Circumcision: A guide for parents

by Professor Brian Morris

Circumcision is a simple surgical procedure that removes the foreskin ­ a sleeve of skin covering the tip of the penis. Parents have the legal right to authorize circumcision. In order to make an informed decision, they must carefully consider the benefits and risks.

Since the foreskin traps bacteria and other infectious agents, as well as accumulating malodorous smegma, its removal improves genital hygiene and reduces risk of diseases and other conditions over the lifetime for the boy and his future sexual partners.

History

Circumcision has been performed for thousands of years as part of the culture of indigenous people who live in hot environments such as in Australia, the Pacific Islands, equatorial countries, the Middle East, Africa and the Americas. In Australia all newborn boys were once circumcised routinely. Circumcision then decreased in the mid-1970s, but is now rising again, in line with research. Over 60% of Australian men are circumcised.

Benefits of circumcision

• Eliminates the risk of phimosis, which affects 1 in 10 older boys and men. This condition refers to a tight foreskin that cannot be pulled back fully, so making cleaning under it, and passing urine, difficult. Phimosis also greatly increases the risk of penile cancer, and is the cause of foreskin and catheter problems in nursing homes.
  
• Reduces by 3-fold the risk of inflammation and infection of the skin of the penis. One in 10 uncircumcised men get inflammation of the head of the penis, which is covered by the foreskin. This rises to 1 in 3 if the uncircumcised man is diabetic. (Diabetic men also have other severe problems.) In contrast only 2% of circumcised men get this condition.
  
• Over 10-fold decrease in risk of urinary tract infection. Whereas risk of this is only 1 in 500 for a circumcised boy; 1 in 50 uncircumcised male infants will get a urinary tract infection. This very painful condition is particularly dangerous in infancy, and in 40% of cases can lead to kidney inflammation and disease; sepsis and meningitis can also result.
  
• Over 20-fold decrease in risk of invasive penile cancer, which has a high fatality rate. One in 600 uncircumcised men get penile cancer, which often requires penile amputation.
  
• Uncircumcised men have 1.5 ­ 2 times the risk of prostate cancer, which affects 1 in 6 men.
  
• Reduces by approximately 3-fold the risk of getting HIV (AIDS), during sex with an infected woman. HIV enters via the vulnerable inner lining of the foreskin of a healthy penis, but can also infect via sores anywhere on the penis (caused for example by genital herpes). In countries such as Australia that have a low prevalence of HIV the risk of a heterosexual man being infected with HIV sexually is generally low. His risk, especially if uncircumcised, will be much greater if he engages in unsafe sex with people of countries in which HIV abounds.
  
• Circumcision also affords substantial protection against sexually transmitted infections such as papilloma (wart) virus, syphilis and chancroid.
  
• Circumcision reduces by up to 5 times the risk of the man's female partner being infected by chlamydia or getting cervical cancer (which is caused by human papilloma virus). The load of infectious bacteria and viruses that accumulate under the foreskin is delivered into the female genital tract during sex. Chlamydia has more than doubled over the past 5 years in Australia and can cause infertility (in both sexes), pelvic inflammatory disease, and ectopic pregnancy.
  
• If not circumcised soon after birth, up to 10% will later require one anyway for medical reasons.
  
• Credible research shows that most women prefer the appearance of the circumcised penis. They also prefer it for sexual activity. Hygiene is one reason.
  
• There is no significant difference in sensitivity of a circumcised and uncircumcised penis.
  
• In general, sexual function is the same or better.

Risks of circumcision

• For 1 in 500 circumcisions there may be either a little bleeding ­ easily stopped by pressure or, less commonly, requiring stitches (1 in 1000), the need for repeat surgery (1 in 1000), or a generalized infection that will require antibiotics (1 in 4000). Although there can be a local infection, often what seems like a local infection is actually part of the normal healing process.
• Serious complications (requiring hospitalization) are rare ­ approximately 1 in 5000.
  
• Mutilation or loss of the penis, and death, is virtually unheard of with circumcisions performed by a competent medical practitioner. Ensure your doctor is experienced.
  
• If a bleeding disorder such as haemophilia runs in the family, then the doctor needs to be advised as circumcision may require special preoperative treatment.
  
• Anaesthetic is imperative, preferably a local, since a general anaesthetic carries risks, and is unnecessary. For age 0-4 months a local, not general, and for older children or teenagers a mild sedative might be considered in addition to the local. Young children who wriggle can be gently restrained. For pain after the anaesthetic wears off, an oral analgaesic medication is often prescribed.
  
• Delay means stitches being used for circumcision of older children, teenagers and men.
  
• So if circumcision is delayed past 4 months, total cost will become increasingly greater.
  

In conclusion

Circumcision confers a lifetime of medical benefits. 1 in 3 uncircumcised boys will develop a condition requiring medical attention. This means various degrees of suffering and, in rare cases, death. In contrast, risk of an easily-treatable condition is 1 in 500, and of a true complication is 1 in 5000. A successful circumcision is very unlikely to have any long-term adverse consequences.

Thus, benefits exceed moderate risks by over a hundred to one!

Further information

may be obtained from the following web sites:
http://www.circinfo.net
http://www.gilgalsoc.org
http://www.medicirc.org
http://www.circumcision.com.au
http://www.circumcisioninfo.com

The author wishes to thank the various international medical experts who helped in formulation of this Guide.

Brian Morris

is a Professor in the School of Medical Sciences at the University of Sydney, where he has taught medicine and science students since 1978.

After graduating from the University of Adelaide, he conducted research for doctoral studies in the departments of medicine of the University of Melbourne and Monash University, at the Austin and Prince Henry hospitals, respectively, from 1972. This was followed in 1975 by further reasearch as a C J Martin Fellow of the National Health & Medical Research Council of Australia, in the School of Medicine of the University of Missouri in Columbia, and the University of California in San Francisco. In 1993 he was awarded a DSc based on his published work, which currently extends to over 230 research articles on molecular biology and genetics, hypertension, and cervical screening. It is the latter topic that fostered his interest in circumcision.

He is not aligned with any religious, political, medical or other group that may have any influence on the topic of circumcision. The views he expresses arise from independent research published in medical journals.