Circumcision: Whose idea was it, anyway?

Breast or formula? Cloth diapers or disposables? Stay-at-home mom or going back to work?

Expectant parents have an overwhelming number of decisions to make in the months leading up toCircumcision their child’s birth. If your baby is a boy, one of those decisions is whether to have him circumcised. In some families this decision receives little consideration…..OF COURSE WE’RE GOING TO CIRCUMCISE HIM! In fact, parents who choose to keep their son intact (the preferred terminology for an uncircumcised boy) often face criticism and second-guessing from grandma, grandpa, aunts, uncles and anyone else who seems to think it’s their business.

Circumcision, or the surgical removal of the foreskin of a boy’s penis, is commonly done on infant boys in the first few days of life. There are a variety of reasons parents choose to have their son circumcised. In some faiths, most commonly Judaism, it is considered a religious requirement. Outside of religious reasons, though, the overwhelming reason parents request circumcision is cosmetic….because they are accustomed to a penis looking a particular way! Other common reasons are that all of their friends had it done, that they don’t know anyone who isn’t circumcised, that he needs to look like his father, or because of some vague idea that a circumcised penis is “cleaner” or “healthier” or “easier to take care of.” Some parents are unaware that it isn’t medically necessary. And while there are some (very modest) medical benefits, parents rarely report those benefits as the driving force behind their decision to circumcise.  So what are the issues to think about?

But everyone does it!
It is true that the majority of boys in the Midwest are circumcised; the regional in-hospital circumcision rate is about 71%. However, that number has been falling for the last 15 years. Nationally the circumcision rate fell to 55% in 2010, meaning that nearly half of US baby boys are NOT circumcised. In fact, in the Western US, most boys are NOT circumcised, with a circumcision rate of 40%.  Some Western states are considerably lower, including Nevada were only 1 in 8 newborn boys is circumcised, and 1 in 6 in Washington.  So there are, in fact, MANY boys who are not circumcised, both locally and nationally. Parents who choose to keep their newborn son intact can be comfortable he will not be the only uncircumcised boy in the locker room in 15 years.

He will look different than daddy

That’s right, he will. And not just because of his penis! He may have different hair color, eye color, shape of his nose, or smile. Little girls do not develop breasts for years, and when they do, they may well look different than her mother’s. We don’t consider these differences to be a problem. We just explain that everyone is different, including genitals. In my family of three generations and 12 males, some circumcised, some intact, never once has anyone been concerned or even commented on the difference. In fact, the most shocking thing for little boys upon seeing their father’s genitals is the obvious difference in size, not the presence or absence of a foreskin!

It will be easier to take care of and cleaner

A newly circumcised penis requires far more care than an uncircumcised one! For a newly circumcised baby, ointment has to be applied to keep it from sticking to the diaper with every diaper change. If poop gets all over it, it can be a real pain to get it cleaned off when you can’t bathe him and wiping it makes it bleed. In some boys, the small amount of foreskin left will scar to the head of the penis and need further treatment from a urologist, sometimes including surgery and general anesthesia.

Compare that to the care of an intact penis. You wipe if off like a finger….and that’s all! The popular belief that you need to retract (or pull back) the foreskin and clean under it daily is not only incorrect, it is HARMFUL! In babies and toddlers, the foreskin is actually completely fused to the glans (or head) of the penis, like your fingernails are attached to your fingers. Forcibly pulling back the foreskin actually rips and tears the foreskin away from the head, causing severe pain, bleeding, and scarring. The foreskin gradually detaches from the head of the penis over the first few years of a boy’s life; most (but not all) boys have a retractable foreskin by about age 5. Once it is retractable, it is appropriate to teach him to gently pull it back, wash with regular soap and water, and replace the foreskin to its usual position. This should be done in the same way you teach your son to wash his hair and ears and feet. As a general rule, the only person who should be retracting a young boy’s foreskin is the boy himself, as he will not pull so forcibly as to cause damage.

