Cutting to the Point on Circumcision

From the WebMD Archives

From the time Debra Sherman and her husband, Mark Wilcox, learned through prenatal genetic tests that they were having a boy, they agonized over whether to circumcise their baby. "I didn't want the first decision we make for him to be a bad one," Sherman says.

In the end, the Chicago couple decided against taking that extra surgical snip of foreskin from their son's penis. Without overwhelming medical evidence favoring circumcision, Sherman says, it would have seemed to her like deciding to cut off his ear lobes.

"From everything we read and everyone we talked to, it seemed like there was no medical reason to do it," says Sherman, whose son, Alex, is 7 months old. "Plus, I'm not religious, Mark's not religious, and I just thought it was an awful thing to do to a baby."

The fact is, the circumcision decision is a very personal one. Experts say parents need to understand the advantages and disadvantages, then decide what's right for them. Here are the latest facts and a look at how some parents are choosing.

Vive la Difference

Locker rooms have a way of reducing each sex to its least common denominator. Peel away the Levi's and Jockeys, put aside sizes and shapes, and the equipment is all basically the same -- at least that was the case when today's generation of new dads were kids.

Parents in the United States have routinely circumcised their sons since the 1940s, in large part because doctors believed it promoted good hygiene and prevented disease. To Jews and Muslims, circumcision is a sacred ritual symbolizing their covenant with God. By the mid-1960s and early 1970s, about 90% of all boys were circumcised.

But that trend is shifting. In 1996, circumcision rates declined to about 65%, although rates differ depending on demographics: 80% in the Midwest, 68% in the Northeast, 64% in the South and 34% in the West. Among whites, the rate is 81%, compared with 65% among blacks and 54% among Hispanics.

In fact, many observers predict that by the time the first generation of boys born in the new millennium is old enough to hit the locker-room showers, the haves and have-nots may be about equally divided.

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The biggest reason for the change is mounting evidence that the medical benefits aren't as compelling as once believed. In addition, anti-circumcision groups have turned up the heat on the debate. They claim the practice is cruel and unnecessary and are spreading the word via Web sites, mailings, bumper stickers, T-shirts and international conferences.

Circumcision rates are much lower in other parts of the world, including most of Europe, Asia and Latin America. Only 48% of boys in Canada, 24% in the United Kingdom and 15% of boys worldwide are circumcised.

Probably the strongest cause for pause among parents, however, came this year when the American Academy of Pediatrics issued a policy statement saying it does not endorse routine circumcision.

"There are potential benefits as well as risks, but the data wasn't sufficient for us to say every newborn male needs to be circumcised," says Dr. Carole Lannon, clinical associate professor of pediatrics and internal medicine at the University of North Carolina, Chapel Hill, and chairwoman of the task force on circumcision. "Each parent needs to make that decision."

To Snip or Not To Snip

A circumcision is usually performed within 48 hours of birth by an obstetrician or pediatrician in the hospital, or on the eighth day after birth for the Jewish ritual, called brit milah or bris. The baby is restrained, then the layer of tissue that covers the tip of the penis is surgically removed. It should take no more than five minutes in skilled hands.

When weighing the pros and cons of circumcising your baby, the most clear-cut medical benefits of circumcision are a four- to 10-fold decrease in the risk of urinary-tract infections during the first year of life, and a three-fold reduction in the risk of penile cancer among adult men.

However, urinary-tract infections and cancer of the penis are rare. The risk of developing a urinary-tract infection in an uncircumcised male infant is no more than 1%, and breast-feeding has been shown to protect against these infections among this group, according to the AAP. Only 10 or fewer men per 1 million get cancer of the penis each year worldwide.

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Studies also show a somewhat higher incidence among uncircumcised men of sexually transmitted diseases, including syphilis and human immunodeficiency virus. However, the AAP says that the data are conflicting and highly controversial since behavioral factors play a larger role in contracting STDs than the existence or absence of foreskin.

Boys who are circumcised avoid the risk of phimosis, a condition that makes foreskin retraction impossible. However, the overall risk of penile problems for uncircumcised boys is unclear. The AAP cited one study that followed 500 boys up to age 8 and found higher rates of penile problems -- typically inflammation -- in infants who were circumcised, but more problems among older boys who were not circumcised.

