Disclaimer: in light of the unexpected and intense public response, I want to clarify that I am not an expert on the subject of circumcision, and this post is not intended to cover every aspect (FGM, sexual functions of the foreskin, psychological impacts on circumcised vs intact males, etc) of such a complex issue. This post is focused strictly on the medical perspective. I’m happy to be learning a great deal about the social, political, cultural and ethical aspects, from anyone and everyone who can share their thoughts respectfully. I do, however, intend to maintain this site as a safe place for my readers. If you’d like to post graphic photos or use disrespectful language, feel free to create your own site. Anyone violating this community standard will be deleted and permanently blocked.

OK, so I found myself watching Sharknado and Malibu Shark Attack and realized – “oh, I should seriously be writing my blog post right now!” I think that since I missed out on all the Shark Week stuff on TV, I feel the need to watch poorly acted and awful special effects featuring some human-hungry attack sharks.

Moving on…

My friend Chrystelle asked me to write a post about the “rules” of circumcision after a friend was told by her son’s pediatrician that she either had to have her son circumcised the week they were born (while still at the hospital) or at 6 months old (ouch, poor baby!) with a urologist, but nowhere in between.

Plus, I wanted to do a research post about what the current evidence says about whether or not it’s indicated to circumcise in the developed world.

For new parents, this post could help answer questions such as: Why is it done? What are the risks? Benefits? Is it really necessary?

I recall a debate on the topic while studying public health (particularly in my “Reproductive Health in Sub-Saharan Africa” course) and then again in nursing school. I think I remember reading that in the United States and other developed countries, the question of hygiene and transmission of STD’s weren’t as big of a concern so therefore it was no longer necessary, but I really couldn’t quite remember what the definitive answer was: yay or nay on the snip snip?

So here we go!

(Throughout this post, I will be referring to UpToDate a lot. UpToDate is a physician and healthcare provider’s software reference tool, that is the most current and kept “up to date” with current medical journals, expert opinion, and evidence-based practice recommendations. The information on UpToDate is not social or popular “opinion,” it is official and sound medical evidence and reference. It is THE go-to resource at all hospitals, and is literally, as current and absolutely up to date as possible. I was having difficulty in finding really good evidence-based articles for this post, so one of my friends who is a Nurse Practitioner hooked me up with some articles with her access from UpToDate. Thanks Heather!) UpToDate references used in this post will be available at the end of this post.

Back to Basics: What’s (Male) Circumcision?

This is relatively common knowledge, but it is the surgical removal of the foreskin (prepuce) surrounding the tip of the penis. It’s a procedure that has been practiced for hundreds of years and is very common in the United States (approximately 80 percent), as well as in other parts of the world.

Circumcisions should only be performed on stable and healthy infants, and only takes a few minutes and rarely has complications. Babies have local anesthesia given (the kind that numbs just the area to be performed) during the procedure to reduce pain.

For the record, as a nursing student and having witnessed a newborn’s circumcision, the baby was crying during the procedure but stopped crying shortly after it was finished. Because of the anesthesia given, most of the baby’s crying was due to their little legs being strapped into position on the surgery table. 

Reasons for Circumcising

The American Academy of Pediatrics recommends that infant boys be circumcised, since any surgical risks related to circumcision are far outweighed by the many benefits. Here are some of the reasons FOR circumcision:

• Religious – most commonly practiced in Jewish, Muslim and Islamic cultures, to symbolize faith in God, and from the Book of Abraham in Genesis where God commands to Abraham that all males be circumcised. Here in the Old Testament, circumcision is referred to as a covenant with God. 
• Social – father was circumcised, family tradition, the social norm, etc.
• Hygienic/Medical – lowered risk of sexually transmitted diseases (research shows between a 50-60% lowered HIV transmission rate in men), lower rates of urinary tract infection (UTI), HPV (cervical cancer-causing virus) infection, HSV-2 (herpes simplex virus 2, one of the genital herpes-causing strain of herpes), penile cancer, penile inflammation, and penile dermatoses (lesions and other abnormalities). It is also believed that removing the foreskin protective and more hygienic, since the presence of a foreskin maintains a warm and moist environment that provides a favorable environment for bacteria to multiply. The foreskin requires daily retraction (pulling back) to thoroughly clean the area of moisture, bacteria, and buildup. 

