When Kathleen Piraino was pregnant with her first son, Jasper, she avidly researched childbirth procedures and found that many medical interventions once considered necessary -- such as episiotomies and constant fetal monitoring -- no longer were. She began to wonder if the same was true of circumcision, the surgery to remove the foreskin from the penis that is performed on the majority of American baby boys shortly after birth. "These were routine practices that we later learned were often unnecessary," she said. "I wondered if circumcision would be the next procedure called into question."
While many arguments in favor of circumcision seemed unconvincing to her, claims from the anti-circumcision camp about the dangers of the practice seemed alarmist. Ultimately Piraino chose to circumcise her son, but the decision was based on the traditions of her husband's Jewish faith, not medical evidence. Like many parents, she was disconcerted that the last 30 years of research and hot debate among the American medical community and the public had failed to produce a definitive answer to many parents' simple question "Should we circumcise our son?"
Consider the policy of the American Academy of Pediatrics (AAP), the first place many parents or parents-to-be turn when making medical decisions for their children: "Existing scientific evidence demonstrates potential medical benefits of newborn male circumcisions; however these data are not sufficient to recommend routine neonatal circumcision." So, is that a yes or a no?
Neither, says Alan R. Fleischman, M.D., professor of pediatrics at the Albert Einstein College of Medicine in New York and a member of the AAP task force on circumcision that drafted the 1999 policy statement. "The AAP has always maintained neutrality and argued that it is the decision of parents in consultation with families and pediatricians," explains Dr. Fleischman. "There are some potential medical benefits of circumcision, and there are some risks of circumcision. The risks tend to be minor and the benefits are significant, but not significant enough to make a recommendation."
What the AAP does advocate is that parents have access to accurate, up-to-date information presented without hype or hostility so they can make their circumcision decision with comfort and confidence. With that in mind, BabyTalk spoke to experts on both sides of the circumcision debate to give you the background you need to make an informed choice.
A brief history
At birth a boy's penis is covered by a layer of skin (the foreskin) over the rounded head (the glans). Circumcision is a minor surgical procedure -- usually done with a clamp in a matter of minutes -- which removes the foreskin, exposing the glans and the urinary opening. An estimated 1.2 million newborn boys are circumcised in America each year. Most procedures are performed in the hospital shortly after birth by either an ob/gyn, pediatrician, or family practitioner, but some are done in other locations by ritual circumcisers in accordance with religious tradition.
Circumcision has been around for about 6,000 years and is part of a number of religious and cultural traditions, including the Muslim and Jewish faiths. Some doctors theorize that circumcision originated among desert-dwelling peoples because sand trapped under the foreskin caused irritations and infections. In this country, circumcision has fallen in and out of favor over the past few decades.
In the 1950s, about 90 percent of American baby boys were circumcised, due in part to research that linked circumcision to a reduction in the rate of cervical cancer in women and penile cancer in men. Foreskin infections that plagued U.S. soldiers during World War II and led to many adult circumcisions were also fresh in the minds of dads and doctors. Infant foreskin removal was considered a good way to improve hygiene for life.
But in the '60s and '70s, routine circumcision came under fire as unnatural and unnecessary. Much of the earlier research was reevaluated and discounted as invalid or inconclusive, and doctors and parents became concerned about self-determination -- in other words, did parents have the right to alter boys' penises without their consent? In its first ever policy statement on circumcision in 1971, the AAP repudiated two decades of medical practice and stated that there were no valid reasons for routine circumcision. By 1988, rates dropped to 61 percent; today they are at about 65 percent.
During the past decade new studies on infant urinary tract infections, HIV transmission, and cervical cancer, plus a careful review of older research, have caused the medical community to rethink its dismissal of circumcision as merely cultural. At the same time, the easy availability of information -- and misinformation -- on the Internet has helped bring the debate over circumcision to a fever pitch.
