Thursday, July 28, 2011

The Great Debate

To circumcise or not?

Liam is circumcised.
(Jack will be circumcised, too.)

It was done in the hospital, 2 days after he was born, after a penile dorsal nerve block was administered.

This was not a decision we took lightly. It was not a decision that we made without research and discussion. It was not a decision based on societal norms or religion and it was not a decision that was a mistake. I have never regretted our decision.

I respect the fact that there are many parents who are opting not to have this procedure done. There are just as many reasons not to do it, as there are to do it-- it's not without risks (no surgery is). I think that parents who make a decision regarding circumcision with no knowledge of the procedure, its benefits, its pain management options, its risks and its potential complications are likely to regret their decision, whatever they choose. We should always do our best to make informed decisions when it comes to our kids.

I do not, however, believe that the decision to circumcise an infant is an uneducated or thoughtless one, as I've had people imply when this topic has come up in conversation.
There are several reasons we believe that circumcision was the right choice for us. I don't list them here to try to convince you that it's the right decision for your family-- rather, to show the thought process that was behind our decision.

Protection against Penile & Prostate Cancer

In a 2000 study done by a large health maintenance organization, surveys showed that 97.7% of the men who were diagnosed with Invasive Penile Cancer were not circumcised. Penile cancer is rare, mostly affects older men & is not a big concern for us-- But this added protection is a bonus to a procedure we were planning on doing anyway. Intact men were shown to be twice as likely to be diagnosed with Prostate Cancer.

Prevention of Infant Urinary Tract Infections

Research has shown that intact infants are 12 times more likely to develop UTIs than circumcised infants. While UTIs are certainly not life threatening (in normal cases), anyone who has had one knows how incredibly painful they can be.

But THE reason-- the one that would convince us to circumcise our boys, even if none of the other reasons existed, is this:

Studies have demonstrated that circumcision can reduce the risk of HIV/STD infection as much as 60%.

When I state this statistic, some people point out the fact that the majority of these studies have been done in Africa. Lack of clean water and sex education have been listed as reasons why these statistics may not be valid. But, clean water does not prevent the spread of HIV/STDs (otherwise America would be free of these diseases), and as many condoms as I may throw at my boys one day, I cannot guarantee that they will protect themselves every time they choose to be sexually active. Yes, it's true that their overall risk is higher in areas where more of the population already has the disease-- but HIV is far from absent in the US. Therefore, I do not believe that it matters where these studies were performed-- they still present valid correlations.

Additionally, it's worth mentioning that there have been studies done in the US, but mostly among homosexual men-- I do not discredit these studies as I cannot guarantee my boys will be heterosexual (and frankly, do not care).

As for the risk of contracting and spreading HPV, not only does circumcision potentially protect my boys, but it also could help prevent cervical cancer (caused by HPV) in their heterosexual partners. As a woman who has experienced multiple abnormal pap smears with precancerous cells (and had them treated via cryotherapy), I would love to see the rate of HPV transmission reduced. In addition to HIV & HPV, it is also suggested that circumcision reduces the risk of acquiring and transmitting other STDs such as HSV (Herpes) and Chlamydia (which can lead to infertility). 

Are there additional ways to reduce STD transmission other than circumcision? Sure. We will teach our boys about safe sex and the importance of using condoms. Gardasil (the HPV vaccine) has recently been approved for use in boys-- our boys will get the series of shots. And as clinical trials continue, hopefully an HIV vaccine will be available long before my boys are sexually active... and maybe even a cure.  
I don't look down on any parent who chooses not to circumcise their son. Handing your precious and perfect baby boy over to a doctor days after birth and letting her remove a piece of his body is not easy. I can understand a parent who looks at the facts above and makes the decision that they are not good enough reasons.

For us, they are.
Several people that I know who have decided to leave their son intact have asked the question, "Who am I to make that decision for him about his body?"

My answer is always the same, "Who am I? I'm his parent. I'm going to be making decisions for him for a long time & I'll do what I believe is best for him."

