Circumcision 101: What You Need to Know to Make the Decision for Your Baby Boy

It's a boy! Whether you're pregant or a new mom, you'll need to decide whether you'd like to have your baby boy circumcised. For some people, it's a simple choice; for others it can be very difficult figuring out what to do. Here's an overview of this common, yet sometimes controversial, procedure so that you can make the best decision for your family:

What is circumcision?
Circumcision is the surgical removal of the foreskin of a penis, which is the fold of skin that covers the tip of it. It’s a relatively simple procedure, one that people have been performing all over the world for thousands of years.

How common is it?
In the United States, about 50 percent of males will get circumcised, experts estimate. However, the rates vary greatly by region and culture. For instance, in some Jewish communities, nearly every male will get circumcised. According to a 2012 report in the medical journal Pediatrics, 74 percent of boys in the Midwest get circumcised, compared with 67 percent in the Northeast, 61 percent in the South, and 30 percent in the West.

Why do parents choose to have their son circumcised?
Parents might choose to have their son circumcised for various reasons, explains Douglas Diekema, M.D., professor of pediatrics at the University of Washington School of Medicine and a member of the American Academy of Pediatrics' task force on circumcision. "Sometimes it's based on the preventative health benefits of circumcision, but it's more commonly based on the personal preferences of one or both parents," he says. For instance, some parents do it for religious or cultural reasons, such as those of Jewish or Muslin faith. Others choose to do it (or not) for aesthetic reasons -- if a man has been circumcised, he might want his son to look the same. And then there are those who have their son's circumcised because they think it's more hygienic -- some parents say a circumcised penis is easier to clean. Bottom line: "Like any other decision you make for your child, deciding whether or not to circumcise your son is very personal," says Robert Mendelson, M.D., spokesperson for the American Academy of Pediatrics and a pediatrician in Portland, Oregon. "Talk to your doctor, educate yourself about the pros and cons, and then decide what to do based on the best interests of your child and your family."

When is it typically done?
If the circumcision is performed in a hospital, it'll usually take place within 24 to 48 hours after your son's birth -- in other words, before you check out of the hospital. "If it can't be performed in the hospital shortly after birth, it may be done later in the pediatrician's office," adds Dr. Diekema. Some parents choose to wait for religious or cultural reasons -- for instance, in the Jewish religion, the circumcision is performed on the eighth day after birth.

Does it ever make sense to wait?
Yes, sometimes parents should wait to have their son circumcised -- for instance, if a baby is born prematurely or has any health problems, doctors often recommend waiting until the infant is strong enough to undergo the procedure. "If a baby is a low birth weight, having breathing problems, or any other medical issues, it's important to hold off on the circumcision," explains Dr. Mendelson. "You don't want to add anything to burden the baby, even something as relatively minor as a circumcision." Your child's pediatrician will help determine when your son is ready for circumcision.

Are there any medical reasons to avoid it?
Yes, in rare cases. For instance, the Centers for Disease Control and Prevention recommends that children who may have hemophilia, a group of rare disorders where a person's blood doesn’t clot normally, shouldn't undergo circumcision because it can be difficult to control the bleeding. However, if you have a family history of hemophilia or any other bleeding/clotting disorder and still want to have your son circumcised, talk to your doctor about taking the necessary precautions such as possibly first consulting a pediatric hematologist. Also, if there's a structural problem with the penis, namely hypospadias, where the opening of the urethra is on the underside of the penis instead of on the end, you should avoid circumcision. The reason: Down the road, a doctor might need to use the foreskin to surgically correct the problem.

What are the possible risks?
As with any surgery, circumcision carries risks, such as infection and bleeding at the surgical site. In very rare cases, the circumcision can lead to more serious complications such as scarring, for example, or even the partial amputation of the head of the penis. That's why it's crucial to find a person who has performed many successful circumcisions prior to performing your son's. It's important to note that circumcision does not affect a male's fertility. Also, some people claim that circumcision can either heighten or lessen a man's sexual pleasure down the road; however, there's no conclusive evidence proving either is true.

What are the medical benefits?
According to the American Academy of Pediatrics, the medical benefits of circumcision outweigh any risks. For instance, evidence suggests that circumcision reduces the odds that a baby will develop a urinary tract infection (UTI) especially during the first year of life. While UTIs aren’t usually a serious condition in adults, they can be for infants and may require a hospital stay, says Andrew Freedman, M.D., director of pediatric urology at Cedars-Sinai Medical Center in Los Angeles and a member of the American Academy of Pediatrics task force on circumcision. Also, studies have shown that circumcised males have a lower likelihood of acquiring HIV among heterosexual men, human papillomavirus (HPV) and other sexually-transmitted infections (STI) than uncircumcised males. Circumcision has also been associated with lower odds of developing penile cancer. Lastly, some parents claim that a circumcised penis is more hygienic. But, experts say that if committed parents clean under the foreskin and teach their son to do the same as he gets older, their hygiene can be just as good. 

