CIRCUMCISION: The Current Debate

One of the most common questions I am asked by parents adopting a baby boy is "Does my baby need to be circumcised?"

The answer is not easy and evokes a lot of emotion. Last year in San Francisco, there was a proposal to place on the November election ballot a ban on circumcision of males under 18 years of age. Circumcision would have been a misdemeanor punishable by a $1,000 fine and up to one year in jail. It was struck down by the courts and never made it to the ballot.

In August 2012 The American Academy of Pediatrics (AAP) published an updated policy statement indicating their recommendations. The following summarizes this report. It's important for all prospective parents to understand the current medical information and to decide what is best for their family.

The AAP Task Force on Circumcision Report reviewed the medical evidence in support of the procedure. They found that there is medical literature to suggest that circumcision causes:

  • a lower incidence of acquiring sexually transmitted diseases such as HIV, syphilis, human papillomavirus and genital herpes;
  • a lower risk of penile cancer and cervical cancer in sexual partners;
  • a lower risk of urinary tract infections in the first year of life.

From a pediatric perspective, the decrease in urinary tract infections is the most significant argument. In reviewing the available literature the Task Force Report concludes that it is "estimated that 7 to 14 of 1,000 uncircumcised male infants will develop a urinary tract infection during the first year of life, compared with 1 to 2 infants among 1,000 circumcised male infants." This is a significant decrease. However, by these statistics, about 100 boys need to be circumcised to prevent one urinary tract infection.

As with any surgical procedure, there are complications, but the incidence is very low. Case reports of complications of newborn circumcision include bleeding, infection, both bacterial and viral (herpetic) and injury to the tip of the penis "Bleeding was the most common complication (0.08% to 0.18%), followed by infection (0.06%) and penile injury (0.04%)." By comparison, according to the AAP Report, the risk of bleeding from a childhood tonsillectomy is 1.9%. So, comparatively speaking, circumcision is a relatively safe procedure.

The AAP advises that circumcisions should be performed only in clinically stable newborns, by trained practitioners using a sterile surgical technique.

The AAP does recommend reducing the pain associated with performing the circumcision. There is evidence that the positioning of the infant in a padded environment during the procedure and giving sucrose pacifiers may help. The best methods of providing pain relief are applying topical creams, such as 4% lidocaine, or performing a penile nerve block.

A common argument given FOR performing circumcisions is to "look" like all the other boys. Interestingly, circumcision rates in the United States vary greatly depending upon which part of the country you live in; averaging around 50-60 % of healthy term infant boys. Rates are highest in the Midwest (74%) and lowest in the West (30%.) These rates are for hospital-based procedures, so it may underestimate the incidence. Rates also vary by ethnicity. One study indicated 88% of white men were circumcised as compared to 42% of Mexican-American men.

One argument AGAINST circumcision is the moral aspect of not performing elective surgery on a child, waiting until he is old enough to give his own informed consent. Not surprisingly, men who were not circumcised at birth were less likely to give consent for circumcision. Circumcision at birth actually has a faster healing time, lower complication rate and a lower cost than performing the circumcision later in life.

The Task Force does recommend that newborn circumcisions be covered by Medicaid and insurance companies, since there are medical advantages to performing the procedure. They cite a Centers for Disease Control cost-effective analysis concluding that newborn circumcision saves health care costs from an HIV-preventing strategy alone.

The real answer to the question "does the baby need to be circumcised?" is that parents need to weigh the health benefits and risks in light of their own religious, cultural, and personal preferences. There are risks which fortunately are very rare; there are also benefits. The AAP Report data justifies that the benefits of the procedure outweigh the risks, but emphasize it is up to the parents to choose.

Parents should discuss the issue with their pediatrician. If possible, this should occur early in the pregnancy or early in the adoption process. This gives families time to discuss the issue without feeling rushed. They should understand that circumcision is an elective (and/or religious) procedure, but with demonstrated health benefits.

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