Newborn Circumcision

The medical column of pediatrician Tafadzwa Kasambira, M.D., M.P.H.


For parents who are uncertain about whether or not to have their newborn son circumcised, the decision can be a difficult one, often with unclear answers. Many parents do not hesitate to have the procedure done within days of the infant’s delivery, while the thought never crosses the mind of others. The non-medical factors that parents cite as influences on their decision to circumcise are many, including whether or not the father is circumcised, concerns about how the child will be perceived by friends in the future, and fears about the child’s sense of self-worth (1). Parents who feel the opposite may cite a similar desire for their son to appear like his father, or have apprehension about the perceived pain of the procedure, its utility, and concerns about the impact on future sexual function.

The Centers for Disease Control and Prevention (CDC) reported that newborn circumcision prevalence rates in the United States had decreased between 1979 and 2010, falling from a rate of 64.5% to 58.3%, although the rate fluctuated during that period (2). This decrease has been attributed to changing demographics in the country, with an increase in the proportion of the population that is Hispanic (who traditionally tend to have the lowest circumcision prevalence rates) in certain states. Circumcision is an elective procedure involves the removal of a layer of skin called the foreskin (or prepuce) that covers the glans (or head) of the penis and part of the shaft. This is achieved using various surgical methods, and the use of topical, local, or oral analgesia (pain medication) is strongly advocated by the medical community (although in one survey, only 45% of practitioners overall used analgesia during the procedure) (3).

In 1999, the American Academy of Pediatrics (AAP) released a Circumcision Policy Statement that stated that the scientific data up to that point in time regarding the potential medical benefits of newborn male circumcision were not sufficient to recommend that the procedure be performed routinely (4). The need for the provision of accurate and unbiased information for parents to help them make their decision, and the recommendation that they be provided the opportunity to discuss this information, were some of the points that were emphasized. A systematic review of the literature over the next several years led the AAP to update its policy in 2012 because the data indicated that the benefits of circumcision did outweigh the risks, and the AAP believed that its recommendations needed to be strengthened (5). The data were not, however, strong enough for the organization to advise that the procedure be conducted universally for all male newborns.

The benefits of circumcision include the prevention of urinary tract infections during the first year of life; a decrease in the risk of invasive penile cancer (which is rare); and later, a reduction in the risk of transmission of the human immunodeficiency virus (HIV) and other sexually transmitted infections. When conducted by trained professionals in a sterile environment with adequate analgesia, newborn circumcision is usually well tolerated, with few complications. There are ample data in the literature to show that infants do experience pain, and as recognition of this fact has become more widespread, many practitioners are taking measures to ensure that adequate analgesia is provided to infants before, during and after the circumcision.

Possible negative factors that are associated with circumcision include the associated pain; the extent of this pain is difficult to ascertain in non-verbal newborns, of course, but as mentioned previously, the data on this are compelling. There is always the possibility of complications occurring during the procedure (such as having too much skin removed, excessive bleeding or the occurrence of a subsequent infection), or (rarely) complications arising as a result of the anesthesia used.

We made the decision on whether or not to have our son circumcised after he was born, only because we were expecting a girl and got a surprise when he appeared. We had to make a quick decision, but it was an easy one, based less on medical reasons and more on cultural ones. Having witnessed circumcisions during my training and counseled patients on the pros and cons of the procedure, I developed my own well-informed opinions about circumcision that we applied when our son was born.

The provision of evidence-based, non-biased information to parents who are considering the decision on whether or not to circumcise their newborn son is paramount. In one survey of 149 families, those with uncircumcised boys were less likely to have been asked by their physician whether they wish the procedure to be done, often felt that they did not receive enough information about the procedure, and were more likely to reconsider their decision (6). Although the survey sample was small, the central point still holds: parents need to have all the options presented to them and be given the opportunity to have their questions answered once their son is born, in order to make a well-informed decision about the option to circumcise. They must then weigh this information in light of their own cultural or religious beliefs, which may, for some families, outweigh the medical benefits.

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Legal Disclaimer: This article is designed to provide general information related to pediatric care. The information presented in this article should not be construed as formal medical advice, nor is it intended to create a doctor-patient relationship. The content is intended solely for informational and not for treatment purposes.

This article is not a substitution for professional medical diagnosis or treatment.

References

1. Brown MS, Brown CA. Circumcision Decision: Prominence of Social Concerns. Pediatrics 1987;80(2):215-219

2. Owings M, Uddin S, Williams S, . Trends in circumcision for male newborns in US hospitals: Division of Health Care Statistics, Centers for Diseases Control and Prevention 1979-2010. NCHS Health E-Stat.

3. Stang HJ, Snellman LW. Circumcision practice patterns in the United States. Pediatrics 1998;101(6):e5

4. Task Force on Circumcision, American Academy of Pediatrics. Circumcision Policy Statement. Pediatrics 1999;103(3):686-693

5. Task Force on Circumcision, American Academy of Pediatrics. Circumcision Policy Statement. Pediatrics 2012;130(3):585-586

6. Adler R, Ottaway S, Gould S. Circumcision: We have heard from the experts; now let’s hear from the parents. Pediatrics 2001;107(2):e20

Dr. Tafadzwa Kasambira, M.D., M.P.H. is a pediatrician who received his undergraduate training at McGill University in Canada, and graduated in 2002 from Tufts University School of Medicine, where he also completed a degree in public health. He completed his pediatric residency training at Harvard University in 2005, and completed a fellowship in infectious diseases at Johns Hopkins University in 2008. He has been a medical officer at the FDA for the last six years. He and his husband are the proud fathers of three children.

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