After extensive review of the literature the Royal Australasian College of Physicians (RACP) reaffirms that there is no medical indication for routine neonatal circumcision.
Circumcision of males has been undertaken for religious and cultural reasons for many thousands of years.
Male circumcision is a 5-10 minute procedure and is typically performed in first few days after birth, or possibly postponed for a couple weeks depending on doctor’s recommendation. It is done under a local anaesthesia, such as a cream applied to the skin.
In Australia, the circumcision rate has fallen considerably in recent years and it is estimated that currently only 10%-20% of male infants are routinely circumcised.
In recent years there has been evidence of possible health benefits from routine male circumcision. The most important conditions where some benefit may result from circumcision are urinary tract infections, HIV and later cancer of the penis.
- Urinary tract infections affect 1- 2% of boys, and may be about 5 times less frequent in circumcised boys, whilst circumcision has a complication rate of 1 – 5%. On current evidence routine neonatal circumcision cannot be supported as a public health measure on this basis.
- Reduces the risk of acquisition of HIV, evidence is conflicting and would not justify an argument in favour of universal neonatal circumcision in countries with a low prevalence of HIV.
- Penile cancer is a rare disease with an incidence of around 1 per 100,000 in developed countries. Even though the evidence suggests neonatal circumcision may reduce the risk 10-fold, universal circumcision is not justified on these grounds alone.
The foreskin is a redundant fold of penile skin which overlaps the glans penis. At the time of birth the foreskin is non-retractable. Separation of the foreskin from the glans occurs spontaneously during childhood. By five years of age most of boys are able to retract their foreskin. A small percentage of boys are unable to fully retract their foreskin until puberty.
The foreskin requires no special care during infancy. It should be left alone. Attempts to forcibly retract it are painful, often injure the foreskin, and can lead to scarring and phimosis.
Later in childhood, the foreskin can be gently retracted to the point where resistance is met and the distal portion of the penis and the urethral meatus become visible. The glans and the inner-surface of the foreskin can be cleaned along with the rest of the body once separation has occurred and the foreskin is fully retractable.
By around the time of puberty, all uncircumcised boys should be able to retract their foreskin and clean underneath it in the bath or shower. It is important that they always return the foreskin to its original position after they have finished. If the foreskin is left retracted behind the glans, it may swell up and become painful (paraphimosis).
As the foreskin separates from the glans, dead skin cells will collect between the two layers. These dead cells appear as white crumbly or cheesy material and have been termed smegma. Smegma may produce a noticeable (and often asymmetrical) swelling beneath the foreskin. This material rarely causes problems and usually discharges spontaneously.
Indications for Circumcision
1. Narrowing of the foreskin that may make retraction over the glans difficult during infancy, this is called Phimosis
2. Recurrent inflammation of both the head of the penis and the foreskin, this is called Balanoposthitis
Contradictions to Neonatal Circumcision
1. Hypospadias and other congenital anomalies of the penis
2. Sick and unstable infants
3. Family history of a bleeding disorder or an actual bleeding disorder
4. Inadequate expertise and facilities
Complications of Circumcision
The complication rate of neonatal circumcision is reported to be around 1% to 5% and includes local infection, bleeding and damage to the penis. Serious complications such as bleeding, septicaemia and meningitis may occasionally cause death.
The difficulty with a procedure which is not medically indicated is whether it may still be in the child’s “best interests” (that is, in the case of circumcision, decreasing the risk of UTI and penile cancer, and ensuring acceptance within a religio-cultural group) on the one hand or whether it may constitute an assault upon the child and be a violation of human rights on the other.
Arguments to justify the “best interests” case are based upon data to suggest a decreased risk of medical conditions later in life, none of which, with the possible exception of UTI’s in boys, requires a decision in the neonatal period, and this could be seen to be an argument to defer a decision until the individual can express his own preferences.
This can be a difficult decision with so much conflicting information, so it’s best to discuss it well in advance as a couple and with your doctor.
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