Uncategorized • Aug 31, 2010

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.
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.
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.