Circumcision: Let's Talk About Dicks

These days, parents of baby boys are faced with a tough decision: whether or not to have their sons circumcised. Just a generation ago, it was a no-brainer--circumcision was widely known to result in a cleaner, more attractive, and socially acceptable penis. Boys with foreskins were the exception, the freaks in the locker-room covering their crotches in shame while the "normal" boys pointed and laughed.

But the world is moving on, and as the years pass and my peers flood the earth with their children, the practice is becoming less common. In fact, only 56% of baby boys born in the US were circumcised in 2008, down from more than 80% in the 1960's. And thanks to the growing intactivism movement, that number is likely to continue decreasing. Parents are becoming more aware of their choices, as well as the potential risks and benefits to accepting or declining the procedure. We've realized that whether or not to circumcise really and truly is entirely up to us. Unfortunately, this means that we get to take the blame if, someday, our boys decide that we made the wrong choice. With all the shouting surrounding this issue, it can be hard to decipher hyperbole from fact. Here's my attempt to cut through the bullshit and help you make a choice both you and your child can be comfortable with.


What does the AAP (American Academy of Pediatrics) have to say about circumcision?

AAP policies reflect the current medical consensus among pediatric practitioners based on the most recent evidence. In the case of circumcision, however, they're not much help. While the AAP acknowledges that "existing scientific evidence demonstrates potential medical benefits," their official policy statement concludes that "...these data are not sufficient to recommend routine neonatal circumcision." In other words, the decision is left to parents and their pediatricians. However, the AAP plans to update this policy in light of new evidence about potential health benefits of the procedure. Whether or not this will affect their recommendations remains to be seen.


Why do people have their boys circumcised?

According to this article on PubMed, circumcision reduces the incidence of urinary tract infections (which are especially dangerous in infants), lowers the risk of many types of STD (including HIV and HPV), has a protective effect against penile cancer, eliminates the medical need to have the procedure performed as an adult (well, duh), and improves "sexual function and creativity". One study found that circumcised men enjoy "...a more elaborate sexual lifestyle," and their female partners report being "...more pleased with the aesthetics of the circumcised penis."  (I'm not sure if that last part counts as a health reason, but hey, I didn't write the article.)

However, the health issue is kind of a red herring, because most parents make this decision for cultural reasons, such as religion or family tradition. One study found that circumcision status of the father, as well as the parents' education level and ages, are the most important factors in the decision. In this same study, mothers-to-be were given an informative brochure put together by the AAP which outlined the health benefits and potential complications. Not one woman changed her mind after reading the brochure.


What is the history of circumcision?

The oldest documented evidence of circumcision comes from ancient Egypt. Many historians believe that the Jews acquired this practice during their period of enslavement to the Egyptians, though competing evidence suggests that it has been a custom in Semitic tribes going back much further than that. The tradition also has roots in Islamic culture, tracing back to the tribal practice of circumcising both boys and girls. It is still a common cultural tradition among orthodox Jews and devout Muslims.

Circumcision didn't catch on in the United States until the late nineteenth century. Doctors who advocated for the procedure recommended it to curb masturbation, or in the words of  John Harvey Kellogg, as a "PREVENTION OF SECRET VICE" (apparently cranks have always had a love affair with caps lock). Kellogg, who helped popularize the practice in the US, believed that masturbation was an act of evil and that the inability (or refusal) to abstain from it constituted a disease. In addition to performing circumcisions (without anesthetic, so the pain would have a "salutary effect upon the mind,")  he encouraged parents to force their children to work long and hard during the day so they would be too exhausted to "defile" themselves at night. For younger children, he suggested tying their hands, or, more effectively, "bandaging the parts" to prevent access. Fortunately, his more extreme ideas did not catch on (such as applying pure carbolic acid to the clitoris if a woman proved unable to "exercise entire self control"), but other doctors of the era took his anti-foreskin fervor and ran with it. To this day, many Americans still consider circumcised penises to be cleaner and more civilized than their intact counterparts.


How is circumcision performed?

I always imagined it to be rather neat and precise: the doctor pulls the foreskin up from the penis between his fingers, the way a barber prepares to trim a lock of hair, then pulls out a specialized penis guillotine that resembles a cigar-cutter, and snip snap snip, the penis is circumcised. The nurses dab off the tiny amount of blood with a soft cloth, and the smiling baby boy is delivered safely to his mother's arms.

But it's not like that at all. The Wikipedia page on circumcision goes into graphic, gory, detail on how it really happens (warning: pictures!). There is a clamp involved, used in conjunction with a "restraining device". The inner lining of the foreskin is "bluntly separated" from the glans so that the clamp can be forced into place. Sometimes this requires a dorsal slit, and sometimes the frenulum band near the urethra needs to be "broken or crushed" so the foreskin can be cut. The clamp stays in place until the penis has healed, at which point it should fall off on its own (the clamp, not the penis).

Most boys have pediatricians (or mohels) who follow AAP recommendations and use local anesthtic, either in the form of a topical cream or by a series of injections. But not all practitioners believe that babies feel pain (or perhaps, like Kellogg, they believe the babies deserve pain), so sometimes the procedure is performed with no pain relief at all.


Do the benefits make it worth doing anyway?

In sub-Saharan Africa, where most of the studies showing a positive benefit were conducted, it probably is worth doing. AIDS and other STD's are rampant, people have limited or no access to contraception, rape is commonly used as a tactic of warfare, and access to clean water and adequate medical care is scarce. In conditions like these, medical interventions that even slightly lower the risk of passing on infectious disease make perfect sense.

Here in the US, it makes less sense. The typical American man has the luxury of plenty of hot water and soap in the comfort of his own home. He can dry off with a clean towel and put on freshly-laundered underwear. He can waltz down to the CVS and pick up a box of condoms any time he likes. He is unlikely to force himself upon an unwilling woman.