It’s just a little snip

While considered a minor procedure, circumcision is far more than “a little snip.” The most common takes about 10 minutes to complete and is performed on an awake baby. The type of pain control provided, if any, is up to the physician. The most effective pain control is to give 2 or more shots of numbing medication into the base of the penis. If effective, the penis is then nearly completely numb. This is not 100% effective every time, and the procedure usually proceeds even if the baby is experiencing pain.  There is also pain from the rubbing of this open wound against the diaper until healing is complete. Finally, not all doctors choose to provide pain control. While not recommended, some physicians still circumcise simply with the baby strapped to a restraint with only a pacifier to soothe his pain.

Then there are the complications to consider. The most serious immediate complications are bleeding, infection, and injury or amputation of part of the penis. Bleeding is the most common and occurs in 1-2% of boys. Further complications are not unusual and may occur months to years after the circumcision. Some may require surgery to correct. These include adhesions (when the remaining foreskin scars to the head of the penis) and removal of too much or not enough of the foreskin. In fact, “circumcision revision,” or “re-circumcising,” is commonly performed when parents are dissatisfied with how the penis looks. Meatal stenosis, or severe narrowing of the opening where urine comes out, occurs almost entirely in circumcised boys and can cause painful urination, problems with urinary stream, and bleeding. It may require further surgery to correct. It occurs in about 1 in 10 circumcised boys.

It’s healthier

The American Academy of Pediatrics released a revised policy statement on circumcision in 2012. After thoroughly reviewing more than 1000 research articles, the most they could say was that the benefits of circumcision outweigh the risks of the procedure but were NOT enough to recommend that all newborn boys be circumcised. Said differently, there are modest health benefits, but they aren’t beneficial enough that we encourage it for everyone.

The strongest benefit is the prevention of urinary tract infection (UTI). Circumcision definitely reduces the risk of UTI in the first year of life. However, even in an intact boy, his risk of getting a UTI is only 1%. There is a 99% chance he wouldn’t get a UTI anyway, and these infections are usually easily treated with antibiotics. Another area of benefit is in the reduction in transmission of HIV. While circumcision has been shown to reduce the transmission of HIV in high-risk populations in Africa, it has not been proven effective in the U.S. Avoidance of risky sexual activities and use of condoms are far more effective than circumcision in preventing the spread of these diseases.

Circumcision is just one of many decisions we must make for our sons. While ultimately the decision falls to you, mom and dad, it’s important to consider all the available information in order to make an informed choice.

St. Louis Children’s Hospital does not deliver babies and, as such, is not a primary site for routine infant circumcision, with the exception of those infants admitted to the NICU immediately after birth.

Kim Hamlin, MD About Kim Hamlin, MD

Dr. Kim Hamlin is a Pediatric Hospitalist with St. Louis Children's Hospital, an Assistant Professor of Pediatrics at Washington University School of Medicine, and a guest-blogger to www.childrensmomdocs.org.

Comments

  1. As I was reading this article I was pretty sure I knew exactly who had written it. When I got to the end I discovered I was correct. Dr. Hamlin, although an excellent doctor, is known to have a deep prejudice AGAINST circumcision and her article shows it. She basically dismisses the health benefits of circumcision and implies any reason a parent might be for it is just silly. This article is very biased and one sided.

  2. Thank you so much for posting a smart, well-rounded discussion about the many benefits of leaving boys intact. It was refreshing to see all the myths about circumcision explained and diffused!