As mentioned earlier, approximately eighty percent of males in the United States aged 14-59 years old are circumcised. According to a literature review on UpToDate, the United States is the only developed country where the majority of male infants are circumcised for nonreligious reasons. That’s not to say that the procedure does not hold legitimacy in the U.S. for reasons other than religious ones. 

What are the Risks with Circumcisions?

As with any surgical procedure, there are of course, risks associated with undergoing the procedure itself. Circumcisions, even though they are done very regularly on a majority of infant boys in the United States with very low risk of complication, are not an exception.

Our babies are precious, and putting them through any type of procedure that requires anesthesia (local or general types) is scary. Heck, even a benign vaccine makes us cringe as we have to help keep our little ones’ limbs still to avoid an unintentional leg jerk and needle stick through red-faced cries and streaming tears.

The risks of complications from a circumcision are very low, and most of those that occur are minor. This is not to say that more serious complications do not occur. In the United States, for infant boys 1 month and younger, the best known rate of complications is 0.2%. That means that 2 out of every 1000 infants experience some sort of complication. Again, though procedure-related complications are uncommon, the more serious complications are rare.

So, in deciding on whether or not to circumcise your baby, here are the associated risks (per UpToDate’s Neonatal Circumcision, and Complications of Circumcision, below):

• Inadequate foreskin removal
  • Would require revision surgery (repeat surgery) to fix the cosmetic appearance.
  • Can occur because the baby initially was not a prime candidate for circumcision at the time it was done
• Bleeding
  • Usually minor and can be controlled with pressure during the procedure
  • Often occurs because of inadequate suturing (stitching) of the incision, by the practitioner
  • Though rare, may require blood transfusion if serious bleeding occurs
  • Bleeding is a more common complication, according to the Scientific World Journal, between 1 and 3 months of age.
• Infection
  • This is always a risk when you make any type of surgical incision, even when performed under sterile conditions (as is the case with circumcisions).
  • Usually mild when it does occur, but if the infection is serious, it can lead to a bloodstream infection (sepsis) and “death has been reported.” 
• Urethral complications (a preventable and very unusual occurrence in the U.S.)
  • Stenosis (narrowing of the urethra)
  • Urethrocutaneous fistula (an abnormal connected hole to the urethra), cited as usually occurring after an improper clamp placement during the procedure. 
• Glans injury 
  • Take a deep breath. They refer to this as “penile amputation.”
    • Occurs extremely rarely 
    • A complication when the physician uses a Mogen clamp, which makes it difficult for the doctor to visualize the penis prior to making an incision on the foreskin.
• Excessive skin removal
  • Occurs when there is an excessive amount of abdominal fat pad (like with an extra adorable chubby baby) that makes it difficult to estimate how much foreskin to remove.
  • Preventive measures include firmly compressing the baby’s abdominal pad to allow the penis to be exposed so the physician can properly determine how much skin to remove
• Epidermal inclusion cyst
  • These types of cysts exist all over the body and are harmless, but these can also happen post-circumcision the way the skin heals and most can be removed without much further risk.
  • Still a relatively uncommon incidence.
• Adhesions
  • This is a medical term I’ve heard so many times as a nurse, but it may sound scarier if you are not in medicine. 
  • This is an abnormal way the skin heals post-incision that can mean the skin did not align ideally or mobilized properly during healing. 
  • More common in babies with “prominent suprapubic fat pads”, meaning that super chubby little baby.
  • Can occur when the post-surgical care routine is not being performed as directed.
  • These may require correction at the doctor’s office under local anesthetic (cream/ointment) or can resolve spontaneously over time, with growth or abdominal/suprapubic fat recedes. 
• Cicatrix – scar that encircles the penis at the incision
• Anesthetic complications
  • Anesthesia on babies 1 month old and younger is limited to local anesthesia (just on the skin itself) to make the procedure relatively pain-free. This is not the type of anesthesia that is expected to hold complications. Topical (local) anesthesia wears off very quickly (circumcisions are very quick procedures) and only affects the area in which it is applied/injected.
  • General anesthesia (being completely “out”) on the other hand, is used when circumcising older babies, so the risks with general anesthesia are present.

