Circumcision decision

We separate foreskin fact from fiction to help you make an informed choice

Centimetre for square centimetre, the scrap of skin covering the tip of the penis has probably been the subject of more confusion, debate and angst than any other body part, at least among North American parents. Known as the foreskin, this tissue is factory issue for newborn baby boys — but some parents opt to have it surgically removed, despite the fact that many major medical organizations have concluded there are no valid medical reasons for routine circumcision. In fact, in most provinces, it’s now considered a cosmetic procedure that parents must pay for out of pocket. What factors should you keep in mind when considering whether or not to circumcise your son?

First, an anatomy lesson — after all, some of us have limited first-hand experience with the foreskin, since removing it during infancy was de rigueur in Canada 30 years ago. At birth, the penis looks like a wrinkly finger. Over time, the skin on the helmet-shaped tip, or glans, separates into two distinct layers. Eventually, the outermost covering (the foreskin, which then acts as a sleeve, with the inside surface resembling the lining of the mouth) can be pulled back past the glans.

Circumcision involves artificially separating the foreskin from the glans, then cutting it away, using a clamp as a guide. The resulting raw area — usually the entire tip of the penis — heals over the next seven to 10 days, toughening up and taking on the appearance of ordinary skin.

Until a decade ago, the procedure was often done without freezing because many people believed newborns didn’t feel or remember pain. Now, however, we recognize that’s simply not true. “Babies feel pain, and may feel pain more severely than adults,” notes Robin Walker, a neonatologist and spokesperson for the Canadian Paediatric Society (CPS). “There’s also pretty compelling evidence that pain in the newborn period actually translates into a heightened response to pain later in life.” Consequently, the CPS now advocates using effective pain control methods during circumcision — see Minimizing Pain.

Why would a parent choose to circumcise? Let’s start with the medical rationale.

Does circumcision confer any health benefits for the average male? Actually, it does seem to protect against certain problems.

For example, circumcision reduces the risk of urinary tract infection (UTI) in the first year of life. However, UTIs are uncommon even in uncircumcised boys, notes Peter Anderson, a professor of urology at Dalhousie University in Halifax. “Less than one percent of uncircumcised boys will ever get a UTI,” he explains, so even a four- to tenfold reduction represents only a tiny advantage, unless a boy has a medical condition placing him at a particularly high risk. Moreover, UTIs are usually easily treated with antibiotics, and there’s no evidence to suggest circumcision cuts the odds of complications such as kidney problems.

Research also indicates that men who were circumcised during infancy are less likely to develop cancer of the penis than those who were circumcised later, or not at all. “On the other hand, this disease is very rare,” says Anderson, affecting approximately one in 100,000 men, and tends to strike those with chronic irritation stemming from hygiene problems — for example, homeless men. Regular washing seems to be protective. Remember: If circumcision was the primary deciding factor, penile cancer would be endemic in countries like Denmark, where circumcision is not widely practised.

Some studies also suggest circumcision could substantially lower a man’s chances of contracting STDs, including HIV. However, critics argue much of this research is flawed, in part because many studies compare groups that don’t share the same risk factors: For instance, in the US, circumcision is more common among the wealthy and middle-class than the poor, who suffer disproportionately from all manner of ills, including STDs.

Some parents also circumcise their infant boys to pre-empt the possibility of needing it done later in life to remedy problems like chronic infections beneath the foreskin. “My cousin had a horror story about her stepson and younger brother who were circumcised at a later age due to repeated infections,” says Judy Sylvester, of Delburne, Alta. Wendy Carey, a former daycare provider in Ottawa, adds: “I’ve encountered a small number of situations where boys of three or four were being circumcised because of the foreskin not retracting properly, or recurring infections.”

Certainly, that idea would make anyone cringe. But let’s put that possibility in perspective. “Medical circumcisions occur in about five percent of the population — so there’s a 95 percent chance your son isn’t going to be in that category,” Anderson emphasizes. Furthermore, he argues some circumcisions done later in childhood are unnecessary, citing the example of a healthy five-year-old whose foreskin isn’t retractable. “He just needs to do some growing,” Anderson says, since this “problem” typically disappears by puberty. Steroid creams may also be used to hasten separation of the foreskin from the glans.

Even if a boy eventually needs to be circumcised, with modern anaesthetic techniques the operation won’t be the harrowing experience it would have been not long ago. “A nerve block works extremely well,” Anderson reassures, noting many parents are amazed to find their sons feel little or no pain the day after surgery.

“In experienced hands, circumcision is not high risk,” Walker says. Life-threatening infection and hemorrhage, and serious injury to the penis, are extremely rare, occurring in perhaps 0.2 percent of circumcisions. “What is much more common is either minor bleeding or minor infection,” which happen in between five and 10 percent of cases, Walker says. As well, about one percent of circumcised baby boys need to have the operation redone because it didn’t turn out properly the first time.

Circumcision also increases the likelihood of a condition called meatal stenosis — a narrowing in the opening in the penis, which may require minor corrective surgery. “We essentially never see this in uncircumcised boys,” Anderson explains. Meatal stenosis is caused by chronic irritation of the opening, something the foreskin guards against. In one study, about seven percent of circumcised boys over age three were diagnosed with meatal stenosis.