  3. Dr. Hamlin, thank you so much for writing this article! I am very grateful that you are working to dispell the myths about circumcision. Would you consider writing a follow-up article that focuses on the functions of the foreskin? If you haven’t seen the 2007 Sorrels study which measured fine-touch in both circumcised and intact men, you might find it very interesting! http://www.doctorsopposingcircumcision.org/pdf/sorrells_2007.pdf

  4. Thank you for this articulate and well-reasoned article! It’s refreshing to have a doctor accurately discuss genital cutting and the untoward consequences of non-therapeutic surgery performed on a non-consenting minor. Parents often do not understand that the foreskin has important functions, including protection of the glans and urinary opening as well as thousands of erogenous nerve endings and a gliding mechanism that enhance sexual experience. To add to your facts, the AVERAGE age of foreskin retractability is 10.4 years. Often, it is the hormones of puberty that help with the process. Some males may not have a retractable foreskin until after puberty or into their mid-twenties. If a male decides he wants his foreskin to be retractile after puberty, gentle stretching usually completes the process. Soap should not be used on the glans (head) of the penis because the covering of the glans is mucosal tissue and soap would dry it out or irritate it. Using fingertips and warm water to rinse the area is all that is needed. And, finally, circumcision can always be done but can never be undone. Let’s let our boys decide what body parts they want to keep when they’re old enough to make such important decisions for themselves. His body, his choice! I hope these points help and, again, thank you for your excellent article.

  5. Thank you for this informative article! It is good to hear from doctors who are aware that circumcision is unnecessary, and that the foreskin is not a bomb waiting to go off!

    I’m especially glad to see you are informed of proper intact care. It’s so hard to hear from parents whose sons were harmed and assaulted by their care providers.

    Hopefully one day this will no longer be considered a ‘parent’s decision’, but the decision of the rightful owner of the genitals being cut.

  6. Thank you for this article. I wish Children’s hospital would put this out in their newsletter, rather than the one they did a couple months ago which was pro-circumcision with vague resources and horrible recommendations for the care of an intact penis.

  7. Wow, did I read this correctly? An American doctor who actually tells the truth? (I though this was impossible; glad I was wrong.)

    Kim, since we’re actually speaking honestly here, I’ll share my story with you. Even when I was 25 years old, I could not wear a condom and actually have sex. I had so much tissue removed that I can’t feel anything with the condom on. That is what circumcision did to me. I had a lifetime of difficult sex thanks to this American abuse of power.

  8. concerned cynic says:

    Dr Hamlin, would you please send a copy of your post to your colleague Clayton Cummings MD who is not on the same page as you are, insofar as this tender topic is concerned?

    You also do not mention the sexual advantages to leaving men intact. To appreciate these advantages, talk to American women who’ve been intimate with both kinds of men. Masters and Johnson completely missed this 50 years ago. The natural penis greatly facilitates masturbation and foreplay. The moving foreskin interacts very nicely with a man’s natural lubrication, and cushions the forcefulness of penetrative sex. There are American women who report that they climax easily or every time with an intact partner, and erratically or never with a circumcised one. Circumcision is a feminist issue, because the missing foreskin can have a major adverse effect on a woman’s sexual experience.

    Even though the routine circumcision of baby boys born in USA and UK urban maternity wards began around 1880, there never has been a study of the consequences of routine infant circumcision on adult sexual function, based on a large random sample. Hence we do not know the correlation, if any, of circ status with PE, ED and vaginismus. We do not know if circumcised men are more or less likely to use condoms during casual sex. Hence when we circumcise a baby boy, we literally do not know how that impacts the realm of adult sexuality. This is an unconscionable situation.

    The main unspoken reason why millions of American parents have their sons circumcised at birth is because they think that the foreskin looks weird. Giving a bath to an intact son, and changing his diapers, takes them out of their parenting comfort zone. They fear that an intact son will be mocked by circumcised boys, and rejected by the women he tries to date. The sex positive “all bodies are beautiful” revolution that has made powerful inroads into female culture has yet to benefit many American men.

  9. Please tell me where I can find all the comments. The comment I submitted yesterday has not been posted, and I am certain there are others. Thank you.

  10. I have a lot of compassion for little boys and men who were circumcised, because in the 1950s they were also circumcising little girls and I was one who was cut in that way. Blue Cross Blue Shield covered clitoridectomies until 1977 and the U.S. finally outlawed female genital mutilation in 1996.

    I have met several women who were also circumcised and they – like many men I have met who are unhappy with their circumcisions – and like women who are unhappy about having been raped – have had childhood and teen suicidal ideation and night terrors, whereas intact people – male and female – did not.

