Tag Archives: Circumcision

Straight, No Chaser: Updated Circumcision Recommendations, Risks and Benefits

December 22, 2014Genital/Urinary844-SMA-TALK, AAP, American Academy of Pediatrics, CDC, Centers for Disease Control and Prevention, Circumcision, Conditions and Diseases, Sterling Medical Advice, SterlingMedicalAdvice.com, Straight No ChaserJeffrey Sterling, MD

This past week, the Centers for Disease Control and Prevention (CDC) released new draft recommendations for healthcare providers on parental and patient counseling on the decision on whether to circumcise. This Straight, No Chaser reviews those recommendations and the logic behind it. It is of note that these recommendations are a step away from prevailing medical thought.

As a medical professional, circumcision has long been one of those things that has made me go hmmm…. If your religious beliefs include this as a ritual or ceremony, fine. I get it, and I have no criticism at all. No disrespect is intended. Otherwise, circumcision has largely been a procedure looking for an indication. Quick, tell me what other elective surgical procedure or harmful activity of any type is allowed on children, much less newborns? While I’m waiting for you to think about an answer that doesn’t exist, let’s recap the procedure and the medical logic behind it.

As you know (and many men are painfully aware – pun intended), circumcision is the surgical removal of the skin over the glans (tip) of the penis. Over the last 30 years, the rate of males receiving the procedure has dropped from 64.5% to 58.3%, according to the National Center for Health Statistics. Worldwide about 30% of males are circumcised, and of those receiving it, the religious influence is largely present. 69% of those being circumcised are Muslim and 1% are Jewish (Circumcision is part of religious rituals in both religions).

Let’s cut to the chase (no pun intended): Here are the best arguments for circumcision.

It helps prevent certain infections (e.g. yeast and UTIs – which most males aren’t especially prone to anyway).
The cells of the inner surface of the foreskin may provide an optimal target for the HIV virus (This is theoretical and not conclusively decided in the medical literature. In any event, this is NOT the same as saying uncircumcised males do or are more likely to contract HIV.). Even more importantly, this is NOT the same as saying uncircumcised males fail to be sufficiently protecting by use of condoms and other means of safe sex.
Circumcised males have a lower rate of penile cancer (which is very low under any circumstances).

Now, there are emergency indications for circumcision, but that really isn’t the topic of discussion here. The one I’ve had to address (twice in twenty years) is an inability to readjust a foreskin that too tightly adhered to the shaft of the penis (paraphimosis). Obviously, that’s a medical emergency and not something frequently seen enough to justify universal circumcision any more than a much higher rate of appendicitis would warrant universal and elective removal of everyone’s appendix.

Here are criticisms of the decision to have circumcision.

Any surgical procedure has complications, and that should be taken seriously. That said, the complication rate for circumcision is very small and includes bleeding infection and pain.
Circumcision is a violation of a child’s body and is unnecessary and disfiguring. The foreskin might not be cut the appropriate length, might not heal properly and may require addition surgery because the remaining foreskin incorrectly attaches to the end of the penile shaft.

Honestly, both the risks and benefits are quite overstated, with exceptions for certain parts of the world with exceedingly high HIV rates. Circumcision doesn’t appear to be a medically necessary procedure, but it isn’t an especially dangerous one. Interestingly, the American Academy of Pediatrics’ latest comment on circumcision is that the benefits of circumcision outweigh the risks, which stops short of recommending routine circumcision for all. Even that equivocal smacks of conflict of interest, given who’s performing the procedure at a significant cost to the consumer. Again, this appears to be a procedure looking for an indication – but…
The CDC appears to be going agains the grain with its latest comments. Their new message is pretty clear: the benefits of the procedure — including reducing one’s risk of acquiring HIV, herpes virus, and human papillomavirus — outweigh the harms. They even go as far as to suggest that adolescents and adult males consider the procedure. Of course, it must be said that the CDC’s focus is on the prevention and control of disease, as opposed to the American Academy of Pediatrics, whose focus is children and their health. This is a subtle yet important decision while likely has played out in the extra consideration given by the CDC.
If I was having this conversation in Africa, where the sexually transmitted infection rate is substantially higher and can be significantly reduced by circumcision, I’m sure I’d be more firmly on board with circumcision. If my Jewish or Muslim friends and colleagues were asking my medical advice on the safety of getting the procedure done as part of their religious ceremonies, we’d be having a different conversation. However, we’re not, and for the population in general, it’s safe to say that – various preferences (for various reasons) aside – there’s no compelling reason to recommend circumcision on all newborn males. It just feels like a recommendation to do so is giving in to the notion that we can’t be trusted to have safe sex.

