Circumcision is a hot topic in the parenting world where discussions of tradition versus medical need have been ongoing. A simple surgical procedure where the foreskin is removed, circumcision can be done at any age in any male, but it is most commonly performed in babies.
Professor Andrew Holland is a paediatric surgeon who performs circumcisions on children.
"The paediatric branch of Royal Australasian College of Physicians' position statement says there is no convincing evidence that we should recommend routine circumcision in a normal healthy boy," said Prof Holland.
"Parents usually face the decision over religious, family or cultural tradition reasons," he said.
"There is a significant emotive element - people feel strongly in favour or against. One of the arguments against is that at this age the boy cannot be consenting to the procedure. The argument here is that no one should be receiving a circumcision until they are able to consent to it themselves. [But] clearly there is an argument if there is a medical indication for the procedure.
"Having said that, if a parent wants this procedure done they are going to find a way for it to be done and I'd rather it be performed with someone who has the appropriate training and experience and it is performed in a humane, clean and appropriate manner," he said.
Medical indications for circumcision
Prof Holland said there very few medical reasons for circumcision to be done on an infant. However, there are some reasons why it should not be done in every male.
"Sometimes what can happen is that the development of the penis is not quite normal and the opening of the urethra doesn't go right to the tip of the penis. This condition is called hypospadias," said Prof Holland.
"It's quite a common condition - somewhere around one in two to three hundred newborn boys will have a degree of this condition, and is usually picked up within the first few days of birth.
"It's very important those boys are not circumcised because the tissue that forms the foreskin is highly likely to be needed in the repair process," he said.
There are some cases where circumcision is recommended for medical indications as circumcision can significantly reduce the risk of infection:
- When a child, especially an infant is experiencing repeated urinary tract infections (UTIs).
- When there is an underlying abnormality in the urinary tract which can lead to more serious infections and potential kidney damage.
"Having said that, UTIs are not life-threatening and can usually be treated with antibiotics."
When there is damage to the foreskin itself, either through scarring or tightness or the foreskin, the penis may become inflamed. If the foreskin has been retracted and is unable to be pulled back into place the foreskin can become swollen and is unable to be reduced over the head of the penis. This can require urgent surgical treatment.
"Performing [circumcision] surgery in the best way possible depends on the age of the child and the indication for the surgery. There has been a lot of work done in determining the 'best way possible' in doing the surgery and in how to manage pain."
Professor Holland deals with more complex cases in a surgical setting, using general anaesthetic in an operating theatre - where children must be at least six months of age.
Outside of a hospital setting circumcision is usually performed with local or regional anaesthesia, which can be done on younger boys and by other doctors such as general practitioners. The most common procedure in Australia uses the Plastibell device.
"It's always important to include the complications of circumcision in a balanced discussion of the advantages and disadvantages of any procedure," said Prof Holland.
"There's always a small risk in using a general anaesthetic. Most common complication following circumcision is bleeding after the surgery and occasionally infection - both manageable. Sometimes the exposed urethra which was formerly protected by the foreskin will rub against nappies or underwear and lead to a narrowing of the opening (meatal stenosis) which will need further operating.
"Parents should have a discussion with their surgeon or doctor about other possible complications that could occur," he said.
Benefits of circumcision
There is a lot of research about the benefits of circumcision in reducing the risk of transmission of infections and diseases including UTIs, HPV, mycoplasma, genital ulcer disease, and possibly syphilis. There is also good evidence of circumcision reducing (not eliminating) the risk of becoming infected with HIV.
However Prof Holland is quick to point out that much of this evidence comes from heterosexual interactions and in countries where hygiene is poor and barrier contraception is harder to access, and that circumcision is not an effective method of prevention.
"You're better off teaching your son about safe sex than simply rely on circumcision to keep him safe from STIs and STDs."
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