Second Opinion:
Circumcision
Written By Jack Maypole, M.D.
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Snip it. Snip it good.
If you've got a boy on the way, good luck. As if labor and delivery weren't emotionally taxing enough, new parents of baby boys must immediately decide about a surgical procedure for their sons — circumcision. Over the past few decades, the number of parents who choose circumcision has dropped dramatically: In the U.S. the rate's gone from about 90 percent in the 1970s to less than 60 percent today, which is still higher than many other countries (see "By The Numbers"). Parents have much to consider, even those whose religion or culture prescribes it, and I get a lot of questions (often from dads, as you might guess): Are there risks? (Some, but problems are rare and usually minor.) Are there benefits? (Maybe, such as reduced susceptibility to sexually transmitted diseases.) Aren't there some boys who shouldn't have it done? (Definitely. An abnormality of the penis might rule out a circumcision.) I wonder, at this point, how many male readers have crossed their legs. In this case, I believe the doctor's role is to present the information, facilitate a discussion, and then get out of the way. With help from my friend and colleague, Benjamin Spencer, M.D., an assistant professor of urology and epidemiology at Columbia University and a certified mohel (he performs ritual circumcisions on Jewish male infants), I'll discuss parents' most common questions and concerns in an effort to shed some light on this private(s) matter.
Risky Business?
With any surgical procedure, we doctors frequently say, there are risks and outstanding circumstances. Fortunately, the most serious risks — substantial damage to the penis or a devastating reaction such as sepsis or hemorrhage — are exceedingly rare. The more common risks are still quite rare, as far as risks go, but include a poor cosmetic effect with too much or too little tissue left over. Occasionally I send kids back for "revisions."
With some abnormalities — most commonly hypospadias (where the urethra opens and urine exits at a site below the tip of the penis) — a circumcision should be avoided, according to Dr. Ben. Premature infants might need to delay circumcision until the equipment is simply larger and easier to attend to.
Ouch.
I've met many parents who are interested in circumcision but can't get past the pain involved for their child. It seems obvious now, but we only began to realize in the last couple of decades that newborns do feel pain. Consequently, and fortunately, there are several pain control methods available for babies before, during, and after a circumcision, including oral doses of acetaminophen, sucrose administered by pacifier, breast milk (really — it works), topical anesthetics, or numbing injections called nerve blocks ("the most humane approach," says Dr. Ben).
Like Father, Like Son
Many parents want their sons to look like other males in their family, be it circumcised or un. Less frequently nowadays do I hear concerns about boys feeling comfortable in the locker room, partly because the locker room scene varies regionally, with higher circumcision rates in the central U.S. than elsewhere. About half the boys born in this decade will be uncircumcised, and I suspect the rate will continue to drop. Whatever they choose, parents can seize this opportunity for a "different strokes for different folks" talk.
Papa Don't Preach
Circumcised males have lower rates of penile cancer and, recent research suggests, a reduced risk of contracting HIV and other sexually transmitted diseases, such as HPV, herpes, and syphilis. The thinking here is that the fragile foreskin may be an easier point of entry for these infections, or that the glandular secretions — a.k.a. smegma (some medspeak is so colorful) — found in uncircumcised males may predispose these males to penile cancer. While I get questions about this topic, I don't find many parents making a circumdecision (okay, not a real term) on this basis. Personally, I'm okay with that, as I don't find the data that compelling at this point. The American Academy of Pediatrics finds these health benefits a reason to favor but not formally recommend circumcision. Helpful, huh?
Big Boy
Parents often have concerns about how their adult son will feel about his circumcision, or lack thereof (especially if they've ever Googled this topic). Some critics call circumcision a violation of human rights and a form of genital mutilation. Others argue that the procedure causes undue lifelong emotional trauma, decreased sensation, or that the medical reasons for it are not merited. Some even advocate for the restoration of the foreskin via plastic surgery or stretching techniques. For my part, I respect these points of view but choose to disagree. I haven't seen convincing data that links circumcision with any long-term impact on self-esteem or sexual satisfaction, and I have yet to meet an adolescent or young adult who requires psychosocial support or intervention due to the loss of his foreskin.
Circumspect
Parents who remain ambivalent or conflicted about whether to circumcise might best defer their decision: Once that skin is gone, it's gone. Parents should know, however, that circumcisions that are performed after a baby is discharged from the hospital (and outside of a religious setting, such as a Jewish bris) are typically done under general anesthesia, so it's a more involved surgery at that point. All said, I'm pleased to report that the overwhelming majority of families and their sons live happily with their choice to circumcise or not. And different looks aside, males will be united in their weak-kneed response to this subject.
By the Numbers
- 57 — Percentage of boys circumcised in the U.S.
- 8 and 9 — Percentage of boys circumcised in Australia and Canada, respectively.
- 1out of 3 — Ratio of circumcised to uncircumcised males, worldwide.
- 16 — Number of states that no longer fund newborn circumcision through Medicaid.
- 50 to 60 — Percentage by which male circumcision lowered female-to-male HIV transmission in a 2006 National Institutes of Health study.
- 0.2 to 2 — percentage of U.S.circumcisions with complications.
Basic Foreskin Maintenance
Number one rule: Never forcibly retract a foreskin. As a doctor and a male I urge parents not to tug, even if the collar of skin seems reluctant to pull back over the glans (tip of the penis). Tugging may cause pain or irritation, and repeated trauma may ultimately lead to scarring or abnormal tightening (called phimosis), which may be treated by circumcision. For most boys, the foreskin will naturally stretch and separate by age 5.
To clean, a few gentle swipes with a baby wipe or soap and water now and then will do. No need to go after smegma (whitish, yellow, or gray debris) aggressively with a cotton swab. Like most secretions, it'll find its way to daylight. If you feel oogey or need some pointers on how to handle and clean an uncircumcised penis, don't be afraid to ask your pediatrician (we get that a lot).
About the Author: Pediatrician Jack Maypole lives with his family in the Boston area. Not surprisingly, his son declined to be quoted in this column.
Next: Circumcision 101
Circumcision 101
Male infant circumcision is done in the first days of life and usually takes only a couple of minutes. The physician (often an obstetrician or family practice doctor) places surgical clamps over the penis to protect the tip and to isolate the foreskin. The foreskin tissue is stretched out like an unfolded turtleneck and trimmed. My friend and colleague Benjamin Spencer, M.D., weighs in: “A dressing is applied to the penis for about 48 hours, or a skin adhesive called Dermabond might be used. Small amounts of bleeding are to be expected, but prolonged oozing or dripping of blood would merit another checkup by the doctor. Infection, fortunately, is rarely a concern.” Dr. Ben should know: He’s an assistant professor of urology and epidemiology at Columbia University and a certified mohel (trained to perform ritual circumcision on Jewish male infants).
For a week or two after the circumcision, parents can place a dab of petroleum jelly on the front panel of the diaper to aid in healing and prevent irritation to the tip of the penis. As everyone knows, the blood supply to that part of the body is ample, allowing for incredibly fast healing. Scabs usually form within a week, and the area appears normal within a fortnight.