However, health issues aside, some people do prefer the aesthetics of the circumcised penis, seeing it as cleaner and more streamilined. Plus, circumcised men don't get smegma (which is not a health risk but is still pretty gross.)


Conclusion

Though circumcision's popularity in the US is fading, it is unlikely that the intactivists will get their wish and put an end to the practice altogether. I personally feel that the procedure is unnecessary and opted out for my son, but I also don't buy the more extreme claims of men feeling violated by their parents and mourning the loss of their foreskins. I'd imagine the average guy doesn't give it much thought; his dick is as familiar to him as the contours of his own face and, as long as it works like it should, he should be happy.

Safe and Effective Cough and Cold Treatment for Children Under Four

Watching your young child suffer through a cold or flu virus is a particularly insidious form of torture. The snot, the ragged breathing, the pervasive crankiness. To add to the misery, the primary caregiver and snot wiper (in our family's case, me) often catches the same bug. The caregiver, however, has the option of taking drugs to alleviate the symptoms. A couple teaspoons of Tussin and I'm good to go, or at least able to breathe again. Not so for my little guy. The warning labels on children's cough and cold medicine have changed since my days in child care, strongly advising us not to administer doses to kids under four.

If you're anything like me, you wonder why. What happened in the past few years to change these products from helpful symptom relief to little-kid poison? Don't these things help children to sleep, breathe, and just plain feel better? What prompted the American Association of Pediatrics to change their guidelines  and what can we do to help our little sickie-poos feel better?

Which cough and cold medicines are affected by the new guidelines?

Antihistamines, decongestants, antitussives (cough suppressants), and expectorants. These active ingredients are found in a wide variety of products marketed for relief of cough and cold.

Pain relievers/fever reducers such as acetaminophen (Tylenol) and ibuprofen (Advil) are still okay for use in infants and small children, provided doses are measured properly.


Why did the AAP make these changes?

According to an FDA advisory panel, these products are ineffective and potentially hazardous when given to small children. There is not enough evidence of efficacy to justify the risk of adverse reaction or overdose.


Ineffective? But doesn't it make kids feel better, or at least help them sleep?

Intuitively, this seems to make sense. The caregiver doses the miserable, crying, phlegmy child with medicine and, usually within the hour, the child becomes drowsy and seems to breathe more easily. The medicine must have worked, right?

Not necessarily. The caregiver has fallen prey to the post hoc ergo propter hoc fallacy--in other words, he or she has confused correlation with causation. I admit I've fallen for this one myself; it's easy to attribute the seeming regression of symptoms to the administration of a drug. However, viral illness is not a fixed, static state. Symptoms fluctuate, with peaks of misery followed by valleys of relative improvement. Chances are, the kid would have calmed down and fallen asleep regardless, with or without the medicine.

In fact, one study comparing dipenhydramine (Benadryl) and dextromethorphan (cough suppressant) to a placebo found that cough and cold medicines are not effective in providing nocturnal symptom relief for children, nor do they improve quality of sleep for their parents. In other words, the family of a sick kid will be awake and miserable whether the kid is medicated or not. But there is a silver lining to this bummer of a study--all families in the study reported significant improvement on the second night, regardless of whether the children were given placebos or drugs.


Are cough and cold medicines really dangerous? 

Not if administered properly; most adverse reactions are due to dosing errors and accidental ingestion. If parents are diligent about measuring doses (and can tell a mL from a tsp), and always keep medicines out of reach, that shouldn't be a problem. Unfortunately, a recent study shows that parents are quite likely to incorrectly measure a dose (especially with the little plastic measuring cups--oral syringes are far more accurate), usually giving more than the recommended amount. In fact, emergency rooms visits for "adverse events" (i.e. overdoses) decreased substantially after the withdrawal of infants' cough and cold formulas from the market.


What about alternative remedies? Are they safe and effective?

While many people swear by Airborne, Oscillococcinum, and Zicam, there is no credible evidence that these products work as advertised.  Not only are they ineffective for symptom relief beyond the placebo effect, but they can also have serious side effects. Airborne containsVitamin A, which is toxic in high amounts. The makers of Zicam were sued and settled out of court after their product caused more than 130 people to lose their sense of smell. And a homeopathic remedy like Ocsillococcinum poisoned children after manufacturing errors led to an excess of an active ingredient (usually active ingredients are diluted until not a trace molecule remains, as in all "true" homeopathic remedies). Considering the typically high price of these products, there seems to be very little benefit to justify the risks.


What can I do to help my poor baby feel better? 

Medically speaking, not much. Cool-mist humidifiers can help ease congestion. If you're brave (and your child will let you), you can use a bulb aspirator to suck snot from the nostrils (be sure you're using it correctly so you don't puff air up there). You can also use saline drops to soothe and loosen the sinuses, and children's Vapo-Rub to help the child breathe (though this is not recommended for children under 2 because of the toxicity of camphor if ingested and the possibility of skin irritation).

Mostly, you just need to be patient. Kids get 6-10 colds a year on average, which tend to last up to two weeks at a time. That's a lot of snotty nights and grouchy days. But if you keep your child hydrated, well-fed, and comfortable, he or she will get better in a reasonable amount of time. Short of keeping children in a plastic bubble, there is no reliable way to prevent or cure occasional viral outbreaks. We just have to get through them the best we can. Children under four should be doing that without the aid of medication.

It's tempting to head to the drug store to buy something, anything, that will help our sick kids. It makes us feel in control, like we're being proactive and doing something to make what's wrong right again. But beyond that fleeting feeling of being a "good" parent, very little is gained from the purchase and administration of over the counter cough and cold remedies.