Complications are more commonly reported when performed on babies considered less-than-ideal candidates for surgery. That means, babies who were born prematurely, newborns with congenital abnormalities that affect the urogenital system, performed on older infants, or by poorly trained physicians. 

Some Benefits of Circumcision

With any procedure, it’s important to consider a cost-benefit analysis, where you weigh the possible risks against the possible benefits. There are many benefits to circumcision, but the ones I wanted to focus on are those I elaborated on below. For more, please see the references I included at the bottom of this post. 

Reduced Transmission of STD’s

• HSV-2 (herpes simplex-2, one of the genital herpes-causing strains)
• HPV (human papilloma virus, the cervical cancer-causing virus strain) to the male’s female partners
• HIV

Reduction of Penile Inflammation and Retractile Disorders

Penile inflammation can occur when bacteria trapped under the foreskin causes irritation and further inflammation of the area. This is more commonly associated with uncircumcised and partially circumcised males.

Retractile disorders include phimosis, paraphimosis, and balanoposthitis. These are all urologic emergencies and are disorders that are associated with the foreskin’s improper retraction.

Phimosis (inability to retract the foreskin over the glans/tip of the penis) and Paraphimosis (result of phimosis): Whether it be the foreskin not returning to its neutral, fully extended position over the glans, forceful retraction, and when the improper placement of the foreskin for an extended period of time (“entrapment” of the retracted foreskin) and results in cutting off circulation to the rest of the penis, causing painful swelling, lack of blood flow, and possible loss of penile tissue if not treated quickly and properly.

Balanoposthitis is an inflammation and infection that occurs when an improperly retracted foreskin and poor hygiene encourages the growth, colonization, and overgrowth (yuck) of bacteria. Recommendation for the treatment of frequently occurring (or complicated and difficult to treat) balanoposthitis is circumcision. 

Circumcision = Lower Risk of UTI’s in Infant Boys

According to UpToDate, though the incidence of a UTI in older males is very rare, it is actually one of the most common reasons for hospitalization in infant males. Since babies have a much more vulnerable and less matured immune system, a UTI can quickly lead to an infection of the kidney system (technically, pyelonephritis) which is a very serious (and common) complication from a UTI, requiring hospitalization.

UpToDate cited a research study (see link in references) where doctors analyzed the bacteria present on the urethra of circumcised versus uncircumcised males. They found that the periurethral flora (normally occurring bacteria around the urethral area at the penis) in circumcised infants had significantly fewer pathogenic (harmful) bacteria at the surface of the urethral tissue than uncircumcised babies.  

Penile Cancer Risk Reduction

I didn’t even realize this when I was getting ready to write this post. I found this pretty impressive and alarming at the same time:

“Compared to uncircumcised men, circumcised men appear to have a lower risk of penile cancer, and their sexual partners may have a lower risk of cervical cancer.“ – UpToDate (Neonatal Circumcision Risks and Benefits)

But, because penile cancer is so rare in this country (1 in every 100,000 males), the protective benefit by circumcision may not carry as much weight as its other benefits (like lowered UTI risk, HPV and HSV-2 infection, lowered risk of penile inflammatory and retractive disorders). However, according to urologist.org, penile cancer “almost never” occurs in men who were circumcised at birth. 

There are clearly many benefits of circumcision, and the practice is still currently recommended over not circumcising. PrePex is a method of nonsurgical circumcision, but its effect on the prevention in the transmission of STD’s has not yet been fully researched. It uses a device to stop blood flow to the covering foreskin so that it “falls off” (for lack of better term) and remaining foreskin area dries up.