We all do what we believe is best for our kids-- whether that's choosing to circumcise or not, vaccinate or not, co-sleep or not, breastfeed or not. We make the best decisions we can with the information we have.

And I know we made the right decision for us.

Feel free to tell me about your decision and why it was right for you.


  1. If Smudgie is a boy we will circumcise. If the decision were left entirely up to me, we wouldn't for some of the reasons you alluded to-- the risks involved in any medical procedure, declining rates overall that will make awkwardness or "not fitting in" less likely, the desire to retain his bodily integrity, etc.

    But LG is Jewish and it's very important to him that his son (if this is a son) be circumcised. And being in an interfaith relationship, I have to respect that, especially given the areas in which he has deferred to my religious feelings or desires.

    The only issue is whether it's done in a hospital or home. I want hospital because they can administer an anesthetic, LG doesn't mind either way--and some members in his family are pushing hard for a full-on bris (which feels religiously disrespectful to me, as we'll be raising and baptising this baby Catholic, while also seeking to give him or her an appreciation and understanding of his/her Jewish heritage).

    Just another one of those things to work out, but I have faith that we will. We're pretty good negotiators.

  2. amen. probably the first pro-circ blog post i've ever read. i really liked the part about being the parent and having to make a lot of decisions for your child.

  3. We circumcised, and I'll admit I didn't give it a whole lot of careful thought because in my circle of family and friends, it's just what is done. I did research the risks and talk to my doctor about it though. Thank you for doing this research and making me feel even better about our decision!

  4. I agree that it is a decision that must be made within each family. We chose not to circumcise. For us the risks of the procedure were greater than the benefits. We spoke at length with both my OB and our pediatrician, and it's what was right for us. When he is ready we will teach safe sex and part of that for us will include the higher risk he could have for STDs if he is not careful. We have a few friends who had boys several months before us and we asked them in an information gathering way what they did. (some did some didn't) There was no judgement. Neither of our families has asked, I assume they think we did as that was most common and unless someone notices during a diaper change I can't imagine it ever coming up. Not that we a hiding it, but more to the point you made that as parents we make decisions that are best for our families and no one else's opinion really matters.

  5. I am still so on the fence about circumcision and as you know, I do regret our decision to but we also had complications from it and that certainly has played a role in my opinion.

    I do agree with this whole heartedly: "Who am I? I'm his parent. I'm going to be making decisions for him for a long time & I'll do what I believe is best for him."

    The only thing I have to really challenge as a pro reason to circ that you posted was it decreases the risk of UTI's. It may, but we don't go to such an extreme to surgically alter baby girls to decrease the chance of UTI's.

    Anyway, thanks for taking the time to write this. It is nice to read a pro circ post that someone actually had REASONS to do it. I read so many that they just did it but never researched or made an educated decision about it.

    Kristin from Our Growing Garden

  6. Very well thought out and well written post - I think we will choose not to circumcise our son when he is born, but I definitely can see that it is a totally personal decision, and, yes, one that a parent has to make for their child one way or the other. Thanks for your viewpoint!

  7. A very well written post. I appreciate how much you respect both choices. If we have a son we will not circumcise. My husband is not circumcised and we do not believe that the risks out weight the benefits. We also feel that the studies indicated higher risks of STDs/HIV did not take into account other important factors like education, poverty and access to contraceptives. Having said that, even if another study were done and similar results were collected we would still choose to abstain from circumcision. It just seems, to us, like unnecessary operation.

    I believe there is a measure in San Francisco right now seeking to ban circumcision in the city. I think that is just preposterous and I can't imagine it could ever pass (protecting religious freedom is just reason why it would be unconstitutional, at least in my mind). It makes me mad when people try to force their beliefs on others in that way. And while I understand that some people might feel circumcision is an unnecessary and painful surgery, it serves and important purpose for many people and I don't think that should be discounted.

    Thank you for presenting this in such an educated and thoughtful manner. It's much appreciated.

  8. @Kristen Reduced risk of UTI's is certainly not a sole reason to perform circumcision. (If that was the only benefit, we wouldn't have done it.) We felt that was one of several benefits.

