Circumcision: Is It The Right Thing To Do For Your Baby?
Circumcision: Is it the right thing to do for your baby?
McKenzie Pediatrics, P.C.
Updated August 2012
Male circumcision is a surgical procedure in which some or all of the skin covering the end of the penis is removed. Considerable controversy surrounds the procedure, especially in regards to its performance in the neonatal period. There is much information to overwhelm the already stressed new parent who is trying to make an informed decision about whether to take off this small piece of skin, or leave it. This handout aims to aid in that decision.
What Is Circumcision?
At birth, boys have skin that covers the end of the penis, called the foreskin, or prepuce. Circumcision surgically removes the foreskin, exposing the tip (glans) of the penis. The procedure is usually performed by a doctor, in the first few weeks of life. An infant must be healthy and stable to safely be circumcised.
Why Do Parents Choose To Circumcise Their Newborn Sons?
Parents may want their sons circumcised for religious, social, or cultural reasons. Some groups, such as followers of the Jewish and Islamic faiths, practice circumcision for religious reasons. Other parents choose to have their sons circumcised because “all the other men in the family were circumcised”, or out of concerns about the attitudes of peers and their sons’ self concept in the future.
In recent decades, infant male circumcision has been declining. A growing number of American parents feel that circumcision is unnecessary, and are choosing not to have it done. The most recent year for which information is available is 2009, a year in which just more than half (54 percent) of newborn baby boys in the U.S. were circumcised; only about one-third of baby boys born in the Pacific states were circumcised.
Since circumcision may be more risky if done later in life, parents may want to decide before or soon after their son is born if they want him circumcised. Since circumcision is not essential to a child’s health, parents need to choose what is best for their child by looking at the benefits and risks.
Is There A Right Or Wrong Decision?
No. While infant male circumcision has been advocated for reasons that vary from symbolic ritual to preventive health measure, and while others have vehemently opposed the practice on human rights grounds, the fact is that there is limited scientific evidence to either overwhelmingly support or repudiate the routine practice of circumcision.
It isn’t an easy decision for parents to have their son circumcised, or leave his foreskin intact. There are risks and benefits to each decision. No parent should ever be made to feel as if making a wrong decision, whatever that decision.
What Is The History of Circumcision?
Ritual male circumcision has been around a very long time. Circumcision arose independently in different cultures for different reasons, some cultural, some religious, and some purely related to hygiene.
There are circumcised mummies, and six-thousand-year-old Egyptian tomb carvings depicting young men undergoing the procedure. Jews have circumcised their male newborns for thousands of years, in order to fulfill God’s covenant with Abraham. Though circumcision is not required or even mentioned by the Qur’an, Muslims traditionally circumcise their boys. Circumcision is mentioned in the Sunnah, the sayings of the Prophet Muhammed, and the Prophet himself was circumcised.
And adolescent circumcision is an ancient rite of passage to adulthood throughout the Pacific islands and much of Africa.
Not all cultures in history have performed circumcision: the ancient Greeks and Romans thought the procedure barbaric, and early Christians including Paul and Simon Peter explicitly denounced the procedure, even though Jesus, as a Jew, was circumcised.
The Catholic Church even condemned the practice of circumcision as a mortal sin, and ordered against its practice, in the Ecumenical Council of Basel-Florence in 1442.
Today, while many American Christians practice circumcision as a cultural norm, the procedure is not a religious requirement within the Christian faith, and is seldom practiced by Christians outside the U.S. Most Christian denominations neither require nor forbid the procedure.
Today, the World Health Organization estimates that approximately one-third of males across the world are circumcised, of whom 70% are Muslim. Among non-Muslim nations, there are few countries in which the majority of men are circumcised, among them parts of Africa, Southeast Asia, Australia, The Philippines, South Korea, Israel, and the United States. In Australia and South Korea, however, circumcision has fallen far out of favor, and today few newborn males in these countries are being circumcised.
The U.S., however, is unique among “western” nations: while about half of newborn American males today are being circumcised, only 1 in 10 Australian and New Zealand newborn males, 1 in 10 Canadian newborn males, 1 in 20 English and Japanese and Latin American newborn males, and 1 in 100 German and Scandinavian newborn males are being circumcised.
In Germany this year, controversy has been raging after a German court ruled that circumcising an infant for non-medical reasons “violates” Germany’s constitutional protection of every person’s bodily integrity – and should thus be a crime. The court felt that a boy’s right to inviolability trumped religious and parental rights. German Jews and Muslims were outraged by the decision, but national polls revealed that six in ten Germans agreed with the court ruling, even as the country’s doctors shared the opinion of most American doctors that the decision to circumcise is best left between the physician and the parents.
What Is The History of Circumcision In The United States?
The United States was settled largely by Europeans who had no religious or cultural tradition of ritual circumcision, and therefore very few newborns were circumcised for the first 125 years of our country’s existence.
That all changed around the turn of the 20th century, when Dr. Peter Charles Remondino of San Diego announced that circumcision was the cure for masturbation and nocturnal emissions. In a series of impassioned medical articles, Remondino called the foreskin an “evil genie” and an “outlaw” that irritated the underlying head of the penis, inducing a young man “to seize the organ”.
