- How It Feels to Be Circumcised as an Adult
- Under the Knife
- Adult Circumcision: The Basics
- Circumcision: Benefits, Procedures, and Risks
- What is circumcision?
- Making a Circumcision Decision
- How is a circumcision performed?
- When should the procedure be performed?
- How is pain controlled during the procedure?
- What are the benefits of circumcision?
- What are the risks of circumcision?
- After the circumcision procedure
- When should the doctor be called?
- When should a circumcision procedure not be performed?
- When it comes to circumcision, earlier is better
- Numbing the surgical site
- Adult male circumcision in Nyanza, Kenya at scale: the cost and efficiency of alternative service delivery modes
How It Feels to Be Circumcised as an Adult
Thanks to my hippie parents, I was never circumcised, even though I grew up in the Midwest, where circumcision is the de facto norm. Because it was slightly unusual where I lived, my sexual partners often asked me what it was like to be uncut. The answer, of course, is that I’ve never known it any other way. I couldn’t possibly compare my uncut dick with the all-American clean-cut penis, because I’ve never had one. My dick is my dick is my dick—it’s always been uncut, and it always will be.
Since the procedure is typically performed in infancy, there’s really no before/after to consider. I’ll never know how it feels to both have foreskin and lack it, but some more do. Though the vast majority of the uncut want to stay that way, there’s no reason they can’t elect to modify their penises as adults—and those men are the only ones who know how being circumcised—compared with being uncircumcised—actually feels.
There are three reasons a man gets circumcised after infancy: for cosmetic reasons, for medical reasons, or as part of a religious rite of passage. A Los Angeles–based urologist I spoke with, who performs between 50 and 75 adult circumcisions a year, also said the procedure is occasionally performed for cultural reasons. In particular, Filipinos sometimes opt to have their children circumcised at eight or ten, citing tradition, but it is quite rare.
Adult circumcision is especially common for Jews who grew up in Soviet Russia, where the procedure was forbidden. That was the case for Leo, who was cut when he was 13.
He learned that to have a bar mitzvah he had to, in his words, “Get the skin cut off my dick.”
Leo emigrated when he was four. After a Jewish assistance organization helped him and his family settle in the US, Leo began attending Sunday school and his family embraced the opportunity to practice their religion.
“When I was eleven or twelve, my parents sat me down,” he told me. “I hadn’t heard of circumcision—we didn’t have the internet or anything. I hadn’t seen a lot of dicks. Frankly, I wasn’t getting a lot of boners, and I didn’t start masturbating until 14.”
“They asked, ‘Do you want a bar mitzvah?'” He did, but in order to do so he had to, in his words, “Get the skin cut off my dick.” His parents told him if he did, they would give up pork in a show of solidarity.
“I met with a doctor,” Leo told me. “He told me they were going to put me under. ‘You’ll have stitches, you’ll feel weird, and then it will go away in a week.'” Leo then had the procedure done. “I can’t remember a boner before then, so I don’t remember it hurting. The stitches looked scary. The scar never went away. Pretty soon after that I discovered masturbation.” All told, it was a pretty normal affair.
Masturbation was more fun with a foreskin, as it acts as built-in lube, but I find sex is better circumcised as the glans gets stimulated more.
He did say right after the circumcision was complete—while he was still unconscious from anesthesia—his parents, his sister, and a rabbi did a celebratory dance around him, something he only found out about after the fact. But otherwise, it was a pretty standard medical procedure. And he said he didn’t regret having it done, that he felt it helped him be “the kind of Jew he wanted to be.”
After it was done and his penis healed, Leo had his bar mitvzah. He never discussed the circumcision with anyone. He said felt a certain amount of shame being circumcised late in life—a feeling he attributed that to being a “shy and private person”—but said talking about it made him feel better. Although he remembered the process vividly, he didn’t have perspective on how a foreskin affects one’s sex life.
Others certainly do. After a drunken sexual experience, 20-year-old Ryan tore his foreskin and a doctor recommended he get circumcised. When I spoke to him, he was still healing from the procedure, which he had undergone just four weeks prior. He described the experience of being circumcised as painful but manageable, and while he had yet to have sex while cut yet, so far he liked it “way more then before.”
The worst was getting an accidental boner a few days after the surgery, which strained his stitches. But after that, he described the pain as being akin to getting a sunburn. As he neared being fully recovered, he said he was just excited to get to use his gear again, and was looking forward to using his new penis.