The CDC officials emphasize that the choice is still left to patients, the document suggests the parents of newborn boys, as well as heterosexually active men of all ages, be told about those benefits, which is reasonable but somewhat leading. If you’re a parent of a newborn, and I tell you there’s a small risk of HIV, HPV and penile cancer in your child if they don’t get circumcised, am I really giving you a choice or burdening you with guilt?
And that’s medical straight talk. Oh, and guys – sorry about the lead picture. That wasn’t a good day.
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Straight, No Chaser – The Week In Review

August 25, 2013Medical Treatment, Public Health, Health Preventionmental-health, No Chaser, Oral rehydration therapy, Straight No Chaser (composition), Syncope, Texas, Vision loss, WordPress, health, American Academy of Pediatrics, CircumcisionJeffrey Sterling, MD

I hope this was another week of good health for you. Let’s review how Straight, No Chaser tried to contribute to your health and wellness. Don’t forget to click on any of the underlined topics for links to the original posts.
On Sunday, we reviewed eye emergencies. Don’t forget that even transient vision loss could be a stroke in progress, and certain causes of vision loss have a limited window of time in which treatment must occur. Act quickly! By the way, I didn’t mention this information that occurs more commonly than you’d think: If you ever have eye discharge so copious that it seems like you’re tearing pus, this is probably gonorrhea. Get it treated, lest you could lose an eye. Now that I have your attention…
On Monday, we reviewed syncope (aka fainting) in two parts, talking about the entity (click here) and the life-threatening conditions associated with faints. You’re way too cavalier with faints; please get them evaluated. Faints can either be the result of significant disease or can secondarily produce significant head and neck injuries from the falls. Stop going to the bathroom (with all the hard stuff in there) when you’re feeling dizzy. That’s not a good place to black out!
On Tuesday, we discussed suicide and depression in-depth, reviewing demographic information, information for your self-assessment, and tips on how to recognize when help is needed (and how you can avoid depression). I’m pleased that you’ve made these topics the most read topics yet, and I sincerely hope this information helps some of you.
On Wednesday, we reviewed the overuse of the emergency room, which will become a major theme of this blog. Those creature comfort visits are 8 times more expensive than the same visits done at a primary care physician’s office. In Texas, the average ER cost is $1020. Just because you’re not necessarily paying up front doesn’t mean the hospital won’t ensure you’ll pay eventually. Remember, hospital bills are the #1 cause of personal bankruptcy in the U.S. Straight, No Chaser was created to point you toward better options. Stick around, and we’ll get you there. Wednesday also brought a review of vomiting and diarrhea (viral gastroenteritis). Learn about oral rehydration therapy. Viral gastroenteritis is a good example of something that feels really… bad but is usually self-limited and will go away on its own, as long as you stay hydrated.
On Thursday, we reviewed end of life decision-making. I know this struck home for a lot of you, bringing back not so fond memories. That said, you must begin to think about how you want to be treated in your last days. There are many tragedies during this time that tear families apart. Use the tools discussed on the post on living wills, power of attorney designations and DNR considerations to make sure your interests are the only consideration being addressed when the time comes.
On Friday, we seemed to prick a nerve or two (no pun intended) discussing circumcision. If nothing else, be an educated consumer. Even now, considerations are perhaps best summed up by the posture of the American Academy of Pediatrics, which declines to recommend routine circumcisions for all newborns but notes that if you are inclined to get the procedure (which should be a big if), the benefits outweigh the risks. Friday afternoon, we reviewed hearing loss and the damage the activities of daily living produce. This is a pretty good example of how we take our health for granted. Just a little bit of protection and prevention over the first 40 years of your life will make a big difference later on.
Saturday, we discussed two different types of sounds that come out of you. First, we discussed snoring (which is always annoying but never boring) and gave you some Quick Tips to overcome it. We also discussed hiccups, which everyone gets at some point, but no one ever wants. We also gave you Quick Tips on hiccup cures here. Remember those ABCDEs!
We continue to listen to your comments and feedback, and over the next few months, some major changes will be occurring. Please continue to forward your topic requests. I promise I’ll get to them all eventually. Maybe I’ll start doing reader submission posts. As we continue to grow, your support, referrals and follows are much appreciated. Have a happy and healthy week.
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Straight, No Chaser: Circumcision – To Do or Not to Do?

