We go through the procedure of male circumcision, how and why it may be done.

Male circumcision is a simple procedure but is often a complex and emotive health issue that can generate great debate in the community and the medical profession. The current prevailing public policy in Australia suggests there is no medical reason for routine circumcision in newborns. However, research has found a higher risk of some health problems in uncircumcised males. 

Ultimately, the child’s welfare should be foremost, and we want the parents' decision to be based on balanced, well-informed, comprehensive information. 

What is circumcision?

Circumcision for medical reasons became popular in the UK and United States in the late 19th century, while in Australia and New Zealand the practice of circumcision was adopted later. It has since become uncommon in Europe and is declining in Australia and New Zealand. 

Circumcision may also be done for cosmetic, religious or social reasons. This is called non-therapeutic (or ritual) circumcision. Non-therapeutic circumcision is still relatively common in the US and South Korea.

Circumcision is usually a safe and straightforward operation but there are risks, mainly of minor complications such as bleeding and wound infection and only rarely, serious complications including meningitis (an infection of the part of the brain) and septicaemia (an infection in the bloodstream). An anaesthetic is required, which may be local or general.

Why might circumcision be practised?

• Phimosis. This is when the foreskin is too tight and difficult to pull back over the glans (the head of the penis). This condition can either be congenital (genetically inherited) or the result of infection. It must be assessed by your GP who may advise circumcision. Alternatively, your surgeon may suggest a procedure called preputioplasty. This involves making one or two small cuts in the foreskin to help it stretch.
• Paraphimosis. If you have a tight foreskin and you force it over the head of your penis, there is a risk it will get stuck there. This condition, caused by a narrow or inflamed foreskin, is called paraphimosis. It usually needs urgent medical attention.
• Recurrent balanoposthitis. Another reason is generalised inflammation of the penis occurring as a complication of bacterial or fungal infection.

What are the potential benefits?

Circumcision may reduce the risk of the following conditions:

• Urinary tract infections. These affect up to four percent of boys, especially in infancy, but may be 10 times less frequent in circumcised boys. This is not considered by doctors to be sufficient reason for circumcision.
• Penile cancer. This cancer is rare but there is an increased risk of cancer of the penis in uncircumcised men.
• Cervical cancer. Uncircumcised men may be more likely to acquire and transmit the human papillomavirus (HPV) that is responsible for most cervical cancers. However, cervical cancer rates are declining in Australia due to effective screening and vaccination programs.
• Penile inflammation and dermatoses (skin disorders). Penile inflammatory disorders are less common in circumcised men but can develop whether or not circumcision has been performed. Uncircumcised males who retract the foreskin while bathing are less likely to experience problems with inflammation. Acute and recurrent problems of the foreskin can sometimes be managed medically but surgical intervention may be required.
• Sexually transmitted infections (e.g. syphilis, gonorrhoea, herpes, HPV, HIV). Although circumcision may slightly reduce the risk of transmission, particularly in high-risk groups, it does not provide protection against sexually transmitted infections and should not replace safe sex practices.

What are the risks?

Circumcision has a complication rate of one to four percent that includes local infection, bleeding and damage to the penis. 

• Pain and distress. Surgical excision of the foreskin is painful. Safe and effective pain control should be offered to all infants undergoing the procedure. Post-operative pain, swelling and bruising are common.
• Cosmetic concerns. Too much or too little skin removal may present problems or abnormal scar tissue may develop. 
• Buried penis. Refers to a penis that is buried under scar tissue that develops at the site of incision. It may occur if too much or too little skin is removed. Treatment is surgical.
• Sexual dissatisfaction. Some men say the end of the penis becomes less sensitive when the foreskin is removed. However, most circumcised males do not describe psychological trauma or decreased sexual function as a result of being circumcised.
• Psychological trauma. Some males resent having been circumcised and increasingly, are requesting a procedure be developed to recreate the foreskin.

When performed on healthy newborn male infants as an elective procedure, the incidence of serious complications from circumcision is extremely low. Serious complications such as uncontrolled bleeding, meningitis and septicaemia are rare but may result in death. 

What's happening in Australia regarding circumcision?

In recent years the rate of circumcision in Australia and New Zealand has fallen and it is now estimated that only 10 to 20 percent of newborn male infants are circumcised.

The Royal Australasian College of Physicians (RACP) issued a policy statement on male circumcision in September 2010. It states, “After reviewing the currently available evidence, the RACP believes that the frequency of diseases modifiable by circumcision, the level of protection offered by circumcision and the complication rates of circumcision do not warrant routine infant circumcision in Australia and New Zealand. However it is reasonable for parents to weigh the benefits and risks of circumcision and to make the decision whether or not to circumcise their sons.”

In Australia circumcision for non-therapeutic reasons is no longer carried out in public hospitals. However, they will continue to provide circumcision where there is an identified need for surgery to improve the patient's physical health. 

Choosing to circumcise or not

Circumcision does have some possible medical benefits, as mentioned above. It does not prevent diseases, however, and good hygiene and safe sex practices are still necessary. Circumcision also carries some risks and there is debate over whether these outweigh the potential benefits. Some people argue against circumcision saying that the foreskin does have a functional purpose – primarily to protect the glans, which is highly sensory tissue. 

Circumcision of male infants in a deeply personal matter, and includes medical, ethical, cultural and social considerations. Parents may need to consider how the child might respond, opinions of family and friends, medical risks and benefits, and whether they should be making such a decision without the consent of the child. 

Ultimately, parents have the right and obligation to make the decision of whether or not to circumcise their sons. The decision, like all medical procedures, should be based on the principle of weighing up the risks and benefits for the long-term wellbeing of the child. It’s important to have access to accurate information so you can make an informed decision. Talking to informed people you trust, such as your GP, can also help with the decision-making process. 

Circumcision should always be performed in a safe, family-friendly environment by an appropriately trained, competent practitioner. It is important that the person carrying out the circumcision is capable of dealing with any complications that may arise, no matter how rare they may be, and is knowledgeable in using appropriate analgesia.

How to care for an uncircumcised foreskin

It’s normal for the inner surface of the foreskin to be fused to the glans in newborn males. Separation of the foreskin from the glans usually occurs spontaneously during childhood. By five years of age most boys are able to retract their foreskin. A small percentage of boys are unable to retract their foreskin fully until puberty.

The foreskin requires no special care during infancy and should be left alone. Attempts to retract it forcibly are painful, often injure the foreskin, and can lead to scarring and phimosis (difficulty in retracting the foreskin). 

Later in childhood, the boy may be able to retract his foreskin gently to the point where resistance is met and the end of the penis and the urethral opening become visible. Only the boy should attempt to retract his foreskin – no one else. He can be shown how to clean the glans and the inner-surface of the foreskin once separation has occurred and the foreskin is fully retractable.

At puberty, all uncircumcised boys should be able to retract their foreskin and clean underneath it with water in the bath or shower. It’s important that they always return the foreskin to its original position after they’ve 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. Accumulation of smegma assists the normal process of separation of the inner surface of the foreskin to the glans of the penis in the young boy.