Spring 1999 Volume Two Number Two

• Circumcision: The Controversy Continues
—pros and cons of the number one surgical procedure of childhood.

The practice of circumsion has always been a flashpoint for opinion; decried by its detractors as a barbaric act and championed by its proponents as a medical necessity. In fact, in the last 30 years, the American Academy of Pediatrics (AAP) has issued three different statements examining it.

Now the AAP has spoken for a fourth time. In summary, it has recommended that although "existing scientific evidence demonstrates potential medical benefit of newborn male circumcision, these data are not sufficient to recommend routine neonatal circumcision." In other words, although there are potential benefits, circumcision is not essential to the well-being of a child so that parents should decide what is in the best interest of their children.

In the United States, 65 percent of newborn males are circumcised. This number may vary depending on what part of the country you're in. In the 1960s, the percetage was in the 90s. Generally, parents take into account cultural, religious and ethnic traditions in addition to medical factors in making this decision.

The AAP said parents should examine the risks and benefits of circumcision prior to making a decision. These include the following:

Circumcision risks. Even though circumcision is minor surgery, it is still surgery and has the same risks associated with it. To minimize the risk of penile damage, the AAP recommends that circumcision be performed with specific types of surgical tools to minimize risk. These are the Gomco clamp, the Mogen clamp or the Plastibell.

The risk of circumcision is estimated at less than one percent with most complications being minor like bleeding. Bleeding risk is minimized with the availability of local measures to control bleeding (pressure, cautery, sutures or clotting agents). Infectious complications are usually just redness and local discharge. Cases of severe outcomes have been rare. Circumcision later in life carries the additional risk of general anesthesia.

Urinary Tract Infection. The risk of a urinary tract infection during the first year of life in an uncircumcised boy is 1 in 100. The risk in a circumcised boy is 1 in 1,000. Different studies have found the foreskin may pose anywhere from 4 to 12 times the risk of an urinary tract infection. However, the greatest risk seems to be in the first year years of life. But again this is a rare occurrence, about a one-percent risk.

Penile cancer. In the last seven decades there have been thousands of cases of penile cancer, with only a handful occurring in circumcised males. But penile cancer is rare, even in the uncircumcised, roughly 1 in 100,000 in the United States. The greatest risk seems to relate to phimosis, the foreskin cannot be pulled back over the head of the penis as boys grow.

Sexually Transmitted Diseases (STDs). Studies suggest uncircumcised males have a higher risk of STDs, but this risk is greatly outweighed by behavioral risk factors.

Penile Problems. Problems are greater in boys that are circumcised (such as meatitis) but are usually minor. After infancy it is the uncircumcised males that have the increased problems (such as inflammation of the head of the penis).

In addition, the AAP stressed that pain control should be used during every circumcision. In the past, pain control was left up to the person performing the circumcision. Some physicians used it and some didn't. Now for the first time the AAP has come out in favor of all infants getting some method of pain relief. Local anesthesia has been shown to be safe and effective. Of the options available for a local anesthetic, the AAP prefers methods involving injection of a numbing agent (lidocaine) over other methods.

So you as parents need to make an informed choice based on accurate information and taking into account social, religious and cultural beliefs. Weigh the risks and benefits. As us if you're not sure about the procedure. Because once you go ahead, it's hard to turn back.

—Andrew Larson, MD