To Cut or Not to Cut?

By Jean Weiss

A newborn baby has an open, vulnerable quality, so it’s hard to imagine causing pain by circumcising an infant at such a precious stage of life. And yet some experts now recommend just that, based on studies that suggest circumcision could offer health benefits when the baby boy grows older.

Circumcision, the surgical removal of the foreskin at the tip of the penis, is once again a topic of debate both internationally and within the US. At the center is research showing that males with circumcised penises are less likely to contract HIV through heterosexual sex. The most recent study, published in February 2007, found that circumcised adult men in Kenya and Uganda reduced their risk of HIV by 50 percent or higher than uncircumcised men.

“The studies in Africa, where HIV is predominantly heterosexually transmitted disease, show that HIV transmission can be decreased 50 to 75 percent if a man gets circumcised; that is really dramatic,” says Peter Havens, MD, professor of pediatrics and epidemiology at the Medical College of Wisconsin and a consultant in infectious diseases at Children’s Hospital of Wisconsin.

The research findings prompted the World Health Organization (WHO) and the Centers for Disease Control (CDC) to recommend male circumcision and instigated a review within the American Academy of Pediatrics (AAP) of its current position that circumcision is not a medical necessity. The AAP may release a revised statement more strongly in favor of circumcision soon, according to the AAP’s president, Jay Berkelhamer, MD, a pediatrician at Children’s Health Care of Atlanta. For now, the AAP says in a policy established in 1999 and most recently reaffirmed in 2005, “existing scientific evidence demonstrates data are not sufficient to recommend routine neonatal circumcision.” The AAP encourages parents to consider cultural, religious, and ethnic traditions to determine what is in the best interest of their child.

Yet some argue this policy falls short by not stating the benefits of circumcision—especially in light of the studies based in Africa. At issue: whether circumcision may be the healthiest option for the child, or if it remains a personal, rather than a medical, choice for each family to make.

Why circumcise?
Advocates of circumcision say that the procedure can significantly reduce a man’s risk not only of getting HIV but of contracting other sexually transmitted diseases, such as gonorrhea and chlamydia. Circumcised men also appear to have lower rates of kidney disease and have female sexual partners with a lower risk of contracting the human papillomavirus (HPV). These health benefits relate in part to the nature of the delicate cells on the foreskin that are more permeable and subject to trauma. The inner foreskin tissue also can trap bacteria and other foreign items, whereas a circumcised penis is easier to keep clean.

But weighing these health risks when deciding whether to circumcise or not means making future predictions about sexual patterns of your baby boy—which may seem like a leap into absurdity. In fact, most parents circumcise because that’s what their family and friends have done and support. “When you think about circumcision, one of the biggest things you think about is what does dad’s penis look like,” says Havens, of how the choice has traditionally been made. “Cultural considerations, and looking like dad, are the strongest factors in making that decision.”

This is what prompted Erin Hansel and her husband to circumcise their baby boy one week after birth. “In Missouri, where we were at the time, everyone had their sons circumcised,” says Hansel. “My husband was circumcised and didn’t want our son to be different or stand out in the locker room.” Hansel says that although they based their decision partly on cosmetics, their main concern was the health and well-being of their son. “We had heard stories of kids or adults who had to have it done later in life because of an infection and didn’t want our son to go through that pain when we could have done it now and he would forget it,” says Hansel. “We also read that circumcised men are less likely to contract HIV.”

Havens, who provides daily medical care to adolescents who get AIDS through heterosexual sex, says it’s not far-fetched for a parent to factor in a child’s future sexual habits when considering whether or not to circumcise. “Kids have sex before they are completely developed enough to make good choices,” says Havens. “Now if I tell you, I know you are looking at this perfect baby, and you can’t imagine this kid going out and having sex with 20 women over a three-year time period. None of us can imagine that from our child. In fact, things may change. In this country, new [HIV] infections in people under age 25 aren’t happening in little babies because we are testing their mothers and treating them. They are happening in sexually active adolescents.” Havens says a parent can do many things to educate his child about safe sex practices, but that for certain populations the decision to circumcise, as part of a multi-tiered approach to help decrease that child’s chance of getting an STD, is valid.

Daniel Halperin, PhD, a research scientist at the Harvard School of Public Health, agrees. Halperin, who classifies himself as a former hippie type from Northern California with a tendency to keep things as natural as possible for an infant, says he bases his pro-circumcision stance on the evidence. In addition to protection from STDs, Halperin says that circumcision can reduce the risk of urinary tract infections, though he admits that risk for uncircumcised infant boys is low, at less than 2 percent.

“When you carefully add up all the risks and medical benefits it would certainly seem that the benefits outweigh the risk,” says Halperin. “Each parent has to decide and no parent should be coerced, but that’s what the medical evidence suggests, and there is no convincing medical evidence against circumcision.”

Both Halperin and Havens recommend circumcising infants, rather than waiting until the child becomes an adolescent or an adult. Doctors circumcise infants with a local anesthetic. Adults, on the other hand, sometimes go under general anesthesia for circumcision, so they face greater medical risks, though some practitioners do use only local anesthetic (see “Snip Impact” on page TK). “There are more complications for adults getting circumcised than for children,” says Havens. “The complication rate is lower in infancy than in adulthood. It is a very safe procedure.” Case in point: An adult man who gets circumcised, may have several erections while sleeping at night, which can affect the stitches and create more potential for scarring than in infant circumcision.

Why not circumcise?
Those opposed to circumcision say the lack of clear medical benefits paired with the ethical factor of changing a child’s penis without his consent weigh heavily in their decision. Parents also want to avoid any risks associated with circumcision, which include scarring, the potential of a retracted penis, and some argue, reduced sensation on the penis tip.

