The Kindest Cut?

When J.J. was born, our hospital gave us a list of outside physicians who performed circumcisions.  My husband called every provider on the list and made an appointment with the second cheapest one -- the same process by which he selects a bottle from a restaurant wine list.  I knew we were in trouble when we were greeted by none other than....

"Hi everybody!"

Actually, Springfield's Dr. Nick was way more professional than this joker, who was dressed in a hospital gown and dirty sneakers.  Without introducing himself or asking if we had any questions, he whipped out his instruments and started operating.  Rick fled, leaving me to comfort J.J. with a bottle.  In the middle of the procedure, the doctor (at least, I hope it was a doctor) said, "Here, hold this," and he handed me the thingy clamped to my son's penis, as he snipped away.  (I'm not a pediatrician or a surgeon, but I assure you that "thingy" is a formal medical term used by internists.)  And no, I wasn't wearing gloves, nor had I told this guy that I was a doctor. I fretted for days that J.J. would develop Fournier's gangrene, and that I would be to blame for his future as a eunuch.  

Fortunately, the risks of circumcision in a developed country are rare (0.2-0.6%) and minor -- typically bleeding, which usually stops on its own.  (We doctors have a saying: "All bleeding stops....eventually."  Think about it.)  But some would argue that there's no reason to put a baby under the knife when it isn't necessary.  And then there are those whack jobs (no pun intended) who blame their unhappy sex life on the loss of their infantile foreskin, not realizing that they can't get a date because they are whack jobs who blame their unhappy sex life on the loss of their infantile foreskin.  In fact, observational studies have been all over the map in terms of whether circumcision is linked to sexual dysfunction.


There are no randomized, controlled trials of circumcision in infants, and there probably never will be.  Since there aren't any studies employing sham mohels, we must rely on the results of observational studies to guide us on the risks and benefits of neonatal circumcision, with their imperfect corrections for baseline differences.  The procedure is linked not only with certain religions, but also with socioeconomic status, with babies born at higher income levels being more likely to be circumcised -- although Dr. Nick and his like-minded colleagues remain a low-cost option for the uninsured.


Circumcision does seem to reduce the risk of urinary tract infections in the first year of life - from 1% to 0.1%.  Not a huge absolute benefit for a surgical procedure, though infant UTIs do present a significant healthcare cost burden.  My pediatrician friends tell me that kidney ultrasounds are routinely performed in male infants with UTIs, to screen for anatomic abnormalities.  They often have to perform suprapubic aspirations (sticking a needle through the skin into the bladder) to obtain a clean sample of urine, which is a low-risk procedure, but not a particularly fun one for baby or parent.


Observational studies have also shown that circumcision is associated with a lower risk of sexually transmitted diseases, including HIV and human papillomavirus, the cause of most cervical, anal and now, oropharyngeal cancers.  But here the data get particularly sticky, since uncircumcised males are more likely to come from a lower socioeconomic status, which in turn, is associated with a higher rate of STDs.


Although there aren't any experimental studies of infant circumcision, there have now been three large randomized, controlled trials of circumcision in over 10,000 adult men.  All of these studies were performed in Africa, with the primary outcome being the subsequent rate of HIV infection.  It turns out that the foreskin is replete with special cells that are prone to invasion by the AIDS virus, so removing the foreskin should reduce the rate of HIV infection.  And indeed it did, by an impressive 50% over a 2-year period.  In fact, all three trials were stopped early, and circumcision was offered to the men in the control groups.  The studies also found reduced rates of HPV infection in both the circumcised men and their female partners.  


Now, a 50% relative reduction is a big deal in parts of the world with high baseline rates of HIV infection.  In these African studies, only 56 members had to be trimmed to prevent one infection at 2 years.  Of course, if you circumcise a baby, the point it to try to reduce his lifetime risk of infection.  The 2004-2005 U.S. data show that the lifetime risk of HIV infection in men is 1.87%.  Some of those are acquired from injection drug use or maternal-child transmission, but the vast majority of infections are due to unprotected sex.  Circumcision should decrease a child's risk of HIV infection, though the magnitude of benefit in the U.S. and other developed countries is unclear, not to mention the risk reduction in the future partners of these boys.

As for the drawbacks of circumcision in the African trials, there were but a few.  Some of the more pleasant "side effects" of the procedure were enhanced sensitivity and sexual satisfaction -- finally, a randomized (if not blinded) trial putting to rest the question of sexual dysfunction.  In fact, some of these trials found increased rates of unprotected sex and number of sexual contacts in the circumcised groups.  The increases were marginal, but remember that they were observed in an experimental setting.  Now that the benefits have been well-established, what if men got the mistaken notion that circumcision was completely protective against HIV, blunting the potential benefits?    I doubt this will be much of an issue in pediatrics, as I can't imagine any parents encouraging their son to sow his wild oats simply because he had been circumcised.

Whatever the studies show, most parents will probably still base their decisions on cultural and personal reasons.  Rick and I had no discussions at all about the benefits and risks of the procedure. I deferred to my husband's wishes, and when it comes to circumcision, that seems to be the rule among the couples we know.  In 1999, the American Academy of Pediatrics acknowledged the "potential medical benefits," but state that "these data are not sufficient to recommend routine neonatal circumcision."  Some have argued that the AAP needs to advocate more strongly for circumcision, now that we have proof that it saves lives.  

As for all you expecting, uncircumcised dads, maybe it's time to start a new family tradition.


*As a doctor, I know I should always use the correct anatomical term.  I fear, though, that too many mentions of the P-word will result in hordes of perverts stumbling on to my blog via their search engines.  (A lot of boys looking for "Girls Gone Wild" were no doubt disappointed to find themselves instead reading about cervical intraepithelial neoplasia.)