To "circ" or not to "circ"

One of the most frequent questions I have been asked by parents is whether their newborn son should be circumcised.  The issue of circumcision has been debated for years and even has been the subject of lawsuits by grown children.  My traditional stance is that parents should do their due diligence about the pros and cons of this procedure before making this decision. The information I provide here isn’t meant to sway opinion one way or the other, rather to help present some information to assist parents in their decision-making.

Early References to Circumcision

The practice of male circumcision is historically documented across many cultures.  Perhaps the earliest known reference to circumcision originates in Egypt in tomb artwork from the Sixth Dynasty (2345 - 2181 BC).  Many who read this are no doubt familiar with references to circumcision of infant males in the Old Testament originating with convenent between Abraham and God in Genesis.  In fact, many cultures over the centuries have accepted circumcision as a practice, citing beliefs that have cultural, religious and medical origins.

Circumcision in the United States

In more recent times there have been broad swings in public opinion regarding perceived advantages or disadvantages of circumcision. In the United States an initial shift in the cultural norm favoring newborn circumcision occurred around the onset of the 20^th century.  As a result the United States continues to have a wider sphere of acceptance of this practice than in other parts of the world. The reason for that initial shift in practice seems to stem from a number of factors.  These include emerging knowledge of germ theory and the accompanying belief that circumcision promotes hygiene, belief that there would be less risk for syphilis, and, in a period of time that saw the emergence of temperance, belief that circumcision would promote chastity and prevent masturbation. Additionally, the increase in births occuring in hospitals rather than at home in the mid-20th century, correlates with an increase in rate of circumcision at that time.

Table 1: International circumcision rates
Country	Year	Neonatal circumcisions (%)
United States	2003	55.9%
Canada	2003	< 14%
Australia	2004	10%-20%
New Zealand	1995	0-5%
**Samoans, Tongans and Niueans in New Zealand continue to practice circumcision, but not in public hospitals, to which these data refer. There are significant ethinc and regional differences in circumcision practices within the United States.  In general, circumcision is more likely to be performed on non-Hispanic white male infants, whereas Hispanic infants have the lowest rate of circumcision. Statements by the medical community, in particular by the American Academy of Pediatrics in 1971, 1989, and 1999, as well as a reaffiramation statement in 2005, have historically taken the position that circumcision is not medically indicated, and in the past several decades more parents opted not to have the procedure performed on their newborn sons. Emerging Medical Data

Although major medical societies in the US as well as in the United Kingdom, Australia, and Canada have formally stated that circumcision is not medically necessary, a series of recent studies have strongly indicated that circumcised males benefit from decreased risk of a number of health problems:

1. Urinary tract infection. There appears to be a significant decreased risk of urinary tract infection in circumcised males. The compilation of data from numerous studies indicates that incidence of urinary tract infections in uncircumcised males is about 1:1000 versus about 1:100 in circumcised males.
2. Cancer of the penis.  In general, this is a relatively rare condition occurring in about 1:100,000 men annually in the United States.The majority of those cases occur in uncircumcised men, and invasive penile cancer, the most severe form, occurs almost exclusively in uncircumcised males.  Of note, cancer of the penis is almost unheard of in Israel, where almost all males are circumcised.
3. Sexually transmitted disease.  Numerous studies have shown decreased transmission of STDs such as syphilis, Chlamydia, human papilloma virus, and herpes not only to circumcised males, but also from males to their female partners. Given the association of HPV with cervical cancer in women, there has been evolving opinion that circumcision is a women's health issue as well. More recently a series of studies in Africa has shown a 60% reduction in the rate of transmission of HIV to males that have been circumcised versus those who are uncircumcised. This is significantly better than the 30% reduction of risk that was target goal of a future AIDS vaccine.

This last point, reduction in transmission of STDs and HIV, has fanned the embers of the circumcision debate.  There have been some strong voices of dissent to the AAP statement calling for a reevaluation of circumcision as an effective means to stem the tide of HIV, particualrly in developing nations.

Surgical Procedure

Circumcision is a surgical procedure, and as such, has associated risks.   In general, the risk of a complication from circumcision is very low (~1/500,000).  These risks include, but are not limited to, bleeding, infection, scarring, incomplete resection of foreskin, and partial amputation of the penis.  In the not too distant past circumcision was performed without anesthesia owing to an ill-conceived notion that infants do not experience pain.  Thankfully, we have come along way, and the current practice of circumcision involves a local anesthetic. The most commonly performed in-patient newborn circumcision methods are done with either a clamp (Gomco or Mogan) or with a Plastibell.  The results can vary depending on the method used and the skill of the person performing the circumcision.  Just as with any surgery, the method and procedure should be explained clearly to you by the person performing the surgery.

As mentioned previously, post-operative complication rate is extremely low and your baby's medical care provider will review how to care for the baby after the procedure.  There are certain infants who should not be circumcised in the neonatal period.  These would include ill newborns, premature infants, infants born with congenital anomalies of the penis ( e.g. hypospadius)  or infants who have a bleeding disorder such as hemophilia.

The "No Circ" Viewpoint

There are strong voices of opposition to circumcision.  The core points are well outlined be the National Organization of Circumcision Information Resource Center (www.norcirc.org). As stated in their website:

No national or international medical association recommends routine circumcision.

Only the USA circumcises the majority of newborn boys without medical or religious reason.

Medicalized circumcision began during the 1800s to prevent masturbation, which was believed to cause disease.

Today's parents are learning that the foreskin is a normal, protective, functioning organ.

Today's parents realize circumcision harms and has unneccesary risks.

Circumcision denies a male's right to genital integrity and choice for his own body.

With regards to the recent studies regarding circumcision and decreased HIV transmission, they strongly advocate more funds being shifted to education on HIV and safe sex. For those who want more information regarding the counter-argument regarding circumcision as a means to reduce the spread of HIV, read the statement from Doctors Opposing Circumcision.

Ultimately, the decision for circumcision is a personal one.  Educate yourselves and make an informed decision for your baby.