The current controversy
When he was training in the 1970s, Thomas E. Wiswell, M.D., agreed with the AAP's anti-circumcision stance so much so that he didn't circumcise his own son, now 21. But Dr. Wiswell, a professor of pediatrics at the State University of New York at Stony Brook and a specialist in neonatology, now favors circumcision. He says observations from his own practice, a review of medical literature, and recent research demonstrate that it is a surgery with minor risks and proven health advantages. He hopes that in its next policy statement, the AAP will come out in favor of making the procedure routine. "I think current evidence favors newborn circumcision," Dr. Wiswell says. "For me it's almost a simple scale of potential benefits versus risks, and which side of the scale is heavier."
But Paul M. Fleiss, M.D., a vocal leader of the anti-circumcision movement, couldn't disagree more. "I don't think you can justify the risks for an elective procedure," says Dr. Fleiss, a Los Angeles pediatrician in private practice and author of What Your Doctor May Not Tell You About Circumcision. "A circumcised penis is a mutilated penis." Interestingly, Dr. Fleiss also started his medical career on the other side of the issue -- approving of and performing circumcisions. He stopped because he felt he was inflicting pain and started studying the foreskin. He concluded that it was not an extra piece of skin, but an integral part of the penis. "Circumcision is not like clipping fingernails," he says. "You are changing the anatomy of a boy forever."
The case for circumcision
What are the real risks and benefits associated with the procedure, and how do they compare? The AAP has identified three key areas where circumcision can improve a male's health profile -- sexually transmitted diseases (STDs), infant urinary tract infections (UTIs), and cancer of the penis -- and some new information bolsters these claims.
When the AAP issued its recommendation in 1999, it called evidence of the relationship between STDs and circumcision "complex and conflicting." The report did state, however, that being uncircumcised has been linked with an increased risk of syphilis and that multiple studies have shown that circumcision reduces the risk of infection with HIV, the virus that causes AIDS. But the task force concluded that in a country with modern attitudes toward the use of condoms (the most effective means of reducing HIV transmission), circumcision was not the way to reduce rates of HIV, says Dr. Fleischman.
The latest research makes the case for circumcision more compelling. A study reported in the New England Journal of Medicine of over 1,900 couples in Spain found that circumcised males were less likely to be infected with human papillomavirus -- which causes genital warts -- and their female partners had a reduced risk of cervical cancer. Also, an article in the American Journal of Pathology reported that cells in the tissue of the foreskin itself were more susceptible to HIV infection than cells elsewhere.
On the subject of UTIs, virtually all studies, both recent and retrospective, show that circumcision has a protective effect. The AAP task force report notes that an uncircumcised male has a 1 in 100 chance of getting a UTI during the first year of life, compared to a 1 in 1,000 chance for a circumcised male. "UTIs in infants are not just simple bladder infections," says Dr. Wiswell, who began to question his anti-circumcision stance when he realized how many of the babies he treated with these infections were uncircumcised. "They are caused by a bacteria that can infect the kidneys and cause scarring." Such scarring, which is estimated to occur in about half of babies who suffer UTIs in childhood, can sometimes lead to high blood pressure and even kidney failure later in life.
The AAP task force, however, felt the chance of a UTI was too slight to use it as a basis for recommending circumcision, says member Jack T. Swanson, M.D., a pediatrician in private practice at the McFarland Clinic in Ames, Iowa. "You would have to do over 100 circumcisions to prevent one case of UTI," Dr. Swanson notes.
Comparative rates of penile cancer are more dramatic. This deadly (it has a 50 percent survival rate) and disfiguring disease is at least three times more common among uncircumcised men, but the AAP determined that it is far too rare to be a reason for circumcision. The American Cancer Society estimates that only 1,200 new cases, most in men over 50, will be diagnosed this year. Also, some countries where the circumcision rate is low, like Denmark, have rates of penile cancer lower than that of the U.S. Other factors, such as smoking, a history of large numbers of sexual partners, and STDs, put certain men at an elevated risk.
Studies also suggest that circumcision can prevent certain minor problems that affect boys' penises. One recent study found that 11 percent of uncircumcised men visiting urology clinics have balanitis, an inflammation of the foreskin, or phimosis, a too-tight foreskin that, in severe cases, requires surgery. But again, many doctors say, and at least one study backs them up, that good hygiene (learning to properly care for an uncircumcised penis) can prevent many cases of inflammation and phimosis.
