The Circumcision Decision

Deciding whether to circumcise a newborn male for non-religious reasons can generate fears, ethical quandaries and conflicting feelings for parents. More often than not, parents opt for circumcision, but the numbers have been declining for several decades, from nearly 90 percent in the late 1960s to about 60 percent today.

A 1999 statement by the American Academy of Pediatrics (AAP) said the potential medical benefits were not sufficient to recommend circumcision and advised the use of pain medication. (See boxed statement below for details.) Some American parents seem to have taken the information to heart, but not in largely significant numbers. According to the National Hospital Discharge Survey, the rates of circumcision dropped 6 percent from 1999-2003.

Jack Swanson, a pediatrician at the McFarland Clinic in Ames, Iowa, and a member of the AAP’s 1999 task force, says it may take several generations before non-religious circumcision is discontinued in this country. “Even though parents are given the information that there is no medical reason to do it, the concept that the fathers are circumcised still weighs heavily on an awful lot of decisions,” explains Swanson.

Swanson says task force members thought insurance companies might stop paying for circumcision, but that hasn’t borne out yet. However, North Carolina is one of 16 states that no longer foot the bill through Medicaid. “I think the rates would go down fairly significantly if insurance didn’t pay for it,” Swanson speculates.

Parents considering circumcision should discuss it at length before the baby is born, recommends Cary pediatrician Karen Todd of Cornerstone Pediatric and Adolescent Medicine. “Circumcision (for non-religious, non-therapeutic reasons) really comes down to a personal decision, not a medical one,” she says.

To Cut or Not to Cut?

No national medical society in the world recommends routine infant circumcision, and some European medical societies recommend against it. Almost 82 percent of the males in the world are uncircumcised, yet circumcision advocates still contend that it results in fewer urinary tract infections, a lower incidence of sexually transmitted disease and prevention of penile cancer.

The claims are questionable, especially when methods other than circumcision are more effective in preventing these diseases. Here is some of the current information surrounding these and other factors in the circumcision debate:

• Urinary Tract Infections: “There is little doubt that the uncircumcised infant is at higher risk for urinary tract infection (UTI), although the magnitude of this risk is debatable,” states the American Medical Association (AMA). UTIs can be up to 12 times as common in uncircumcised boys during the first year, but only about 1 in 100 to 200 uncircumcised boys contract UTIs in the first year.

• Sexually Transmitted Diseases: A recent study showed that circumcised males have a lower risk of syphilis and HIV, but the AMA clearly states that circumcision does not protect against these diseases. The best prevention is safe sex.

• Penile cancer: Cancer of the penis occurs almost exclusively among uncircumcised men, but the incidence is extremely low, accounting for only .2 percent of cancers in men and .1 percent of cancer deaths in men in the U.S. The American Cancer Society states: “It has been suggested that this practice provides some protection against cancer of the penis by helping to improve hygiene. Whether circumcision actually reduces risk is uncertain.” Other factors like hygiene, family history and sexual history are more significant.

• Cleanliness: Smegma, a thick white substance, can accumulate under the foreskin and sometimes cause inflammation, but this is not common.

• Sexual Pleasure: There are no recent scientific studies on whether circumcision reduces sexual pleasure. A Masters and Johnson study did not confirm any difference in tactile sensation. The foreskin is filled with nerve endings and is highly sensitive to the touch.

About Circumcision

A circumcision is performed every 28 seconds in the United States. Like any surgery, it requires anesthesia and carries risks such as bleeding, infection and surgical errors.

In North Carolina, the surgery is often performed by an obstetrician. The infant is placed on a board with his hands and feet restrained. The foreskin is either removed from the glans (head) of the penis by cutting or by Plastibell method, which involves placing a plastic bell on the glans, cutting and stretching the foreskin over the bell and tying it off with string to cut off blood supply. Any remaining foreskin sloughs off within two weeks.

Pain management options include a topical cream (which takes effect in 30 minutes) or a penile block, which involves injecting the penis with a local anesthetic. The cream can be used prior to injections for a combination of pain relief.

Dr. David Horowitz of Triangle Pediatrics has practiced in the area for more than 20 years. He says pain medication is now routinely used at area hospitals, but circumcision techniques vary depending on the obstetrician.

Horowitz has noticed a slight decline in the numbers of parents choosing circumcision, but he says the change feels it is negligible. “Frankly, the only changes I see are the ethnic and cultural backgrounds as a major determinant,” he says. “With Hispanic and Asian populations increasing, I think those are groups that traditionally don’t do circumcisions as much.” — CP

According to the AAP

“Existing scientific evidence demonstrates potential medical benefits of newborn male circumcision; however, these data are not sufficient to recommend routine neonatal circumcision. In circumstances in which there are potential benefits and risks, yet the procedure is not essential to the child’s current well-being, parents should determine what is in the best interests of the child. To make an informed choice, parents of all male infants should be given accurate and unbiased information and be provided the opportunity to discuss this decision. If a decision for circumcision is made, procedural analgesia should be given.”

AAP Task Force on Circumcision, 1999-2000