    So I do not believe it’s just a little snip. I believe circumcision is an introduction to some level of PTSD. The real loss goes beyond skin. The real loss is in quality of life – not being able to trust others, not feeling good about your body, feeling unlovable, feeling powerless because at that point you were powerless, lifelong sexual frustration, anxiety, fear, anger, rage, grief, depression, etc. Circumcision is something I wish on no one, under any conditions, ever.

  11. Thank you for the informative tone of this article. I believe that the pros and cons were covered very nicely. For the record, in his 22 years of life, my intact son has never had a UTI, never had an STD, has not contracted HIV. Plain and simple.

  12. Craig Adams says:

    I was circumcised at birth at Holy Name Hospital in Teaneck, NJ in 1974 without my parents’ informed consent. It completely injured me. Flash forward to 2013. I became a father at age 38 to a son. I was very surprised when each day at Morristown Medical Center where my son was born, a nurse would ask, “Are we circumcising?” Each day, we said “No.” The last day, the head nurse said to my son, “You are a lucky baby.” I thought to myself, Is this a hospital or a horror show? In looking at my son, I can see just how much tissue was removed from me and it makes me sad and and it makes me feel violated. I finally had the courage to research circumcision. In learning about all the risks and complications of this surgery; and learning about the important functions of the foreskin in protecting the glans, providing the extra tissue needed for a comfortable erection, and in facilitating and enhancing intercourse; and after watching a video of a circumcision on the Internet, I have been at a loss for words as to why U.S. hospitals offer to routinely perform this cruel and irreversible surgery on non-consenting minors. I attended baby classes at my son’s hospital, but the hospital gave no info on circumcision. The instructor did not indicate they would be soliciting this surgery. The instructor only said that circumcision is a personal choice for the parents to make. I thought to myself it’s not my choice. It’s not my body. So long as hospitals continue to offer to perform genital reduction surgery, I ask: when will good and ethical doctors require hospitals and pediatricians, OB/GYNs and urologists to provide circumcision educational materials to parents that include the many risks and complications as well as the important role of the foreskin. I think hospitals should be required to show a video of a circumcision. I also think hospitals should be required to give parents adequate time to think about this important decision, say 1 month. It is such a disgrace to all U.S. medical professions that “medical professionals” are allowed to amputate healthy tissue from the genitals of healthy newborn males in the first place. Performing unnecessary and non-therapeutic surgery on minors is unethical. First do no harm! Girls are protected by U.S. law from unnecessary genital cutting. Why aren’t boys? The 14th Amendment guarantees equal protection under the law for both sexes.

  13. Gary Harryman says:

    Wow! One of the most carefully reasoned and clearly stated articles I’ve ever read on this subject. Thank you.

  14. C. Bharara says:

    Great to read such an article from an American doctor.

  15. Melinda B says:

    “While circumcision has been shown to reduce the transmission of HIV in high-risk populations in Africa, it has not been proven effective in the U.S. Avoidance of risky sexual activities and use of condoms are far more effective than circumcision in preventing the spread of these diseases.”
    Are African penises different than American? No. She completely disregards this serious health concern. If there is something a parent can do for their child to decrease their risk for HIV, I think it should be done. Perhaps Dr. Hamlin doesn’t come into contact with HIV enough to think it’s a serious issue in the US, too. You can teach your kids to use condoms as much as you want, but if they forget once at least they have this decreased chance of getting HIV just in case they are exposed.
    Her dismissal of this is repulsive.

  16. Craig Adams – 1) did you do any research about female genital mutilation before you said that comment? It can cause so much scarring that women who have this done may need to be cut with a knife before penetration with a penis is possible. The two are slightly different, most people would say.
    2) There is 9 months before a baby is born for the parents to decide on circumcision. Do they really need an extra month?
    3) Why do you trust a nurse’s opinion over a Doctor’s? Pretty sure one of them has considerably more education.

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