One of the major responsibilities of parents is to make decisions on behalf of your children. You decide what food you will offer them, what vaccines to give them and when, what movies they should/should not see and even whether they can go over to their friend’s house for the afternoon. Indeed, the list of decisions you make for your children is endless. Sometimes the choice is easy, but often times you feel less certain about which choice is best. So you gather information and weigh the pros and cons. You fret about it and talk it over with friends and partners and when you finally make a decision, you hope it is the “right one.”
If you are the parent of a boy, one of the first decisions you make on behalf of your son is to circumcise or not to circumcise. Though circumcision is an ancient practice that has been around for thousands of years, it is extremely controversial. Passions run deep on both ends of the spectrum and the controversy is understandable. Babies and penises are both very important and you wouldn’t want either of them to be harmed. If you do circumcise, you may cause pain and injury to your precious son, but if you don’t your child may be at greater risk for certain infections and complications later in life. Hopefully, the following information will help guide you to make the decision that feels best for your family.
What is a circumcision?
First off, it’s important to know what exactly a circumcision is. A circumcision is a minor surgical procedure that involves the removal of the foreskin, which is the skin that covers the glans or the “head” of the penis. The United States is the only developed country where circumcision is still routinely performed. Recent data suggests the average rate of circumcision in this country is around 80% though this rate varies depending on your cultural background and where you live. (1)
A circumcision is generally performed in the first 1-2 days postpartum while the newborn is still in the hospital, though some newborns need to wait longer due to certain medical conditions. Some pediatric or obstetric providers offer newborn circumcisions in the office within the first few weeks postpartum. It is possible to do a circumcision with local anesthesia up to 3 months postpartum, but not all providers feel comfortable doing this and may refer the infant to a specialist.
There are three common devices used in circumcision: the Mogen clamp, the Plastibell and the Gomco clamp, each with its own associated technique. The provider performing the circumcision decides which device to use based on his or her training since most providers feel more confident using one technique over another. Though you may not have much say in which device is used, it may be helpful to ask your provider which device he or she prefers and why.
What are the benefits of circumcision?
The documented benefits of circumcision are numerous. Circumcision has been shown to reduce the risk of a urinary tract infection (UTI) in childhood, penile inflammation and retractile disorders, penile cancer, cervical cancer in female partners and transmission of certain sexually transmitted infections. Though this list is impressive, many of these diseases can be prevented using other less invasive measures such as practicing good genital hygiene, using condoms and vaccinating against the Human Papilloma Virus.
Urinary Tract Infection
A decreased risk of UTI is the principle benefit of circumcision. Uncircumcised boys are 7-14 times more likely to develop a UTI in childhood compared with circumcised boys. This sounds like a lot, but the actual number of UTIs in uncircumcised boys remains small. Only 7-14 uncircumcised boys out of 1000 will develop a UTI in childhood compared with 1-2 circumcised boys. (2) Fortunately, most UTIs resolve easily with antibiotic treatment and long term complications are rare in boys with a normal urinary tract.
Penile inflammatory and retractile disorders
Occasionally, boys can develop inflammation in the penis. Most cases of penile inflammation occur due to poor hygiene. Though the inflammation is usually treated easily, permanent scarring can result from chronic inflammation, which can lead to more problems later. Uncircumcised boys may be up to twice as likely to have penile inflammation (3), which is probably due to the fact that the area beneath the foreskin may be more difficult to keep clean.
Uncircumcised boys can also experience problems with the foreskin pulling back or retracting over the glans. In utero and at birth the foreskin is essentially stuck to the glans like glue. Eventually the foreskin will naturally begin to pull back over the glans during an erection, but this does not begin to happen until at least age 3 and may not even occur until adolescence. Sometimes, however, the foreskin may never retract (phimosis) or it may retract, but be unable to return to its normal position (paraphimosis). These conditions can cause pain or lead to problems with urination or sexual activities. It is thought that around 3-5% of uncircumcised males will have some type of retractile disorder. (3)
There is evidence that women whose male partners are circumcised have a lower risk of developing cervical cancer (4). This is because uncircumcised men are more likely to be infected with HPV, the virus that leads to cervical cancer, and transmit HPV to their female partners. Now that more boys and girls are being vaccinated against HPV, however, circumcision may play less of a role in reducing the risk of cervical cancer.
Circumcised men may also have a lower risk of developing penile cancer. This is especially true for men with a history of phimosis. Since the incidence of penile cancer in the United States is rare, affecting only 1 in 100,000 males, this small protective benefit may not be worth the cost and potential complications of the procedure (5).
