Monday, January 2, 2012

To circumcise or not to circumcise?

I have long promised Rachel a post about why we chose to circumcise Judah.  Weird topic? Maybe. Except that for new moms of boys, it's a huge topic. Initially I put off this post because I knew it was a controversial topic and I didn't think my post-partum emotions could handle it. Then I was awaiting the rumored release of an update to the Center for Disease Control's recommendations on circumcision, but that never came. Then I was just busy and didn't get around to it.

So, here we are one year later.

When the question of whether or not we'd circumcise came up I was taken aback because I'd never thought about it before. Circumcision is fairly standard in the evangelical American world but without many good reasons, and there is heavy push back now from folks who say circumcision is a completely unnecessary cosmetic procedure, akin to infant mutilation.

I reacted against the rhetoric on both sides and dove into research. I read up on medical sites, blogs, called our pediatrician and my OB, and talked to parents, and friends. My own experience of my infant brother being circumcised made me both take it seriously and also take seriously that the procedure could be done painlessly and safely.

Dismissing Weak Reasons Supporting Circumcision
I concluded that there are a lot of bad reasons to circumcise. It doesn't make sense to me to circumcise just so a boy is like his father. It's too serious of a procedure if that is your only reason. It's true that the Old Testament prescribes circumcision for Israel, but that is to mark them as the Israelites, and the NT clearly says that the followers of Jesus need not follow suit. Circumcision reducing penile cancer is a very small reduction of a very rare form of cancer that really doesn't justify the risk of a serious medical procedure on an infant, in my opinion. There's a lot of old wives tales that people used to hold about circumcision that simply aren't true, and there's no evidence about circumcision affecting sexual pleasure one way or another.

Dismissing Weak Reasoning Against Circumcision
I wrestled with the arguments against circumcision and found that so many of them are guilt and emotion-ridden rather than based on fact. A lot of people talk about how how different organizations "don't recommend" circumcision, but I found that to be misleading because they also don't specifically speak against it. They don't recommend circumcision. They also don't recommend leaving kids intact. They simply don't recommend at all, but try to educate parents.

As I said, I don't buy the arguments that it's necessarily a terribly painful process, because doctors can make it next to painless with painkillers, and yet potentially causing my baby pain is something I take very seriously. It's false to say that Americans are the only people who circumcise, since most Jewish, Muslim, Coptic, and some indigenous African, Australian, and Pacific people also circumcise (though I don't envy the Muslim cultures that circumcise on entry into adolescence!).   I don't buy the argument that we shouldn't make this sort of choice for our child. Circumcising and choosing not to circ are equally choices that we make for our kids, since a child can grow up and decide he wants to be circumcised but desperately not want to have to go through it as an adult when they will carry the memory of it and (arguably) experience more pain.

So, I knew essentially that circumcision is a surgical procedure that I should take seriously. The essential question is whether it was beneficial or harmful.

The stories people told
A huge factor for me was actually anecdotal. Personal stories are powerful, ya'll! When we started discussing this, Isaac told me the story of a friend of ours that I'd never heard. He wasn't circumcised but contracted an infection when he was a young teen that was so bad he had to be circumcised and it was terrible. He wished he'd been circumcised as an infant. When I talked to our pediatrician he shrugged his shoulders and said it was controversial and we could go either way, it was our personal choice. However, when I pushed harder he told me that his father was not circumcised and wished he had been so he'd circumcised both of his sons, and that as a doctor he'd never met an adult that wished they weren't circumcised but had met those that wished they were. Both he and my OB and it seemed like many others I talked to knew someone that had to be circumcised as a teen or adult because of an infection and wished they'd had it done as an infant instead.

Does circumcision have health benefits or risks?
Those stories were a large influence, but I also wanted to see what medical world said. The vast majority of professional organizations around the world take a hands off approach. It's controversial, there's not a lot of solid research, and so they think parents should be informed and not forced either way. The exception is the World Health Organization, which cites tests in Africa on the effect of circumcision on the transmission of HIV. They say that tests show transmission drops by 60% in heterosexual men that are circumcised, which is pretty dramatic. The findings are dramatic enough that I was surprised to hear Bono talk about it on the Jon Stewart show recently about finding hope that we could begin to reduce the AIDs pandemic.

