To circumcise or not to circumcise?
Parents must weigh medical and social factors
Monday, September 12, 2005
Why the disagreement?
Some cite medical benefits as a reason to circumcise; others cite medical risks as a reason to avoid it.
In reality, no comprehensive studies have been done to evaluate the risks or benefits of circumcision. But after reviewing smaller studies on circumcision, the American Academy of Pediatrics (www.aap.org) concluded the known medical benefits are not significant enough to recommend routine circumcision.
So for many, the circumcision decision comes down to religion or social acceptance.
But parents earnestly weighing this decision need to understand the pros and cons.
Circumcision began as a social ritual at least 6,000 years ago and remains part of the Jewish and Muslim faiths.
Today, the United States is the only country in the world where the majority of newborn males are circumcised, most for nonreligious reasons.
There is no precise data on the U.S. circumcision rate, but a 1997 study in the Journal of the American Medical Association showed the rate rose from about 30 percent in the 1930s to about 80 percent in the 1960s. It has slightly declined since. Overall, 77 percent of the U.S.-born men in the survey were circumcised vs. 42 percent of non-U.S.-born men.
The rate of minor complications such as bleeding and infection is about 3 percent, according to the American Urological Association. Circumcised infants are also at risk for meatitis or meatal stenosis, an inflammation or narrowing and constriction of the penis opening in response to irritation from urine and fabric. The rate is between 8 and 21 percent, according to the American Academy of Family Physicians (www.aafp.org). Meatal stenosis sometimes requires surgery.
More serious complications include poor cosmetic outcome requiring surgical reconstruction, as well as rare cases of injury leading to loss of some or all of the penis and occasionally death.
Pediatric urologists spend as much as a quarter of their time correcting poorly performed circumcisions, says Dr. Clare Close, director of pediatric urology at the University of Chicago Hospitals. Close says parents often mistakenly think circumcision is a routine procedure anyone can perform.
"This procedure should not be taken lightly," Close says. "The baby’s penis needs to be well evaluated, and the person doing the procedure needs to be well trained and experienced." Circumcision should not be performed if the opening of the penis is not exactly at the tip, if the penis looks twisted or bent or if the penis is concealed or buried.
Although all major medical associations (including the American Academy of Pediatrics) recommend using local anesthesia, some physicians perform the procedure without it. So parents who choose circumcision should make sure the latest recommendations are followed.
On the plus side, circumcision decreases a baby’s risk of urinary tract infections in the first year from 7 to 14 in 100,000 to 1 to 2 in 100,000, estimates the academy.
Newborn circumcision also decreases the risk of penile cancer, a rare disease that usually occurs in elderly men, from about 3 in 100,000 to 1 in 100,000, the academy says.
A small percentage of uncircumcised boys may experience problems later in childhood, such as inflammation of the head of the penis (balanitis) or inflammation of the foreskin. It is possible uncircumcised boys may experience phimosis, tight foreskin that does not retract easily, or paraphimosis, where the foreskin becomes trapped and cannot be pulled down to cover the head of the penis. Both usually can be treated without surgery, the academy says.
Some studies suggest uncircumcised men are at a higher risk of getting and spreading sexually transmitted diseases, including HIV. But the American Academy of Pediatrics says "behavioral factors appear to be far more important than circumcision status."
For many parents, the issue of social acceptance weighs more heavily than the medical rationale.
"We struggled with this decision," says Keeley Sorokti of Chicago, whose 6-month-old son was circumcised. "We didn’t want our son to wonder or ask why he looks different."
Parents who decide against circumcision should be prepared to explain why their son is different, says Dr. Thomas Cummins, a pediatric psychiatrist at Children’s Memorial Hospital in Chicago. Parents can explain boys are born with foreskin and some parents choose to have their babies undergo a minor operation to remove it. Social implications may come up in the junior high years—if not before—when children are changing together in gym class. But there is no reason to think being uncircumcised will cause ostracism, Cummins says.
Melissa Gallagher of DeKalb has one boy who is circumcised and one who is not. She says she wasn’t completely supportive of her 9-year-old son’s circumcision. "But my husband really wanted it, and I felt some family pressure."
For her second son, Gallagher chose a home birth with certified nurse midwives, who did not perform circumcision. At that time, Gallagher and her husband were self-employed and their health insurance would not pay for the circumcision, which would have cost about $2,000 as an operation independent from the baby’s birth.
"From my standpoint, I was glad, and the cost made it easier for my husband to deal with," Gallagher says.
Practitioners usually charge around $200 to perform a newborn circumcision and the procedure is often covered by health insurance.
Circumcision and hygiene
Care and hygiene may also sway parents toward circumcision. While care of the uncircumcised penis is not difficult or complicated, problems can arise if hygiene is neglected. And attempts to retract the foreskin and clean the penis before the foreskin is naturally retractable can do more harm than good.
"Never let a physician force the foreskin back," Close says. "There is a general feeling in the primary care physician community that foreskin needs to be retractable by age 5, but there is no magic age at which the foreskin will retract."
The foreskin is fused with the head of the penis at birth and is not easily retractable in a boy's early years. Forcibly pulling the foreskin back may result in bleeding, scarring and the subsequent need for circumcision.
Close recommends tub baths for uncircumcised children, gentle retraction of the foreskin without forcing and gentle cleaning with soap and washcloth. Little boys should be taught to pull the foreskin back very slightly during urination so urine does not flow into the foreskin. When the boy becomes sexually active, Close says, it is important for him to wash prior to and after intercourse to reduce the risk of spreading an infection.
Tracy Binius is a writer living in Oak Park.