Much Ado About Foreskin: A No-Sweat Approach To The Circumcision Decision

There are few pediatric topics that fuel as much passionate debate (among physicians and laypeople alike) as to whether healthy newborn boys should be routinely circumcised. One camp argues that the procedure is essential to avert potentially catastrophic illnesses whereas the opposition go as far as calling the procedure a wanton violation of human rights.

 

Claims from the most ardent advocates on either side can be strident and silly, which is not helpful to parents caught in the middle. Much of the controversy, I believe, stems from the fact that circumcision is the only elective surgical procedure that is performed on neonates. Unfortunately, a policy statement from the American Academy of Pediatrics and its recent revision have neither doused the flames of controversy nor imparted clarity on the debate.

Circumcision is the only elective surgical procedure performed on neonates.

For many well-meaning parents, the entire issue is befuddling and adds unnecessary stress to what should be a joyful time. To the anxious parent, I’d like to offer a simple message: relax! The choice you make is not likely to have a major impact on your child’s health one way or the other. And your child, I assure you, will not be asked his circumcision status on his application to Harvard. To stress the point, I am told that there have been great men who have made significant contributions to human society and lived healthy lives well into their nineties both with and without their foreskins.

What I do advise parents to do is to become aware of the issues involved so that they can be comfortable with whichever decision they settle on. Know why you chose what you chose.

Part of the reason this issue is mired in controversy is that it is colored by religious and cultural considerations. If you wish to circumcise your child for religious reasons, this article is not for you. You already know the reason behind your choice, and presumably, you are comfortable with it.  Go in peace. But please do not misinterpret this as my supporting the procedure for religious reasons. It’s just that the reason for your choice is outside the purview of this particular article. On the other hand, if you are interested solely on the potential health benefits of circumcision, please read on.

The best place to start in making sense of the debate is to glance at the policy statement from the American Academy of Pediatrics (available in its entirety here: http://pediatrics.aappublications.org/content/early/2012/08/22/peds.2012-1989). The Academy proposes that the “preventive health benefits of elective circumcision of male newborns outweigh the risks of the procedure… Although health benefits are not great enough to recommend routine circumcision for all male newborns, the benefits of circumcision are sufficient to justify access to this procedure.”  This is a more enthusiastic endorsement of the procedure compared to the 1999 position that stated that there were some potential health benefits to circumcision “yet the procedure is not essential to the child's current well-being, parents should determine what is in the best interest of the child.”

So, what are these health benefits?  The AAP cites a reduction in the rate of urinary tract infections, penile cancer and some sexually transmitted diseases (STDs) including HIV infection. That sounds pretty impressive, but what the AAP statement does not specifically address is whether the risk of these diseases needs to be addressed in the newborn period or whether the procedure is the most effective way at preventing these conditions. Let’s break them down one by one.

Urinary tract infections

About 1% of uncircumcised boys will develop a urinary tract infection in the first year of life (UTIs in older boys are much rarer). Boys that are circumcised have only a 1 in 1,000 risk of developing a UTI in the same time period. Some people look at this data and are impressed by the fact that circumcision imparts a 10 fold reduction in UTI. Others look at the same numbers and conclude that a 1% risk is not so bad for a condition that can be readily treated with a course of oral antibiotics.  To be clear, a UTI in the first 3 months of life does carry additional risks and typically requires hospitalization.

The prevention of urinary tract infections in the first 3 months of life is, without a doubt, the single most compelling argument in favor of routine circumcision in the newborn period.

The prevention of urinary tract infections in the first 3 months of life is, without a doubt, the single most compelling argument in favor of routine circumcision in the newborn period. But to analyze whether a surgical procedure is warranted we must consider a statistical tool known as the Number Needed to Treat (NNT) which asks, ‘how many patients must undergo a treatment in order to prevent a single case of the disease we’re trying to prevent?’  According to a study published in the Archives of Diseases in Children in 2005, the NNT for preventing UTI is 111.  That is, 111 boys must be circumcised in order to prevent 1 case of UTI. Another way of phrasing it is to say that 110 out of every 111 boys circumcised will not derive a benefit from the procedure in terms of UTI prevention. But that one baby who will be spared a UTI may avoid possible hospitalization and multiple interventions.

Penile cancer

I wish I could tell you I was an expert on cancer of the penis but I most certainly am not. I’ve never seen a case of cancer of the penis and I’ve never met anyone who’s had the condition or even one who knows of someone who’s had the condition. That’s because this is an extremely rare form of cancer. (Thus my lack of personal expertise.)

