No need to circumcise most boys

Doctor says routine circumcision of baby boys is wrong

FOR THOSE OF YOU who read my last column and the letters to the editor that followed, you already know that my comments about anti-circumcision demonstrators at the recent  American Academy of Pediatrics meeting in D.C. were not well received.

My column was about SIDS prevention, but I slipped in a little joke about the demonstrators being mostly graying hippies and having bumper stickers like, Not Circumcised? You Lucky Stiff!

While I was trying to be funny, and make light of the controversy at our conference, I apparently offended people all over the U.S. and Canada. And all this for a column that wasn't even about circumcision. Obviously, people feel very strongly about this issue.

The funny thing is, I agree with the demonstrators. I don't think circumcision should be routinely performed on newborns.

I don't do circumcisions. I was trained to, and had to do them while still in the Navy. But in our area, unlike where I trained in California, Ob/Gyn doctors perform most circumcisions. Even if they didn't, I still would not perform them.

Like the demonstrators, I believe that removing a healthy body part for cosmetic reasons is not appropriate. Well, let me rephrase that, because I have no problem at all with liposuction in a consenting adult. But in most cases of neonatal circumcision, we're talking about a helpless newborn losing a very sensitive part of the body for no good medical reason. Certainly there are religious reasons for some families--more on that later.

In the U.S., most people who choose to circumcise their newborns do it so that the penis looks normal and so that it will be cleaner. Neither of these reasons is valid. Isn't the normal penis the one that God created? Whatever happened to, If it ain't broke, don't fix it? In fact, 80 percent to 85 percent of the world's male population is not circumcised. So that is more normal.

I hear fathers say they worry that if their son does not have it done, he'll wonder why he doesn't look like his dad. Well, that is just as easy to explain as questions like, Dad, why do you have hair there and I don't? Or, Dad, why do you have blue eyes and I have brown eyes?

Hygiene is also a nonissue for most people. There are rare cases, like soldiers out in the field for days and days without bathing, in which the uncircumcised penis is more prone to infection. But in most cases, boys who are uncut learn to care for their penises just like they learn to brush and floss their teeth, and it's no big deal.

Let me mention that there are religious reasons for circumcision in the Jewish and Islamic faiths. I consider that to be very different than the routine circumcision done just because everybody else is doing it.

In the Old Testament, circumcision is described as a symbolic act by which a Jewish male enters into a covenant with God. This is a long-standing tradition, and the bris ceremony is very important in the Jewish faith. However, I have learned that the practice is beginning to be questioned by many Jews (see  jewishcircumcision.org).

It is unclear why Christians took up the practice, or why it occurs more in the U.S. than any other country in the world. There are Christian organizations such as Catholics against Circumcision ( catholicsagainstcircumcision.org) which state that the New Testament has passages that recommend against the practice.

Several resources I read mentioned that the practice became more widespread in the late 1800s in the U.S., and was touted as a way to cure masturbation (which was thought at the time to cause insanity, blindness and all sorts of horrible things). The circumcised penis is certainly less sensitive, due to the loss of a ring of tissue near the tip of the foreskin, which is the most sensitive part of the penis. But, I'm not really seeing that this was a cure.

Anyway, routine circumcision goes on in many areas, despite the fact that the American Academy of Pediatrics, American Academy of Family Practitioners, and the American Medical Association have all published statements that do not support routine neonatal circumcision. These are echoed by medical organizations all over the world, including the Australian Association of Paediatric Surgeons, which put it like this: We do not support the removal of a normal part of the body, unless there are definite indications to justify the complications and risks which may arise.

As the American Academy of Pediatrics notes in its position statement, there are potential medical benefits, but they are minimal and do not outweigh the risks. (You can read the statement online at  aappolicy.aappublications.org/cgi/content/full/pediatrics;103/3/686).

There are definitely fewer urinary tract infections in male infants under 1 year of age who are circumcised. However, fewer than 1 percent of uncircumcised baby boys get UTIs, so the increased risk is still pretty minimal. The same goes for the increased risk of penile cancer in uncircumcised men. There is a slightly increased risk, but this cancer is quite rare.

Potential complications of circumcision are more likely and include bleeding, poor cosmetic results, adhesions (I see a lot of those), scarring of the urethral opening, infection, and very rarely, penile amputation or death.

Then there is another issue I never thought about until I started researching this article. In the U.S., 1.2 million circumcisions are performed each year, yet this is considered a medically unnecessary procedure. The cost adds up to somewhere between $150 million to $270 million per year. Just think of how that money could be better spent!

In Virginia, Medicaid still pays for circumcisions. If that money was saved, it could pay for many of the infant's immunizations, for example. Several states, including California, Arizona, Florida, Washington and Oregon, already have disallowed Medicaid coverage of circumcision.

Having to pay $100 upfront to be circumcised was certainly a big deterrent at my last practice in California. In California, circumcision is in the minority--approximately 33 percent of newborns are having it done. In Virginia, it is still more widespread than that, but seems to be decreasing in popularity. (Exact numbers are difficult to come by, but I think we are in the range of 75 percent).

It seems like I end almost every column this way: Be informed. Know the risks and benefits before you decide. If you choose to have the surgery performed on your newborn, be sure that analgesia is used. Lidocaine injected into the base of the penis is very helpful in reducing pain during the procedure. Also, giving the baby sugar on a pacifier decreases their pain response.

Hard to believe, but even a few years ago it was routine practice not to use any analgesia or anesthesia for newborns being circumcised.

Now, it's considered the standard of care.

If you choose not to circumcise your son, you don't need to do anything special to care for the penis--just normal bathing. Do not try to retract the foreskin! This should not be done until years later, and will happen naturally with time. For more information on care of the intact penis, see  NOCIRC.org or  doctorsopposingcircumcision.org.

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