To cut or not to cut- that is the question.

​Our clients are faced with a tough decision when it comes to having a baby boy. Should we circumcise our baby? Once in midwifery care, they are used to taking in all the information and making an educated decision. The circumcision decision seems to have good information both for and against its practice and sorting through it can be challenging. There are also societal pressures, family emotions, and anxiety about making the wrong choice for your baby. We are going to sort through as much of that as we can here and leave you with some excellent resources to continue your own research, as well.

What is male circumcision, and how is it viewed in the US?

• A surgical procedure in which the foreskin of the penis is removed. Circumcision is done as a religious ritual, cultural custom or medical practice. Modern newborn circumcision forcibly separates the foreskin from the glans (head of the penis), clamps it in place with a surgical device and applies pressure and/or a blade to remove the foreskin, leaving the glans completely exposed.
• Worldwide, about 15-25% of males are circumcised. In the United States about half of newborn boys are circumcised; the huge majority of these procedures are done as a cultural custom and are considered elective, cosmetic procedures. 
• The rate in the US is on the decline in recent years, from nearly 65% in 1995 to just over 50% in 2010. Less than 25% of Texas newborn males are circumcised. One of the biggest contributors to the decline is both the CDC and AAP (American Academy of Pediatrics) ceasing to recommend circumcision as a routine newborn procedure for males, due to the lack of scientific evidence in support of it. There is, however, according to AAP, enough evidence for potential benefits that the AAP feels it should remain available for families that choose it.

There are many different sources of information to consider when discovering the pros and cons- and we will get to those below I promise. First, let's take a look at some of the common aspects of this topic that come up when we talk with parents in our prenatal visits about circumcision:

Objections to Circumcision:

• Altering the way baby was created
• Changing normal penis anatomy
• Female circumcision is illegal
• A painful surgical procedure
• Complications in healing
• Decreased sexual sensation as an adult
• A permanent procedure performed on non-consenting babies

Objections to Intact Foreskin:

• Hygienically superior
• Religious tradition
• Genitals that match Dad's
• Societal pressure
• Cosmetic ideals

Here are some facts about the foreskin that some families aren't aware of:

• The foreskin is more than skin- it's a functional fold of smooth muscle tissue, blood vessels, nerves, skin and mucous membrane.
• The purpose of foreskin is to cover and protect the glans penis (the head of the penis) and the urinary meatus (the opening of the urethra) from contaminants, abrasions and trauma.
• The foreskin also acts as a natural lubricant and is an anatomical "prepuce" (which includes the clitoral hood in women.) The prepuce for both men and women is meant to keep the glans as an internal organ unless aroused. 

And Finally, What the Research Says... 

Circumcision Risk:

• Not all babies will be completely protected from a painful experience even with anesthesia. A very small percentage of babies have complications due to the anesthesia and pain medication.
• 30 in 1000 babies experience mild to moderate surgical complications
• 3 in 1000 experience severe surgical complications
• 10 in 1000 will need to undergo a repeat surgery
• 1 in 1000 will develop a UTI before age 1
• 1 in 1 million circumcised males develop cancer of the penis annually
• Circumcision may slightly reduce HIV and STI acquisition 
• Expert opinions conflict on whether circumcised males experience better sexual performance

Intact Foreskin Risk:

• 10 in 1000 need a medical circumcision later in life
• 10 in 1000 will develop a UTI before age 1
• 3 in 1 million uncircumcised males develop cancer of the penis annually

* There is critique on this research stating it's compiled from data obtained from adult circumcision in sub-Saharan Africa, where hygiene and medical practices, resources and public health education is very different than in US culture. One argument against the foreskin risk is proper penis care and education effectively reduces morbidity in these areas without surgical removal of functional reproductive tissue.


Sooo, If Research Doesn't Support It, Why Do We Still Do It?

As we mentioned at the beginning of this post, sometimes medical research is not the only piece of information being considered. We are complex beings with complex motives and both societal pressure and norms, plus personal beliefs and ideals play a part in the choices we make.


What About Adult Circumcision?

• There are more reports of adult circumcision complications, but that may be because adults can verbally report if there is excess pain or delayed healing and infants are not self-reporting. There is no evidence that properly performed adult circumcision is actually riskier. 
• It is more costly, but that has to do with the anesthesia and not the procedure itself. General anesthesia is the most appropriate pain control method for circumcision at any age but is contraindicated for newborns. Adult circumcisions with general anesthesia costs about $3000 out of pocket; insurance coverage varies.

What About Religious Ritual Circumcision?