For more details on the other protective mechanisms of circumcision, please see the original UpToDate source here. 

Timing of Circumcision

Since this was the original question brought to my attention, this is what I found about timing of circumcising.

• If done at birth, only performed on stable, healthy infant boys
• If done at the neonatal (first thirty days of life) period, costs are lower, complications are fewer, and the baby is less mobile, meaning less discomfort and easier and quicker healing time. 
• Circumcision should be delayed (not done at birth, but during the first year of life) if the following are present:
  • premature birth
  • blood disorders
  • congenital abnormalities (like “hypospadias” which is a condition where the urethral opening is not fully formed)
• Fewer complications occur when males are circumcised in infancy rather than childhood or adulthood (bleeding, infections, discomfort, longer healing time, older age means a more complicated procedure)
• Newborn circumcision typically occurs between day 0 and day 10 after birth, while the family is still in the hospital before discharge.
• 86% of parents were in favor of neonatal (first thirty days) circumcision, over a delayed procedure.

So in summary, it looks like the best time to have your baby boy circumcised is while he’s still an infant (before 1 year), preferably before they become mobile. I didn’t find any research or expert recommendation that specified at which month it should be performed, if not performed immediately after birth, but the consensus is: the earlier the better. I can’t imagine the urologist’s rationale between waiting until the baby is 6 months old (rather than earlier, like 3-6 months). The only reference I found that makes an argument for waiting for a circumcision until after 3 months of age, is if the first month window is missed (least risk of complications), because of the increased risk of bleeding between 1 and 3 months old. 

I personally would want my son to be circumcised at birth rather than any time later. Their cries are more intentional after they get older and older, even throughout the first few months. And, healing time is about a week when performed within the first week(ish) of life. Besides, their umbilical cord stump is healing at the same time anyway, with that falling off within the first couple weeks, too. I don’t by any means mean “the more the merrier” regarding procedures and healing. But, by month 5, Jia was already pulling at my earrings, so I can only imagine how bothersome a fresh surgical wound would be to a little boy at that age or anywhere close!

If You Choose NOT to Circumcise (Remain “Intact”)

Follow these guidelines:

• The penis should be washed and cleaned regularly and treated similar to the rest of the body, in terms of hygiene.  A rule of thumb: clean what you see. To note: as the foreskin becomes fully retractable in childhood (around age 5 up to 10 years), a young boy should be taught to retract the skin and clean underneath, and pat dry after bathing. 
• Soap can be used, provided it’s safe for the age of the baby and it is non-irritating.
• Frequent diaper changes, to keep the penis clean, and to prevent skin irritation and diaper rashes
• Retract the foreskin gently (not forcibly) when cleaning and after rinsing. This means – NO FORCEFUL RETRACTION. It shouldn’t ever be forcefully retracted. Did I say it enough? Do not force the skin over the penis. The skin should be always pulled back down to its normal position, covering the glans (tip) of the penis. Failure to pull the skin back over the glans will lead to very painful swelling (phimosis) of the penis, as it can decrease blood circulation past the skin. Prolonged phimosis can lead to loss of tissue and functionality. 
• Regular retraction to the degree where the skin is easily mobilized is important during cleaning to “train” the skin to retract and then return to its natural position over the glans. Let me be clear in that I am not promoting to force the foreskin to retract. Depending on the degree to which the skin is easily moved, you should clean what are able. With a newborn/young baby boy/young male: “If you can clean under the skin or it retracts easily, then it should be cleaned. If you can’t, don’t, and it will work itself out at puberty.” Dr. James Ferrell, Urologist. 
• Again, an explicit note: If your baby’s foreskin is fused/attached to the glans, do not pull it back. In most newborn and infant males, the foreskin may not retract much, if at all. Only about 4% of newborn males have a completely retractable foreskin (separation from the glans/head begins during late gestation during pregnancy). And, “In more than half of newborn males, the foreskin cannot be retracted far enough to visualize the urethral meatus.” (UpToDate “Care of the Uncircumcised Penis”)