“When it healed, it had scars all around it. We called it Frankenpecker.”
Medical-related circumcision isn’t always a matter of fixing a sexual escapade gone wrong. Take 29-year-old Tom, a Californian who was circumcised at 27 after years of dealing with phimosis, a condition where the foreskin cannot be fully retracted from the head of the penis. It can make even having an erection quite painful. The condition worsened in his mid 20s, to the point where his frenulum would regularly tear during sex and masturbation. After trying stretching and steroid cream, he decided he’d had enough of the pain and went to drop the $1,500 and get cut.
Unlike Leo, Tom had experienced sex and masturbation both cut and whole. He described it like this:
“Although the level of sensitivity was higher before, I feel like it comes from more places now. Pleasure is just as good, maybe even better because I don’t have issues of soreness in the frenulum like I did before. Masturbation was more fun with a foreskin, as it acts as built-in lube, but I find sex is better circumcised as the glans gets stimulated more. I sometimes use lube now when masturbating, which I never really did before, but it’s not a must.”
Of course, since he’d regularly associated sex with pain, a frenulum-tearing free sexual experience was obviously preferable.
Not all circumcisions go so smoothly. While foreskins can be (sort of) “restored” with stretching weights, circumcision is not 100 percent reversible. And some men who get cut regret it deeply.
Allan, a 37-year-old from Nova Scotia, was circumcised at 19. He had experienced slight discomfort during sex on account of an overly-tight frenulum. His partner at the time, who was circumcised, advised he get cut. It did not go well.
“They had to cut it with a scalpel and stitch it up. And it was horrible, those big old-fashioned stitches all around. It was painful, and it was awkward,” he told me. “After I first got it done, I wasn’t interested at all in getting a boner. When I did— ouch. I popped a stitch. I got an infection. It was all a nightmare. When it healed, it had scars all around it. We called it Frankenpecker.”
Allan also claims that his penile sensitivity has decreased significantly since being circumcised. “It’s night and day,” he said. “The head used to be the most pleasurable part. There was natural lubrication. It was fun. Afterwards, I had to relearn how to work my bird. Everything was up in the air. It was like learning to walk again.”
Allan said he regrets having it done, and would have rather just dealt with the pain. He looked into foreskin restoration using weights, “but it looked like a lot of effort and the results seemed to be mixed.”
The urologist I spoke with was even less kind concerning the restoration industry. “It’s voodoo,” he said. “They’re stretching their skin, but their foreskin is not going to come back. By and large those people are fighting much larger demons.”
Allan’s case is certainly not the norm. The urologist I spoke with said complications arising from circumcision are exceedingly rare. He also mentioned getting circumcised as an adult is a much more complex procedure than it is for infants—”30 to 45 minutes versus 30 to 45 seconds.” While he has performed elective cosmetic circumcisions, he says he advises patients against them. “I always ask them ‘Why?’ If you’ve done fine with it to this point, just let it be.”
Circumcision is, to put it mildly, a divisive issue. After all, it’s a permanent body modification usually performed on a thing that can’t really consent to the procedure. This point of contention is cited most often by vocal anti-circumcision activists a.k.a. “intactivists,” who argue that infants can’t consent to being cut.
Anti-circumcision folks tend to take a hard line. Intact America, a prominent intactivist organization, refers to circumcision on their website as “painful, risky, unethical surgery that deprives over a million boys each year of healthy functional tissue.” The MGM Bill, introduced to Congress in January 2014 by intactivists, called itself “A Bill to End Male Genital Mutilation in the US.” (Anti-circumcision folks’ feelings on the issue are strong enough that the urologist I talked to—who is pro–infant circumcision—asked to remain anonymous.)
Circumcision also has its staunch defenders. The practice is a revered cultural rite of passage in many societies; in Judaism, the practice dates back thousands of years. Modern health officials have also made a case for widespread circumcision from a public safety standpoint. While the CDC stopped short of recommending default circumcision, the organization noted in December 2014 that circumcision drastically lowered a man’s risk of contracting STDs via heterosexual sex: HPV by 30 percent, genital herpes by 30 to 35 percent, and HIV by 50 to 60 percent.
