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Family Health Magazine - CHILDHOOD

Circumcision
Changing attitudes about a difficult decision

For centuries newborn boys routinely underwent circumcision, or surgical removal of the foreskin of the penis. This is an important religious ritual for many and a social custom for others. Recently, we have begun to debate the pros and cons of routine, non-ritual circumcision of male babies. By contrast, circumcision for medical reasons causes almost no controversy.

Parents often consider three common concerns when deciding about circumcision.

Family tradition - Often parents want their son to look like dad or brother. Grandparents may also have definite ideas about what is right. Many parents often forget that it may be more important to fit in with peers, rather than looking different from all the other boys in the locker room. Since one-third of Canadian boys are circumcised, a boy will fit regardless of what the parents decide.

Possible need for circumcision in later life - Many of us have heard stories of an older boy or adult who needed circumcision, and want to prevent future discomfort. The chance that a circumcision will be necessary later is between two and five per cent, about the same as having a complication from the procedure.

Hygiene - Some parents worry that teaching their son proper care of his uncircumcised penis may be awkward. In the past, we thought that the foreskin needed to be pulled back on young boys in order to clean properly. However, this practice can lead to scarring and a higher risk that circumcision will be needed later in life.

Parents may also worry that their son may not be able to practice good hygiene in his older years, either due to his environment (such as wartime in the desert) or to later disability.

Although concerns are valid, the Canadian Paediatric Society says there is no good medical reason for routine circumcision. With proper care and hygiene, the chance of needing circumcision or having problems in later life is very small.

Recent evidence suggests that young boys may have a lower risk of urinary infection in their first few years if they have been circumcised. Since these infections are rare, this is not a major factor unless something is wrong with the baby's urinary system.

Men who are not circumcised do not have a greater risk of prostate cancer. Nor does being uncircumcised cause cervical cancer in female sexual partners. Uncircumcised men have a slightly higher risk of cancer of the penis. Still, the risk is so low that thousands of circumcisions would have to be done to avoid one case.

Those opposed to circumcision believe that the foreskin is normal healthy tissue that should not be removed unless necessary. The rich nerve supply to the foreskin is thought to be an important part of normal sexual pleasure later in life. Unfortunately, this theory is hard to prove.

Newborn boys should not be circumcised if they have a family history of bleeding disorders, or if the penis has not developed normally.

Development and care of the foreskin

When a boy is born, his foreskin is attached to the head (glans) of the penis by many fibrous strands. In most infant boys, the glans and the opening of the urethra (the tube that carries urine from the bladder to the end of the penis) are barely visible.

In a boy who is not circumcised, these fibrous strands gradually stretch. As they break away completely, the glans may be completely exposed when the foreskin is retracted (pulled back). This process takes place over one to six years, sometimes longer. It should happen naturally without parental or medical interference.

The foreskin retracts naturally when the penis becomes erect (often seen when a baby boy is about to pass urine), or with normal handling of the genitals that is part of the child's own body exploration. The only time the foreskin actually needs to be retracted is for sexual intercourse.

Normal care of an uncircumcised penis involves daily cleaning with mild soap and water. The foreskin should never be pulled back in an attempt to 'stretch' it, but can be gently tugged until the loose skin at the tip of the foreskin unfolds. In this way, the small amounts of soap, feces from bowel movements (in a diapered baby) and greasy material that collect there can be gently rinsed away. Eventually, the foreskin will naturally roll down to expose more of the glans.

For young boys, normal hygiene begins when they start playing with themselves in the bath. Stretching and tugging on the foreskin usually begins to pull the skin back, allowing water to rinse away normal secretions that have collected.

In some cases, the foreskin does not pull back off the glans. It may even become scarred down to the glans or narrowed at the opening, sometimes when the foreskin has been pulled back too vigorously. If this interferes with passing urine, or causes infections or pain, circumcision of the older child or adult may be necessary.

Circumcision procedure

During circumcision, the foreskin's fibrous strands are separated from the glans and the foreskin is rolled back and trimmed off just below the base of the glans. Though many techniques are used, all do essentially the same thing. The training and experience of the doctor doing the circumcision, as well as the age of the child, will affect the method. When discussing circumcision with the doctor, ask about the technique. Remember to discuss the risks of the surgery and the type of anesthetic (to decrease sensation and pain) to be used.

As with any surgical procedure, circumcision carries risks. Although rare, there is a possibility of bleeding and infection. A miscalculation when trimming the foreskin could damage the glans or leave the foreskin longer or shorter than desired.

In an infant, a nerve block may provide anesthesia. Two small nerves travel up the penis, one on either side. A small amount of local anesthetic injected just below the head of the penis allows complete or almost complete pain relief with few risks. Some doctors use penile nerve blocks, where local anesthetic is injected into the abdomen around the nerves at the base of the penis. Local anesthetic creams are now often being used.

Other doctors may simply try to work quickly, without anesthetic, secure in the knowledge that the baby will settle quickly once the 10 to 15 minute procedure is complete. However, current pediatric opinion is that anesthetic should be used. Most doctors prefer to circumcise a newborn when he is less than two weeks of age, as this seems to be the time with fewest complications.

The older the child, the more distress he seems to experience. A boy's penis becomes a very important part of his identity when he is only a few years old. By the age of six, the penis has become a treasured and top-secret part of a little boy's anatomy. To interfere with it before he can understand the reasons why may cause him unnecessary distress. He may even see it as a punishment. Generally, this means waiting until the boy is more than six years old.

Older boys find the first few days after circumcision extremely painful. Using an athletic support to prevent rubbing on clothing and prescription-strength painkillers may help. The doctor may also prescribe ointments or petroleum jelly with frequent dressing changes to keep bandages from sticking to the penis.

No matter whether it is done as a religious or personal consideration, or if it is medically advised, circumcision is a surgical operation. The final decision comes down to the parents. Being well informed can help parents make the best decision for their boy.

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FAMILY HEALTH is written with the assistance of
Alberta College of Family Physicians
FAMILY HEALTH is written
with the assistance of
The College of Family Physicans of Canada
Alberta College of Family Physicians
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