Why is it controversial?
Circumcision is nothing if not a personal choice. The American Academy of Pediatrics' circumcision policy statement states, "Although health benefits are not great enough to recommend routine circumcision for all male newborns, the benefits of circumcision are sufficient to justify access to this procedure for families choosing it and to warrant third-party payment for circumcision of male newborns….Parents ultimately should decide whether circumcision is in the best interests of their male child. They will need to weigh medical information in the context of their own religious, ethical, and cultural beliefs and practices." However, some people, often called intactivists, believe that circumcision is unethical and unnatural. "A small fraction of the population say circumcising a baby violates his basic human rights and that males should make the decision whether or not to have one when they are adults," says Dr. Diekema. Some experts might agree with this idea, but others don't because, as Dr. Mendelson explains, having a circumcision later in life is "more dangerous and incredibly more painful." Talk to your doctor about what's right for you and your child.

Will insurance cover the procedure?
Some insurance providers will cover circumcision, however others will not -- many state Medicare programs, for instance, do not cover the surgery. It's important to find out how much you will spend out of pocket before the circumcision -- talk to your doctor's office manager or the person who will be performing the surgery (such as a mohel, a person who performs ritual Jewish circumcisions) to find out exactly how much you'll have to pay. The surgery can cost up to several hundred dollars, depending on where you live and who is performing it. After you've determined what those fees will be, check in with your insurance provider to see what portion may be covered.

Is circumcision safer in a hospital?
Not necessarily, experts say. "The location of the circumcision doesn't matter nearly as much as the skill of the person performing it," says Dr. Mendelson. And that doesn't have to be a pediatrician, family doctor, or an obstetrician -- in fact, mohels and other providers in religious communities can be just as skilled. "Many mohels are proficient at this procedure -- they perform so many circumcisions that they very rarely, if ever, make a mistake," says Dr. Diekema. They key is to find a doctor, mohel, or other religious officiant -- usually through word of mouth -- and ask questions such as how many circumcisions have they performed, what kind of training they underwent, how they will maintain a sterile environment during the surgery and what they will do to control the pain both during and after the procedure.

What should I expect during the circumcision?
If the circumcision is taking place in the hospital, the baby will be taken to the nursery. He’ll then be restrained in some way -- in many cases, he’ll strapped onto a plastic board with Velcro straps to keep him very still. The penis will be cleaned and some sort of anesthetic will be applied. The doctor will then use a clamp to separate the foreskin from the penis -- this minimizes blood loss and discomfort. He’ll then remove the foreskin with a scalpel. The whole procedure takes just a few minutes. If the circumcision is part of a religious ceremony, often a relative will hold the baby during the procedure and the mohel or other officiant will say prayers. In the case of babies of Jewish descent, for instance, the infant will also be given a Hebrew name.

What about pain management?
While some people just dip a little wine or sugar water on the baby's pacifier to calm him down, many experts say these techniques aren’t enough in terms of pain management. "If you opt to have your son circumcised, you have an obligation to him to try to prevent pain," says Dr. Diekema. Talk to your doctor or the person performing the circumcision about using a topical anesthetic that contains lidocaine 45 minutes before the surgery and/or an injectible anesthesia. Also, ask whether or not you should give your son any pain medication such as Infant Tylenol and, if so, how much and when.

How long will it take my son's penis to heal?
Usually, it takes around a week or two for the penis to heal. At first, the tip will appear slightly swollen and red, and there might be a few drops of blood and a little yellow discharge. Whitish or yellowish patches might also develop on the head of the penis. This is normal, experts say. Call your doctor right away if you notice any excessive swelling or redness on the shaft of the penis, if your son has a fever or seems to have trouble urinating or if there's a thin, runny discharge draining from the wound. "It's important to get any infection or complication under control right away, because a baby’s immune system isn't as mature as an adults," says Dr. Mendelson. If necessary, for instance, your doctor can prescribe oral or topical antibiotics to treat an infection. Rest assured that in the vast majority of cases, any problems that arise due to the circumcision are easily corrected.

How should you care for the penis after the procedure?
It's important to ask the person who performs the circumcision for specific instructions as to how to care for the penis the two weeks after the surgery -- providers might vary in their aftercare suggestions depending on how they performed the circumcision. Typically, at first, your son might have a bandage or a piece of gauze on his penis -- this often comes off the first time he urinates after the surgery. If not, carefully remove it the next day, says Dr. Mendelson. Then, every time you change your baby's diaper, gently clean the area with warm water and unscented soap. "The most important thing is to keep the penis clean," says Dr. Diekema. Your doctor might also recommend putting petroleum jelly or some other ointment on head of the penis and around the incision for up to ten days so it doesn't stick to the diaper and cause discomfort. Also, stick with sponge baths until the penis is healed (and the umbilical cord falls off).

If my son isn't getting circumcised, how should I clean his penis?

"Wash your son's penis with soap and water -- however, don't wash under the foreskin," says Dr. Freedman. Dr. Mendelson explains, "There are adhesions between the foreskin and the penis that belong there. They will go away within a few months or years, but if you forcibly retract the foreskin you might break up adhesions which can bleed and cause a scar." Eventually, the foreskin will widen and retract naturally -- at that point, you can teach your son to pull it back when he bathes.

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