If you think U.S. parents are conflicted on the topic of male circumcision, you might blame the murky stance taken by the American Academy of Pediatrics (AAP). Its latest word on male circumcision, published on its parent-focused “Healthy Children” website in May 2015, is that “circumcision has potential medical benefits and advantages, as well as risks.” The group continues: “Evaluation of current evidence indicates that the health benefits… outweigh the risks and… the benefits justify access to this procedure for families who choose it, however, existing scientific evidence is not sufficient to recommend routine circumcision.” In other words: Parents, you decide.
For some parents, the decision to have their newborn son circumcised stems from cultural or religious beliefs. (Worldwide, two-thirds of circumcised males are Muslim.) For others, the decision to have their son circumcised is based on the belief that it is healthier. Some parents decline circumcision out of the belief that it is a violation of the child’s right to make decisions about his own body. For most parents, whether or not to have their baby circumcised is a decision made after careful consideration of the benefits and risks.
What is circumcision?
Boys are born with skin (called foreskin) covering the head of their penis. Circumcision is the surgical removal of the foreskin from the head of the penis, so that the tip of the penis is exposed.
Circumcisions are usually performed by a doctor in the hospital within a day or two of the baby’s birth. (Those done as part of a religious ceremony, such as a brit milah, take place at home when babies are 8 days old and are performed by a mohel, a member of the Jewish faith who has been trained to perform circumcisions.) The entire procedure is quick, and often performed in the hospital’s nursery. The penis and the surrounding area are washed with an antiseptic solution. To ensure that the procedure is painless, the penis is numbed with a topical or injectable anesthetic. A special clamp or a plastic ring is attached to the penis to prevent bleeding while the foreskin is cut away. Finally, an ointment (such as petroleum jelly) is placed on the penis and a piece of gauze is loosely wrapped around the penis to protect it while it heals.
It usually takes about 7–10 days for the penis to heal completely. During each diaper change, parents are instructed to put a small amount of ointment on the tip of the penis and to change the gauze, in order to keep the diaper from sticking to the penis during healing. If a plastic ring was used, parents are told to expect the ring to fall off in about a week. Parents are also told to call their baby’s health care provider right away if the baby is unable to urinate or if the parent sees bleeding, swelling, or signs of infection such as redness or fever.
When circumcision is done during the newborn period, complication rates are “considerably lower” than when the procedure is performed later in life. The World Health Organization (WHO) notes that complications occur in 0.2–0.4 percent of neonatal circumcisions and are typically minor.
How common is circumcision?
The WHO estimates that about 30 percent of all males worldwide are circumcised. In some countries circumcision is rarely done, while in others it is fairly common. In recent years, between 55 and 58 percent of U.S. male newborns were circumcised prior to hospital discharge. According to data from the National Center for Health Statistics (NCHS), 58.3 percent of male babies born in U.S. hospitals were circumcised during 2010, the most recent year for which data are available. (Note that this data does not include circumcisions performed as part of a religious event after hospital discharge, or at any later age.) The data show regional differences, with the highest rate (71 percent) in the midwest and the lowest rate (40 percent) in the west.
However, in looking at trends, the popularity of circumcision is decreasing. In the U.S., the national rate has declined about 10 percent since 1979. This may be in part because of statements made by the AAP in the early 1970s. In 1971, the AAP reported that there were no valid medical indications for circumcision in the neonatal period. As a result, the decline in rates of circumcision that began in 1965 continued until 1989. That year, the AAP issued a statement citing “potential benefits” from circumcision, and declines halted. In 1999 rates started to decline again, after the AAP issued another statement on circumcision saying that there were insufficient data to support a recommendation either for or against neonatal circumcision. But in 2005, the AAP once again modified its position stating, “[e]xisting scientific evidence demonstrates potential medical benefits of newborn male circumcision; however, these data are not sufficient to recommend routine neonatal circumcision.”
Most recently, in 2012, the AAP and the American Congress of Obstetricians and Gynecologists (ACOG) came out in support of male circumcision, with the release of a policy statement that “the health benefits of newborn male circumcision outweigh the risks” and “the procedure’s benefits justify access to this procedure for families who choose it.”
Are there benefits?
