Separating facts from myths and misinformation
In my local Mama’s Support Network on Facebook, circumcision is one of 4 issues considered a ‘hot topic’ on which post comments are likely to be locked. Washington’s 12% circumcision rate for newborns is one of the lowest in the country, still every few months a post appears asking for recommendations for doctors to perform the procedure. The lack of basic knowledge many pregnant mamas have about the facts and posited benefits of the procedure is dismaying, but not altogether surprising.
Every expectant parent should know the basic facts about circumcision.
When I attempted to research circumcision during my first pregnancy, I found that it was very difficult. It seemed like everything I found was either vehemently anti-circumcision or vehemently pro-circumcision. Finding basic facts or information about the way that circumcision is viewed in our culture today felt impossible. It didn’t seem to exist. I wasn’t given any information by my obstetrician or the pediatrician I’d chosen for my son. I hope that by providing this information in an objective way, I can help other parents reach an informed decision that’s based on facts and evidence rather than outdated myths or questionable benefits.
What is male circumcision?
Circumcision is the permanent removal of the foreskin from a boy/man’s penis.
What IS the foreskin and what does it do?
The foreskin is a double-layered fold of skin and mucous membrane that makes up roughly half of the penis’s skin when left intact. Though many people think of it as just an extra flap of skin, in an adult man the foreskin is 12–15 square inches of skin that contains about 20,000 nerve endings. This post on Peaceful Parenting about the difference between a circumcised and intact adult penis is a great resource for comparison photos.
From birth into childhood, the foreskin is adhered to the head of the penis in much the same way a fingernail is adhered to the nail bed. As children grow, the foreskin will begin to retract and un-adhere from the head of the penis. This can happen anywhere between toddlerhood and late teenhood. For almost 80% of boys, it will fully retract on its own by age seven. There is no need to forcibly retract an intact foreskin.
The purpose of the foreskin is to protect the glans and opening to the urethra when the penis is not erect. The foreskin is the male equivalent to the hood of skin that covers and protects the exposed portion of the female clitoris. At maturity, the foreskin is fairly stretchable. It helps to keep the glans, which is the primary sensory part of the penis, moist and protected. In intact males, the glans is an internal organ. The foreskin also helps facilitate sexual intercourse by providing a natural lubricant.
How is a typical circumcision performed?
Several methods of circumcision are practiced depending on the doctor. The first step is for the baby to be restrained, usually on a specially designed board where their arms and legs can be strapped down. Some doctors give a pacifier, sometimes with sugar water, for the baby to suck on. Many doctors administer a local anesthetic by injection or topical cream.
Since the foreskin is adhered to the head of the penis, the first step is placing a tool under the skin and moving it around to create a separation. One of several techniques is then used to cut the foreskin off. Afterward, the infant’s penis will usually be covered with some type of ointment to prevent the raw area from sticking to his diaper or other skin, and wrapped loosely with gauze. The procedure generally takes around 10 minute to perform.
Other options for circumcision outside the hospital include having the procedure performed by a Jewish Mohel, pediatrician, or pediatric urologist. Here are two video examples of routine circumcisions. By their nature, they are graphic:
Is Circumcision Painful for Babies?
Yes. Many studies have been done on pain reception in infants and preemies. In a 2001 study on prevention and management of pain in newborns, researchers found that “NEWBORNS routinely experience pain associated with invasive procedures such as blood sampling, immunization, vitamin K injection, or circumcision.”
Though many doctors inject an anesthetic into the base of the penis before performing the procedure, a 1998 study found that only 45% of respondents said they used anesthesia for circumcision procedures. It can be hard for babies to express their feelings. Some infants seem to experience pain during urination after circumcision. Babies experience pain, and circumcision creates a wound on the baby’s body.
How many babies are circumcised?
In its 2007 report on male circumcision, the World Health Organization estimated that 30% of men age 15 and over worldwide were circumcised. According to the CDC, the rate of male infants leaving the hospital in the United States circumcised after birth has dropped 10% since 1979, and in 2008 stood around 56%. It is difficult to get accurate data on circumcision rates in the United States because not all hospitals report their data: in fact, as low as 5% do, and even with those reports babies born and/or circumcised outside of the hospital setting are not accounted for. Some estimate the circumcision rate in the US has dropped as low as 30%, and the rate is lowest on the Pacific Coast.