    Since the topic of girls was brought up-- If we had a daughter and a similar procedure with similar benefits was available, we would have have the procedure performed on her as well.

  9. Circumcision is rare in Australia - so much so that it's incredibly difficult to have it performed unless there's a medical indication. Public hospitals are not allowed in circumcise based on parent's wishes (at least in my state) - any parents wanting circ have to find a private surgeon who performs the procedure (and not may do) and pay for a private hospital. I imagine however that traditional Jewish circumcisions are performed at home.

    As a medical professional I do believe that circumcision reduces the risk of STIs, particularly HIV. In my eyes, it's a simple fact. If you remove the area of epidermis that is most vulnerable to HIV transmssion you will reduce said transmission. In Africa this makes a substantial difference to HIV spread. In developed countries with low HIV rates to start with, whether circumcision is likely to make a noticeable difference to transmission is less clear.

    I'm not strongly for or against circumcision. Before I was pregnant I though that I'd probably have my son circumcised (although no men in my family are) but once I realised how difficult it is to do so here, and once I realised that my husband was strongly against the idea, I decided not to.

    I really don't think there's a right or a wrong here - just like most decisions in parenting!

  10. This is such an interesting topic, and I really enjoyed reading your research and the comments of others here.

    I have no idea what we'd do if we had a boy. It would take a lot of careful thought. Right now, I lean towards not cutting bits off of my baby, but I admit that that is a 'gut feeling' rather than a logical, researched decision. I am certainly not against circumcision, and I think the circumcised penis is more attractive (I mean, that isn't really a good reason either, but it does count for something!).

  11. I've really debating responding to this post, but ultimately decided I should, just in case anyone else reading continues to be on the fence about circ'ing or is interested in the perspective of someone who pointedly chose not to have her son circ'ed. It's not that I have any huge agenda about circumcision; it's not really anything I'd ever considered until I became pregnant. I'm not an "intactivist." I firmly believe my son's penis is no one's business but his.

    I worked on on a labor & delivery/mother+baby floor in a hospital, which meant I frequently interacted with newborns. Here the medical professional responsible for a hospital-based circ is the mother's OB. I have seen some ridiculously horrifying hack jobs on baby boys in my nursery. No one ever stops to consider, when determining their OB, if they are at all competent in conducting a circumcision. There were abundant OBs who practiced at this hospital who had a reputation (among the nurses and social workers) who were AWFUL, who took off entirely too much skin, who set babies up for very poor recoveries. Having seen some of the stuff that happened in our nursery, I began to question the necessity of circumcision, and found that it simply is NOT necessary. At all. (You can have it done as an outpatient w/a pediatric urologist though, and I'd be more likely to trust a ped uro than an OB.)

    Circumcision is not necessary to prevent disease. Proper hygiene and safe sex practices are all that is necessary to prevent STD, HIV, HPV. As a parent it is my responsibility to educate my child about adequate hygiene and safe sex practices, and I have his entire childhood and adolescence to reinforce the importance and his competence in these matters. I find flaw with the assertion about circumcision and HIV; the U.S. is the only developed nation that circumcises its boys without religious or medical reasons--and we still have high rates of HIV/AIDS. If a circumcised male has sex with an unknowingly HIV-infected partner, his circumcised penis isn't going to protect him. Everybody needs to wear a condom regardless of the status of his foreskin.

    The foreskin has a protective purpose. Contrary to myth, it doesn't make the penis dirtier when appropriate hygiene is implemented. It's just like your eyelid's function for your eye and protects very sensitive areas from irritants.

    Circumcision, which is typically done in the early days after birth, can interfere with a baby's initial grasp of breastfeeding--especially if they're also dealing with the wake of other birth interventions. Talk with any hosptial-based lactation consultant and they'll tell you this. This doesn't mean that a circ'ed baby won't BF, but it can be an unnecessary hurdle in the BF learning curve for mom and baby.

    It *is* painful, no matter if meds are used. I've been around the babies in the nursery who, despite their analgesia, were crying in pain afterwards. The nurses were constantly having to bring them down with Sweet-Ease, rock them, etc.

