The Circumcision Decision

Today’s Parent. Volume 13, Issue 5. August 1996.

Circumcision is not a new topic. Etchings on Egyptian tombs, dating as far back as 2400 B.C., bear witness to the antiquity of the ritual. Jews and Muslims have long performed it as a religious rite. In the secular world, however, its history is relatively brief and certainly more controversial. Indeed, today in Canada the question of whether to cut or not to cut is so hotly debated—in both medical and lay circles—that it’s clear circumcision, once a routine procedure, is hardly routine anymore.

Today, about one-sixth of the world’s population practises circumcision—the surgical removal of the foreskin that covers the penis. It was embraced by doctors during the Victorian era, who touted it as a “cure” for masturbation. In North America circumcision flourished in the 20th century for hygienic reasons and by the 1960s, it was performed as a matter of course on about 60 percent of all newborn Canadian boys (with rates as high as 80 percent in English Canada).

In the past two decades, however, there has been a sea change in medical opinion. In 1975, the Canadian Paediatric Society (CPS) stated “there is no medical indication for circumcision during the neonatal period.” A revised CPS statement, issued this past spring, reiterates that position. Health Canada’s parent-information pamphlet offers a similar opinion. In addition, four provinces (British Columbia, Alberta, Quebec and, most recently, Ontario) have deemed routine circumcision non-essential for newborns and no longer cover its cost under their medical plans.

Yet despite a clear signal from the medical community that newborn circumcision is unnecessary, the rate in Canada remains relatively high (about 48 percent, according to Statistics Canada) putting us second only to the United States among English-speaking countries. Rates do vary from province to province, with Ontario at about 50 percent, Newfoundland near zero, and the Western provinces hovering in the middle.

The reason that the procedure has not fallen completely out of favour is simple: The decision to circumcise rests with the child’s parents, and their choice is determined, for the most part, by non-medical factors. Foremost among those considerations, according to several studies, is the status of the father. That’s the reason Toronto dad Steve Davison and his wife, Deborah, chose to have their son circumcised. “The decision was straightforward,” he says. “It had to be done. You know what they say, ‘Like father, like son.'” Oakville, Ontario mom Vivian McColl puts a different twist on the same story. “We were advised by professionals and friends to have our son look like his father,” she explains. “They said it was really important for his sexual growth and development to feel he was not unusual. So, his dad’s not [circumcised], and he’s not.”

Other parents may choose based on their ethnicity, geographical location, and the attitudes of family members. Rigaud, Quebec parent Linda Gallant, who sees circumcision as “the natural thing to do,” recognizes that her environment made her open to the idea. “It’s interesting,” she muses. “You do it because your dad did it, and he did it because his dad did it, and soon we forget why it was done in the first place.”

Certainly, the medical profession recognizes parents’ right to choose. Dr. Ted Boadway, executive director of health policy for the Ontario Medical Association (OMA), suggests that the physician’s role is to give parents “dispassionate advice” on the potential medical benefits and risks of circumcision. Then, no matter what the parents decide, “even given that the majority of those decisions are not going to be based on medical fact, [the physician should] be supportive.”

Perhaps the only thing that can be agreed on in the debate is that the delivery room is not the setting to make this decision, particularly since many physicians are opting out of performing circumcisions, and a referral (which requires planning) may be necessary.

Here are the answers to some common questions about circumcision:

Does circumcision have any benefits?

Recent studies suggest that uncircumcised boys are at greater risk of contracting urinary tract infections. UTIs can lead to kidney infections and other complications. As a result of these studies, the American Academy of Pediatrics, whose position since the ’70s has been virtually identical to the Canadian society’s, softened its stance in 1989, allowing that circumcision has “potential medical benefits and advantages.” Dr. Robin Walker, who is chief of neonatology at the Children’s Hospital of Eastern Ontario in Ottawa and who sits on the CPS’s fetus and new-born committee (FNC), says simply that the Canadian committee examined the same data and came to a different conclusion: “Clearly the risk of [a urinary tract] infection is much greater in uncircumcised infants. But it is still only about one percent and in the vast majority of those infants, it is easily treatable.” The bottom line for the CPS, says Walker, is that the risks to an infant from the circumcision itself outweigh the increased risk of a UTI.

Circumcision has also been said to reduce the risk of cervical cancer in female partners (the CPS says the link is inconclusive). As for the the reduced risk of penile cancer, according to Walker, good hygiene may be equally effective in preventing what is, in any case, a very rare occurrence.

As well, several studies suggest circumcision lessens the risk of contracting sexually transmitted diseases, including HIV infection. But Dr. Douglas McMillan, who chairs the FNC, contends that no cause-and-effect relation linking HIV to uncircumcised males has been established.

Isn’t a circumcised penis more hygienic?

Not necessarily. It’s worth noting that circumcision gained acceptance at a time when bathrooms were not commonplace. Part of the problem today, says Sue Hodges, who heads the Canadian Institute of Child Health’s postpartum parent support program, is that some parents are “afraid and unknowledgeable about care of the foreskin. They think it’s a lot more complicated than it is. I tell them it’s like brushing your teeth. It becomes a part of their boy’s daily hygiene routine.”