It seems at this point we know circumcision reduces transmission, but we don't know how (here's a Scientific American article on the question). It also seemed despite a lot of rhetoric to the contrary, the real medical studies pointed to a decrease in urinary tract infections in circumcised males (University of Michigan study here, other cited in sources below). It just makes sense to me that in general, tests and research seem to show that circumcision increases resistance to infection.

With that in mind, we moved forward and had Judah circumcised. Research and personal anecdotes point to there being medical benefit to the procedure. It's not enough to make me (or major organizations) say that everyone should do it, but it made me comfortable enough to go ahead with the procedure and feel like we were doing something good for our son - I believe he is safer from infection this way, and not just sexually transmitted infection.  This is from the Center for Disease Control :
"A large retrospective study of circumcision in nearly 15,000 infants found neonatal circumcision to be highly cost-effective, considering the estimated number of averted cases of infant urinary tract infection and lifetime incidence of HIV infection, penile cancer, balanoposthitis, and phimosis. The cost of postneonatal circumcision was 10-fold the cost of neonatal circumcision [37]."
From an article in the Journal of the AAP:
In the 1989–1999 decade, multiple studies confirmed the beneficial effect of newborn circumcision in preventing infant UTIs19–21 and transmission of HIV.22,23 The safety and efficacy of local anesthesia were established also. Since 1999, further convincing data have documented the preventive health benefits of circumcision.

Our Choice
Circumcision is still a procedure that requires an incision, so it carries some risk and should only be done professionally, and I'd say with painkillers.  For me, the potential health benefits made it worth it because I thought it could be done painlessly.

All that said, I did have some anxiety about actually having Judah circumcised - I did not want him in pain even though I'd been told it would be painless. I get why people choose not to circ. Our pediatrician did the circumcision with a topic anesthetic as well as giving Judah his first paci for comfort (covered in sugar water, which he took eagerly). The doctor told me Judah didn't cry - I'm sure he wants to comfort worried parents, but I'm hoping I can take him at his word. We were given instructions to care for the circ, and Judah wasn't any extra teary over the next days. He slept an extra amount that afternoon. When we changed his diaper we had to be careful how we cleaned him up so as not to cause any discomfort, but by just dripping lukewarm water on him we cleaned him up without bothering him at all. He didn't cry over it and it healed up in a few days - my fears allayed

US News and World Report articles here and here
NY Times article here and on the HIV efforts with circumcision here.
Other articles quoted and sourced above. 


Heather said...

There was a study I read too, that Jewish women have a very low rate of cervical cancer, and they said it's related :) I agree, very hot topic. :)

Rach said...

Thanks for the post. I appreciate it a lot. It helps me understand how someone who has actually researched circumcision could make this decision--I feel that most people do not research at all and circumcise by default.

That being said, I disagree with you on a personal level. Although I recognize that anecdotes powerful, I don't think it is a good way to make medical decisions. I could tell you horror stories (from my friends, not hear-say) about botched infant circumcisions that were completely unnecessary. Does it mean no person should circumcise? Of course not.

I do think that circumcision could be a valuable tool in certain populations of African men, WITH the vital caveat that those been be men able to consent to the procedure. I would never use those studies as a defense of routine infant circumcision in the United States. Why? Transmission was reduced only in female to male sex, which is definitely one of the less common forms of HIV transmission in the US, and it only reduced it by 60% at most. Jason and I plan to teach Judah about safe sex--that it happens perfectly only through abstinence/careful sex partner choice, but we have no qualms teaching him condom usage and discussing STDs in depth. Honestly, condom usage is so far superior in reducing STDs compared to circumcision (and so much less invasive), that it is mind-boggling to me that circumcision would be even considered a comparable alternative.