    It's an intimate decision, for sure. And I don't care who circ's their baby or not. I just didn't want my baby to go through it. There wasn't enough evidence to support its necessity, in my opinion.

    And, um, all penises are FREAKING WEIRD LOOKING. ;)

  12. @andtherewerethree

    Thanks for expressing your opinion regarding why circumcision wasn’t right for your family. I respect that leaving Arlo intact was the right choice for you and for him. You made a few points in your comment that I’d like to address:

    It’s horrifying to hear that you’ve personally witnessed some extremely poorly performed circumcisions done by the doctors in your former hospital. I’d venture to judge that circumcision is not the only area of patient care where we might these “professionals” to be lacking. You said, “No one ever stops to consider, when determining their OB, if they are at all competent in conducting a circumcision.” That’s absolutely not true. Who would circumcise our baby was a discussion that we had with our OB as soon as we found out we were having a boy (here it’s typically an OB, although sometimes it’s the pediatrician). When our OB told us it would be her, Rob and I had a discussion about whether or not we trusted her to perform such an important procedure and discussed her experience. We also asked important questions about the procedure itself, pain management, potential complications, etc. Uninformed parents do not consider this. Parents who choose circumcision because it’s “what you do” do not consider this. But educated parents who are actively researching and attempting to make decisions to better their child’s health who ultimately choose to have their son circumcised DO consider this. Rob and I are both that kind of parent.

    I agree that HIV/AIDS rates are higher than they should be in a country that has the resources to educate its population about safe sex— but somehow not the desire to do so. (Sarah Palin’s second out of wedlock grandchild attests to that!) We rank 64th in the world in regards to HIV/AIDS infections (rankings calculated by dividing number of people infected by total population)—a number that we can see as low (63 countries ahead of us!) or incredibly high (Australia ranks 117!). While I completely understand your point that our transmission rates are still high, despite being a country that routinely circumcises the majority of boys, I think you can concede that the current state of sex education is not effectively bringing down the transmission rate, either. I’m not suggesting that either circumcision or sex education can stand alone in preventing STDs. I personally don’t consider either of them unnecessary.

    My assertion that circumcision could protect my sons against STDs was not an excuse to avoid sex education with them. I will certainly not be teaching the boys that since they are circumcised they have all the protection they need—I hope that’s not how my post was interpreted. You are absolutely correct when you say that everyone should wear a condom regardless of foreskin status. But, we both know that doesn’t always happen. You may have had quite a different experience since you’ve been with N for so long, but Rob and I didn’t meet until I was 26 years old and he was 37, so we both had quite a bit of dating experience before we met (i.e. multiple partners). It’s not uncommon that once people have been in a relationship for months or even years, they ditch condoms and rely on birth control pills as the sole contraceptive. This is how I contracted HPV—from someone who I dated for a very long time and was unaware that he even had it. (Sorry dad, if you’re reading this.)

  13. @andtherewerethree

    Circumcision, to me, is kind of like choosing whether or not to give your child the Gardasil vaccine. Sure, if they use condoms every time they are sexually active (and the person they marry does the same) there’s no need for the shot—but if I give them the shot, and if they slip up there is an added layer of protection (that is not fool proof!). I realize that choosing to remove a piece of your child’s penis and giving him a shot are NOT the same thing, but the intentions behind them are entirely the same.

    I do not believe that intact penises are dirty or gross— that’s why I didn’t mention appearance or hygiene in my post. Any boy can be taught to properly care for his penis—foreskin or not.

    Perhaps my original post wrongly implied that there was ZERO pain associated with this procedure. Although Liam never seemed to be particularly bothered by it, the state of his penis during those early bath pictures makes me wince. Of course it must have hurt when he soiled his diapers and when we changed the dressings. When I spoke of the penile dorsal nerve block, I merely wanted to mention that this procedure was not performed without local anesthesia as some people suggest happens during routine circumcision—I’ve never known a parent who would allow their child to have this done without anesthesia. I certainly wouldn’t.