But here are the facts.  According to the American Cancer Society, in the United States penile cancer is extremely rare, affecting only 1 in 100,000 men and accounting for about 1% of all cancers. The cancer arises from the foreskin (the tissue cut off by circumcision) 21% of the time, and from the head of the penis 48% of the time. The remaining 31% of these tumors arise from the shaft of the penis and are likely not influenced by whether the individual is circumcised or not.

Penile cancer is a disease of older men, with the prevalence rising abruptly after 60 years of age, with a peak in incidence at age 80. In 2005, 310 men died of this disease in the United States representing a mortality rate of 24.8% among sufferers of this condition. This number reflects a frequent delay in diagnosis due to a reluctance to seek care for the disease. With early treatment, cancer of the penis is highly treatable.

The NNT to prevent cancer of the penis has been calculated to be 909.  That is, 909 boys must be circumcised to prevent a single case of invasive cancer of the penis many decades later.  Look, there are plenty of things to worry about when your baby is born – cancer of the penis ain’t one of ‘em!

Sexually transmitted diseases/HIV

Studies in countries where heterosexual HIV is epidemic (the United States is not one of those countries) have demonstrated a lower rate of HIV in men who are circumcised. However, the link between HIV and circumcision in developed countries is not nearly as clear cut. Some studies have found no difference in rates of HIV among men based on their circumcision status whereas others found a mild association. 

One thing is clear: the likelihood that a man will develop STDs including HIV in the United States is related to his sexual practices including the number of partners he has and whether he engages in high-risk sexual activity. Public health interventions that reduce high-risk sexual behaviors are going to be far more effective at reducing HIV in the United States than circumcision will ever be.

But to follow through with number needed to treat analysis, all we can say is that the NNT varies dramatically by region. In Uganda, the NNT for HIV prevention via circumcision is 55. In Canada, on the other hand, more than 5,000 circumcisions must be performed to prevent a case of HIV infection (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2231534/).

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Anatomical variations

Many parents are just not comfortable with the appearance and the perceived need for special care of the uncircumcised penis, particularly if the father of the baby is circumcised.  They are alarmed when the foreskin cannot be retracted past the head of the penis (a completely normal situation in the first few years of life, known as physiologic phimosis) and they sometimes complicate matters by unnecessary manipulation of the foreskin leading to a painful and urgent condition known as paraphimosis, where the skin gets stuck behind the head of the penis.

These conditions can be easily handled and prevented with simple care, though many doctors contribute to this problem by dispensing misguided advice (read Forcing the tissue in Why Doctors Believe Weird Things: http://pediatricsincrisis.blogspot.com/2013/06/800x600-normal-0-false-false-false-en.html).

Risks of circumcision

In the hands of an experienced surgeon, the risks of circumcision are quite low. The rate of immediate complications ranges from 0.2% to 10%.  The most commonly reported problem is bleeding. Rare catastrophic complications include amputation of the penis, kidney failure and overwhelming infection.  Late complications include meatal stenosis (a narrowing of the opening of the urethra) and, among some men, the report of an alteration in the sensitivity of the penis, particularly in the act of sexual intercourse.

Certainly, another downside to the procedure is the pain associated with it. In years past, this was brushed away with the breezy argument that babies do not perceive pain the way older children do, and wouldn’t it be best to have a painful procedure done when the child will not remember it (and can’t fight you off quite as effectively)?  It goes without saying that infants do perceive pain, and the sensation of pain in the newborn period interferes with sleep and feeding and may even modulate the perception of pain later in life.

Putting it all together

Circumcision is a common and generally safe procedure in the newborn period.  It is the only elective procedure that is performed in neonates. The most compelling medical reason to have the procedure performed is to reduce the likelihood your baby will experience a urinary tract infection in the first year of life.  Other health benefits are minimal or less well established and can be addressed with more effective strategies and interventions. At a minimum, some of the purported health benefits involve issues that probably don’t need to be dealt with in the first 48 hours of life when other challenges, such as the successful establishment of breast feeding, are far more important.

If you've decided you’d like to have your baby circumcised, I advise the following: 

1. Understand your reasoning in reaching this decision and be sure you’re comfortable with your choice. Almost always, this is best achieved by having a frank discussion with your baby’s doctor.

2. Decide on the most appropriate timing to establish your goals.

3. As with any procedure, select a practitioner that is experienced in performing the procedure and who is able and available to deal with the odd complication. 

4. Discuss the method of pain control selected by the surgeon. General anesthesia is only used in older children due to the higher risk of complications with its use in newborns. But all babies deserve some form of pain control during and after and surgery. 

5. Be sure you understand and are comfortable with all post-operative care.

And whatever choice you make, don’t sweat it. It’s unlikely that it will have a major, lasting impact on your child’s health either way.