Finally, some people argue circumcision may rob men of some sexual sensation, since scientists recently discovered the foreskin is much richer in nerves and blood vessels than once believed.

The health bottom line

So how do the risks stack up against the benefits? Several expert panels (including the CPS’s fetus and newborn committee) have systematically reviewed the medical evidence and concluded it’s a wash, at best.

Since even a safe operation is still surgery, parents in the “if it ain’t broke don’t fix it” school aren’t willing to take on even a small risk. “Babies don’t get their appendix or tonsils removed to prevent future problems,” observes Kristine Guenther, of London, Ont. Some parents also feel that in the absence of any immediate medical threat, the choice doesn’t rest with them. “What right do I have to take away something he was born with, that I can never give back?” asks Lisa Elia, the mother of a four-month-old boy in Niagara Falls, Ont.

Religion
In some faiths, circumcision is more than a medical procedure. For example, in Judaism, it’s part of a ritual that represents a covenant with the Creator and, in Islam, it’s done to emulate Muhammad. However, Eva Goldfinger, rabbi of Toronto’s Oraynu Congregation for Humanistic Judaism (a movement that doesn’t demand circumcision, instead advocating informed decision making) notes some members of the community she serves choose to retain the ritual naming ceremony and celebration, but skip the circumcision. That said, as a therapist Goldfinger also counsels parents to think about what their sons may miss out on if they forgo circumcision. “If a child is circumcised, he is welcomed everywhere into the Jewish community,” she says, noting that even most Reform rabbis she’s aware of insist on circumcision.

Culture
Many parents who choose to circumcise do so because they believe an uncircumcised penis is difficult to keep clean. “I think circumcision is more hygienic,” explains Vicki Gagnon* of Toronto.

While this may sound like a health concern, it’s actually cultural. “It mostly relates to a lack of education on how to care for an uncircumcised penis — which is to leave it alone until the foreskin is retractable,” says Walker. Anderson explains the issue this way. “There’s no evidence there’s any need to clean under the foreskin before puberty,” he says. (That’s when hormones prompt glands in the foreskin to start secreting a lubricating fluid.)

Another culturally rooted rationale for circumcision is the belief that a boy should look like Dad. (In fact, Dad’s status is one of the strongest predictors of Junior’s.) “I didn’t want my son to question me in future about why his penis looks different than his dad’s,” explains Lucy Menna of Hamilton, Ont. However, Andrea Kerr, whose spouse and son don’t match, doesn’t believe her son will bat an eyelash. “Boys and men look different in so many other ways,” says the Thornhill, Ont., mom. Even if her boy broaches the subject, Andrea thinks explaining he didn’t have an operation but daddy did won’t be a big deal.

Other parents feel it’s more important for boys to resemble their peers — which is an argument against circumcising, since even in PEI, where rates are highest, only about 30 percent of newborn boys now undergo the operation. (According to one estimate, approximately 14 percent of Canadian baby boys were circumcised in 2003, but these statistics don’t include procedures performed outside of hospitals.) However, being odd man out isn’t the end of the world: A Swedish study that followed 117 circumcised boys — members of a tiny minority in that country — found none suffered psychological problems.

That fact should also quell parental fears like “women don’t like uncircumcised men,” since what we consider normal or attractive depends on what we’re brought up with. After all, Scandinavian men don’t seem to have any more trouble finding wives and girlfriends than men in countries where circumcision is common practice.

But wives, and even locker rooms, are years off yet. In the meantime, now that you’ve weighed both sides of the issue, you’ll be able to make an informed choice. “At the end of the day, it’s a personal decision for the parents to make,” Anderson concludes.

*name changed by request

If you’ve already decided to circumcise for religious or cultural reasons, how can you make the process as safe and pain-free as possible?

Choose an experienced practitioner. As with any operation, circumcision seems to be safer when it’s done by someone who’s had lots of practice — a few hundred procedures a year. Your family doctor, local hospital, rabbi or imam may be able to provide you with a list of candidates. Call ahead and ask how many circumcisions the practitioner does. You may also want to ask what kind of clamp he or she uses: Neil Pollock, a Vancouver physician specializing in circumcision, says the Mogen clamp allows him to perform the procedure in less than a minute, versus up to 10 using other clamps.

Opt for effective pain control. Studies suggest nerve blocks offer the best pain control. Pollock uses a four-pronged approach: topical anaesthetic (to numb the area before giving the needle) plus the nerve block, a sugar soother (shown to decrease distress) and acetaminophen. This doesn’t necessarily rule out having a religious circumcision: Some mohels (ritual circumcisers) are also doctors — Pollock, for example.

Does circumcision confer partial protection against HIV infection? Some comparisons between certain groups suggest HIV/AIDS is less prevalent in populations that practice circumcision, but this could be due to the fact that people who belong to certain cultural or religious backgrounds may share behaviours that influence their risk — say, having few sexual partners. Scientists have only recently started trying to tease apart whether circumcision itself makes a difference, by randomly assigning men to either undergo the procedure or have no treatment. One such study, involving more than 3,000 South African men, found that those who underwent the procedure were 60 percent less likely to become infected with HIV over a given period. While more research is needed, clearly circumcision offers less-than-perfect protection — which means it can’t replace proven practices like consistent condom use.