It’s a messy debate, to be sure. And it’s pretty split: In 2007, circumcision rates in the scissor-happy US fell to its lowest number in decades, at just 55 percent of boys. Then again, the American Pediatrics Association came out in 2012 in support of the practice, saying there are “benefits” to infant circumcision. Although they still advised that when it comes to lopping off foreskins, the final say “should be up to the parents.”
Leo and Ryan and Tom and Allan are all cognizant of life before and after circumcision. Their experiences differ. But what unites them is what unites every man who’s circumcised: There’s no going back.
“If there were a way to go back to how it was before,” Allan told me, “hell yeah, I’d do it.”
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Under the Knife
In this study, Senkul enrolled 42 men — all about 22 years old — who had not been circumcised. All but a few wanted circumcision for religious reasons. All were heterosexual and sexually active, and none was using a medication or device to promote erections.
Before the circumcision, doctors evaluated their sexual performance by asking about sex drive, erection, ejaculation, problems, and overall satisfaction.
The men were also asked to note how long they took to reach ejaculation — during at least three sessions of sexual intercourse.
Twelve weeks after the surgery, the men again answered detailed questions about their sex lives. They reported on how long reaching ejaculation took.
The results: Everything was working smoothly — except ejaculation, which took “significantly longer” after circumcision.
Adult circumcision may lessen the penis’ sensitivity, resulting in a delay to reach ejaculation, Senkul speculates. Or the boost to the guy’s self-esteem — since Muslims consider circumcision to be a “must of manhood” — might cause the slow down.
“We can say with more certainty that adult circumcision does not adversely affect sexual function,” writes Senkul. The increase in time to reach ejaculation “can be considered an advantage rather than a complication.”
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Whether you’re expecting a baby boy or have just welcomed your new little guy into the world, you have an important decision to make before you take your son home: whether to circumcise him.
For some families, the choice is simple because it’s based on cultural or religious beliefs. But for others, the right option isn’t as clear. Before you make a circumcision decision, it’s important to talk to your doctor and consider some of the issues.
Boys are born with a hood of skin, called the foreskin, covering the head (also called the glans) of the penis. In circumcision, the foreskin is surgically removed, exposing the end of the penis.
Approximately 55% to 65% of all newborn boys are circumcised in the United States each year, though this rate varies by region (western states have the lowest rates and the north central region has the highest). The procedure is much more widespread in the United States, Canada, Africa, and the Middle East than in Asia, South America, Central America, and most of Europe, where it’s uncommon.
Parents who choose circumcision often do so based on religious beliefs, concerns about hygiene, or cultural or social reasons, such as the wish to have their son look like other men in the family.
Routine circumcision is usually performed during the first 10 days (often within the first 48 hours), either in the hospital or, for some religious ritual circumcisions, at home.
If you decide to have your son circumcised at the hospital, your pediatrician, family doctor, or obstetrician will perform the procedure before you bring your baby home. The doctor can tell you about the procedure and the possible risks. Circumcision after the newborn period can be a more complicated procedure and usually requires general anesthesia.
In some instances, doctors may decide to delay the procedure or forgo it altogether. Premature babies or those who have special medical concerns may not be circumcised until they’re ready to leave the hospital. And babies born with physical abnormalities of the penis that need to be corrected surgically often aren’t circumcised at all because the foreskin may eventually be used as part of a reconstructive operation.
The Pros and Cons
On the plus side, circumcised infants are less likely to develop urinary tract infections (UTIs), especially in the first year of life. UTIs are about 10 times more common in uncircumcised males than circumcised infants. However, even with this increased risk of UTI, only 1% or less of uncircumcised males will be affected.
Circumcised men also might be at lower risk for penile cancer, although the disease is rare in both circumcised and uncircumcised males. Some studies indicate that the procedure might offer an additional line of defense against sexually transmitted diseases (STDs) like HIV in heterosexual men.
Penile problems, such as irritation, inflammation, and infection, are more common in uncircumcised males. It’s easier to keep a circumcised penis clean, although uncircumcised boys can learn how to clean beneath the foreskin once they’re older.
Some people claim that circumcision lessens the sensitivity of the tip of the penis, decreasing sexual pleasure later in life. But none of these subjective findings are conclusive.
Although circumcision appears to have some medical benefits, it also carries potential risks — as does any surgical procedure. These risks are small, but you should be aware of both the possible advantages and the problems before you make your decision. Complications of newborn circumcision are uncommon, occurring in between 0.2% to 2% of cases. Of these, the most frequent are minor bleeding and local infection, both of which can be easily treated by your doctor.
