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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.

Arguments in favor of (non-religious) 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.)

Arguments for an intact (uncircumcised) penis

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

 

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