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The Informed Parent

Circumcision: New Pediatric Policy Statement

by Shanna R. Cox, M.D., F.A.A.P.
Published on Mar. 29, 2004
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Over the years there have been many differing opinions on the benefits and risks of circumcisions. During circumcision a surgical instrument removes the skin overlying the head of the penis. Currently, estimates indicate that approximately sixty percent of males in the United States are circumcised. The American Academy of Pediatrics recently revised their statement on circumcision concluding that current evidence available is not sufficient to recommend routine circumcision of the male newborn. Therefore, the decision is left to parents and may be based on any number of cultural, social, or medical issues.

Researchers have examined many different variables relating to the practice of circumcision. In adapting their current policy statement, the American Academy of Pediatrics looked primarily at health benefits and risks associated with either a circumcised or uncircumcised penis. Traditionally, and historically, one of the strongest recommendations for circumcision was improved hygiene leading to fewer skin or urinary infections. With current societal standards this concern has diminished, but is contingent upon good parent education on the care of an uncircumcised baby. This involves not only routine cleaning but also eventual routine retraction of foreskin and removal of a substance known as shmegma--an accumulation of skin cells that proliferates with the separation of the foreskin from the body of the penis. It also entails observing a strong urinary stream versus a dribbling one. Urine accumulation under the foreskin may predispose to infection or swelling of the local area. In looking at incidences of urinary tract infections, the overall percentage is low. It still is noted to be higher in the uncircumcised male at a rate of 1/100 versus 1/1000 circumcised males. There is also a slightly higher incidence of penile cancer in the uncircumcised male. However, this disease is so rare that the Academy deemed this difference minimal. Previously, the incidence of sexually transmitted diseases was believed to be increased in the uncircumcised. However, most studies support that behavioral choice rather than anatomical differences are the main factor affecting this measurement.

Circumcision is usually performed in the newborn period, either in the hospital or as part of a religious ritual such as a Bris. As with any surgical procedure there are risks of bleeding and infections. Therefore, any family history of bleeding disorders or immune system suppression would be particularly important to discuss with your doctor. Another new addition to the American Academy of Pediatrics policy statement on circumcision is the endorsement of some form of anesthesia for the procedure. During the newborn period this most commonly would be accomplished with a local or oral agent. While in circumcision outside of the newborn time frame general anesthesia is used, and circumcision is performed in an operating room. Clearly this situation also carries its own risks. Typically an obstetrician or pediatrician may perform a circumcision to a newborn, while a pediatric urologist more commonly performs circumcisions on older children.

Outside of cultural or religious issues that may endorse or dissuade a family from choosing circumcision, social pressures often affect this decision. A father’s appearance and experience with the choice made for him offers a strong source of influence. Children are inquisitive about differences in the body from a young age. Parents may choose to mirror the father’s anatomy for gender identification or simply family likeness. Conversely, a father may chose differently for his son, believing this choice to be better than the one made for him.

In the end, circumcision is a personal choice for a family that can be made either with or without the input of a physician. As a surgical procedure, it does require a signed contract of informed consent. As with any life choice, common sense questions should be addressed, such as:

  1. How experienced is the person performing the circumcision?
  2. What complications, if any, have their previous patients developed?
  3. What should be expected after the procedure?
  4. What care should the newly circumcised male receive?

Alternatively, parents choosing to leave this skin intact should request information for the best care of an uncircumcised male. Particularly, they should be aware of the signs of infection or swelling that may indicate a visit to the doctor.

The American Academy of Pediatrics web site aap.org offers many related articles that parents may find helpful, as does their endorsed site medem.com. Of course your local pediatrician is always happy to be of assistance!




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