Circumcision rates vary greatly by geographic location, with the Midwestern states being highest. States where medicaid does not pay for circumcision tend to have lower rates. This may be because medicaid influenced the market and fewer insurance companies in total will pay for the procedure in those areas, because people do not want to or cannot afford to pay out of pocket for the procedure, because people are paying out of pocket for non-hospital circumcisions, or for some other reason entirely.
Is a circumcised penis cleaner?
A well-cared for penis is cleaner! Circumcised or not, the only way to keep a penis truly clean is through good hygiene. The misconception that intact penises are less clean may come from a misunderstanding about smegma. Smegma is a combination of exfoliated skin cells, skin oils, and moisture that is white in color and sometimes looks ball-like or creamy. Men and women both produce smegma, men under the foreskin, and women around the clitoris and folds of the labia. The presence of smegma on the penis does not indicate poor hygiene.
Far from being unclean, the foreskin is self-cleaning (in the same way the vagina is) since smegma is antiviral and antibacterial. No soap is required, just warm water, especially once the child is older and the foreskin begins to retract on its own. For babies and young children, all that is needed is the usual baths in clean, warm water to keep the area clean. Since the foreskin is adhered, it is not necessary to retract or ‘get under’ the extra skin to clean it.
Is circumcision medically necessary?
There are no health organizations in the world that support routine infant circumcision. Many insurance companies no longer pay for it because it is considered a cosmetic procedure.
In 1999, the American Academy of Pediatrics revised their statement on infant circumcision, saying “Existing scientific evidence demonstrates potential medical benefits of newborn male circumcision; however, these data are not sufficient to recommend routine neonatal circumcision.” However, in 2012, they revised this statement again. Their current statement includes the following:
Evaluation of current evidence indicates that the health benefits of newborn male circumcision outweigh the risks and that the procedure’s benefits justify access to this procedure for families who choose it.
Although health benefits are not great enough to recommend routine circumcision for all male newborns, the benefits of circumcision are sufficient to justify access to this procedure for families choosing it and to warrant third-party payment for circumcision of male newborns. It is important that clinicians routinely inform parents of the health benefits and risks of male newborn circumcision in an unbiased and accurate manner.
Parents ultimately should decide whether circumcision is in the best interests of their male child. They will need to weigh medical information in the context of their own religious, ethical, and cultural beliefs and practices. The medical benefits alone may not outweigh these other considerations for individual families.
Effectively, they do not support the routine circumcision of infants, but at the same time their official stance is that the benefits outweigh the risks.
Risks and Benefits
When considering risks and benefits of any procedure, you must look at the data. The risks and benefits listed are those most commonly associated with circumcision. Also provided are some statistics and links to further information. Many of the numbers are very small, or have wide ranges, and unfortunately it is sometimes hard to assess their accuracy.
Because circumcisions are often performed in the hospital, and then babies are sent home, complications that arise may not ever be attributed to the circumcision procedure. There is also no requirement on doctors or hospitals to report their circumcision rates. When evaluating statistics, always consider the size of the study, when it was done, and whether the outcomes were statistically significant.
What Are the Risks of Circumcision?
Studies estimate circumcision complication rates at anywhere between 0.1 to 35%, clearly quite a large margin. Though some studies say that the risks of complications from circumcision are as low as 0.1 or 0.2%, The American Academy of Pediatrics says “the true incidence of complications after newborn circumcision is unknown.”
Risks of circumcision include:
- Excessive bleeding (1 in 1,000)
- Infection (3 in 5000)
- Foreskin adhesion (7.8 in 100)
- Need for subsequent surgery (1 in 1,000)
- Systemic infection (1 in 4,000)
- Loss of penis (1 in 1,000,000)
- Death (as high as 9.01 in 100,000)
Other risks include too much skin being removed resulting in painful erections or restricted growth, too little skin being removed, and scarring.
