- Chris Woolston, M.S., and Laurie Udesky
- Posted March 11, 2013
Male circumcision is perhaps the world's oldest operation. It's depicted on ancient Egyptian tombs, and it's mentioned -- commanded, actually -- in the book of Genesis in the Bible. Over the years, it has been prescribed as a cure for epilepsy, asthma, alcoholism, insanity, and other maladies. Today, doctors realize that the only thing it really eliminates is the foreskin.
The days of cutting off foreskins to preserve sanity are long gone, but many misconceptions remain. If you're trying to decide whether or not to have your son circumcised, you'll have to look beyond the rhetoric and consider the basic facts. But even after weighing all of the pros and cons, you still might have trouble making up your mind.
Simply put, circumcision has both some benefits and some risks, and even doctors can't agree that one option is clearly better than the other. In 1999, the American Academy of Pediatrics revised its official stance on circumcision. After promoting the operation for many years, the academy decided to become neutral.
"Now we tell parents up front that there's no compelling medical reason to have their child circumcised," says Jack Swanson, a pediatrician in Ames, Iowa, who helped guide the academy's change in policy. When viewed in that context, it's basically a cosmetic procedure. Swanson doesn't urge parents to forgo circumcision, either. The decision is entirely up to the parents, he says. And many decide to have their child circumcised "The majority of parents I see have made up their minds well ahead of time," he says.
A United States tradition
Most men worldwide are uncircumcised, but the operation is still very common in the United States. As recently reported in the Journal of Urology, nearly 80 percent of American-born men have been circumcised, almost always as infants. Most Jews and many Muslim males born in the U.S. are circumcised, but for the rest of the country, the practice usually isn't done for religious reasons. Many parents simply feel that a circumcised penis is healthier, cleaner, and more "normal" than the intact model.
But these days, even for some Jewish parents, the issue isn't so clear. Dan Pine, who is Jewish, had mixed feelings about circumcising his son. "My wife and I had read the literature against it, and it made sense to us," said the 49-year-old journalist. Although he wasn't religious at the time of his son's birth and his wife was not Jewish, he wanted to do it as a matter of tradition. So he contacted a "moyel," a Yiddish term for a person who performs circumcisions. "All moyels are orthodox, and because my wife wasn't Jewish, they wouldn't touch our case, so we dropped the whole idea," explains Pine.
While Pine's son was a baby, there was no problem, but by the time the boy turned 11, he demanded to be circumcised. "It had nothing to do with Judaism. He didn't like the way it looked," his father says. "No one else in his gym class had a foreskin, and he found it embarrassing."
So the 11-year-old had a circumcision in a hospital. "He got what he wanted, and in a way we got what we wanted," says Pine, who became more involved in Jewish practices several years after his son's birth.
Circumcision may be the norm in this country, but it has plenty of opponents. A quick search of the Internet will uncover many sites devoted to stopping what some consider a "barbaric" practice. Several anticircumcision organizations have formed in recent years, including the National Organization to Halt the Abuse and Routine Mutilation of Males (NOHARMM).
Pros and Cons
So should you have your son circumcised? Here are some important things to keep in mind when making the circumcision decision:
The idea that circumcision makes a penis "cleaner" goes back for centuries, and it's a common belief today. The reality is that uncircumcised penises can be kept clean with very little effort. "I reassure parents that it's not a major problem," Swanson says. For the boy's first few years of life, the head of the penis will probably stay hidden under foreskin. At this age, regular baths will help keep the penis clean. When the foreskin opens up, parents simply need to teach their sons to wash the head of the penis and the inside folds of the foreskin with soap and water.
Urinary tract infection
Even with proper hygiene, bacteria can thrive inside the folds of the foreskin, especially in a boy's first six months of life. Recent studies show that uncircumcised boys are up to 10 times more likely than other boys to develop a urinary tract infection (UTI) before their first birthday. Infections are still rare -- only about one in 100 uncircumcised boys will have a UTI -- and most are mild and easily treated with simple antibiotics.
Risks of surgery
While no operation is risk-free, circumcision is generally a very safe procedure. Serious bleeding is the most common complication, but it happens in only about one out of 1,000 operations. Even less often, the surgery site can become infected. In extremely rare cases, a botched surgery could remove the head of the penis or lead to the death of penile tissue. Complications are more likely when the physician is inexperienced, so it's a good idea to find a physician who has performed many, many circumcisions.
