Tuesday, August 13, 2013

To circumcise or not to circumcise. . .

I know, I know, you already have an opinion. Acknowledge it.

You're circumcised, and it's the only way to be.
You think circumcision is torture, and you would never do it to your sweet baby boy.
You're Jewish, and Jews don't think about it, they just do it.
You've been with an uncircumcised man, and immediately after you suffered a terrible yeast infection (which you are certain was directly related to his intact foreskin).
You think it's dirty to have a foreskin.
You think it's sexy to have a foreskin.
You think it's dangerous to have a foreskin.
You think an uncircumcised penis is really weird looking.
You think a circumcised penis looks too manicured and--dare I say it--naked.

So, imagine this: You are eight months pregnant. You are pretty certain you are having a boy, and you and your partner just cannot come to a shared decision about this. Should you circumcise him or not?

After turning to your mom and dad (and his mom and dad), your great uncle, the great world wide web (please do be careful), your brother, your pastor, and a psychic (or two), you decide to come to me-- your trusted family doctor-- to ask for my opinion. This is what I would say:

1) Circumcision is a sociocultural phenomenon. Your kid may or may not look like his buddy in the locker room. It depends on so many factors: where you live, what education level you have, what ethnic background you are, what sociocultural background his friends are, and a smattering of other random influences. You may be interested to know that in 2009, 54.5% of newborn boys in the US were circumcised. (Whenever numbers runs around 50%, I almost always feel like one cannot go wrong). Interestingly, rates of circumcision vary markedly based on US regions: highest in the Midwest at 75.2% and lowest in the West at 24.6%. For more details see this AHRQ report on circumcision.

2) There is good data that circumcision will protect your child from some medical conditions. Two main ones, to be precise: urinary tract infections (UTI) and sexually transmitted diseases (STD). Circumcision decreases a baby boy's risk of UTI in his first year of life (the risk of a UTI in an uncircumcised male infant is pretty freaking low, usually quoted at about 0.07 (or 7 cases per 1000 babies) and the risk reduction brings it down to .018 or 1.8 per 1000 babies. Darn rare. Circumcision has no effect on UTI after your baby boy turns one). Circumcision has also been shown to reduce heterosexual transmission of HIV by 60% (pretty impressive!)-- these are all really interesting studies coming out of sub-Saharan Africa and probably cannot be translated to mainstream US, but that's still a moving target (maybe another post, but here is a link, if you are interested).

3) The American Academy of Pediatrics (AAP) changed their official stance on circumcision pretty recently in 2012 (here's their statement). In 1999, they concluded the medical benefits were not proven to outweight the risks. In 2012, they decided that the preventive health benefits of circumcision outweigh the risks of the procedure. Much of their decision was based on these new studies coming out of Africa around HIV transmission. After AAP's official statement in 1999, rates of circumcision went down about 12%. Now that they changed their mind again, will rates go up? Time will tell, but probably yes (especially because insurers will likely start paying for circumcisions again).

4) I have NO idea whether or not removing your child's foreskin will affect his sexual life (or the sexual life of his partners). I have no idea how to help you determine the validity of this claim. You're on your own.

5) The procedural part of me (that part that loves taking off your moles and putting in your IUD) really loves doing circumcisions-- I promise I will do a good job and make him look handsome. I will be careful. I will perform the procedure with love and finesse and get him back in your arms asap. You can even watch me do it, if you wish.

6) But you should know that the scientist and evidence-based gal in me, the one that swore to do you know harm and minimize risks vs. maximize benefits really questions the benefit of circumcision for your little guy. His risk of having a UTI in the next year is so low, and his risk of STDs can be mitigated in so many other, less permanent ways. I am not sure I buy the AAP's new stance. Though the risks of circumcision are small, I will be tying down your newborn, injecting him with anesthesia, causing him to bleed (just a bit) and using a razor blade to remove a bit of extra skin on his penis.

In the end, the obvious reality is that YOU are the parent(s). You get to decide this in the first few hours or days of your sweet boy's life, but please do realize this is only the FIRST of countless important and unimportant decisions you will be making for and about your little boy:

Will he use a binky?
Does he have to wear shoes when he is running around outside?
Will you give him cow's milk?
Will you make him eat all his peas?
Does he sleep in his own bed or yours?
Can he have a toy gun?
What about peeing on the tree in front of your house?
Will he go to public kindergarten?
What is your policy on video games?
Can he watch a PG movie at age 8?

