ways anyway -- hair color, eye color, body shape all may
differ -- as may the penis. |
|
| Worry about
being "strange" |
In the past,
some adult men have requested circumcisions because they
have heard from sexual partners that their penises were
"strange," they were teased as children or they
felt embarrassed in locker room situations. |
The statistics
have changed so dramatically that, whatever your decision,
your baby is unlikely to be considered "strange”
in this regard. (In any case, children should be taught
to respect individual differences.) |
|
| Reason |
Supporting Evidence
|
Arguments against |
|
| No medical
reason for the circumcision |
Why remove
a part of an infant's body that functions perfectly well?
Circumcision interferes with the way nature intended the
body to be. |
For full-term
healthy infants, few risks are entailed in removing the
foreskin, while there are some possible medical benefits. |
|
| Fear of complications |
As with any
surgery, risks are involved, including excessive bleeding,
infections or injury to the penis. There are also cosmetic
concerns, as the foreskin can be cut too long or too short
or can heal improperly. |
Complications
are very rare. This is among the safest of surgical procedures;
cosmetic complaints are rare. The complication rate is
thought to be one in 200 to one in 500. |
|
| Pain of the
procedure and the memory of the pain after the procedure |
Studies show
infants experience substantial pain from the procedure,
as shown by increased heart rate and blood pressure; the
"memory" of the pain lasts, as infants circumcised
without analgesia have increased sensitivity to vaccinations
at four months. |
The AAP now
recommends that some form of pain relief be used for all
circumcisions. Complications from these pain medications
are rare. |
|
| Possible risk
of conditions that develop because a foreskin is not present |
When the foreskin
is removed, the glans can become irritated, causing the
opening of the penis to become too small. Ultimately,
this leads to urination difficulties and requires surgery.
Other possible conditions are tight, painful erections
or adhesions and skin tags. |
Penile problems
developing on a circumcised penis are uncommon. |
|
| Worry about
decreased sexual sensitivity |
Some people
feel the glans toughens up without its protective cover,
and the penis is desensitized. |
No study has
shown that circumcised men experience less sexual pleasure. |
|
| Lack of consent
for a potentially life-changing operation |
Why not wait
until the boy has the chance to choose for himself? Subjecting
an infant to an unnecessary surgery that will change his
body is unfair. |
Later in life,
circumcisions are more painful and more dangerous. Parents
have to make many life-changing decisions on behalf of
their infants; that’s the nature of parenthood. |
|
| Financial
reasons |
In some areas,
insurance companies or Medicare will not cover the cost
of the circumcision (viewing it as an elective procedure). |
Many circumcision
costs are still covered within the U.S. (but not in Canada);
you must check with your insurance provider to verify.
The surgery is generally not expensive. |
|
Pain
relief
One thing is abundantly clear: Pain relief should be provided
to the infant undergoing a circumcision, as the ridiculous belief
that infants do not feel pain during circumcision has been completely
refuted. The American Academy of Pediatrics now recommends analgesia
for all circumcisions, as it is "both safe and effective."
The three primary forms of pain relief are a topical numbing cream
(EMLA), a dorsal penile nerve block (a local anesthetic injected
into the penis) or a subcutaneous ring block (also a local anesthetic).
Circumcision information
checklist
If you do decide to circumcise your son, use the following checklist
to make sure everything goes as smoothly as possible:
• Have you discussed the
issue with your doctor? Make sure that you understand exactly
what will happen during the operation, what type of pain relief
will be used, what the possible risks are of the surgery and
of the analgesia (pain relief).
• Have you made sure that the right doctor will perform
the surgery? Often your ob-gyn will do the circumcision, but
pediatricians also perform the surgery. Especially in an area
or hospital that doesn't have a high rate of circumcision, ask
about the doctor's experience with circumcisions and the complication
rate. If you are unhappy with your doctor's answers to your
questions about the surgery or pain relief, or if you don't
think he has enough experience with circumcision, find another
doctor to do the surgery. You are your child's advocate.
• Have you checked with your insurance company as to whether
it will cover the surgery? Have you asked about the cost of
the procedure?
• Have you written your wishes in a birth plan and read
the consent form very carefully?
• Have you talked to your doctor so that you know what
to expect as the circumcision wound heals?
©
Elizabeth Pantley; excerpted from Gentle
Baby Care
Parenting educator Elizabeth Pantley
is the author of numerous parenting books, including the widely
cited The No-Cry Sleep Solution: Gentle Ways to Help Your
Baby Sleep Through the Night. Buy her books at Powells.com.
She is a regular radio show
guest and is quoted frequently on the web and in national family
and women’s publications. Her next book, Gentle Toddler
Care, will be available in 2004. Elizabeth lives in Washington
state with her husband, their four children and her mother. Visit
her at www.pantley.com/elizabeth