Also, I think that a slight reduction in UTI occurrence due to circumcision in no way mitigates the risks of infant surgery. Girls get at least times more UTIs than boys; however, surgery of any sort is not considered for infant girls except in extreme circumstances, after medical need has been indicated.

Finally, my biggest issue with infant circumcision is the "infant" part of it. I'm sorry Kacie, but as a postpartum doula who cares for infants (most of the boys I've seen are circ'ed), most babies do not have a circumcision or recovery as easy as your Judah did. :( I'm glad it went well for him, but if I can avoid a screaming circ'ed diaper change, caring for a raw little penis, and listening to a mom who thought she had to circ but was traumatized by it--then I will. Infants deserve what little autonomy we can afford to give them; for me, one of those rights is waiting until they're old enough to make the choice to have any body parts removed for themselves, unless medically necessary.

One more note about the pain thing: why should we assume that circumcision hurts an infant less than a grown man? It is the same operation. Just because someone can put words to their pain does not make it more valid.

Kacie, I respect you a lot, but I think we may always disagree on this one. Thanks again for the post--it does help me understand the other side of this debate a bit better.

Rach said...

I've linked to it before, but I think this link about why Africa's HIV studies do not apply to routine infant circumcision in America is worth reading:

Yes, it is by Doctors Opposing Circumcision, so it has an obvious agenda. However, it also links to some fascinating studies. And let's face it--many adult males feel strongly about their penises, so any given article may have unknown author bias. ;) Also, just read this to my husband and he says to let you know that he would have preferred to not have been circumcised. So, you can tell your pediatrician that you DO know someone who wishes his parents had left that decision up to him.

Kacie said...

Yeah, in general I think the evidence points to circumcision reduces infection in general. That's why the HIV studies matter to me.

I don't know if infants feel pain less, but my goal was to have their be no pain at all, and I was told that was possible and it seemed to be so with Judah. I do think infants heal faster and with thus with less pain, and they will not remember it, whereas our friend vividly remembers his 12-year old circ.

Kacie said...

Also - dang, how do women not know they have a choice on it? The way it worked with us is that they asked us months before the birth while filling out hospital paperwork if we wanted to circ or not. Not knowing my answer is what set me on the journey of research. I'm sure they can't do a circ without permission, I suppose if women are asked last minute and haven't had time to think, they'll feel trapped into it sometime.

I absolutely think that parents should be educated and make an informed choice in it all. There's no question about that.

Rach said...

It's hard for me to feel like there isn't a logical fallacy in the pain argument. Either circumcision can be done relatively painlessly (which in my experience, it isn't), or it is a painful procedure, regardless of age. It either is traumatic, or it isn't. Granted, I do think there are ways that you can reduce the pain/trauma (as you did with Judah, kudos), but those apply both to infants and adults.

As for recovery time, I totally get how it may be easier for an infant to recover, as they don't move around a lot. However, they also require 10+ diaper changes a day, which I think must mitigate any benefits to recovering at that age--most adult males don't have to wipe their feces off of their penis. This is why I don't think it is fair to play off of the pain/age argument. Circumcision can be really painful or less painful, regardless of age.

I agree that moms should be informed and have the chance to be informed, but in my experience, they often are not. If I hear one more "well, I did it because he needs to look like daddy" argument....sigh.

Kacie said...

For me, there is risk on either side. On the one hand, risk of adult infection requiring adult circumcision which in my opinion would be worse than infant circ because of longer recovery time and memory. On the other hand, risk of a botched procedure (which should be lessened by picking a good doctor and sterile environment).

If there had also been pain involved for Judah, I wouldn't have picked to circ. Assuming the procedure could be pretty much painless, I wanted to alleviate the risk on the side that was more concerned about.

So - whether or not pain was a part of the procedure was a big deal to me.

Rach said...

I'm glad Judah didn't experience much pain. However, in the moms I know (most with circ'ed babies), that was not their experience.

