Should your child be circumcised?

At birth, males have skin that covers the end of the penis, called the foreskin. Circumcision surgically removes the foreskin, exposing the tip of the penis. Circumcision is usually performed by a doctor on stable healthy infants within the first few days of life. The practice of circumcision has been recorded throughout history, and may be the oldest planned surgical procedure in civilization, dating back to 2200 BC. But despite the historical significance of circumcision, the procedure has been a perpetual source of controversy. Scientific studies show many medical benefits of circumcision. However, these benefits are not sufficient for the American Academy of Pediatrics (AAP) to recommend that all infant boys be circumcised. Because circumcision is not essential to a child’s health, I believe the best approach for any parent considering circumcision for their child is to gain a general understanding of the procedure including the risks and benefits and then choose what is best for their child. And because circumcision may be more risky if done later in life, parents should decide before or soon after their son is born if they would like it done.
 
Circumcision can be performed on the newborn male by three commonly used techniques all which include the use of devices: the Gomco clamp, the Plastibell device, and the Mogen clamp. Complications associated with the procedure are almost uniformly minor and rare, ranging between 0.2% and 0.6% by most studies. Studies have shown that neonatal circumcision is painful, as measured by raised heart rate, blood pressure and serum cortisol levels, and reduced oxygen saturation. However, various methods of analgesia during neonatal circumcision have shown significant pain reduction, the most effective being dorsal penile block and ring block. The use of analgesia during circumcision, therefore, is now the standard of care.
Advantages:
There are a variety of reasons why parents may choose circumcision for their child so let’s go over most of them. There are the medical benefits which include:
1. A slightly lower risk of urinary tract infections (UTIs) in the first year of life.
2. A lower risk of getting cancer of the penis. However, this type of cancer is very rare to begin with in all males.
3. A lower risk of acquiring sexually transmitted infections (STIs), including HIV. This will be discussed further later.
4. Prevention of foreskin infection and phimosis, a condition in uncircumcised males that makes foreskin retraction impossible.
5. Easier genital hygiene.
There are also social reasons why many parents choose to have it done. In the US there is a desire to conform to what most of the population already does or because “all the other men in the family” had it done and they do not want their sons to feel “different.”  Religious or cultural reasons also play a role in circumcision. Many groups such as followers of the Jewish and Islamic faiths practice circumcision for religious and cultural reasons.
 
Disadvantages:
There are also many reasons parents may choose NOT to circumcise their child. Because it is a medical procedure many parents are concerned about the complications. As stated previously they are rare and usually minor but may include bleeding, infection, cutting the foreskin too short or too long, and improper healing.
There is also the belief that the foreskin is needed to protect the tip of the penis and without it the tip of the penis may become irritated and cause the opening of the penis to become too small.
Many also believe that proper hygiene can lower health risks. Boys can be taught proper hygiene that can lower their chances of getting infections, cancer of the penis, and STIs.
Finally there is the belief it can affect sex. Some feel that circumcision makes the tip of the penis less sensitive, causing a decrease in sexual pleasure later in life. Although there are anecdotal reports that penile sensation and sexual satisfaction are decreased for circumcised males, Masters and Johnson noted no difference in exteroceptive and light tactile discrimination on the ventral or dorsal surfaces of the glans penis between circumcised and uncircumcised men. However a survey of adult males using self-report suggests more varied sexual practice and less sexual dysfunction in circumcised adult men.
 
Circumcision’s New Hot Topic: Most of the new studies and data on circumcision in the last few years focus on infection. Because much of the evidence so far is quite compelling, the AAP is in the process of revisiting its stance on circumcision to reflect this new data.
In response to the urgent need to reduce the number of new HIV infections globally, the World Health Organization (WHO) and the UNAIDS Secretariat convened an international expert consultation in March 2007. They found strong evidence from three randomized controlled trials that male circumcision reduces the risk of heterosexually acquired HIV infection in men by approximately 60%. Based on the evidence presented male circumcision is now recognized as an additional important intervention to reduce the risk of heterosexually acquired HIV infection in men.  Another recent study released in the New England Journal of Medicine noted that in addition to decreasing the incidence of HIV infection, male circumcision significantly reduced the incidence of HSV-2 (genital herpes)infection and the prevalence of HPV infection.
Again I would like to emphasize that each parent considering circumcision for their child should take the time to familiarize themselves with the procedure. The American Academy of Pediatrics states that neonatal circumcision has potential medical benefits and advantages, as well as disadvantages and risks. Either way, it is essential that both options are given to patients’ families and that they make an informed decision to do what is best for their child. Do not be afraid to ask who would be performing your child’s circumcision and what technique and pain control they would be using for your child.
Anyone who wishes to more be more fully updated on all aspects of circumcision can see the AAPs most recent policy statement at: http://aappolicy.aappublications.org/cgi/content/full/pediatrics;103/3/686
 