As for the argument that circumcision improves hygiene, "that one doesn't really hold up," says Dr. George Kaplan, a clinical professor of surgery and pediatrics at University of California at San Diego and AAP task force member. "If you're not circumcised, I think that as long as you wash your penis, that's probably fine," Dr. Kaplan says. Bathing an uncircumcised baby simply requires washing the penis with soap and water. After the foreskin becomes retractable (typically by age 5), boys can be taught to gently pull back the foreskin to clean the tip of the penis.

On the other side of the coin, circumcision also presents some clear disadvantages.

For one thing, it hurts. Doctors used to think that infants didn't feel pain like adults and that circumcision didn't require anesthetic. Not anymore. Although it's hard to know just what they're feeling, it's clear that babies who are circumcised experience temporary changes in heart rate, blood pressure, oxygen saturation and hormone levels.

New research even shows that early exposure to pain may have long-term effects. One study found that infants who underwent circumcision without analgesics were more sensitive to pain during immunizations at four months and six months. Another found that newborns exposed to pain by circumcision or illness were more anxious about pain as children and adolescents.

If parents choose to circumcise their baby, the AAP recommends local anesthesia. Doctors can use a topical anesthetic, a dorsal penile-nerve block (injected with a needle), or a newer procedure called a subcutaneous ring block, which proved to be more effective than the other two methods in one study.

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Another disadvantage of circumcision is the risk of surgical complications, although they are rare -- maybe 0.2% to 0.6%. Bleeding is the most common complication, occurring in 0.1% of circumcisions, although it's rarely bad enough to warrant a transfusion. Minor infection is the second most common problem.

Less common are complications, such as improper or excessive cutting, which can impair function. In a few instances, circumcision has resulted in loss of the penis or even death. A 1-month-old infant in Cleveland, Ohio, died last year from anesthesia complications as doctors were repairing his circumcision.

It's also more expensive. About 1.2 million newborn males are circumcised annually at a cost of $150 million to $270 million. An individual circumcision can range from $225 to $500.

Opponents of circumcision also claim that the procedure desensitizes the penis and decreases sexual pleasure. That's because the foreskin, which makes up about half the skin of the penis, contains highly sensitive nerve endings.

No studies have been done to back those claims, although some men who were circumcised as adults reportedly say that sensitivity decreased significantly. On the other hand, one study found that circumcised men remained sexually active longer.

Parents Sound Off

For Hugh and Kalei Damon, of Newport Beach, Calif., the decision to circumcise Cole, now 14 months, came down to conformity. Not only is Hugh Damon circumcised, but he's banking on the fact that most boys Cole's age will be, too.

"I remember growing up seeing my dad naked and his looked the same as mine. I just felt psychologically, if it didn't there might be questions why," says Damon. "Mostly, I just didn't want him to feel different in the locker room or from me."

Religious tradition was the determining factor for Doug Gertner and Maggie Miller, of Denver, Colo. Just as Gertner's own Jewish ritual ceremony connected him to his ancestors and heritage, so too would his son's. Jordan is now 1.

"It was a powerful, beautiful event, and the community went out of its way to be there and support him as he went through this rite of passage," says Gertner. "Hopefully he'll appreciate that anything I did to him was chosen thoughtfully, and not just pain inflicted."

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However, some Jews are among those questioning the ancient ritual. Michael Kimmel and Amy Aronson of Brooklyn, N.Y., came up with a creative alternative. They found a mohel, who performs ritual circumcisions, to perform the ceremony -- without the circumcision.

"We discovered that there is a long tradition of opposition to circumcision within the Jewish community, mostly from women," Kimmel says. "Circumcision is wrong and cruel and medically unnecessary, but we didn't want the occasion of his birth to go unmarked or to feel that to our family he wasn't being brought in as a Jew."

They ended up having the naming ceremony and communal gathering but replaced the traditional circumcision with another common ritual among desert cultures they discovered after doing some research: They welcomed Zachary into their home by washing his feet. "In the end, the family, even our fathers, felt OK with that."

Pain was the deciding factor for Sherman and Wilcox in choosing not to circumcise their son Alex. They talked about all the ramifications, including what it might do to his sex life. Indeed, one survey indicated American women prefer a circumcised penis by a margin of 3 to 1.

Sherman admits he was concerned how a future girlfriend might react to his son's uncircumcised penis. His ultimate answer? "If she's never seen one before, she's going to freak out anyway, and if she's already seen a lot of them, she'll probably appreciate the diversity."

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