Male circumcision: For some parents, it’s not so clear-cut

SINGAPORE — When her son was two months old, Ms Anna Tan (not her real name) had him circumcised, mainly for hygiene reasons.

Her son felt no discomfort during the procedure, which took 15 minutes and was carried out under local anaesthesia. He remained well and cheerful after that.

Ms Tan’s husband, an American, was also circumcised in his childhood and she felt the procedure would lower the risk of infections for her son, who is now four-and-a-half.

The 33-year-old Singaporean writer’s only regret was sharing the information online, which drew flak and allegations that it was a form of abuse.

“Some people (online) said it was abuse and that my son should have the right to decide for himself when he grows up,” she said.

“However, I heard that the infant procedure is way simpler than the adult one. I still stand by my decision — I’ve never heard of a circumcised man complain about the lack of foreskin or any woman say they prefer their partners to be non-circumcised.”

While fairly common in Singapore, male circumcision continues to be a subject of debate, drawing strong reactions from various quarters.

The procedure involves removing part of the foreskin covering the head of the penis, and is usually performed as a day surgery by a surgeon in the hospital or by some general practitioners in a clinic setting, said paediatrician Leo Deng Jin from Thomson Paediatric Centre (Bukit Panjang).

According to the Ministry of Health, 1,921 adult and child male circumcisions (day surgery) were carried out in hospitals here between July last year and June this year. The number excludes cases seen at private clinics.

While the majority of procedures here are carried out for religious reasons, a number of parents like Ms Tan have their baby boys snipped for health or medical reasons.

The National University Hospital (NUH) has seen a 28 per cent increase in the number of cases in the last three years, the. It performs about 165 circumcisions per year, of which about a-fifth are carried out for non-religious reasons, said Dr Dale Lincoln Loh, its head of paediatric surgery.

The KK Women’s and Children’s Hospital (KKH) carries out about 1,000 to 1,200 cases of childhood male circumcisions per year. About 10 to 15 per cent are done on medical grounds including foreskin infections or urological problems that predispose the child to urinary infections, said Associate Professor Low Yee, head and senior consultant of KKH’s department of paediatric surgery.

TO SNIP OR NOT TO SNIP?

Those who are not in favour of the procedure say it is unnecessary and poses risks to the boys.

Some overseas advocacy groups, such as the Seattle-based Doctors Opposing Circumcision (DOC), oppose such “medically-unnecessary” procedures being performed on babies and children. The group, which comprises an international network of physicians, said the procedure has no justifiable benefits.

Recent reports of botched circumcisions across the Causeway that resulted in accidental amputations in young boys have also highlighted the risks of the procedure.

According to Dr Loh, some potential surgical risks include post-operation bleeding, wound infections, scarring and recurrence of phimosis and meatal stenosis, which is the narrowing of the opening at the tip of the penis.

In 2012, however, the American Academy of Paediatrics (AAP) said in a statement that the benefits of newborn male circumcision outweigh its risks. Although the benefits are not so great as to recommend routine circumcision for all male newborns, they are sufficient to justify providing the service for families who choose it, according to the AAP.

Two years later, the United States’ Centres for Disease Control and Prevention took a similar stance. It found that medically-performed male circumcision could lower the risk of contracting the human immunodeficiency virus and other sexually-transmitted diseases, among other health benefits.

Circumcision also reduces the risk of urinary tract infections and foreskin infections, as well as a lower risk of penile cancer, said Dr Leo of Thomson Paediatric Centre. An uncircumcised male infant has a one in 100 chance of developing a urinary tract infection in the first year of life, while their circumcised peers have a one in 1,000 chance, he said.

WHY SOME PARENTS OPT IN

Most parents who approach Dr Leo to enquire about circumcision have children with a condition known as phimosis, where the foreskin is too tight and affects the stream of urine.

“In some boys, the foreskin may be so tight that it disrupts a smooth urinary flow. This may result in a slow dribble or the urine may pool within the foreskin during urination, forming a ‘balloon’ at the tip of the penis when the child tries to pee,” said Dr Leo. If this happens, it is advisable to see a doctor for an assessment, he said.

NUH’s Dr Loh said about 95 per cent of boys with phimosis should be able to retract their foreskin by the age of 13, and the child can be left uncircumcised if he does not experience problems such as infections.

Other common reasons cited by parents include hygiene, ease of cleaning or the child’s foreskin perceived as being “too long”, said Dr Loh.

There is also a cultural or social element. For instance, it is common for parents from the Philippines, Australia and the United States to request for non-religious circumcisions, he said.

The cost of the procedure varies. It costs approximately S$1,200 at NUH for a private patient, and about S$400 for a subsidised patient.

Circumcisions carried out for medical reasons are eligible for Medisave use, up to a maximum of S$650, said KKH’s director of business office Sally Oh.

NOT ADVISABLE FOR BABIES, SAY SOME EXPERTS

When the procedure is performed before the age of two months, there are some advantages such as faster healing. It can also be done without general anaesthesia, said Dr Loh. However, it is not advisable to circumcise babies who do not have proven history of medical issues like urinary tract infections, he said.

While circumcision is “simple and safe”, KKH does not recommend or practise neonatal or infant circumcision unless it is for medical reasons, said Assoc Prof Low. This is because anaesthesia risks are higher at a very young age. Many religious circumcisions are carried out at around the age of four to eight, she said.

Another possible complication that can occur in boys who are circumcised in the first two years of life — before they are toilet-trained and are still in diapers — is the development of meatal stenosis, said Dr Loh. This will need to be corrected through a second operation.

The doctors advised parents to weigh the pros and cons of the procedure.

“The decision to circumcise a child or not is best made by parents, in consultation with their child’s paediatrician, after weighing the benefits versus the risks,” said Dr Leo.

For Ms Tan, circumcising her son was a personal decision she had made after consulting her husband, some male friends and doctors. She said she would probably not have gone ahead with the procedure after her son was older than two months, as it might be more traumatising for him.

“My son may blame me for the decision (to circumcise him) in the future. But if I didn’t (go ahead with the circumcision) and he wanted it later, he might also blame me for not doing it when he was younger and now he has to go through a lot of pain. Either way, parents may get blamed. The best we can do is to decide what is the best for our children,” she said.

Her advice for other parents is to discuss the issue as soon as they know they are going to have a baby boy.

“If mums don’t know what to do, then let the father decide. They should know better (about the male anatomy),” she said.

CIRCUMCISION FOR BOYS: WHAT TO EXPECT

According to paediatrician Leo Deng Jin of Thomson Paediatric Centre (Bukit Panjang), male circumcision can be carried out using various methods including traditional knife incision, the use of laser technology or a plastic contraption called the plastibell. Speak with your child’s surgeon to decide which method best suits him.

If your child is under eight weeks old, the procedure can be carried out using only local anaesthesia, said Dr Dale Lincoln Loh, head of paediatric surgery at National University Hospital.

“This should keep the child pain-free during the operation and up to four hours after the procedure. Afterwards, simple analgesia like paracetamol should be sufficient to control pain,” said Dr Loh.

Older boys would require general anaesthesia with a penile block (local anaesthesia of the penis), he added. After the procedure, they will need painkillers for three to four days.

A light dressing is usually placed over the wound, which will take about seven to 10 days to heal, said Dr Leo. Post-op, the area must be kept as clean as possible.

Parents should look out for signs of complications such as:

• Excessive bleeding
• Difficulty in urinating hours after the procedure
• Signs of infection such as worsening redness, swelling or excessive yellow discharge around the wound. A small amount of yellow discharge may be normal in the first few days.