What is circumcision?

Circumcision is the surgical removal of the sleeve of skin and mucosal tissue that normally covers the glans (head) of the penis. This double layer, sometimes called the prepuce, is more commonly known as the foreskin.

Parents are encouraged to read as much as possible about circumcision. They should make themselves aware of the complexities of the circumcision procedure itself. Speak to your doctor about the step-by-step procedure. If possible, ask to observe a circumcision at your hospital, so that you will know fully what is involved.

Pictures and video of a circumcision are available on the Circumcision Information and Resource Pages (CIRP) website.

What is the foreskin there for?

The foreskin serves three functions: protective, sensory, and sexual.

In most cases, the foreskin is still fused to the glans at birth and will separate over a variable period of time over the first few years. During the diaper period, the foreskin protects against abrasion from diapers and feces. Throughout life, the foreskin keeps the glans soft and moist and protects it from trauma and injury.

Parts of the foreskin, such as the mucosa (inner foreskin) and frenulum, are particularly sensitive and contribute to sexual pleasure. Specialized nerve endings enhance sexual pleasure and control [19].

The inner foreskin (mucosa) is the skin directly against the glans. Like the lining of the mouth, this tissue is thinner and of a different texture and color than the remainder of the skin covering the penis (shaft skin). The frenulum is a particularly sensitive narrow membrane that runs down the ventral groove of the glans and attaches to the inner foreskin. The frenar band is the interface between the inner foreskin (mucosa) and the shaft skin. It often "puckers" past the tip of the glans. The band contains whorled smooth muscle fibers, giving it pronounced elastic properties that allow the foreskin to be retracted. The frenar band has a tactile sensitivity equivalent to that of the lips.
The foreskin provides ample loose skin for the penis to occupy when erect. It is a movable skin sheath for the penis during intercourse, reducing chafing and the need for artificial lubricants, and allowing the glans and foreskin to naturally stimulate each other. Warren and Bigelow described some of the physiological functions of the foreskin in sexual activity.

What are some reasons that circumcision is performed?

Circumcision is primarily performed for cultural or religious reasons.

Because a large number of men in English-speaking Western countries are circumcised, many think of the foreskin as an unnecessary part of the penis. Many circumcisions are performed because a circumcised father often does not want to feel that he is different from his son.

It is often said that a circumcised penis is cleaner, or easier to keep clean, than an intact penis. Smegma (a natural substance composed of dead skin cells, normal flora, and secretions containing the natural antibacterial agent lysozyme) is more likely to accumulate when the foreskin is present.

Medical grounds for circumcision that are most commonly cited are: Reduced risk of urinary tract infections (UTI); reduced risk of penile cancer; reduced risk of cervical cancer in partners of intact males; reduced risk of sexually transmitted disease (STD).

There is contradictory evidence in the research literature as to whether circumcision reduces UTI [16,17], but this seems to be the strongest of all medical claims in favour of circumcision, because UTI can have serious consequences. These infections can, however, in most cases be treated by antibiotics. The frequency of UTI in US male infants is approximately 1%, but is higher for females. There is evidence that babies who are breastfed have a lower incidence of UTI.

Penile cancer is an extremely rare form of cancer. It occurs mostly in older men, and most doctors will not recommend infant circumcision as a preventative measure. Penile cancer can occur in both circumcised and intact men: The Maden study (an ongoing study of penile cancer at Fred Hutchinson Cancer Research Center in Seattle) observed that 37% of penile cancer cases occurred in circumcised men.

The theory that wives of men with intact foreskins are more prone to cervical cancer has been disproven. The theory that the presence of a foreskin may cause an increased risk of sexually transmitted diseases was disproved by a new study. The question of HIV warrants further study. Although there is an apparent geographical correlation between male non-circumcision and HIV infection on the African continent, this is not true globally, and the pattern seen in Africa could easily be due to other factors.

The only known effective means of preventing HIV infection are fidelity, condom use and abstinence.

Hygiene

The foreskin is easy to care for and the intact penis is easy to keep clean. The foreskin usually does not fully retract for several years and should never be forced. When the foreskin is fully retractable, boys should be taught the importance of washing underneath the foreskin every day.

Gently rinsing the genital area while bathing is sufficient. Harsh soap and excessive washing can irritate the penis, which can lead to inflammation of the glans (balanitis).

Smegma is a white waxy substance that can appear under the foreskin. It consists of natural secretions and shed skin cells. In the past it was feared that smegma might be carcinogenic, but this has been disproven. Good general hygiene and common sense are key to preventing infection and disease.

If my son isn't circumcised, won't it have to be done later?

Abnormalities or diseases of the foreskin can be treated conservatively, if and when they occur, on a case-by-case basis.

Probably the most common abnormality of the penis is "phimosis", or tight foreskin. (This is not the same as the natural attachment of the foreskin to the glans in very young children, which is completely normal.) The foreskin can normally be retracted by adolescence.

If retraction is not possible, a number of newer treatments are available which do not involve circumcision: Steroid creams, stretching, and preputioplasty. Some of these treatments have only been published recently, and not all doctors are aware of them.