The risks involved
There isn't much firm data on the risks of circumcision -- perhaps because some surgeries are performed outside the hospital setting, but doctors say that over a million circumcisions are done each year with few ill effects. About 1 in 500 boys will have complications from the surgery, most minor and short term, including moderate bleeding, pain, irritation, and infection. To reduce this risk, circumcision should be postponed if a baby is premature or has birth defects or a family history of bleeding disorders.
While the idea that infant pain should be treated was not acknowledged until fairly recently, research (such as monitoring heart rate, crying, and breathing) indicates, not surprisingly, that circumcision hurts. In 1998, the AAP strongly recommended the use of local anesthesia during circumcision. "I think we know now there is pain in circumcision," says Dr. Fleischman. "But there are ways to provide excellent pain relief and they should be used."
Severe complications of circumcision are extremely rare: About 1 in 10,000 circumcisions results in bacteremia, or infection entering the bloodstream. There are also what doctors refer to as "isolated case reports," perhaps one every few years, of horrific and frightening complications like accidental amputation of the penis. In 50 years and 100 million circumcisions, there have been three deaths, two of which occurred because the boys had the blood disorder hemophilia. (Any male with a family history of hemophilia or any bleeding disorder should be tested -- either in utero or from a cord blood sample at birth -- before circumcision.)
Myths about the risks of circumcision still abound and have been given new life by the Internet. Many sites against circumcision argue that circumcised men are more prone to sexual dysfunction, cannot achieve true satisfaction, and even suffer from post-traumatic stress disorder and other mental conditions due to the loss of the foreskin.
Though there are anecdotal reports (from individuals) that circumcision decreases sensation, Masters and Johnson, the noted sex experts, reported no difference in sensation between the circumcised and uncircumcised penis. What's more, the AAP reported that at least one survey suggests less sexual dysfunction among circumcised men. "We can't say that what the anti-circumcision camp is saying is not important," says the AAP task force's Dr. Swanson. "But we did all of our recommendations based on proven evidence, and good studies have not shown their claims to be fact at this point."
Making a decision
Although the risks of circumcision are minor and medical benefits do exist, circumcision isn't essential to your newborn boy's well-being now or later. Parents can also reject the notion that the foreskin is somehow unclean, despite claims dating back to ancient Egypt that equate circumcision with good hygiene. We don't live in the desert without running water, and we're not stuck in the WWII trenches. The AAP states that parents should understand how to keep their son's penis clean -- regardless of circumcision -- and then, eventually, teach him to do it himself.
Many non-medical factors must also go into parents' decisions, such as how boys will feel as they mature. Dr. Fleischman says the AAP task force considered these, but issues like locker room teasing and whether it's important for a boy to think his penis resembles his dad's are highly individual and not the subject of studies, so the task force left them to the discretion of families. "Culturally, families need to both look to their heritage and the present environment and put these in context," he says.
Though she says she has never encountered teasing over circumcision in 18 years of working with children, Judy Freedman, a licensed clinical social worker based in Glencoe, Illinois, and author of Easing the Teasing: Helping Kids Cope with Name-Calling, Ridicule, and Verbal Bullying, comments that children list differences in appearance as the number one thing they are teased about. But parents shouldn't make the circumcision decision based on their desire to protect their children, because bullies will always find something to ridicule. "Parents who have a child with any difference can work to prepare him in terms of how to deal with it," says Freedman. And with roughly 65 percent of boys being circumcised today, it's likely that there will be a mix of appearances in the locker room.
You should make your decision based on what you believe are the best interests of your child. Talk it out with your husband and physician, and consult with family or religious advisers if cultural traditions are a factor. Though it may be tempting to wait and let your son decide for himself, it's not recommended. Circumcisions done after the neonatal period are higher risk and generally more traumatic to the individual. Remember, this is only the first of many decisions you'll make regarding the health of your baby boy. And the fact that you care enough to make it thoughtfully shows you're off to a good parenting start.