Remondino wrote and spoke in favor of circumcising little boys, because “it insures them better health, greater capacity for labor, longer life, less nervousness, sickness, loss of time, and less doctor-bills.” Remonidino even wrote a blistering condemnation of Saint Paul, the first Christian opponent of circumcision, and wished he were still alive so that he could kill him.
Remarkably, Remondino’s theories were widely praised and adopted by physicians and citizens alike, and circumcision as a health measure soon entered the American mainstream. Even Protestant churches soon took up the cause of circumcision, sermonizing that circumcision would “reduce the adulterous notions of men”. By the 1960s, over 85% of American newborn males were being circumcised soon after birth.
By the early 1970s, however, the medical community began to reexamine the risks and benefits of the procedure, and by the 1990s most medical organizations opposed or at least took a neutral position toward circumcision.
Consequentially, circumcision rates have been steadily declining over the past 15 to 20 years in the U.S., as attitudes among physicians and parents have slowly changed, and as more insurers – especially Medicaid (in 18 states) – have decided not to cover the procedure.
Some of the decline can also be attributed to immigration from Latin America and Asia, where the procedure is generally rare.
What Are The Positions Of U.S. Medical Societies On Circumcision?
Since 1971, the American Academy of Pediatrics has repeatedly reiterated its conclusion that there was no absolute medical indication for routine infant male circumcision.
However, in 2012, the Academy moved away from strict neutrality because of newer studies from sub-Saharan Africa that revealed reductions in HIV by as much as 60 percent in circumcised males as opposed to males uncircumcised. While the AAP stopped short of routinely recommending the procedure, the Academy adopted a position that now leans in favor. The new AAP position states that:
“Evaluation of current evidence indicates that the health benefits of newborn male circumcision outweigh the risks and that the procedure’s benefits justify access to this procedure for families who choose it.”
However, the AAP does go on to state that the:
“…health benefits are not great enough to recommend routine circumcision for all male newborns…”
The American Academy of Family Physicians recommends only that “physicians discuss the potential harms and benefits of circumcision with all parents or legal guardians considering this procedure for their newborn.”
Outside the U.S., the Royal Australasian College of Physicians in 2004 “reaffirm[ed] that there is no medical indication for routine neonatal circumcision” and that “there is no evidence of benefit outweighing harm for circumcision as a routine procedure in the neonate.” In 2012, the College went further and stated that “the frequency of diseases modifiable by circumcision, the level of protection offered by circumcision, and the complication rates of circumcision do not warrant routine infant circumcision in Australia.”
The Canadian Pediatric Society, also in 2004, stated that “the overall evidence of the benefits and harms of circumcision is so evenly balanced that it does not support recommending circumcision as a routine procedure for newborns.” Finally, the British Medical Association states that “the evidence of such benefits [of circumcision] is insufficient as the sole reasons for carrying out a circumcision.”
The bottom line is that routine infant male circumcision has medical advantages and benefits as well as disadvantages and risks. Given that neither the risks nor benefits are particularly compelling, this is a decision most medical professionals feel is best made by the parents of the newborn.
How Is Circumcision Performed?
There are a variety of devices for foreskin removal, each with its own boosters, but the end result is the same: when all is done, the foreskin is gone, leaving the glans (head) of the penis exposed.
Modern devices for circumcision include the Gomco clamp (the method chosen by the physicians of McKenzie Pediatrics), the Plastibell, and the Mogen clamp. With each, the same basic procedure is followed. First, the amount of foreskin to be removed is estimated. The foreskin is then opened and bluntly separated from its attachment to the glans. A dorsal slit is then made, and the device is then placed and remains there until blood flow has stopped. Finally, the foreskin is amputated.
With a Gomco clamp, a section of skin is crushed with a hemostat and then slit with scissors. The foreskin is drawn over a bell-shaped portion of the clamp, and inserted through a hole in the base of the clamp. The clamp is tightened, crushing the foreskin between the bell and the base plate. After five minutes, the bleeding underneath has usually stopped, and the foreskin is cut away with a scalpel from above the base plate. The bell and clamp are then removed, and a dressing is placed around the newly exposed head of the penis.
Is Circumcision Painful?
When done without any form of anesthesia, circumcision is unquestionably painful. Most physicians today give the baby an injection of Lidocaine on each side at the base of the penis (a procedure called a Dorsal Penile Block) before beginning the procedure. Lidocaine does not completely eliminate the pain felt by the baby, but it can greatly reduce it. Problems with using Lidocaine are rare, and usually not serious.
The baby is also allowed to suck on his pacifier during the procedure, and a sweet solution of Sorbitol is provided into which the pacifier can be repeatedly dipped in order that the baby can be enticed to continue vigorously sucking during the procedure.
Afterwards, most babies experience minor pain from the healing, and generally are soothed by more frequent feeding over the next 24 hours. The especially fussy baby may be given acetaminophen (Tylenol™), though only after the baby’s temperature is taken to assure that he does not have a fever (a temperature above 100.4 degrees Farenheit).
What Are The Risks of Circumcision?