In addition to the immediate physical risks of complication during circumcision, many studies have been done about the effects of circumcision that may be carried into adulthood. These include possible links to premature ejaculation, sexual difficulties, decrease of sexual pleasure, lasting psychological effects due to trauma, and loss of sexual enjoyment (both for the man and his partner). Reduced sensitivity is a given with circumcision because of the number of nerve ending that are removed during the procedure. Some think that this leads to less satisfaction as adults.
What Are the Benefits of Circumcision?
Reduction in Rates of Urinary Tract Infection (UTI)
Some studies show that there is a decrease in the rate of urinary tract infections (UTIs) in circumcised boys. Boys are significantly less likely than girls to develop UTIs and by age 5, only 1–2% of boys will have had a UTI. Circumcision decreases the risk of a UTI by less than 1%, so though the procedure may help prevent UTIs, the decrease is statistically insignificant. Additionally, in a 2005 study, researchers found that to prevent one UTI, two babies would experience complications from the circumcision procedure.
Reduction in Rates of Penile Cancer
The American Cancer Society’s official guidelines now state that circumcision should not be recommended as a sole way to prevent penile cancer, and that “In weighing the risks and benefits of circumcision, doctors consider the fact that penile cancer is very uncommon in the United States, even among uncircumcised men.” Circumcision does seem to reduce the risk of penile cancer in some cases. Penile cancer occurs in less than 1 man in 100,000 and accounts for less than 1% of cancers in men in the United States.
Reduction in Rates of HIV
Many studies exist regarding the relationship between circumcision and reduction of HIV infection rates in Africa. Whether these studies are relevant to the lives of people who live outside of Africa is questionable. The data is not always easy to interpret, and forming an opinion on the circumcision-HIV issue requires digging into some research. The CDC has found that in the United States, circumcision does not affect the rates of HIV in U.S. men. Here are some other links on HIV and circumcision:
Reduction in Rates of HPV
Human Papillomavirus (HPV) has come into the spotlight in recent years with the development of a vaccine that is now available for teens. HPV is the leading cause of invasive cervical cancer in women. In terms of health, HPV has much more of a potentially damaging effect on females, but males are able to transmit the disease. Some evidence suggests that circumcision reduces the transmission of HPV. This study, done among heterosexual men on 5 continents, found that neither condom usage nor circumcision was associated with the HPV DNA prevalence. In either case, it must be used in tandem with other safe sex practices.
Prevention of Phimosis
Phimosis is a condition where the foreskin is unable to retract. Because a normal foreskin does not retract for many years after birth, a diagnosis of phimosis given at a young age should be carefully considered and possibly suspect. The foreskin remains tight through puberty and this is a normal condition. Less than 2% of adult males experience phimosis and of those, over 75% usually respond well to treatment with steroid creams. Circumcision is a treatment for phimosis, however due to the low occurrence of phimosis in intact adult males, some doctors are starting to prefer it as a solution for only the most difficult cases.
Some religions include circumcision as part of their faith or common religious practices. Circumcision is practiced as a religious rite in Islam, called Khitan, and in Judaism the rite of brit milah is traditionally performed on the infant’s 8th day of life. In all faiths, there are a wide berth of beliefs and practices.
Whatever your faith, it is up to you to decide what is right for you and your family, and how it will fit in with your faith. Resources exist for those who are struggling with this question, including the Jewish Circumcision Resource Center. Christianity is the most prominent religion in the United States. Some think that the bible dictates circumcision, and others believe exactly the opposite.
Social aspects of circumcising vs. keeping their baby intact are often have a very strong influence on new parents. These are the aspects that often feel most gutteral and personal to people. Some of the questions parents ask include:
- Will my son get made fun of?
- Shouldn’t my husband make this decision, after all, he’s the one with the penis?
- Isn’t it better to do it now when he won’t remember it?
- Won’t he be happier if he looks like/matches his father?
- But his brothers are circumcised, won’t it be a problem if they’re not all the same?
On her blog, birth educator Donna Ryan provides some great answers to some of these questions.
Beyond statistics and studies, the personal experiences of parents who are willing to share can be really helpful. These are individual experiences, and should be taken as such.
My sons are both circumcised, but I no longer believe in circumcision as a routine procedure. I didn’t know then what I know now, and don’t feel that I made the most informed decision I could have. I hope that by sharing these resources, I can help to prevent other parents from feeling the same way.