If your son has a serious problem with his foreskin, such as a severe infection (balanitis xerotica obliterans) or gangrene, perhaps related to diabetes, removal of the affected area may be a medically advisable option.

If my son isn't circumcised, won't he be teased?

Children can be cruel, and will find things to pick on another child about, whether it be his chubbiness, glasses, or freckles. Some parents think that their son should be circumcised so that he will "match" his father, brothers, or friends. As parents, we can help our children to feel good about their bodies and to respect individual differences.

Parents often express a fear that their son will "feel different in the locker room" if he is intact. There is good evidence that proper education is the answer. Boys who are taught from an early age that they are normal, whole and healthy will have a lesser chance of suffering embarrassment in the locker room, especially if some of the other boys are also intact.

Nonreligious infant circumcision is not an issue in European, Asian or South American countries. In Canada the average rate of infant circumcision for boys is roughly 25%, with large regional variations. The rate in the United States has dropped to less than 60%, and will drop below 50% in a few years if present trends continue. This is already true in the Western US (35% in 1993).

What are some reasons not to have my son circumcised?

Your son's foreskin is a healthy, natural part of his body. It is possible, though very unlikely, that it will cause serious problems during his life. When he becomes an adult, he may prefer not to be circumcised. Leaving your baby's foreskin alone preserves his right to a whole and intact body.

Circumcision will be painful for the baby (see below).

The medical evidence in favor of routine circumcision of healthy babies is not persuasive. If your son has a problem with his foreskin, such as a severe infection (balanitis xerotica obliterans) or gangrene, perhaps related to diabetes, your doctor may recommend partial or complete circumcision or removal of the affected area. Phimosis (nonretractable foreskin, if it persists much longer than normal) can usually be treated by gentle stretching and/or steroid creams. The vast majority of boys will never have any foreskin problems that necessitate surgery.

Is circumcision painful?

The often repeated statement that babies can't feel pain is not true. It is documented in the medical literature that babies are as sensitive to pain as anyone else, and perhaps more so.

Most circumcisions are performed without anaesthetic, because there are risks involved with using anaesthetics on babies. Sometimes local injections are used, but this does not eliminate pain. Most babies will show signs of pain during the procedure and in the week or ten days following circumcision. Recent studies have shown that the pain is remembered long beyond the time of the procedure itself.

While pain may help parents decide against circumcision, parents should look at the long term effects of their decision first, not only during infanthood, but all the way to adulthood. Your decision will affect your son for the duration of his life.

Does infant circumcision have risks?

Circumcision is surgery, and like all surgery it has risks. These include:

• Excessive bleeding
• Injury to the glans
• Infection (raw wound is exposed to feces and urine in diaper)
• Complications from anaesthesia, if used
• Surgical error, including removal of too much skin
• In rare cases, complications can be life-threatening.
• Up to 20% of circumcised males will suffer from one or more of the following complications, to some degree:

Meatal stenosis (narrowing of the urethral opening due to infection and subsequent scarring, that occurs almost exclusively in circumcised boys) extensive scarring of the penile shaft skin tags and skin bridges bleeding of the circumcision scar curvature of the penis
tight, painful erections psychological and psychosexual problems
The surface of the glans becomes dry if not protected by the foreskin. It is believed that dryness and abrasion may cause progressive loss of sensation in the glans, especially in later life. Circumcised men on the whole do enjoy sex and are able to orgasm.

What if we want to have our son circumcised?

Circumcision does not need to be done right away. There is no need to feel pressured by your doctor. Take your time.

If you intend to ask your doctor to have your son circumcised, ensure that the procedure is carried out by an experienced surgeon. Sometimes circumcision is considered "minor surgery" and inexperienced residents are given the task of performing it. This leads to a higher rate of serious errors and complications.

You may desire that your son will retain some inner foreskin, and especially the frenulum, to preserve as much sexual sensitivity and function as possible. Another method is the dorsal slit. This method does not involve the removal of tissue, but allows the glans to be exposed.

Your doctor can help you decide how much skin will be removed and how much of the glans should remain covered if desired. However, in most cases, once your signature is on the consent form, the physician has absolute license to execute the circumcision as he/she sees fit. You must ensure that your intentions are in writing before the operation occurs.

To lessen the pain, speak to your doctor about the use of an anaesthetic for your baby.

When and why was routine neonatal circumcision introduced in English-speaking Western countries?

Doctors in the English-speaking countries started circumcising babies in the mid-1800s to prevent masturbation, which some doctors claimed caused many diseases, including epilepsy, tuberculosis and insanity. Of course, these arguments are not accepted today.

Where can I get more information?

The organization NOCIRC can provide help and advice, as well as free telephone referral of physicians in your area who are trained in the proper care of the intact penis. Telephone (415) 488-9883, or write to: NOCIRC, P.O.Box 2512, San Anselmo CA 94979-2512, USA. A list of local NOCIRC centers in the USA can be found at the NOCIRC Website: http://www.nocirc.org/