• Jewish and Muslim cultures use circumcision as a religious ritual. Traditional Jewish circumcision was done by just removing the tip of the foreskin, by pulling the foreskin up over the glans and making one cut, without forcible retraction or leaving the entire glans exposed after the procedure.
• Modern Jewish circumcision is done in a variety of ways, many with a mohel (rabbi/physician), liturgy and ceremony on the 8th day of life. 
• Christians in the US tend to make up a higher percentage of families choosing circumcision for their sons, stating religious tradition as a reason. The bible tells us that because of the life, death and resurrection of Christ we have freedom in the new covenant and no longer have to meet the standard of old testament law. “For in Christ Jesus neither circumcision nor uncircumcision counts for anything, but only faith working through love.” Galatians 5:6 

What About The Look Of The Penis?

• Many parents choose circumcision because they prefer the look of the circumcised penis or they are worried about what others will think about the look of their child's penis. I don't have an argument for this. You are simply choosing a surgical procedure for your child, in order to alter the appearance of their genitals.
• Some fathers worry about how their circumcised adult penis might look different to a child who is intact and have a desire for their parts to "match". We would beg to offer that adult genitalia always look different than a child's- consider the appearance of adult female labia compared to a small girl's labia. We recommend using simple and frank ways to describe any difference in any anatomical feature, genitals or otherwise. One of our client's told his son, "Daddy has an old fashioned penis" when asked, and opened the conversation up to physical autonomy and consent.

Decisions, Decisions

You won't have come to a clear choice of if you should circumcise your baby or not by the end of this post necessarily, but when you do, there are some important things to consider with either option that make your decision informed and responsible as a parent:

Choosing Circumcision:

• Can the desired benefits be obtained if parents wait for an age that the child can reasonably consent to the procedure?
• Always choose a licensed physician who is well-trained and very experienced with the procedure and addresses your concerns respectfully beforehand. Untrained providers have the highest rate of complications. The most common circumcision providers are pediatricians, OB/GYNs and urologists.
• Proper analgesia is key. Babies should be given a penile nerve block as the primary source of anesthesia. Adjunct measures like sucrose pacifiers, topical lidocaine and acetaminophen are to be used in addition to a full nerve block.
• There are 3 common devices used as clamps during circumcision; Gomco, Mogen and Plastibell. They are not created equal, do some research on each and know which options exist with your chosen provider. 
• Circumcision as a cultural custom is an elective cosmetic procedure. For this reason, many insurance companies do not cover this procedure. Out of pocket cost can be $800+.
• Some providers won't perform a circumcision without vitamin k injection, knowing this ahead of time can help you make a decision about standard newborn procedures. It should be noted that babies will synthesize their own stores of Vit K by the end of the first week of life. Many providers will perform this procedure without Vit K if baby is at least 8 days old. 
• Sometimes our clients tell us they don't want to know what the procedure is or to think about it or be present for it with their baby. This is understandable, circumcision can be very traumatic for everyone. We strongly recommend, however, that parents embrace their choice, watch an educational video on the procedure beforehand and advocate for their baby in person during the procedure. 

Choosing Intact Foreskin:

• Do not retract an intact penis, never push or pull the foreskin back to clean under it- it is harmful and painful. During puberty, the erections that come with normal growth and development gradually loosen the foreskin from the glans.
• Gently wipe from the base to the tip or rinse with warm water (no soap at the tip).
• Include the above information in how you educate your son in other hygiene matters (like brushing teeth and toileting) as he grows and learns to take care of his body.

Additional Considerations:

• It is one of the most common surgical procedures in the country and the complications are fairly low. Of course, so is the cesarean and we learn that common doesn't always equal normal, right or necessary. Questioning, researching and discussing before making a decision is wise.
• For parents that choose circumcision, there are ways to exercise discernment in procedure timing. We do not advise families leave the house for non-urgent outings or appointments in the first 2 weeks because rest, bonding and nursing are so important. We also advise to wait and see breastfeeding as well-established before a circumcision is done; Another common but often vital surgical procedure for the newborn involves releasing oral restriction to make breastfeeding successful. There is understandably a hesitation for this when a baby is already recovering from a circumcision done within the first week.
• There are ethical issues to consider from our perspective as midwives who deeply value physical autonomy and consent. You will not hear us give blanket recommendations for a permanent, elective procedure on a brand new baby. 
• Informed decision-making is supreme here. We support any choice made after gathering all the information and considering multiple perspectives and research sources.

​For Additional Research:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4364150/
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2878423/
https://i1.wp.com/thebirthhour.com/wp-content/uploads/2017/03/Circumcision-infographic.png
https://pediatrics.aappublications.org/content/130/3/e756
https://worldpopulationreview.com/state-rankings/circumcision-rates-by-state
http://intactwiki.org/wiki/Jewish_Circumcision
https://health.costhelper.com/circumcision.html
http://www.cirp.org/library/history/
http://www.drmomma.org/2009/09/functions-of-foreskin-purposes-of.html
http://www.thewholenetwork.org/twn-news/proper-care-of-the-intact-penis-from-baby-to-teenager