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Neonatal circumcision, removal of the foreskin of the penis, is the oldest known planned surgery (Alanis & Lucidi, 2004). Although it is uncommon throughout much of the world, about three-quarters of males in the United States are circumcised (Morris et al., 2016). As shown in Figure 4.15, there are regional differences, with nearly twice as many infant circumcisions in the Midwest as in the West (Owings, Uddin, & Williams, 2013). In recent years, circumcision has come under increasing scrutiny within the United States as some charge that it places the newborn under great distress and confers few medical benefits.

For decades, many scientists and physicians believed that newborns did not feel pain, leading many to perform circumcision without pain management. We now know that even the fetus feels pain (Benatar & Benatar, 2003). Newborns show many indicators of distress during circumcision, such as a high-pitched wail, flailing, grimacing, and dramatic rises in heart rate, blood pressure, palm sweating, pupil dilation, muscle tension, and cortisol levels (Paix & Peterson, 2012). Analgesia (pain relief in which the newborn remains conscious) is safe and effective in reducing the pain associated with circumcision (AAP Task Force on Circumcision, 2012). Treatment as simple as administering a sugar solution to infants aids in pain management (Matsuda, 2017).

The medical benefits of circumcision are debated (Beal, 2017; Freedman, 2016). Benefits include reduced risk of having urinary tract infections, developing penile cancer, and acquiring HIV (AAP Task Force on Circumcision, 2012; American Medical Association, 1999; Morris et al., 2017). Some argue that these are relatively rare conditions and that the evidence regarding HIV transmission comes from research with adult males in Africa. Whether the same effects apply to infants in Western industrialized countries is uncertain (Alanis & Lucidi, 2004). Moreover, behavior is a more important factor in preventing HIV infection than is circumcision.

In 1999, both the American Medical Association and the American Academy of Pediatrics (AAP) joined medical associations in Canada, Europe, and Australia in concluding that the benefits of circumcision are not large enough to recommend routine circumcision; instead, it is a parental decision. However, in 2012, the AAP modified its view to note that although it is a parental decision, the benefits of circumcision justify providing access to the procedure (by insurance companies) to families who choose it. Critical physicians and representatives of medical associations in Canada, Australia, and several European countries counter that the revised recommendation was not based on medical evidence but instead reflected cultural bias on the part of the AAP to support social practices common in the United States (Frisch et al., 2013).

Regardless, formal recommendations by medical associations may ultimately have little sway on parents (Freedman, 2016). Cultural traditions and religious factors influence parental decisions about circumcision. For example, in Jewish cultures, a boy is circumcised on the eighth day after birth in a ritual celebration known as a bris, in which the boy is welcomed as a member of the community. Parents’ decisions are also influenced by social factors such as whether the father is circumcised and the desire that the child resemble his peers (Bo & Goldman, 2008). The decision is complicated, as parents weigh health risks and benefits with contextual factors such as religious and cultural beliefs, as well as personal desires, to determine what is best for their child.

Description

Figure 4.15 Rates of Circumcision Performed, 1979–2010

Source: Owings et al. (2013).

Notes: Rates represent circumcisions performed during the birth hospitalization. Circumcision is identified by International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) procedure code 64.0.