Circumcision has never been as controversial as it is today. This is what doctors want you to know about the procedure.
When their first child was born, Karin Davidson and her husband decided to have him circumcised. But if they have another son, they're not sure they'll make the same choice. "I know all the men in our immediate families are circumcised, so it wasn't a question for me at the time," says Davidson, of Madison, Wisconsin.
But after reading up on the subject recently, she started questioning the origins of the practice -- "I even read that in the past some people advocated for it in order to reduce masturbation among boys," she recalls -- as well as the validity of the research on its pros and cons. "I want to base my decision on whether there are any real medical benefits to it and whether it's important for two boys to match each other and their dad."
Granted, these are tricky issues to sort through. In a survey of more than 1,000 Parents readers, 81 percent of respondents said that circumcision would be the right decision for their family. When asked how they feel about circumcision in general, 14 percent thought that most mothers and fathers aren't aware of possible negative outcomes of circumcision, and 7 percent consider it a bygone tradition that's no longer relevant.
While newborn circumcision rates have declined from 65 percent in 1981, approximately 58 percent of all boys born in American hospitals still undergo the procedure, according to the National Center for Health Statistics. "The U.S. is one of only a handful of countries where circumcision is common," says Marvin Wang, M.D., director of newborn nurseries and an associate pediatrician at Massachusetts General Hospital, in Boston. "In the majority of the world, it's generally almost never done, except for religious reasons."
Fights Over Foreskin
The decision has never been easy for many parents, but it has become increasingly controversial and even political. Eighteen states have cut Medicaid coverage for routine circumcision, and researchers at the UCLA Luskin School of Public Affairs found that this may be part of the reason for the declining rate. In recent years, bans on circumcision have been proposed in San Francisco and Santa Monica. Opponents such as the advocacy group Doctors Opposing Circumcision (DOC) and Intact America assert that circumcision is an unnecessary and potentially risky procedure -- and that it's essentially a violation of human rights on a par with female genital mutilation.
"Medical ethics state that parents only have the right to make medical decisions that are in a child's best interest," asserts physician and DOC president George Denniston, M.D. "All mammals have a foreskin and that's the way nature intended it. Circumcision shouldn't be done to children because they can't give informed consent. They have the right to an intact body."
In 2012, the American Academy of Pediatrics (AAP) published an updated policy statement declaring that new scientific evidence shows that the medical benefits outweigh the risks of the procedure. However, it went on to say that the advantages are not substantial enough to make it a routine practice and that the decision should be made by parents in consultation with their doctor. "The AAP has taken a fairly neutral stance on the subject of circumcision since 2000 -- but some people have found the lack of a strong recommendation to be annoying and unhelpful," says Douglas Diekema, M.D., a member of the AAP Task Force on Circumcision and a professor of pediatrics at the University of Washington School of Medicine, in Seattle. "Although parents often want to be told how to best take care of their babies, this is an area where some neutrality really is appropriate, because of the potential for both harm and benefit from the procedure."
The Case For -- And Against
Any medical procedure carries some risk. A new study in JAMA Pediatrics found that among babies younger than 1, adverse events occurred in less than 0.5 percent of circumcisions (though the risk jumped to between 10 and 20 times higher when performed after infancy). Complications include minor bleeding or oozing from the wound; rarely, babies can get a skin infection that is treated with antibiotic cream. "It's generally a safe procedure, especially with an experienced provider," says Lise Johnson, M.D., division chief of newborn pediatrics at Brigham and Women's Hospital, in Boston. Opponents claim that circumcision leads to decreased sexual sensitivity and function later in life, though Dr. Diekema and other experts say there's no compelling data to support these contentions.
Studies have shown, however, that circumcised males have a decreased risk of urinary-tract infections in the first year of life, as well as of cancer of the penis and sexually transmitted diseases such as herpes and human papillomavirus (HPV) later in life. Recent research found that adult male circumcision in Africa reduces the risk of acquiring HIV by up to 60 percent. There is clear evidence showing that male circumcision offers protection against STDs in both men and their female partners, notes Aaron Tobian, M.D., associate professor of pathology and epidemiology at Johns Hopkins University, in Baltimore.
What's interesting is that when Dr. Tobian and his wife had their first child in 2005, they'd decided against circumcision before they even knew the baby's sex. They had a daughter, so it was a moot point. But when their son was born in 2008, they had him circumcised. "We were swayed by the numerous medical benefits found in randomized trials," says Dr. Tobian.
Approximately 3 percent of boys who are not circumcised will end up needing the procedure when they get older, because of an infection or the fact that their foreskin doesn't retract properly (a condition known as phimosis). The procedure is slightly more complicated for teenagers or adults because a larger piece of tissue needs to be removed, it requires stitches, and the surgery needs to be done under general anesthesia in an operating room.
Beyond medical considerations, there are religious factors. In the Jewish faith, a boy is circumcised when he's 8 days old in a bris ceremony performed by a specially trained professional. Routine circumcision is also a tradition in the Islamic faith. It's standard protocol with many Americans as well, but not in Latino or European cultures.
Naturally, parents can have very strong feelings about the topic. Despite objections from family members, Morgan Roberts and her husband, who is circumcised, decided they wouldn't circumcise their son, now 3. "When my son was born, I looked into his gigantic blue eyes and at his chubby, soft body and thought he was absolutely perfect in every way -- who were we to alter a newborn, especially when he has no say in the matter?" explains Roberts, who lives in Southbury, Connecticut.
On the other side of the fence is Nicole Emmi, who has three sons under age 9, all of whom are circumcised. "I wanted them to look like their dad in that way and I also felt most comfortable with circumcision from a hygiene perspective," explains Emmi, of Ferndale, Michigan.
Ultimately, it's best if you can balance the potential risks and benefits with your own personal feelings about the procedure. You might also want to discuss the matter with your doctor, especially if you or your spouse have any doubts. If you decide in favor of circumcision, you'll want it to be done by a practitioner (usually an obstetrician or a pediatrician, sometimes a pediatric urologist) who has plenty of experience. The procedure is typically covered by private insurance; Medicaid picks up the cost in 32 states. Otherwise, the price starts at around $250 for newborns.
One of the issues parents really wrestle with is how to handle it when a child is circumcised but his dad isn't -- or vice versa. And what if the first son in a family is but the second or third isn't? As the kids get older, what's the best way to explain why some boys in the locker room have a foreskin while others don't?
Fortunately, the issue of "being different" may not be as big a deal to a child as parents often fear it is. "If you really listen to what he's asking, usually it can be answered in a pretty straightforward way, by telling him that sometimes parents decide to have that skin taken off when a child is a baby and sometimes they don't," Dr. Johnson says. "You don't need to explain the whole backstory."
That's what Morgan Roberts says she plans to do as soon as her son is old enough to ask why his penis looks different from his father's. "We'll tell him that some men will look like he does, and others will look like Daddy, but that everyone is special."
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Originally published in the September 2014 issue of Parents magazine.
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