“When we found out we were having a boy, I talked to my husband to see if he had strong feelings either way as a circumcised male,” says Diane Hampton, the mother of fraternal twin babies, one male, one female. “He said, ‘No.’ We did some research, talked to people, and we decided we didn’t really have religious or ethical or ethnic reasons to circumcise. From what we can tell from the research, there don’t appear to be any medical benefits. Mostly it seems to be for aesthetic purposes.”

The Hamptons considered the studies done on African male heterosexual populations, yet decided they weren’t pertinent to their decision. They plan to educate their son and daughter early about safe sex practices. “I guess the research just didn’t have a very strong impact on us in the sense of what we know, what are the benefits of not being circumcised,” says Hampton. “We felt there was minimal risk for our son.”

Many medical experts agree, comparing the choice to circumcise with that of piercing an infant’s ears, for example. Both change the way a child looks, both put the child at increased risk for infection, both may reflect cultural or parental preference.

“I believe there is no true medical reason to circumcise an infant boy,” says Tamara Cullen, ND, an adjunct faculty member in pediatrics at Bastyr University. “The only possible evidence that has come up [indicates] that uncircumcised infant boys do tend to get more urinary tract infections, but that is preventable and treatable and is typically not a life-threatening condition.”
In addition, Cullen cites the risks associated with circumcision, which include scar tissue and adhesions on the penis, a retracted penis, and decreased sensation. Reports about reduced sensation in circumcised penises seem to be anecdotal. And, in fact, some studies show that uncircumcised males can have penile problems, too, such as an inability to retract the foreskin that can result in a lot of pain and prevent the man from having intercourse.

Cullen agrees that the link between circumcision and a reduced risk of STDs once a man is sexually active is significant, but not for an infant population. Hampton opted not to circumcise her son because she didn’t want to inflict unnecessary pain on her infant, or leave him no choice about the way his penis looked. She was specifically bothered by “the idea that there is no informed consent on his part, that there is pain during the procedure and afterward, and that there could be complications.”

Typically Cullen’s patients have already decided not to circumcise and want to hear information on how to maintain and clean the penis, rather than the pros and cons of circumcision. Although no alternatives to circumcision would achieve the same lowered risk of STDs and UTIs as circumcising the penis, Cullen says keeping the penis clean once the foreskin is naturally retractable decreases infection risk.

Talking early to your child about hygiene and about STD risks will better protect him, says Cullen. “Certainly, condom use in men is the best alternative to decrease exposure to the HIV virus. I do hope that this new study does not give a false sense of security to circumcised men.”

A statistic or a person?

While the AAP examines its position on circumcision, and the medical community at large debates the merits of both options, parents must sort through conflicting interpretations of the data. The AAP hopes to help out soon with this confusion.

“This is one of those areas where people feel very passionate,” says Berkelhamer. “There are people who feel extreme on both sides of this issue. We are trying to stay with the evidence, to see if [the AAP] statement needs to change in any way.”

One result of the AAP stance on circumcision is that some private insurance companies and Medicaid coverage in 16 states have pulled funding for circumcision. This means in some areas only people with resources have access to the procedure.

Regardless of what the AAP determines once it fully reviews the updated literature, the decision remains individual and personal. “When I’m meeting with a patient one on one, it is about what is best for that family, what is best for that child, what is their religion, their culture, their behaviors, their risks,” says Cullen. “When you bring it down to an individual perspective, it is a lot easier to make that decision, whereas when you look at it from a public health perspective, you are more likely to make the response to circumcise.”

Jean Weiss is an anthro-journalist who studies cultural trends for a market research company. She writes frequently on issues of health and wellness and is a regular contributor to MSN.com.

The Numbers
Over the past decade, the US has trended away from circumcision. In 1994, for example, roughly 63 percent of the infant male population left hospitals circumcised, a decision made in part for cultural reasons. By 2004, roughly 57 percent of US infant boys left hospitals circumcised, a 6 percent decrease over a 10-year period.

Help for Making the Decision

American Academy of Pediatrics, 847.434.4000, www.aap.org. Read the AAP’s circumcision policy at
http://aappolicy.aappublications.org/cgi/content/full/pediatrics;103/3/686

Centers for Disease Control and Prevention, 800.311.3435, 800.CDC.INFO, www.cdc.gov, or try www.cdc.gov/hiv/resources/factsheets/circumcision.htm

www.circumcisioninfo.com, a site that offers great resources, but firmly pro-circumcision

Circumcision: What Every Parent Should Know, by Anne Briggs (Birth and Parenting Publications, 1985).

Snip Impact: Infant Versus Adult Circumcision
Some parents and healthcare providers say it’s safer and has less impact to circumcise a newborn infant because the penis hasn’t fully formed yet; others think the male should be able to choose for himself when he’s older. What is circumcision like for an infant versus a grown man? We did some digging to compare the two procedures.

Infant circumcision
Penis status: not fully developed; the glans and inner foreskin may still be attached; the foreskin cannot yet be pulled back
Procedure lasts: up to 10 minutes
Anesthesia and meds: local anesthesia, acetaminophen prior and following
Recovery time: 1 to 2 weeks
Side effects: swelling, redness, some bleeding
Trauma impact: unknown
Results: less scarring, quicker healing

Adult circumcision
Penis status: fully formed, glans and inner foreskin detached, and foreskin able to be pulled back in most men though some have problems with this
Time: approximately 20 to 30 minutes
Anesthesia: Local, sometimes general, various pain meds following
Recovery time: several weeks, up to a month before you can resume sex
Side effects: burning, swelling, general soreness
Trauma impact: Low when elective
Results: Potential for more scarring, because of the heavier sutures needed to keep the wound closed during night erections