At birth, the foreskin is tightly attached to the head of the penis. Parents should simply wash the penis with soap and water. The foreskin usually becomes retractable of its own accord, most often by the time the child is three or four years old, but sometimes not until the boy is in his teens. (Parents should not forcibly retract the foreskin before it is ready as this can lead to infection and other complications.) Once the foreskin is retractable, parents should teach their son how to retract it himself and clean the skin underneath. Evidence suggests that daily hygiene helps reduce the risk of infection and inflammation, complications which may necessitate circumcision later in life (when it is done under general anaesthesia).

What are the risks?

As with any surgical procedure, circumcision has its risks. The most common, occurring in five to ten percent of cases according to Walker, are bleeding (which is usually controllable with pressure) and minor, local infection. The newly exposed tip of the penis sometimes becomes irritated by pressure from diapers or ammonia from urine. Frequent diaper changes and a protective coating of petroleum jelly can alleviate these problems, usually within a few days. A patient information sheet from the American Academy of Family Physicians advises parents to call the doctor if they notice a blood stain on the diaper larger than the size of a quarter, or signs of infection (including a temperature of 100.4degreeF or higher, redness, swelling and/or a yellowish discharge).

Significant complications occur in an estimated 0.2 percent of circumcisions. These include scarring, meatus stenosis (where the tip of the penis narrows, obstructing urination, and has to be surgically re-opened), skin bridges (which inhibit good hygiene, can be painful and require minor surgery to correct), and phimosis (which results from an inadequate circumcision and necessitates a repeat procedure).

What about pain?

Until the early 1980s, it was believed that infants did not experience pain to the same degree as adults, and circumcision was generally performed without anaesthesia. However recent studies have shown that infants feel pain as acutely as adults. As a result, the CPS now says that if circumcision is done, “the evidence of the need for pain control is strong.” Some hospitals already have pain-control policies in place, but the practice is far from universal. Recent research suggests that a sugar soother can ease a baby’s pain. A similar analgesic effect may be at work when Jewish babies are given a wine-soaked cloth to suck on during their circumcision ceremony.

Unfortunately, the CPS does not say what is effective and safe pain control. One method currently used is the dorsal penile nerve block. This involves putting a needle into the base of the penis to freeze the nerves, a procedure which, in itself, is painful and not risk-free. (Some hospitals use a recently developed topical anaesthetic called EMLA. A research review, underway by the CPS, indicates that the cream is generally effective, and safe if used in a single application. However, there is a concern that the cream may be absorbed into the baby’s bloodstream with serious, adverse effects if repeat applications are necessary.)

Dr. Murray Katz, medical director of the Tiny Tots Medical Centre in Montreal, agrees that pain should be minimized, but contends that doctors are trained to use the wrong instrument. Katz performs circumcisions, and trains other doctors in the practice, using the Mogen clamp, a device traditionally used in Jewish ceremonies. He says his procedure puts newborns through only a brief, 30-second period of pain and allows them to be picked up and comforted quickly. According to Katz, the Gomco-clamp technique commonly used by Canadian doctors hurts unnecessarily because it involves administering a local anaesthetic through a needle inserted into the penis, and restraining the baby not only during the three-to five-minute procedure itself, but also during the five minutes needed for the freezing to take effect. Dr. Victor Marchessault, executive vice president of the CPS, doesn’t buy that argument. “Devices don’t prevent pain,” he says. “We would not support [the use of any] device without anaesthesia. Even if it’s only 30 seconds, 30 seconds of pain is painful.”

What about sexual and psychological issues?

In recent years, anti-circumcision groups have condemned the procedure, arguing that it is psychologically scarring and inhibits sexual pleasure. Allen MacDonald, a Penetanguishene, Ontario father of two grown sons, is head of VOICE (Victims of Infant Circumcisions Enounce). “There is a scar on my penis,” he says, “where a normal, healthy, functioning part of my body used to be. It has dulled my sensitivity over the years, and taken away my enjoyment of sex.” MacDonald contends “we should recognize that a baby is a person and will grow up to be an adult who should be able to make this decision for himself.”

As yet there are no studies to support the contention that circumcision causes medical or psychosexual problems later in life. And certainly many doctors question the fruitfulness of elevating the argument either for or against circumcision to this highly charged level. Says the OMA’s Ted Boadway: “When circumcision is described as either psychologically, emotionally or physically damaging almost beyond recovery, I must say the debate leaves me cold.”

When is circumcision a must—or must not?

Are there any medical indications for circumcision in a newborn? According to Ottawa paediatrician Robin Walker, who sits on the CPS’s fetus and newborn committee, only rarely—for example, if there is some abnormality of the penis and the foreskin obstructs the flow of urine. As your child gets older, conditions may develop that necessitate circumcision: recurrent infection or inflammation; painful or difficult urination; or a tightening of the foreskin over the penis or above its tip. These conditions will not be present in a newborn but may affect between two and ten percent of older males.

When should a newborn not be circumcised? Babies who are ill, premature or under normal birthweight should not be circumcised because their risk of infection is higher and their resistance lower. In addition, newborn circumcision is contraindicated if there is a family history of a bleeding disorder.