Australian researcher Brian Morris in a recent article published in Bioessays, attempts to make a strong case for circumcision. Morris claims that circumcision can be a surgical “vaccine” against a wide range of infections including sexually transmitted diseases (STDs). Morris also contends that circumcision can reduce the risk of a variety of medical conditions such as penile and prostate cancer, as well as cervical cancer for female sexual partners.

Morris would have parents believe that the decision to circumcise is clear-cut (no pun intended.) And for some parents, the decision is simple, given their cultural or religious beliefs. But for most parents, the benefits and risks must be carefully considered.

What is circumcision?

Circumcision is the surgical removal of the foreskin from the head of the penis, so that the tip of the penis is exposed. Ouch!

Even those not faint of heart would likely admit that the procedure sounds a bit gruesome. The penis and the surrounding area are washed with an antiseptic solution. Then the penis is numbed with a topical or injectable anesthetic. A special clamp or a plastic ring is attached to the penis to prevent bleeding while the foreskin is cut away. Finally, an ointment, such as petroleum jelly is placed on the penis and a piece of gauze is loosely wrapped around the penis.

It usually takes about 7-10 days for the penis to heal. During each diaper change, parents are instructed to put petroleum jelly on the tip of the penis and to change the gauze in order to keep the diaper from sticking to the penis. If a plastic ring was used, parents are told to expect the ring to fall off in about a week. Parents are also told to call their baby’s health care provider right away if the baby is unable to urinate or if the parent sees bleeding, swelling, or signs of infection.

How common is circumcision?

The World Health Organization estimates that 18 to 33 percent of all males worldwide are circumcised. Which means as many as 2 out of 3 males are NOT circumcised—a majority. In some countries circumcision is rarely done, while in others it is fairly common.

According to data from the National Center for Health Statistics (NCHS), 65.3 percent of all babies born in U.S. hospitals were circumcised in 1999, with the highest rate (76 percent) in the Midwest and the lowest rate (37 percent) in the West. In other words, 3 out of 4 baby boys in St. Louis, Missouri were circumcised compared to only 1 out of 3 in Portland, Oregon.

The Circumcision Reference Library (CRL) reports that the nationwide the U.S. circumcision rate has been fluctuating in the low 60 percent range for nearly 60 years. Non-circumcision has been the norm in the Western Region for more than a decade and 2004 data show that rates in the Southern Region are approaching 50 percent. Rates declined from 2002 to 2003 in all four census regions—Western, Northeast, North Central and Southern. However, the overall circumcision rate increased slightly to 66.4 percent in 2004 from 64.7 percent in 2003.

U.S. circumcision rates parallel the increase in hospital births, with circumcision rates reaching a peak of 85 percent in 1965.

In 1971, the American Academy of Pediatrics (AAP) reported that there were no valid medical indications for circumcision in the neonatal period. As a result, the decline in the circumcision rates that began in 1965 continued until 1989, when declines were halted by an AAP statement citing “potential benefits” from circumcision.

It wasn’t until 1999 that rates started to decline again, after the AAP issued yet another statement on circumcision saying that there were insufficient data to support a recommendation either for or against neonatal circumcision.

Other medical societies, including the Royal Australasian College of Physicians (RACP) have issued similar statements recommending against routine circumcision of boys. The RACP policy is currently under revision.

Are there benefits?

While opinions vary greatly, some data suggest that circumcised males may have a slightly lower risk for:

• Sexually transmitted diseases including HIV (the virus that causes AIDS), syphilis, and human papillomavirus (the virus that causes genital warts and cervical cancer)
• Urinary tract infections (1 in 500 for circumcised boys compared to 1 in 100 for uncircumcised boys)
• Penile cancer (a rare condition that occurs in only 1 in 100,000)
• Penile problems related to narrowing of the foreskin

With the exception of sexually transmitted diseases, all of the conditions cited above are extremely rare. And where HIV is concerned, circumcision should not be used as a substitute for appropriate public health measures including condom use.

Circumcision advocates argue that the penis is easier to wash, while those opposed to circumcision counter that males can be easily taught how to care for their penis along with other body parts.

Those who oppose circumcision claim that it diminishes sexual satisfaction for men as well as for their partners, citing as evidence a study by Taylor and colleagues suggesting that there may be a concentration of specialized sensory cells in the foreskin.

Are there risks?

Whenever a medical procedure is performed there are associated risks, and circumcision is no exception. While the incidence of immediate complications is small, data show that circumcision increases the risk for:

• Excessive bleeding
• Infection
• Pain
• Poor outcome should the foreskin be cut too short, too long, or not heal properly

In addition, there are complications that can occur later including meatal stenosis, skin bridges, chordee, and poor cosmetic appearance, some of which require surgical correction. In rare cases, complications have resulted in amputation of the penis.

Last but not least, because circumcision is considered an unnecessary medical procedure, many insurance companies will not pay the cost of circumcision, which in the U.S. are estimated to be between $150 and $270 million annually.

Are there ethical considerations?

The legal and bioethical issues surrounding newborn circumcision were the subject of an article by Svoboda and colleagues. While informed consent is the gold standard for medical decision-making, in the case of infants and young children unable to decide for themselves, parents have the right and responsibility to make decisions on their behalf.

Confusion occurs when a procedure is not medically indicated but is done for cultural, social, or religious reasons. This makes it difficult to determine whether the procedure is in the child’s best interest or is a violation of the child’s human rights. So far the courts have avoided jurisdiction in this area. But as circumcision becomes less common, arguments in support of newborn circumcision may be more difficult to defend.

Why do parents decide to circumcise?

Parents who are members of the Jewish and Islamic faiths circumcise for religious reasons. Some parents circumcise for reasons related to health or hygiene. Others circumcise for social reasons—all the other men in the family are circumcised and they don’t want their sons to look or feel different. In some cases, albeit rare, circumcision needs to be done for medical reasons, such as when the foreskin is too tight.

Why do parents decide not to circumcise?

Some parents decide not to circumcise due to the risks associated with circumcision. Many believe that the foreskin is there for a reason—to protect the penis and prevent future problems. Others believe that removal of the foreskin makes the tip of the penis less sensitive, resulting in a decrease in sexual pleasure later in life.

Caring for an uncircumcised penis

The foreskin serves to protect the penis and is best left alone. Parents and caregivers should be instructed to wash only the outside, and no attempt should be made to retract the foreskin. Your child will know when his foreskin can be retracted without pain and trauma, so the first person to retract the foreskin should be the child himself.

Two things must happen before the foreskin becomes retractable and each usually takes many years. The fusion between the head of the penis and the underside of the foreskin must separate and the narrow tip that prevents retraction has to become large enough to allow the foreskin to retract. When these happen vary widely. Complete separation of the foreskin may not occur until after puberty. The foreskin is fully retractable in 44 percent of boys by age 10, 90 percent by age 16, and 99 percent by age 18.

How do parents decide?

There are those who strongly favor and those who strongly oppose circumcision of boys. Parents need to clearly understand the possible benefits as well as the known risks. Only then can they make an informed decision about what is best for their child.

If parents decide to have their child circumcised, they need to make certain that the circumcision is done by an experienced and qualified health care provider and that appropriate pain relief is used.

In closing, I would like to express my sincere thanks to all those who have shared their comments on circumcision and more specifically, the care of non-circumcised males. As a mother of two adult sons (both circumcised) and no grandchildren in the wings, I have learned a tremendous amount. I am so grateful to the gooroo community for taking the time to share their knowledge and experience.