One of the hardest parts of the decision to circumcise is accepting that the procedure can be painful. In the past, it wasn’t common to provide pain relief. But the American Academy of Pediatrics (AAP) recommends it and studies show that infants undergoing circumcision benefit from anesthesia, so most doctors now use it. But because this is a fairly new standard of care, it’s important to ask your doctor ahead of time what, if any, pain relief your son will receive.
Two main types of local anesthetic are used to make the operation less painful for a baby:
- a topical cream (a cream put on the penis) that requires at least 20 to 40 minutes to take its full effect
- an injectable anesthetic that requires less time to take effect and may provide a slightly longer period of anesthesia
In addition to anesthesia, acetaminophen is sometimes given. This helps reduce discomfort during the procedure and for several hours afterward. Giving a pacifier dipped in sugar water and swaddling a baby also can help reduce stress and discomfort.
Caring for a Circumcised Penis
Following circumcision, it is important to keep the area as clean as possible. Gently clean with warm water — do not use diaper wipes. Soapy water can be used if needed.
If there is a dressing on the incision, apply a new one (with petroleum jelly) whenever you change a diaper for the first day or two. Even after the dressing is no longer needed, put a dab of petroleum jelly on the penis or on the front of the diaper for 3 to 5 days. This can help avoid discomfort from rubbing and sticking to the diaper.
It usually takes between 7 to 10 days for a penis to heal. Initially the tip may appear slightly swollen and red and you may notice a small amount of blood on the diaper. You also may notice a slight yellow discharge or crust after a couple of days. This is part of the normal healing process.
If you notice any of the following problems, call your doctor right away:
- persistent bleeding or blood on the diaper (more than quarter-sized)
- increasing redness
- other signs of infection, such as worsening swelling or discharge, or the presence of pus-filled blisters
- not urinating normally within 12 hours after the circumcision
However, with quick intervention, almost all circumcision-related problems are easily treated.
Caring for an Uncircumcised Penis
As with a penis that’s circumcised, an uncircumcised one should be kept clean. Also, no cotton swabs, astringent or any special bath products are needed — just warm water every time you bathe your baby will suffice.
Initially, do not pull back the foreskin to clean beneath it. Over time, the foreskin will retract on its own so that it can be pulled away easily from the glans toward the abdomen. This happens at different times for different boys, but most can retract the foreskin by the time they reach puberty.
As your son grows up, teach him to wash beneath the foreskin by gently pulling it back from the glans, rinsing the glans and the inside of the foreskin with warm water, then pulling the foreskin back over the head of the penis.
The Circumcision Decision
After reviewing multiple studies on circumcision, the AAP reports that “the health benefits of newborn male circumcision outweigh the risks.” But at the current time, the scientific evidence is not strong enough for the AAP to recommend routine circumcision of all newborn boys. Instead, the AAP advises parents to learn the facts about circumcision and weigh the pros and cons.
In addition to considering the medical factors, religious and cultural beliefs might play a role. If these are important to you, they deserve to be seriously considered.
Talk to your doctor to help you make the choice that’s right for your son.
Reviewed by: Larissa Hirsch, MD Date reviewed: June 2016
Adult Circumcision: The Basics
Circumcision, one of the oldest surgical procedures in existence, may be performed for cultural, religious, or health-related reasons, or simply reflect personal preference.
Adult circumcision is an option for men who were not circumcised as infants.
According to the U.S. Centers for Disease Control and Prevention (CDC), about 79 percent of American men report that they are circumcised.
Reasons for Adult Circumcision
Some men may choose to get circumcised because they think that a circumcised penis will be more sensitive and enhance their sexual experience. Studies on this are conflicting.
Although some circumcised men do report an improvement in sexual functioning, most studies actually suggest a slight decrease in penis sensitivity after circumcision.
Here are some medical reasons why a man might choose to get circumcised:
Phimosis: This is a medical condition in which the foreskin covering the penis is too tight and is hard to retract.
Penile cancer: Although rare, penile cancer is less common in a circumcised penis.
Sexually transmitted diseases (STDs): Risks for genital ulcers, chlamydia, human papillomavirus (HPV), syphilis, and type 2 herpes have been shown to be lower in men who have circumcised penises.
