To cut or not to cut? For parents of newborn boys, that is the question, and lately, the circumcision debate has grown more heated. In fact, when we asked readers their views about it on American Baby's Facebook page, we were quickly hit with hundreds of responses. "We chose to circumcise our sons mainly because of the health issues," one reader wrote. "I read they'd be less likely to have bladder infections." Another mother responded, "Our son was born perfect, so there was no need for us to change him!"
For many families, particularly those of the Jewish and Muslim faiths, circumcision is a given. For others, though, deciding whether or not to do it can be fraught. Mounting research over the past decade has shown that surgical removal of the penis's foreskin has potential health benefits. Yet there are risks, and the percentage of American families choosing to circumcise has actually decreased in recent years. In 2010, a researcher at the Centers for Disease Control and Prevention made news when he presented data indicating that the U.S. rate of circumcision at hospitals and reimbursed by insurance had dropped from more than half of boys in 2006 to about one third in 2009. The exact numbers are difficult to pin down, but it is clear that many parents are opting out. The cost of circumcision may be one reason, especially because fewer insurance companies are covering it, says Ronald Gray, M.D., a professor of epidemiology at Johns Hopkins University in Baltimore. But America's changing demographics also affect the number of boys undergoing the procedure. "The increased proportion of black and Hispanic births in the U.S. affects rates, because these groups are less likely to circumcise," Dr. Gray says.
Benefits and Risks
The American Academy of Pediatrics (AAP) takes a fairly neutral stance, acknowledging the probable medical benefits of circumcision but stopping short of universally recommending it. An updated statement is expected for 2012, but as of press time, the group had not announced it. "The surgery risks remain the same as when the last statement was written 12 years ago, but from the new research we have, it is clear that circumcision does provide protective health benefits, particularly with regard to HIV and HPV [the human papillomavirus]," says Douglas Diekema, M.D., a member of the AAP's circumcision task force. Circumcision's ability to reduce the risk of contracting HPV, the most common sexually transmitted disease (STD), can in turn protect against genital warts as well as cervical cancer in women (men pass on the infection).
It's difficult enough for most moms to picture their tiny newborn saying Mama, much less growing up to have an active sex life, so prevention of STDs is almost too abstract to contemplate. But the results of three randomized clinical trials of adult men in Africa were sufficient for the World Health Organization to endorse male circumcision as an effective way to reduce the risk for HIV acquired through heterosexual sex in regions with heterosexual epidemics, high HIV rates, and few circumcised men.
As for a more immediate benefit, the AAP reports that circumcised boys have a lower chance of getting a potentially serious urinary tract infection during their first year than uncircumcised boys do (1 in 1,000 vs. 1 in 100).
Those who are against circumcision bring up the question of sexual pleasure, pointing out that there are thousands of nerve endings on the foreskin that will be excised. It's impossible to study the difference in sexual sensation for men who were circumcised at birth, but Dr. Diekema notes that the few studies done with African men who were circumcised as adults show that some find intercourse better afterward, some describe it as worse, and the vast majority say it is pretty much the same as before.
Regarding the risks of the surgery itself, if circumcision is performed by an experienced physician in a sterile environment, they should be low. One to 3 percent of circumcisions will result in minor complications, such as extra bleeding or infection, which topical antibiotics can clear up. More serious complications, such as removal of too much skin or other damage to the penis requiring follow-up surgery, are rare, estimated at less than 1 percent. Still, many families who choose to forgo circumcision say they simply can't imagine putting their child through a painful procedure when he can live a healthy life without it.
And yes, the surgery will hurt. "Newborns do feel pain," Dr. Gray says. Prior to the incision, all infants should be given anesthesia, either a topical cream or an injection. With proper care and infant Tylenol, your son's penis should heal comfortably in a few days to a week.
A Personal Decision
Whether your baby is circumcised comes down to what is right for you and your family. "We decided that things would be simpler for us to explain to our son later if his parts looked more like his father's," wrote one mom who had been on the fence but ultimately went ahead with the procedure. However, if you're leaning toward circumcision so your boy's penis will eventually match the others in the locker room at school, consider this: If the current trend continues, at least a few other boys in his class will be unsnipped.
It can be tempting to put off the decision until later. Some parents argue that circumcision isn't their call to make. Still, the AAP points out that the risk for complications is much greater for older boys than for infants, so it's better to do it when your child is a baby. "Plus, if he waits to make the decision as an adult, he will have missed out on the protective benefits during any previously sexually active years," Dr. Diekema says.
In some cases, though, the choice not to circumcise (or at least to wait) is a medical one: Baby boys with hypospadias (a condition where the opening of the urethra, the tube that empties urine, is in the wrong place) should not be circumcised, because a surgeon may eventually use the boy's foreskin for a reconstructive procedure. If you have a family history of bleeding disorders, consult your pediatrician before getting your son circumcised. And if your baby is born prematurely, he will need to wait until he is healthy enough to leave the hospital before having the surgery.
Prepping For Surgery
Ideally, you should make your decision before your child is born. If you opt for the procedure, you'll have time to find a practitioner you trust, consider whether you want to be in the room when it takes place, and ask important questions about anesthesia.
If you elect to have the circumcision performed in the hospital, the 10- to 15-minute procedure is usually done right before the baby is discharged, either by the physician on call, or an OB, pediatrician, or family doctor of your choice.
If you are Jewish and have your child circumcised at a bris (a ceremony that generally takes place on a baby's eighth day of life), seek out a mohel who is also a medical doctor. Ask friends and family, your pediatrician, or your rabbi for recommendations.
The doctor or mohel will give you instructions on how to clean and care for the wound. There may be a protective plastic ring on the penis; don't pull it -- the ring will fall off on its own after about ten days. If there is gauze on the wound, gently remove it with a warm, wet washcloth after 24 hours, and then continue to clean the penis with warm water twice a day and after every poopy diaper, applying Vaseline or an antibiotic ointment for two weeks to keep the wound from sticking to his diaper and to aid healing.
The tip of the penis may appear very red immediately after the procedure, and some yellow discharge or crust is normal, but phone your doctor if there is swelling, more than a few drops of blood, a black or blue bruise, or if your baby runs a fever. Also, keep an eye on your child's diaper. If he doesn't urinate within eight hours or so, call your M.D.
Originally published in the April 2012 issue of American Baby magazine.
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