August 23, 2013Medical Treatment, Pediatrics/Kids Health, Public Health, Genital/UrinaryNational Center for Health Statistics, American Academy of Pediatric, American Academy of Pediatrics, Circumcision, Foreskin, health, medicine, Sexually transmitted disease, Surgery, United StatesJeffrey Sterling, MD

As a medical professional, circumcision has long been one of those things that’s made me go hmmm…. If your religious beliefs include this as a ritual or ceremony, fine. I get it, and I have no criticism at all. No disrespect is intended. Otherwise, circumcision is largely a procedure looking for an indication. Quick, tell me what other elective surgical procedure or harmful activity of any type is allowed on children, much less newborns? While I’m waiting for you to think about an answer that doesn’t exist, let’s recap the procedure and the medical logic behind it.
As you know (and men are painfully aware – pun intended), circumcision is the surgical removal of the skin over the glans (tip) of the penis. Over the last 30 years, the rate of males receiving the procedure has dropped from 64.5% to 58.3%, according to the National Center for Health Statistics. Worldwide about 30% of males are circumcised, and of those receiving it, the religious influence is largely present. 69% of those being circumcised are Muslim and 1% are Jewish (Circumcision is part of religious rituals in both religions.).
Let’s cut to the chase (no pun intended): Here are the best arguments for circumcision.

It helps prevent certain infections (e.g. yeast and UTIs – which most males aren’t especially prone to anyway).
The cells of the inner surface of the foreskin may provide an optimal target for the HIV virus (This is theoretical and not conclusively decided in the medical literature. In any event, this is NOT the same as saying uncircumcised males do or are more likely to contract HIV.).
Circumcised males have a lower rate of penile cancer (which is very low under any circumstances).
Now, there are emergency indications for circumcision; the one I’ve had to address (once in twenty years) is an inability to readjust a foreskin that too tightly adhered to the shaft of the penis (paraphimosis). Obviously, that’s a medical emergency and not something frequently seen enough to justify universal circumcision any more than a much higher rate of appendicitis would warrant universal and elective removal of everyone’s appendix.

Here are criticisms of the decision to have circumcision.

Any surgical procedure has complications, and that should be taken seriously. That said, the complication rate for circumcision is very small and includes bleeding infection and pain.
Circumcision is a violation of a child’s body and is unnecessary and disfiguring. The foreskin might not be cut the appropriate length, might not heal properly and may require addition surgery because the remaining foreskin incorrectly attaches to the end of the penile shaft.

Honestly, both the risks and benefits are quite overstated. Circumcision doesn’t appear to be a medically necessary procedure, but it isn’t an especially dangerous one. Interestingly, the American Academy of Pediatrics’ latest comment on circumcision is that the benefits of circumcision outweigh the risks, which stops short of recommending routine circumcision for all. Even that equivocal smacks of conflict of interest, given who’s performing the procedure at a significant cost to the consumer. Again, this appears to be a procedure looking for an indication…
If I was having this conversation in Africa, where the sexually transmitted infection rate is substantially higher and can be significantly reduced by circumcision, we’d be having a different conversation. If my Jewish or Muslim friends and colleagues were asking my medical advice on the safety of getting the procedure done as part of their religious ceremonies, we’d be having a different conversation. However, we’re not, and for the population in general, it’s safe to say that – various preferences (for various reasons) aside – there’s no compelling reason to recommend circumcision on all newborn males. Make your judgment based on facts, not a whim. And that’s medical straight talk. Oh, and guys – sorry about the picture. That wasn’t a good day.