Transmission of Sexually Transmitted Infections
Evidence suggests that circumcision decreases the risk of becoming infected with certain sexually transmitted diseases. Studies from South Africa, Kenya and Uganda found that being circumcised reduces a man’s risk of getting HIV by about half (6). The tissue on the underside of the foreskin is especially receptive to HIV so removing the foreskin makes it less likely that HIV will get into the blood stream. These studies in Africa, however, looked at rates of HIV transmission in heterosexual encounters and cannot necessarily be applied to the United States population where HIV is more commonly transmitted through IV drug use and men having sex with men. It is therefore difficult to know how many boys would need to be circumcised in the United States to prevent one case of HIV transmission.
Circumcision also appears to provide a protective benefit against acquisition of HPV, HSV and trichomonas.
What are the risks?
Like many surgical procedures, the most common risks of circumcision are bleeding complications (0.8%), infection (0.06%), injury (0.02%) and complications with anesthesia. The overall the complication rate of circumcision is around 0.2% or 2 out of every 1000 procedures (7). Most of these complications are minor and easily treated without long term problems. Some severe complications, however, including death have been reported.
Procedural pain is also a concern for many parents and if you Google “circumcision” you can find many heartbreaking videos of screaming newborns getting circumcised. There was a time when most circumcisions were done without any pain relief, but it is unusual nowadays for a provider not to use a local anesthetic. Most providers who perform circumcisions do a nerve block to provide pain relief. This involves a small amount of lidocaine injected near the base of the penis before the procedure. Many infants may also get a pacifier with some sugar-water during the circumcision, which provides some additional comfort and pain relief for the infant. With these measures, many babies don’t cry at all during their circumcisions.
After reviewing all the existing data on circumcision, the American Academy of Pediatrics (AAP) concluded that the health benefits of newborn circumcision outweigh the risks and that circumcision should be available to all families who want it (8). The AAP statement stops short of formally recommending routine newborn circumcision, but instead leaves the decision up to families.
So what do you do? Decisions such as these can be some of the hardest to make as a parent. There are multiple factors to consider, both medical and cultural, and there are potential long-term consequences regardless of which option you choose. The question is which set of risks or which set of benefits matter more to you and your family. Familiarizing yourself with the pros and cons of either choice is the first step in helping you answer that question. If you still remain uncertain or continue to have questions, you can talk it over with your pediatric or obstetric provider; another objective voice may help you choose what is best for your family. In the end, remember the decision you make will be the right decision.
Jody Lindwall is a Certified Nurse Midwife and CenteringPregnancy group leader at the Peterkort South Office of Women’s Healthcare Associates, LLC in Portland, Oregon. She also provides one-on-one obstetric and gynecological care. After attending Yale University for her bachelor’s degree, Jody spent three years in Costa Rica before returning to school to study midwifery under a National Health Service Corps Scholarship. She obtained her Master of Science degree in nurse-midwifery from Vanderbilt University in Tennessee. She is dedicated to empowering women to make informed decisions regarding their reproductive health and advocating for their right to make those decisions. Jody is fluent in Spanish.
- Mayo Clin Proc. 2014 Mar 28. pii: S0025-6196(14)00036-6. doi: 10.1016/j.mayocp.2014.01.001. Circumcision Rates in the United States: Rising or Falling? What Effect Might the New Affirmative Pediatric Policy Statement Have?
- Male circumcision. Blank S, Brady M, Buerk E, et al. Pediatrics. 2012;130:e756.
- Neonatal circumcision and penile problems: an 8-year longitudinal study. Fergusson DM, Lawton JM, Shannon FT. Pediatrics. 1988;81(4):537.
- Male circumcision, penile human papillomavirus infection, and cervical cancer in female partners. CastellsaguéX, Bosch FX, Muñoz N, Meijer CJ, Shah KV, de Sanjose S, Eluf-Neto J, Ngelangel CA, Chichareon S, Smith JS, Herrero R, Moreno V, Franceschi S, International Agency for Research on Cancer Multicenter Cervical Cancer Study Group. N Engl J Med. 2002;346(15):1105.
- Incidence trends in primary malignant penile cancer. Barnholtz-Sloan JS, Maldonado JL, Pow-sang J, Giuliano AR. Urol Oncol. 2007;25(5):361.
- Male circumcision for prevention of heterosexual acquisition of HIV in men. Siegfried N, Muller M, Deeks JJ, Volmink J. Cochrane Database Syst Rev. 2009.
- Risks from circumcision during the first month of life compared with those for uncircumcised boys. Wiswell TE, Geschke DW. Pediatrics. 1989;83(6):1011.
- Circumcision policy statement. American Academy of Pediatrics Task Force on Circumcision. Pediatrics. 2012;130(3):585.