You can also find useful information under patient education on the AAPs website at: http://www.aap.org/healthtopics/stages.cfm#inf
 
Other articles directly used include:
 
Austin PF. Is neonatal circumcision clinically beneficial? Argument in favor. Nature Clinical Practice Urology 6(1):16-7, Jan 2009.
 
Golden MR and Wasserheit JN.  Prevention of Viral Sexually Transmitted Infections – Foreskin at the Forefront. NEJM 360(13):1349-51, 26 Mar 2009.
 
Tobian AA et al. Male circumcision for the prevention of HSV-2 and HPV infections and syphilis. NEJM 360(13):1298-309, 26 Mar 2009.

Clayton Cummings, M.D. About Clayton Cummings, M.D.

Clayton B Cummings, M.D., is a pediatrician at St. Louis Children's Hospital and an Instructor of Pediatrics at Washington University School of Medicine. He received his undergraduate education at University of Missouri Columbia in Business Administration and is a 2000 graduate of University of Missouri School of Medicine. He completed his internship and residency in Pediatrics at Kosiar Children's Hospital with the University of Louisville in 2003 and has sinced worked at St. Louis Louis Childrens Hospital. He is board certified in Pediatrics and an active member of the AAP. He is a varsity assistant coach and the junior varsity head coach of Clayton High School Boys Lacrosse team since 2006. His other interests include adventure racing, triathlon and multisport training, basketball, volleyball and skiing. He remains the national design and training director for cycling with spinning for endurancefilms.com.

Comments

  1. Sorry Dr., but it should not be the parent’s decision.

    I was circumcised as a baby, without my consent!

    That is the main issue, it should not be anyone’s decision except the owner of the penis.

    Just the chance that the child will be dissatisfied later is cause enough to leave a child intact. Also there is a lowered sexual response, the foreskin itself contains more fine touch receptors than any other part of the penis and circumcision results in a great loss of sensation as nearly 1/3rd of the infant penis is chopped off.

    I don’t see any articles discussing the benefits of female circumcision, because this practice is not accepted any more. The only reason there is a discussion about this is because it is accepted. If you actually look at the research circumcision was initally done to prevent children from masturbating.

    I hope that you as a doctor step outside the dogma and realize there is no reason to surgically amputate part of a child’s penis, even if there is some slight reduction of STDs, it is ridiculous.

  2. concerned cynic says:

    I start with some raw facts. Continental Europe and Japan have never circumcised. The UK (New Zealand) used to, but gave it up in the 1950s (1970s and 80s). In Australia and Canada, the rate is down to 15% and 30% respectively. The only advanced countries other than the USA to circumcise large numbers of boys are South Korea and Israel. There is no evidence that the few countries that do circumcise routinely have better health outcomes than the many countries that do not. The American peer reviewed literature has ignored this fundamental point for 30+ years.

    Circumcision makes HIV less likely? Tell that to the quarter million American and Canadian gay men who have died of AIDS since 1975. The vast majority of these men were circumcised. HIV and other STDs are LESS common in Europe and Japan, which do not circumcise, than in the USA, which does. Only American authors claim that routine circumcision has prophylactic benefits. They rig the outcomes of their studies by using subjects from the Third World or from the American urban underclass. These studies tell us nothing about whether it is advisable to circumcise a baby boy born into the families of nearly all readers of this blog.

    Many American doctors refuse to inject lidocaine before performing a circumcision. When they do inject, they do not allow enough time for the lidocaine to have full effect. Pain experienced by a neonate apparently is not a concern for the majority of American obgyns. It is a concern for me.

    1. A slightly lower risk of urinary tract infections (UTIs) in the first year of life.
    ME. Girls have much higher rates of UTIs than boys. These UTIs are treated with antibiotics. Why not do likewise for baby boys?