    I’m really glad that you wrote about your experience and position on circumcision—I’m thrilled that this became a post for thoughtful debate and respectful discussion. I can understand that you believe that the reasons we chose to circumcise are not good enough reasons for your family & they don’t have to be. They were good enough reasons for us. I’m glad that you made the right decision for Arlo & that we made the right decision for Liam (& Jack!).


  14. Of course! I hope I didn't imply that I thought you and Rob wouldn't appropriately educate your boys about these kinds of things! From our blogging relationship I have total confidence that these kinds of dicussions are a parenting priority for you. I absolutely respect your decision to circumcise, and I hope my post didn't reflect otherwise. I don't feel that the penises in your family are any of my business. :)

    I apologize for my overstatment that "no one" stops to consider who will be circ'ing their infant. Poor word choice on my part! There are, of course, conscientious parents who consider that. In my professional experience, it was really unfortunate to see those moms who chose to see prenatal care from a large OB practice--they had their primary OB, Dr. A, who they hoped and prayed would be on call when they delivered, but it was, like, a 1 in 10 chance that they'd get their primary OB. So, you've got Dr. B who comes in to deliver her, and then she discharges on day 2, and Dr. C is on that day, so Dr. C ends up doing the circ, and she doesn't even know Dr. C, she had the circ convo with Dr. A, and those docs are poor at giving report and reading each others' notes, and Dr. C has *the worst* rep for overcutting.

    ANYWAY, I think it's interesting, again, to point out that TIO, who lives in Australia, can't find a doc to perform a circ bc it's such an uncommon practice there, but Australia is 117 in the HIV rankings.

    I think what rankles me is that there is a lot of fearmongering out there, and I would hope that people could think more critically about issues like these. I feel frustrated when a message is something like, "Circumcision is the healthier choice" and what is heard is "Not circumsising is an unhealthy choice." I don't think they're mutually exclusive, and I think it's dangerous to push that message. I am not setting my son up for a life of risk and disease by not circumcising him.

    In my parenting choices I have almost consistently found myself in the margins: exclusively breastfeeding and potentially extended breastfeeding; not circumcising; sharing sleep; creating an alternative vaccine schedule; cloth diapering; etc. I don't want to be associated with some of the extreme folks in these margins, because that's just not who I am. I don't have any agenda whatsoever. I didn't come to these decisions out of some kind of granola ethic, but out of lots of research and following my parenting instinct. I guess my point is that if you educate yourself and follow your parenting intuition, you can't go wrong.

  15. It's fantastic that there's been such great discourse about this post.
    Whether someone chooses to circumcise their son or leave them uncircumcised, what I truly hope is that it's an informed decision, and for me that has been the over-riding theme of this post and it's comments.

  16. @tio Hear, hear! So many people get really negative reactions when they write these kinds of posts. I've been so pleased with everyone's input and decorum!

  17. @andtherewerethree

    Fantastic point about the uncertainty of delivery docs. You probably remember that my OB walked out towards the end of my labor, turning me over the the doc on call-- a person that I didn't know, didn't trust, and quite frankly, didn't even like. (He brought Liam into the world safely, so I guess that's what matters most, but the dude was lacking any decent bedside manner.) Anyway, after the birth, I made it VERY CLEAR that I did not want him to perform the circumcision and that MY doctor should be the one to do it. But I could easily see how an exhausted and excited new parent could just let whatever happens, happens... and end up with shitty Dr. C.

    Another fantastic point about fearmongering-- It's interesting that I feel the same way about messages against circumcision. I can completely understand how it irks you when people make crazy statements about leaving your son intact being "unhealthy." That's simply not true. Likewise, from my side of the debate, once the words "genital mutilation" are uttered by someone who is anti-circ, the conversation is over.

    I don't think you are an extremist, in any way. I think you are one hell of a smart mama & I respect your breastfeeding, cloth diapering, non-circumcising, co-sleeping, delayed vaccinating choices!

    Best point of all: "If you educate yourself and follow your parenting intuition, you can't go wrong." Couldn't have said it better!