Non-Political Post - Circumcision - Yes or No?
Circumcise or Don’t? Quandary for Parents
Before giving birth to her first son three years ago, Allison Manley, now 40, gave a lot of thought to childbirth (she wanted a drug-free delivery), diapers (cloth), vaccines (spaced out) and breast-feeding (absolutely).
But she did not think much about circumcision, and she went along with her obstetrician’s recommendation to have her son circumcised.
In recent years, however, the routine, nontherapeutic circumcision of infant boys has become the subject of proposed legislation, public debate and considerable controversy. Opponents say circumcision is an unnecessary operation to remove a healthy body part and often call it “genital mutilation.”
At the same time, new medical evidence, mostly from Africa, suggests that circumcision may reduce a man’s risk of contracting sexually transmitted infections, including H.I.V., from a female partner.
So what’s a parent to do? Three weeks ago, after Ms. Manley gave birth to her second boy, she and her husband were in a quandary.
“We really grappled with the decision,” said Ms. Manley, who owns a design firm with her husband in Chicago. The couple ultimately decided to circumcise their second boy, as they had the first. But doubts persist.
“If we had to do it all over again, we probably would have left them both uncircumcised,” she said. “We tend toward thinking that less is more — the fewer medical interventions, the better.”
More and more parents are starting to think seriously about whether to circumcise their newborn boys. And many of them are finding that it’s a question without easy answers, not least because guidance from many leading medical organizations has been equivocal. Although rates have declined in recent years, well over half of all boys born in American hospitals undergo the procedure.
The American Academy of Pediatrics does not recommend routine neonatal circumcision, saying its medical benefits — including a slightly lower risk of urinary tract infections early in life, a lower risk of rare penile cancer and a lower risk of sexually transmitted infections later — are meager.
“There’s no compelling medical reason to do it,” said Dr. Douglas S. Diekema, a member of the academy’s task force on circumcision. “There’s also no compelling reason that it’s not a valid choice for families to make.”
“There are some small benefits,” he added, “and these need to be weighed against the risks.”
The academy has been in the process of updating its recommendation on the subject for several years. Meanwhile, the debate has moved into high gear.
Opponents say parents should be informed that even though the surgery is considered very safe, any medical procedure carries potential risks. Botched operations can result in permanent damage to, or even amputation of, parts of the penis. Anesthesia is not always used, and in very rare cases, babies die following circumcision. An estimate that about 117 boys a year die as a result of neonatal circumcision — put forth by a prominent opponent of circumcision, based on a review of infant mortality statistics — is cited often by critics of routine circumcision but widely disputed by medical professionals. A spokeswoman for the Centers for Disease Control and Prevention said the agency does not track deaths from infant circumcision because they are exceedingly rare. In the agency’s last mortality report, which looked at all deaths in the country in 2010, no circumcision-related deaths were found.
Still, circumcision “is not necessary, it’s invasive and it’s risky,” said Georganne Chapin, executive director of Intact America, an advocacy group based in Tarrytown, N.Y., that opposes routine circumcision. She notes that the sensitive foreskin is laced with nerves and blood vessels and protects the head of the penis.
Yet public health officials are mulling whether to actively encourage neonatal circumcision as part of a long-term strategy to curb the spread of AIDS in the United States. The Centers for Disease Control and Prevention will be releasing new recommendations on routine circumcision in the “near future,” a spokesman said.
The new recommendations will take into account data from clinical trials in South Africa, Kenya and Uganda, which found that adult men who were circumcised were less likely than those who were not to have been infected by an H.I.V.-positive female sex partner. Circumcision reduced their risk of infection between 55 percent and 76 percent over a two-year period.
Researchers also have found that circumcised men are less likely to infect their female partners with the human papillomavirus, or HPV, which is linked to cervical cancer in women.
“What we’ve found is that male circumcision is protective against a wider range of infections than we previously thought, including reducing the risk of acquiring herpes, though it’s not 100 percent protective,” said Maria Wawer, a professor at the Johns Hopkins Bloomberg School of Public Health. “The mucosal layers under the foreskin are a prime target for the entry of viruses, particularly H.I.V.”
But critics say the AIDS epidemic in Africa is very different from the one in the United States. A majority of American men with H.I.V. or AIDS were infected through sexual contact with other men, not women, and circumcision does not appear to reduce infection risk for men who have sex with men.
“Heterosexual transmission is a small piece of the pie” in the United States, said Dr. Robert Van Howe, a clinical professor of pediatrics at Michigan State University. In any case, he noted, adult men in this country already have “one of the highest rates of circumcision of Western countries.”
Then there is the question of cost. While circumcision is usually covered by private insurance, nearly 20 state Medicaid programs have dropped coverage of the procedure in their efforts to trim their budgets. Medicaid covers nearly half of all births in the United States.
The cost of newborn circumcision while the baby is in the hospital is relatively low, between $200 and $400, but even that may be a burden for young or low-income parents.
“This is a time in the life cycle when people don’t have a lot of money, so having the procedure paid for makes a big difference in their decision making,” said Arleen A. Leibowitz, professor emeritus of public affairs at the University of California, Los Angeles.
For parents who may be making a decision on circumcision, here is some advice:
PLAN AHEAD A decision about circumcision should be part of your birthing plan. Take time to research the pros and cons so you can make a dispassionate decision, and make sure you and your partner are on the same page.
Think carefully before announcing the decision to family and friends; opinions on the subject can be surprisingly strong.
FORGOING CIRCUMCISION If you are breaking with family tradition, seek out a supportive pediatrician who can provide guidance on hygiene, knows about normal development of the foreskin, and has experience dealing with infections and inflammations (and will not immediately suggest circumcision if these problems occur).
It is normal for a boy’s foreskin not to retract fully until he is older, and a small percentage of children will develop an inflammation of the foreskin called balanitis, said Dr. Edmond T. Gonzales Jr., chief of the pediatric urology service at Texas Children’s Hospital in Houston.
The foreskin may also produce oily secretions that make parents nervous but are not abnormal, he said.
CHOOSING THE PROCEDURE Approach the surgery as you would any other operation. Inquire about the surgeon’s experience with newborn circumcisions, and ask whether anesthesia will be used and how to treat postoperative pain.
Circumcision can be delayed for a medically frail or premature infant.
Follow postoperative care instructions carefully and seek medical attention for excessive bleeding or other complications.
This article has been revised to reflect the following correction:
Correction: September 24, 2012
An article on Aug. 27 about a conclusion by the American Academy of Pediatrics that the health benefits of circumcising infant boys outweigh the risks referred incompletely to complications that arise from the operation. An estimate given in the article, that about 117 boys a year die as a result of neonatal circumcision — put forth by Dan Bollinger, a prominent opponent of circumcision, based on his review of infant mortality statistics — is cited often by critics of routine circumcision but widely disputed by medical professionals. A spokeswoman for the Centers for Disease Control and Prevention said the agency does not track deaths from infant circumcision because they are exceedingly rare. In the agency’s last mortality report, which looked at all deaths in the country in 2010, no circumcision-related deaths were found. (An article on Aug. 23, 2011, about decisions by parents on whether to circumcise their sons also referred incompletely to the complications from the operation, citing the same mortality estimate.)