    2. A lower risk of getting cancer of the penis.
    ME. Not true when both kinds of men take daily showers, and when phimosis is treated in young adults/

    3. A lower risk of acquiring sexually transmitted infections (STIs), including HIV.
    ME. There is no evidence that this is the case, when both circumcised and intact boys are from similar middle class families.

    4. Prevention of foreskin infection and phimosis, a condition in uncircumcised males that makes foreskin retraction impossible.
    ME. Phimosis and balanitis are easily treated in nonsurgical ways.

    5. Easier genital hygiene.
    ME. The AAP has explicitly rejected this argument. Cleaning an intact penis is trivial. And enjoyable :)

    Finally there is the belief it can affect sex.
    ME. It does. Ask sexually experienced American women, something that American medical researchers never think of doing.

    Some feel that circumcision makes the tip of the penis less sensitive, causing a decrease in sexual pleasure later in life.
    ME. It is a very common American misconception that the glans penis is the sexiest part of the human male. The sexiest parts of man, and the most richly enervated parts, are precisely the parts which circumcision ablates. The consequences of this ablation for sexual pleasure and function are often not evident until after age 40 or even 50. Masters and Johnson, and dozens of subsequent clinical studies, have missed this point, because American and Canadian investigators are either circumcised males or the spouses thereof.

    However a survey of adult males using self-report suggests more varied sexual practice and less sexual dysfunction in circumcised adult men.
    ME. Presumably you have Laumann et al (1997) in mind. There is no evidence that the foreskin is correlated with sexual dysfunction once you control for income and education. Never forget that in the USA, foreskin was correlated with being born in poverty, and poverty is strongly correlated with bad health outcomes and irresponsible sexual practices. Do circumcised men truly have more varied sexual practices, or are they simply more willing to admit or invent sexual practices, because they are more educated? In the USA last century, being circumcised was strongly correlated with being born into the sort of urban middle class family that was highly supportive of sending a son to college. Being born into that sort of family is also positively correlated with responsible sexual behaviour.

  3. Cristiana Spiridigliozzi says:

    Europe Council votes on circumcision as human rights violation, a violation of the physical integrity of children.

  4. No health professional who has any medical insight can support an elective surgery on a newborn!
    Promoting or even performing genital cutting on healthy babies or children (boys or girls) is a violation of all medical ethics.
    There are no valid health benefits to wound babies, in fact, it isn’t even recognized as being anything else than religious/traditional. No doctor in his/her right mind would even have gotten such an idea if it wasn’t for religion.
    The mere origin of circumcision was to reduce masturbation and sexual pleasure so performing this is clearly a human right’s violation!
    From one doctor to another, I urge you to consider following things:
    - a newborn can’t metabolize proper pain medication or anaesthetics, they stress liver and kidneys and even lidocaine can lead to seizures in newborns and should not be used!
    - a newborn boy feels more pain than a adult male due to the lack of testosterone
    - severe pain being the first feeling a baby boy gets from his genitals (especially in the most important imprinting phase!) is psychological questioning!
    - the body indeed has a pain memory!
    - the stress hormones skyrock and not only alter brain functions, they also interfere with the bonding hormone oxytocin (in case you are not aware of this fact: this was meant by nature for women to stop labour, when danger approaches)
    - the glans is still fused to the foreskin in infancy, it has to be ripped off which leaves an open wound in a soiled diaper (high risk of MRSA infection)
    - you can’t even tell if he is hemophiliac yet!!
    - the foreskin of a grown man is highly innervated and has huge blood vessels, removing those can lead to ED later in life
    - the glans is supposed to be an inner organ, like the eyeball, and must be protecte from the elements and lubricated. If you remove the proetction, it becomes callous which adds to the lack of feeling
    - another thing you should be aware of: naturally, the glans is only seen on an erect penis (fused in infancy and early childhood) and the sight of the glans triggers sexual thoughts in a mammal’s brain. Forcing this look onto a child is not only perverted, but also disgusting.
    - also, the STD example does not apply to children, but even in grown men, it’s not working: circumcised men are even more at risk to get STD’s, because they are usually less likely to use condoms, either due to the lack of feeling (harder to orgasm with a condom) or because they are fooled to think they are safe now.
    Europe doesn’t do genital cutting and has a much lower rate of HIV (and even of penile cancer!), than the USA.

    In short, there are ZERO medical benefits on RIC, only harm and risks.

Speak Your Mind

*