Not long ago, most doctors didn't worry much about the pain of circumcision, Swanson says. After all, the thinking went, babies are too young to remember the pain, so why try to prevent it? Thankfully, this attitude is changing. Most doctors now use some sort of analgesia (pain reliever) when performing circumcision, Swanson says. "The operation is not traumatic as long as they use analgesia," he says. "I would strongly recommend that parents seek out a doctor who will use it."
The combination of a local anesthetic -- injecting numbing medication at the base of the penis -- and allowing the baby to suck on sugar water during the procedure seem to diminish the pain significantly. Doctors have observed that with topical anesthetic and injection of numbing medication, most babies cry very little and seem not to exhibit signs of significant pain afterwards.
Anticircumcision groups often claim that the foreskin is a vital part of a man's sexual equipment. But there's no real evidence that adult men who were circumcised enjoy sex any less than men who were never circumcised, says Kenneth Fink, a urologist and researcher for the Agency for Healthcare Research and Quality.
Fink and others have studied how circumcision of adults affects sexual functioning, and the results have been mixed. Some men say that the head of their penis feels less sensitive during sex, but others report no changes. A few men actually appreciated a small loss of sensation because it allowed them to last longer during sex, Fink says. He emphasizes that studies in adults may not have much relevance to boys who were circumcised shortly after birth. "You get used to what you have," he says.
Sexually transmitted diseases
Because the inside of the foreskin can be an inviting place for germs, some studies suggest that uncircumcised men are slightly more likely than other men to catch a sexually transmitted disease (STD). According to a report in the March 26, 2009, issue of the New England Journal of Medicine, adult males who were circumcised saw a decreased risk of herpes and HIV. However, a man's overall risk has much more to do with his sexual practices than his foreskin. Any man who has unprotected sex with many partners is at high risk for an STD, whether or not he's been circumcised. Likewise, a man who practices safe sex will have a low risk.
Being uncircumcised seems to slightly increase the risk of penile cancer, but the condition is still exceedingly rare. A more serious concern is the threat to a man's partner. A study published in the New England Journal of Medicine found that uncircumcised men are more likely to harbor human papillomavirus (HPV), a sexually transmitted virus that can cause cervical cancer in women. And there did seem to be an increased risk to the woman if her uncircumcised partner had had six or more previous sexual partners. A study of 285 men over 18 months reported in the February 1, 2009, edition of The Journal of Infectious Diseases found that circumcision appears to actually protect men from persistent HPV infections by enabling their bodies to get rid of the virus more easily than uncircumcised men can. As with sexually transmitted diseases, the overall risk has as much -- or more -- to do with sexual practices than circumcision.
Put all of the scientific information together, and circumcision doesn't appear to be medically necessary. But, in the hands of a trained surgeon who gives the baby some form of pain relief, it's not especially dangerous or traumatic, either. The choice is yours.
Interview with Jack Swanson, MD, a pediatrician in Ames, Iowa.
Interview with Richard Stevens, MD, a pediatrician in Billings, Montana.
Interview with Kenneth Fink, MD, a urologist and researcher for the Agency for Healthcare Research and Quality.
Interview with Dan Pine, father of uncircumcised boy who decided later on circumcision.
Mayo Clinic. Why It's Done. February 2010. http://www.mayoclinic.com/health/circumcision/
Lerman S. et al. Neonatal circumcision. Pediatric Urology. 48(6): 1539-1557.
Alanis M. et al. Neonatal circumcision: a review of the world's oldest and most controversial operation. Obstetrical & Gynecological Survey. 59(5):379-95. May 2004.
American Academy of Pediatrics. New AAP Circumcision Policy Released. March 1999. http://www.aap.org/advocacy/archives/marcircum.htm
American Academy of Pediatrics. Circumcision Policy Statement. March 1999.
Collins, S. et al. Effects of Circumcision on Male Sexual Function: Debunking a Myth? Journal of Urology. 167: 2111-2112. May 2002.
American Academy of Pediatrics. Circumcision: Frequently asked questions.
Fink, K. et al. Adult circumcision outcomes study: Effect on erectile function, penile sensitivity, sexual activity and satisfaction. Journal of Urology. 167: 2113-2116. May 2002.
Castellsague, X. et al. Male circumcision, penile human papillomavirus infection, and cervical cancer in female partners. New England Journal of Medicine. 346(15):1105-1112. April 2002.
Male Circumcision Reduces Risk of Genital Herpes and HPV Infection, but Not Syphilis. NIH News. Wednesday, March 25, 2009.
Lu B, et al. Factors associated with acquisition and clearance of human papillomavirus infection in a cohort of US men; a prospective study. J Infect Dis. 2009 Feb 1;199(3):362-71.
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