Cutting to the root of painful family tradition

AS A family tradition, all boys in the family were circumcised for hygiene purposes.

Now, as a proud father of a five-year-old boy, I am really having a second thoughts on the family tradition, as I really had a tough time during and after the operation.

Although I was in kindergarten, I still remembered the pain and trauma during and after the operation.

My Dad convinced my brother and I to undergo the cut without anesthesia, and we were told it was quick and painless.

Sadly, I felt every cut during the procedure and the experience haunted me even till today.

I took my son to see a doctor, who suggested he do it under general anesthesia for safety reasons.

However, my wife and I are a bit doubtful and are having second thoughts about circumcision all together.

Therefore, we would like to put Dr. G on the spot for the necessity of elective circumcision.

Firstly, what are the true benefits of circumcision?

Is the evidence robust that boys with no foreskin have less chance of infection?

I understand in the United States, most circumcisions are done within a few days of birth without anesthesia. Is that true?

Is it true that young children experience no pain at all during the operation?

Lastly, is general anesthesia safe for a five-year old?

I really need your help.

Warmest regards

Painful Paul

The foreskin is the natural sheath that covers and protects the head of the penis. The skin is completely adherent to the glans penis from birth, and therefore unable to pull back before the age of five in most boys.

The foreskin should be easily retractable, allowing gliding during sex and the ease of cleaning in adolescent boys.

Circumcision is the surgical removal of the skin covering the glans penis, which has been practiced since the ancient Egyptian times, with the origin in religious rites. Clearly, no anesthesia was applied in those days.

Today, many parents make the decision to have their sons circumcised for religious and medical reasons.

The moist glans penis can create the ideal environment for pathogens to incubate, making it susceptible to infections. This may include bacteria, fungus and sexually transmitted infections such as herpes and HIV.

World Health Organization (WHO) recommends using circumcision as part of HIV prevention as medical trials concluded that circumcision reduces the risk of HIV infection amongst heterosexual men in sub-Saharan Africa by as much as 50%.

Sex partners of men with foreskin are also recognised to have higher risks of bacterial vaginosis. And one of the treatments for boys who get recurrent urinary tract infections is circumcision.

The question of the usage of anesthesia on infants while performing circumcision has been long debated. It is known that neonates have low pain scores compared to the older infants.

Well, that must be true, as a baby must endure the resilience of “pain” passing through the narrow birth canal during childbirth. In view of the pliability and tolerance of the newborns, it has been argued the pain reactivity appears to be inhibited during fetal life, and this led to the suggestion that performing any invasive procedure within ninety days after birth would have minimal impact on the child.

Critics, however, often argue it is cruel to put an infant through an operation with no anesthesia. The neonates are believed to experience pain but are just unable to convey the displeasure, they say.

Anesthesia was not usually advocated for infant circumcision, as it was believed the procedure caused little or no pain to the child. It is now known that infants do experience pain, and such experience may interfere with mother-infant interaction and even results in behavioral changes in adulthood.

Therefore, the usage of analgesia and anesthesia are generally encouraged.

The utilisation of anesthesia can be applied locally or in a general manner. The injection of lidocaine as a ring or dorsal block is simple and safe, even for premature low birth-weight newborn infants.

The use of anesthetic cream on the foreskin, before the operation, has also been shown to be effective. General anesthesia is another option for parents to consider, as the benefits of steady child under the knife outweighs the negligible side effects.

Apart from the anesthesia during the circumcision, it is also crucial to ensure post-operative pain is minimised. Paracetamol and non-steroidal anti-inflammatories are generally adequate to manage post-operative pain.

Despite the benefits and proven safety of anesthesia for infants undergoing circumcision, a recent study in the United States revealed the non-usage of anesthesia is ranging from 54-96%. Another study demonstrated only 71% of pediatricians, 56% of family practitioners and 25% of obstetricians offered anesthesia to infants when discussing the operation.

An estimated one-third of men in the world are circumcised, with most of the surgery done for religious reasons for Muslims and Jews.

Elective non-religious circumcisions are also commonly performed in countries like the United States and parts of South East Asia. The removal of the foreskin, although it is a simple centuries old practice, it is still the most controversial and hotly debated operation.

This is reflected by the positions of the world’s major medical organisations on circumcision. These beliefs can range from “elective circumcision has a modest benefit that outweighs the risks”, to stands that say “elective circumcisions carries significant risks with minimal long term benefits”.

The famous American author, poet, actress and singer, Maya Angelou once said: “History, despite its wrenching pain, cannot be unlived, but if faced with courage, need not be lived again”.

Although the age-old practice of circumcision without anesthesia dates back centuries, the marvel of modern medicine ensures the safety and benefits of such protection of the vulnerable infants.

So, Dr. G’s advice is: “Have a heart, don't let the painful family tradition come back to haunt you in the future!”