Date: Wed, 22 Mar 1995 10:54:32 -0500 From: CircInfoNe@aol.com Subject: Action Alert, SF Peninsula Parent This appeared in the San Francisco Peninsula Parent/March 1995 ----------------------------------------------------------------------- WEIGHING THE PROS AND CONS OF NONRELIGIOUS CIRCUMCISION Be sure you understand the potential medical advantages and surgical risks before deciding whether or not to have your son circumcised. By Jean Tips The birth of a son immediately presents one of your first significant decisions as his parent...do you circumcise or not? For those of Jewish and Muslim faiths, circumcision is performed routinely for religious and cultural reasons. If four reasons for considering circumcision are not religious ones, the decision can be difficult., as you attempt to project the risks and benefits on your little one's life. Opinion varies somewhat on the subject, but the purely medical indications are not as clear as you might imagine. Here are a few facts. PRACTICE BACKGROUND Circumcision, or the cutting off of the foreskin or ring of tissue that covers the head (glans) of the penis, is a surgical procedure normally performed in the first few days of a boy's life. The procedure takes place before the baby is discharged from the hospital or in the first few days after birth. Doctors suggest that it be done before the child is 6 weeks old, or weighing 12 lbs. Usually there is some swelling as a result of the procedure, but this is gone normally in a week and recovery is very quick. Nonreligious circumcision became popular in English speaking countries between 1920 and 1950 because it was thought to prevent sexually transmitted diseases, but circumcision has never been a common practice in Asia, South America, Central America or most of Europe, according to nationally respected pediatrician Dr. Barton Schmitt. Now according to Schmitt, fewer children are being circumcised than several years ago. In 1986, some 60 percent of newborns were circumcised, down from 90 percent in 1979. Worldwide, more than 80 percent of the male population is not circumcised. Rates have fallen to 1 percent of newborn males in Britain, 10 percent in New Zealand and 40 percent in Canada. REMOVING THE FORESKIN Removal of the foreskin prevents infections under the foreskin (posthitis) and persistent tight foreskin (phimosis); however both of these are rare problems. Posthitis is usually due to excessive attempts to retract the foreskin, according to Dr. Paul Meguerian, associate chief of Pediatric Urology at Lucile Packard Children's Hospital. "Until recently parents were instructed to pull back the foreskin for cleaning,' says Merguerian. "Presence of whitish infant smegma is not necessarily indication of an infection, and current advice is to avoid retracting the foreskin at all until the child is older and can do it for himself, around age 3 or 4. Until then, washing of the exterior skin with soap and water should be sufficient hygiene. Recurring incidence of infection might indicate later circumcision, Merguerian continue, but again this is rare. If necessary, physicians agree it should be done before a boy is much older, when the recovery becomes longer and more uncomfortable. Phimosis is common in newborns, Merguerian says, and usually takes care of itself over time. If phimosis persists in a boy older than 5, circumcision may be indicated for hygienic reasons. One recent study shows that circumcision may also protect against urinary tract infection (UTI) during the first year of life. "An uncircumcised male is 10 to 20 times more likely to develop a urinary tract infection in infancy," says Marguerian. "But these infections only occur in one percent of boys." Dr. James Mellema, a Los Gatos pediatrician, agrees. There seems to be some increased incidence, but it is not common, and we certainly don't see an epidemic amongst those cultures who routinely don't perform the procedure." Long-term consequences of recurring urinary infections may include hospitalization involving a variety of invasive tests, possible renal scarring and potential renal insufficiency, but again this is rare. Another reason sometimes cited for circumcision has been that neonatal circumcision seems to protect men against the rare incidence of penile cancer. Findings of a 1993 study published in the Journal of the National Cancer Institute suggest lack of neonatal circumcision and complications relating to poor hygiene to be among the factors linked to increased risk (along with such things as a history of smoking, sexual activity with 30 or more lifetime partners, and infection with human papilloma virus or HPV). Penile cancer, however, accounts for less than one percent of all male cancers. LEAVING THE SKIN INTACT The foreskin is the male's "standard equipment" and serves to protect the glans against urine, feces, and other types of irritation. Although rare infection and scarring of the urinary opening occur almost exclusively in a circumcised penis. The foreskin may also serve a sexual function later on by protecting the sensitivity of the glans. The circumcision procedure itself is painful, and until the determination several years ago that babies actually do feel pain, no anesthetic was given. Today this discomfort is minimized by use of a local anesthetic to block the nerves of the foreskin. But like any surgical procedure, circumcision may cause complications. Potential problems include either insufficient reduction of the foreskin or removal of too much skin, skin infections, bloodstream infections, bleeding gangrene, scarring and surgical accidents. Dr. Merguerian reports a 0.2% percent national rate of significant complications associated with the procedure. "two to three circumcision related deaths occur yearly in the U. S.," says Merguerian. Circumcision has not been proven to prevent sexually transmitted diseases. A study conduced in Nairobi, Africa reported an increase of AIDS in uncircumcised males there, but physicians in the U. S. have questioned the validity of the study, in part due to the fact that most African males are uncircumcised. OTHER IMPORTANT CONSIDERATIONS Beyond the physical implications, you will want to consider if your child will look different from his father or the other boys at school and how that might affect him. According to Schmitt, there has been no documentation of psychological harm resulting a boy looking different from his father due to a circumcision. Being singled out as different by one's peers in a locker room, however might be emotionally painful if he is the only uncircumcised boy. That is unlikely in this section of the country, Mellema says. Teaching acceptance of physical differences may allow a boy more comfort with himself and others. For some parents the consideration of cost and insurance coverage is an important part of the decision. Because some $200 million is spent on this medically optional procedure each year in the U. S., circumcision has become a controversial issue in todays world of managed care. Does your insurance plan cover it? Only one in five HMOs do. If you have to pay out of pocket, it may cost several hundred dollars. In the end the decision is yours. Ask your pediatrician or family practitioner for advice and information before your baby is born. Be sure you understand the potential medical advantages and surgical risks, and consider the emotional issues that may face your son later. "If you choose circumcision, the best time is when your child is a newborn." Mellema says. "If you choose not to circumcise, proper hygiene is important." ___________________________________________________________________ Jean Tips is the public relations manager at Lucile Salter Packard Children's Hospital at Stanford. She is the mother of three sons. All correspondence should be sent to S. F. Peninsula Parent, P. O. Box 1280, Milbrae, CA 94030 Jean Tips, Lucille Salter Children's Hospital 725 Welch Road, Palo Alto, CA 94304 Tel: 415-497-8000