Circumcision is not without risk. Circumcision is a generally safe procedure but there are risks of minor complications and some rare but serious complications. The biggest risks are of bleeding and infection in the short-term, and of scarring or adhesions in the long-term.
Most babies experience a little bleeding after the procedure, as the newly cut tissue begins to heal. Parents might discover a small spot of blood on the dressing with each change. Very seldom is active bleeding noted, and usually this can be quickly stopped with a few minutes of direct pressure.
Infection occurs very seldom after circumcision, and usually not until 24 to 48 hours have passed. Increasing redness, tenderness, fussiness, or new green or yellow discharge should alert parents to the possibility of infection. If you suspect infection, contact the baby’s nurse. Any fever of 100.4F or greater should be brought to the immediate attention of the physician, even after clinic hours.
Scarring is also possible after circumcision, though seldom does this cause any more than cosmetic concern. On occasion, the healing process is so overactive that adhesions develop between the shaft of the penis, and the glans. Sometimes, these adhesions have to be cut, or lysed, later in childhood if they cause discomfort, especially when the penis is erect. About 1 in 100 circumcised boys will someday need another, usually minor, procedure.
Finally, there is always the risk of an undesirable cosmetic outcome. Sometimes, the foreskin is so thick that only a part of it can be taken off during the procedure, leaving what doctors call a “turtleneck” appearance to the exposed glans. While perhaps not cosmetically “perfect”, this will not affect the function of the penis.
What Are The Benefits Of Circumcision?
Male circumcision has been shown to significantly reduce the risk of HIV acquisition by men during penile-vaginal sex, though it does not reduce the spread of HIV from infected men to their female or male partners.
Most of the studies on the relationship between acquiring HIV and being circumcised have been conducted in developing countries, particularly those in Africa. Because of the challenges with maintaining good hygiene and access to condoms, these results are not generalizable to the U.S. population.
However, the World Health Organization is promoting circumcision as an important strategy for reducing the spread of the AIDS virus in sub-Saharan countries, given the region’s high rates of HIV infection. Studies in Africa show that between 20 and 70 infant males have to be circumcised to prevent 1 case of HIV infection.
Circumcision may also reduce the risk of penile cancer in later years, though the evidence supporting this claim is weak and controversial. Nonetheless, such cancer is already quite rare, afflicting only 1 in 100,000 men.
Circumcision reduces the risk of urinary tract infection in young boys, though the absolute risk reduction is only one percent, and only 1 in 100 uncircumcised boys will experience such infection. Studies show that 111 infant males have to be circumcised to prevent one young male from developing a UTI.
Circumcision has long been thought to reduce the risk of acquiring a sexually transmitted infection (STI) in adolescence or adulthood, though recent studies in the U.S. and elsewhere have shown this NOT to be the case.
Circumcision also has the benefit of easier genital hygiene, though almost all uncircumcised boys can be taught proper hygiene that can lower their chances of getting infections, cancer of the penis, and STIs.
Finally, circumcisions do reduce the risk of penile bacterial and fungal infections in older children, though the procedure actually increases the risk of such infections in the first three months of life. About 1 in 5 uncircumcised children will experience a fungal or bacterial infection once or more times in childhood, usually responsive to over-the-counter topical medication.
Medical cost-benefit analyses of circumcision have been done in many studies in many countries. Most have found that the benefits and risks balanced each other out.
Does Cutting Off The Foreskin Affect Sexual Function Or Pleasure?
There is no question that the foreskin contains the most sensitive parts of the penis, with thousands of touch receptors and other highly erogenous nerve endings, many of which are lost to circumcision. While there are anecdotal reports that penile sensation and sexual satisfaction are decreased for circumcised males, no study has conclusively determined this to be the case.
When Is Circumcision Best Performed?
We now know that circumcisions performed in the hospital setting, in the first days after birth, can negatively affect infant-maternal bonding, lowering the rate of successful outcome to breast feeding. Therefore, most physicians today perform circumcision on newborn males at 1 or 2 weeks of age, when the baby has successfully demonstrated good growth & feeding patterns, and good bonding with his mother.
However, a baby that is struggling to grow, or is premature, or is experiencing underlying medical problems, should not be circumcised until he is stable and thriving. If that is not until after the first 4 to 6 weeks of age, most physicians elect not to perform the procedure in the office setting, because babies older than 4 to 6 weeks are often too big for the circumcision equipment, and too difficult to anesthetize properly with just a local Lidocaine block. Parents still wanting their infant son circumcised may need to wait until the procedure can be performed by a urologist, under general anesthesia, usually around the first birthday.
What Is The Opinion Of The Pediatricians At McKenzie Pediatrics?
Drs. Hokari and Huffman perform the Gomco circumcision for parents who request them, but we do not encourage the procedure.
However, again, there is not a “right” or “wrong” answer when it comes to circumcision. While circumcision is an increasingly important tool in the fight against HIV in developing countries, the benefits to the procedure here in the U.S. are not so overwhelming as to recommend the procedure as standard treatment for all boys.
Bottom line: Parents have to do the pro-and-con weighing for themselves, and decide what’s most important to them. The decision whether to circumcise is not so much a medical one as a cultural one.