The real lowdown on circumcision

To circumcise or not: That question gets parents more hot and bothered than debating cloth versus disposable diapers or even breast versus bottle. After all, choosing to surgically remove the skin sheathing the tip of a baby boy’s penis is an intensely personal decision. And since the procedure has declined in popularity in the past few decades, those who do opt for it may have a harder time getting their questions answered. That’s why we went to the experts to get the facts on circumcision FAQs.

Q: What do the medical experts say about circumcision?

A: Back in 1996, the Canadian Paediatric Society (CPS) concluded that there was no medical reason for routine circumcision, says Robin Walker, a professor of paediatrics at Dalhousie University in Halifax. The organization didn’t comment on doing the procedure for personal, religious or cultural reasons.

The panel found the proven benefits and risks are roughly equal; however, they decided since circumcision carries a slight risk of serious complications including death, it’s not worth doing merely to reduce the already low risks of diseases that are either easily treated (urinary tract infections during babyhood, for example) or largely preventable by other means (such as sexually transmitted infections and cancer of the penis) later in life. In 2007, the CPS revisited the issue, and the statement is under revision. There’s no word yet on what the changes will be, though it’s possible they’re related to recent research showing circumcision reduces the chances of HIV infection.

Q: How common is infant circumcision in Canada?

A: Hard to say. Since circumcisions now typically take place outside of a hospital, and provincial and territorial health plans no longer pay for non-medical circumcisions, it’s tough to accurately track how many are being done. While the Canadian Institute of Health Information reported that, in 2005, 9.2 percent of newborn boys were circumcised, the actual number may be higher.

Q: What can be done to minimize the pain?

A: Thankfully, things have changed since the days when babies were circumcised without anaesthesia because doctors mistakenly believed newborns couldn’t feel or remember pain. But while there are now methods that can make the procedure nearly painless, not all doctors use them, says Keith Barrington, chair of the CPS’s fetus and newborn committee, and a professor of paediatrics at Montreal’s McGill University, so you may want to do some detective work before booking a circumcision for your son.

First of all, some surgical techniques hurt less than others; research indicates a device called the Mogen clamp causes less discomfort than other instruments. Studies have also shown an injection called a nerve block offers the best pain control, in combination with a topical anaesthetic to numb the area where the needle is given, and a taste of sugar to calm the baby, notes Neil Pollock, a Vancouver physician who specializes in infant circumcision. Acetaminophen eases soreness after the procedure. And like any other operation, circumcision is safer and probably less painful in skilled hands, so if you do opt to circumcise, look for a practitioner who does at least a few hundred per year.

Q: What kind of care does a baby need after being circumcised?

A: The most important thing is to keep a close eye on your little guy for the first few days: More than a few drops of bleeding, a fever (rectal temperature above 38°C/100.4°F), a baby who seems sick or off, and any swelling and redness that hasn’t begun to improve within 48 hours are all reasons to call your doctor. Otherwise, keep the area clean by washing it gently with soap and water during frequent diaper changes. Do a new dressing during each diaper change, applying Vaseline to keep it from sticking. Usually, the raw area will heal within a week.

Q: If a baby isn’t circumcised, what are the odds he’ll need the procedure for medical reasons later?

A: The chance of this happening is in the same range as needing to have your appendix removed — about three to four percent, says Paul Thiessen, a clinical professor of paediatrics at the University of British Columbia and medical director of the intermediate nursery at BC Women’s Hospital in Vancouver. The number of boys needing a medical circumcision has shrunk over the past 10 years or so, he adds, since doctors discovered strong steroid creams can often loosen and stretch a foreskin that’s too tight or small to retract fully. While this is still one of the most common reasons a circumcision might be recommended, time often corrects the problem, according to Peter Anderson, a paediatric urologist at the IWK Health Centre and a professor of urology at Dalhousie University in Halifax. By puberty, normal growth usually fixes any size mismatch between the foreskin and the rest of the penis.

If a child is older than a few months of age, a circumcision is usually done under general anaesthesia to prevent any mishaps that might occur if a boy moves, and to minimize distress. It’s mainly the anaesthetic that slightly increases the risk of the operation, compared with newborn circumcision. For more info on childhood circumcision, visit the Canadian Urological Association website, cua.org, and click on Patient Information.

Q: Is there any truth to the notion that poor hygiene is a valid reason for circumcision?

A: Yes and no. Recurrent urinary tract infections (UTIs) and repeated bouts of posthitis (an inflamed or infected foreskin) are both valid medical reasons for circumcising. However, the culprit isn’t necessarily lack of soap and water. Some boys are prone to UTIs because their bladders don’t empty normally. And sometimes foreskin infections may actually stem from overzealous attempts to clean underneath it, Barrington notes. How? Forcibly pulling back the foreskin before it separates fully from the head of the penis (something that typically doesn’t happen until at least age three and often not until much later) may cause tiny tears that allow bacteria to enter.

Q: I’ve read circumcision reduces the risk of HIV infection. Does this mean I should have my baby circumcised?

A: That depends on whom you ask. True, recent studies conducted in Africa found men who were circumcised as adults were 50 to 60 percent less likely to contract HIV. However, some doctors and scientists believe the findings aren’t relevant here, in part because HIV is far less common in Canada than Africa, and practices like consistent condom use reduce risk to a much greater degree. Says Bhagirath Singh, scientific director of the Institute of Infection and Immunity at the Canadian Institutes of Health Research: “Is circumcising to reduce HIV risk beneficial in a country like Canada? I don’t see it.”