Also, a number of prominent organizations DO out strongly against circ:

The Royal Dutch Medical Association, May 2010: "The official viewpoint of KNMG and other related medical/scientific organisations is that non-therapeutic circumcision of male minors is a violation of children’s rights to autonomy and physical integrity. Contrary to popular belief, circumcision can cause complications – bleeding, infection, urethral stricture and panic attacks are particularly common. KNMG is therefore urging a strong policy of deterrence. KNMG is calling upon doctors to actively and insistently inform parents who are considering the procedure of the absence of medical benefits and the danger of complications."

Canadian Paediatric Society, "Circumcision: Information for Parents", November 2004, and "Neonatal circumcision revisited", 1996. The 1996 position statement says that "circumcision of newborns should not be routinely performed", and the 2004 advice to parents says it "does not recommend circumcision for newborn boys. Many paediatricians no longer perform circumcisions."

The Royal Australasian College of Physicians (RACP; 2009) state that "after extensive review of the literature" they "[do] not recommend that routine circumcision in infancy be performed".

I'm sure you probably already know this, so I'm posting this for the benefit of your readers. I don't want them to think that all medical orgs reserve judgement on this issue; some come out quite strongly against routine infant circumcision.

Jaimie said...

No one is talking about how much more attractive the penis is when it's circumcised. Anything that can be done to make the penis more compelling should be done. I mean I put on makeup every day. Guys can do something too.

Rach said...

Jaimie, I sincerely hope you are kidding. Infant circumcision isn't "putting on makeup every day." This is surgery. Would it be OK for a guy to tell small-breasted women they should get implants to be more attractive to fit some subculture's petty definition of beauty? Ugh, so messed up.

Kacie said...

Yet again, Rach, a quick search says the first group actively is opposing circs, but the other two are recommending against ROUTINE circs, which I'd also oppose because it should be up to the choice of the parent. Not specifically recommending it is different than specifically recommending against it, which they do not.

And Jaimie, the reason I didn't bring that up is because... generally it doesn't seem to be really an issue. :)

Kacie said...

actually the canadian pediatric society information handout to parents is really helpful. Points out the risks on both sides and the tension I felt when I was making the decision:
Of every 1,000 boys who are circumcised:

The stats they quote:
In 1000 circs - 2-3 end with complications that need more treatment. 2 will have a UTI before they're one. 10 will have to have circs repaired because of a poor result.

Of every 1000 not circumcised - 7 will be hospitalized for a UTI before they are one.10 will be circed as an adult for medical reasons.

Rach said...

I think we have different definitions of routine--I think it means in this context, "not out of immediate medical necessity." Maybe that is why I still interpret those statements as speaking against circ?

Also, that excerpt from the Canadian org is helpful. I would never see those particular risks of uncircumcised as worthy of surgery, especially since the autonomy of the circ decision is so important to me. But I think it is great to have the actual numbers for those things, and I may cite that in the future. Thanks!

Kacie said...

yeah, Rachel, I've understood it differently.

I've understood it as all of these orgs reacting against the systematic routine circ of infants by the medical community as it was done a generation ago. So - they recommend the medical world NOT routinely circ. That's what I've understood, and I totally agree with that.

Now, how do we find out what they all actually mean when they say "routine"! I could be people are operating on different definitions.

Sarah said...

Thanks for a well-reasoned post on a hot button issue. I heard a good friend of mine say recently that her son "had to get circ'd" in a way that sounded like they did not have a choice in the matter. That's the kind of thing I really don't understand. Perhaps some physicians frame up the question assuming parents will circ?

Both my midwife group and our family doctor discouraged circ. Well, our family doctor is very open to less popular alternatives, and he just said that he did not choose to circ his own son and the choice was up to us.

I understand why you choose to circ based on preventing infections, but that argument is not strong enough for me. You don't preemptivly remove the appendix or gallbladder so why the foreskin? Also, it doesn't make sense to me why God would create the foreskin if it's best just have it cut off at birth.

I agree with Rach about the meaning of routine here. I read that Canadian study before my son was born too, and I felt they were advocating keeping infants intact.

Anonymous said...

Thanks so much for this post; it's helpful to me to hear arguments on either side of the issue that are both well-thought-out and show concern for their son!