The list is endless.
Good luck.
(And it's not fair to ask me what I decided to do with my little one. It shouldn't matter. The decision is yours to make).


  1. Veronica,
    I'm leaving my comment here rather than emailing you because I know how exciting it is to get a comment on your blog :)
    First of all - I love that you're making time to write and inspired to get back to my writing on a more regular basis, now that I'm post-move.
    Second of all, I really enjoyed reading your posts. Your blog will definitely fall in the category of "blogs I shouldn't read if I don't have time to get off on a tangent thinking." Which is a good thing.
    Finally, is my mom paying you to remind me to give her a call? :)

    1. You were my first commenter! (And you're right, it IS exciting).

  2. From your mother-in-law --
    Wow! I am so happy you are beginning your writing endeavors in this form. I've enjoyed the postings already and expect to learn and reflect on future writings. As always from you, I expect to learn much. We don't always agree, but I do enjoy the debates and always learn something new. Good job!
    Second, don't ignore my grandson to write these postings:)
    Finally, do you really remind Amy to call? If so, I am sorry you have had to add this to your day.

    1. Thanks, Jackie. It's fun to disagree sometimes, no? And I'm excited to engage any type of discussion (as you know). If you have any topic ideas, please let me know!

  3. When we had Braxton it was interesting because our insurance will not cover the procedure in the hospital. We knew we would have Braxton circumcised, I was just surprised that we would do it at our 2 day check up at the pediatricians office. I actually liked that. I guess it would also give parents a few more days to make sure they fully agree to have it done or not have it done. What a great procedure to have done by YOUR pediatrician! The one person who you trust the MOST!!

  4. It is definitely true, Elisa, that I would be sure to trust the doctor doing your kiddo's circumcision! The whole insurance/payment thing is interesting and odd. . .as are many financial aspects of medicine!

  5. My question is why does the AAP never say anything about the _age_ at which circumcision is performed? We know the UTI thing is negligible, and if the STI issue is the real game-changer (as AAP policy suggests), it seems to me the reasonable, evidence-based solution is to recommend it for older kids/young adults (e.g. along with the Gardasil IMZ), or even at age 18, when the foreskin-owner in question would be able to actually give informed consent (to say nothing of feedback as to quality of the anesthetic provided ;p). Granted, I can't think of a single older kid/teen/adult who would voluntarily submit to a circumcision in the interests of halving their HIV infection risk, but it seems terribly wrong to me to submit a newborn to a procedure that no informed adult would consent to for themselves...

    1. Interesting thoughts. Thanks for sharing! I definitely agree that informed consent is ideal (it's pretty hard to get un-circumcised). The usual argument against older-adolescent or adult circumcision is that the procedure tends to be more complicated, require more intensive anesthesia, and takes longer to heal. While an infant circumcision is done in the office, takes under 10 minutes and needs no stitches, an adult/older child circumcision is generally done in an operating room, takes longer (about an hour) and requires some sutures and several days' recovery time (though surgeons often use absorbable sutures that don't need to be removed). It's definitely a very tough decision-- mostly I want my patients to think deeply about it and make as informed a decision as possible.

    2. This is a great blog! thanks for your work!

      I have to admit that, to a European, medical professionals advocating for routine circumcision feels a lot like hustling. If more than a few parents were considering routine circumcision for health reasons surely we'd also see an equivalent level getting their sons vaccinated against HPV. As it is the rates for HPV vaccination -even for girls- in this country are peculiarly low. It seems that by endorsing routine circumcision the AAP is essentially legitimising what is actually a cosmetic procedure.

      It's great that you're encouraging parents to think about their decision in this way. I hope that if they do choose circumcision then then also consider HPV vaccination when the time comes and teach their children about routine screening for chlamydia, gonorrhea etc.

    3. Thanks, Lucy, for your thoughts. I do agree that we should be thinking carefully about all the healthcare decisions we make-- and I do agree with you that STD screening and prevention (including talking to our children about safe sex and condoms) should be included in this. Certainly, the HPV vaccine discussion is an important one (and one I believe in). I'll add it to my list of topics!

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