“In the first several years your son’s foreskin will separate from the tip of the penis. Some foreskins separate soon after birth or even before birth, but this is rare. When it happens is different for every child. …foreskin retraction should never be forced. Until the foreskin fully separates, do not try to pull it back. Forcing the foreskin to retract before it is ready can cause severe pain, bleeding, and tears in the skin.” – HealthyChildren.org (link below)

See more care directions in the reference below “Care of the uncircumcised penis.” (This section has been edited since its initial publish date, in order to provide better explanation of the newborn foreskin, and to reiterate what the author originally wrote)

There you have it. I went into writing this article expecting to read some new recommendation that strayed away from the outdated and not convincingly compelling arguments to continue the tradition of circumcision, but I didn’t.

Both the AAP and the medical community recommend male circumcisions, for the health and medical benefits. Though they DO STATE that there lacks strongly compelling evidence-based evidence to recommend circumcision for all baby boys, here is the current Circumcision Policy Statement from the AAP (revised and published September 2012):

“Evaluation of current evidence indicates that the health benefits of newborn male circumcision outweigh the risks and that the procedure’s benefits justify access to this procedure for families who choose it. Specific benefits identified included prevention of urinary tract infections, penile cancer, and transmission of some sexually transmitted infections, including HIV… The medical benefits alone may not outweigh these other considerations for individual families…  Parents ultimately should decide whether circumcision is in the best interests of their male child. They will need to weigh medical information in the context of their own religious, ethical, and cultural beliefs and practices. The American College of Obstetricians and Gynecologists has endorsed this statement.“ From the American Academy of Pediatrics Policy Statement/Task Force on Circumcision (read full policy statement, linked below)

You can read on your own about the other benefits or limitations of circumcision (societal norms, psychological impact, sexual pleasure, etc.) on your own, but I wanted to focus on the overall medical recommendation in support of male circumcision.

You may find some other references and organizations that side with the “I want him to decide on his own to circumcise, I don’t want to make that decision for him,” or “it’s an unnecessary procedure that unnecessarily puts my baby in pain,” but with regards to expert opinion, the research all points to maintaining this evidence-based practice. 

As with a lot of things having to do with your babies, it’s ultimately about how you feel. Vaccinating on the other hand, is not a social-opinion decision to make. It’s the only healthy and smart choice. 

Sources:

Mayo Clinic: Circumcision (male) http://www.mayoclinic.org/tests-procedures/circumcision/basics/definition/prc-20013585

HealthyChildren.org Should the Baby be Circumcised? https://www.healthychildren.org/English/ages-stages/prenatal/decisions-to-make/Pages/Should-the-Baby-be-Circumcised.aspx

National Library of Medicine’s recommended list to find information on various cultural practices on circumcision http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2216737/

Neonatal circumcision_ Risks and benefits (PDF UpToDate reference 6/25/15)

Prevention of sexually transmitted infections (PDF UpToDate reference 6/29/15)

Medscape: Paraphimosis http://emedicine.medscape.com/article/442883-overview

Medscape: Balanoposthitis http://emedicine.medscape.com/article/1124734-overview

Krill A., Palmer L., Palmer J. Complications of Circumcision. ScientificWorldJournal. 2011; 11: 2458–2468. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3253617/

Morris et al. A ‘snip’ in time: what is the best age to circumcise? BMC Pediatrics. 2012; 12(20). FULL TEXT: http://www.biomedcentral.com/1471-2431/12/20#B13

Care of the uncircumcised penis (PDF UpToDate reference 6/29/15)

Care of the Uncircumcised Penis – AAP’s HealthyChildren.org https://www.healthychildren.org/English/ages-stages/baby/bathing-skin-care/Pages/Care-for-an-Uncircumcised-Penis.aspx

BBC: Ethics Guide – Religions and Circumcision http://www.bbc.co.uk/ethics/malecircumcision/religions_1.shtml

PEDIATRICS Vol. 130 No. 3 September 1, 2012 pp. 585 -586 http://pediatrics.aappublications.org/content/130/3/585.full.pdf+html