The AAP, ACOG, and Centers for Disease Control and Prevention (CDC) identify the following benefits of circumcision:
- reduced risk of urinary tract infections (UTIs)
- reduced risk of penile cancer
- some prevention against sexually transmitted infections, including HIV
Prior to publicly supporting elective male circumcision for infants, adolescents, or adults, members of the AAP’s Task Force on Circumcision examined peer-reviewed journal articles from 1995–2010, including clinical trials conducted in Africa from 2005–2010. They concluded that male circumcision “is well tolerated when performed by trained professionals under sterile conditions with appropriate pain management,” complications are “infrequent,” and severe complications “rare.” As noted above, rates of complication are lower for neonatal circumcision than for circumcisions performed later in life, which is why the AAP recommends parents consider this decision during pregnancy.
Parents should note that although the AAP does recommend that families have access to circumcision and that insurance companies cover the cost of the procedure, the pediatric organization does not recommend routine circumcision for all male newborns. Rather, the AAP recommends that health care providers—pediatricians and obstetricians—discuss benefits, risks, and available pain medications with parents to aid decision-making. In their 2012 policy statement, the AAP directs providers to “routinely inform parents of the health benefits and risks… in an unbiased and accurate manner” and that parents “decide whether circumcision is in the best interests of their male child,” considering medical information alongside personal “religious, ethical, and cultural beliefs and practices.”
Are there risks?
Whenever a medical procedure is performed there are associated risks, and circumcision is no exception. While the incidence of complications is small, data show that circumcision may increase the risk for bleeding, infection, pain, and poor outcome if the foreskin is cut too short or too long or does not heal properly. Also, complications like meatal stenosis (narrowing at the end of the urine channel of the penis) or chordee (curvature of the penis) can develop later as the child grows. In the U.S., complications are “infrequent,” most are minor, and serious complications are rare.
Caring for an uncircumcised penis
The foreskin of an uncircumcised male serves to protect the penis and is best left alone. Parents and caregivers should be instructed to wash only the outside, and they should not attempt to retract the foreskin. Forcible retraction can cause severe pain, bleeding, and tears in the skin. The child will be able to discern when his foreskin can be retracted without pain and trauma, so he should be the first person to retract it. For some males, complete separation of the foreskin may not occur until after puberty. The foreskin is fully retractable in 44 percent of boys by age 10, 90 percent by age 16, and 99 percent by age 18.
After the onset of puberty, the child should gently clean beneath his foreskin with soap and warm water as part of his usual daily hygiene routine. If the foreskin is able to be retracted prior to puberty, the AAP notes that “an occasional retraction with cleansing beneath” is sufficient.
Parents of uncircumcised babies should be aware that the risk of urinary tract infection (UTI) is higher. Also, uncircumcised males are at higher risk for balanitis (inflammation of the penis) and phimosis (a condition in which the foreskin is tight and unretractable, which may be present at birth or develop over time). Signs of balanitis include redness, irritation, and soreness of the end of the penis, with or without discharge; signs of phimosis include inability to retract the foreskin, and ballooning of the foreskin while urinating. These conditions may be treated with steroid cream or, in some cases, circumcision.
Why do parents choose for or against circumcision?
While informed consent is the gold standard for medical decision-making, parents have the right and responsibility to make decisions on behalf of their infants and young children.
Difficulty arises when a procedure is not medically necessary, when public health recommendations seem to swing back and forth over time, and when cultural, social, or religious reasons are in play. It can be difficult to determine whether the procedure is in the child’s best interest.
Parents who are members of the Jewish and Islamic faiths circumcise for religious reasons. Some parents circumcise for reasons related to health or hygiene. Others circumcise for social reasons—all the other men in the family are circumcised and they don’t want their sons to look or feel different. In some cases, albeit rare, circumcision needs to be done for medical reasons, such as when the foreskin is too tight.
Some parents decide not to circumcise due to the risks associated with circumcision. Many believe that the foreskin is there for a reason—to protect the penis and prevent future problems. Others believe that removal of the foreskin makes the tip of the penis less sensitive, resulting in a decrease in sexual pleasure later in life.
Ultimately, there are those who strongly favor and those who strongly oppose male circumcision. Parents need to clearly understand the possible benefits and risks of both the circumcised and uncircumcised penis. Only then can they decide whether circumcision is in the best interests of their male child.
Parents who decide to have their baby circumcised should discuss the procedure with their child’s doctor and make certain that the circumcision is done by an experienced and qualified health care provider.