HIV transmission: Several international studies show that circumcision lowers the risk of HIV transmission.
The U.S. Centers for Disease Control and Prevention (CDC) recommends that men consider circumcision as an additional measure, along with safe sex, to prevent HIV.
Adult Circumcision Risks
Adult circumcision is a surgical procedure, so it does carry certain risks as well as possible side effects; these include pain, bleeding, and infection.
Although these health risks are low, they are higher than for infant circumcision.
Unless adult circumcision is being performed for specific medical reasons, such as infection or phimosis, it will probably not be covered by insurance, so it may be expensive.
The cost of adult circumcision varies, but it will be higher if you have general anesthesia instead of local anesthesia and if you have the procedure done in a hospital instead of an ambulatory care center.
Discuss your options with your insurance provider.
If you are considering an adult circumcision, talk to your doctor and go over all the risks and benefits carefully.
What to Expect
If you decide to get circumcised, here is what you should expect:
- You will be given local or general anesthesia.
- Your doctor will retract the foreskin and trim it off.
- Small, absorbable sutures will be used to close the incisions.
- You will be able to go home on the day of surgery.
- In the first few days after surgery your penis may be swollen, bruised, and painful.
- A dressing is usually placed over the entire circumcised penis that you will remove at home by soaking in a warm bath.
- Swelling goes down after about two weeks, but you may be instructed to avoid intercourse and masturbation for up to six weeks.
A good argument in support of adult circumcision can be made from the standpoint of reducing the risk of STDs and HIV.
The CDC supports this option, but cautions that adult circumcision is no substitute for other proven safe sex measures.
On the other hand, there are the costs, the temporary discomfort, and the possible risks associated with the procedure to consider, and a circumcised penis will probably not add anything to your sexual experience.
Circumcision: Benefits, Procedures, and Risks
When you learned that you were having a boy, you probably started thinking about circumcision. The decision to have your son circumcised can be difficult and can involve a number of considerations, including your culture, religion, and personal preferences.
What is circumcision?
Boys are born with a covering over the head of the penis, which is called the glans, or foreskin. During circumcision, the foreskin is surgically removed, exposing the glans. Circumcision is usually performed in the first two to three weeks after the baby is born.
Making a Circumcision Decision
The American Academy of Pediatrics has not found sufficient supporting evidence to medically recommend circumcision or argue against it. Despite the possible benefits and risks, circumcision is neither essential nor detrimental to your son’s health.
Typically the decision to circumcise is based on religious beliefs, concerns about hygiene, or various other cultural or social factors. Circumcision is common in the United States, Canada, and the Middle East.
According to the National Center for Health Statistics, the latest numbers released through 2006 show a declining rate in circumcision. Circumcision is less common in Asia, South America, Central America, and most of Europe.
Before deciding one way or the other, it is helpful to understand how the procedure is performed, the risks, and the benefits. No one should pressure you into making a decision one way or the other regarding circumcision.
How is a circumcision performed?
Hospital/Doctor’s Office: The procedure can take from 5 to 20 minutes and will usually be performed before leaving the hospital. Your baby will be placed in a padded restraint chair and usually be given anesthesia.
Since there are several different types of possible procedures, you should ask your care provider to explain the type they will be using. Procedures include the Plastibell, the Gomco clamp or Mogen clamp which all require the use of a scalpel. These procedures first separate the foreskin from the glans with a device followed by surgery with the scalpel to remove the foreskin.
Home/Jewish Facility performed by a Mohel: Often called a “bris” or “holistic circumcision”, this procedure takes about 15-30 seconds. The foreskin is separated from the glans, often using the Mogen clamp, and then a single cut with a scalpel is used to remove the foreskin.
The parents hold the baby during the procedure. Afterward, the mother is encouraged to nurse within the first minute following the procedure. This procedure is usually performed on or shortly after the 8th day from birth when clotting factors in the babies blood are at their highest levels.
When should the procedure be performed?
Most doctors recommend that circumcision be done within a few days from the delivery of the baby. Some doctors recommend waiting two or three weeks. When the birth occurs in a hospital, circumcision is usually done within 48 hours.
If the baby was born in a birth center or if it was a home birth, circumcision can wait up to two weeks and can be performed either in your pediatrician’s office or with a Jewish Mohel.
How is pain controlled during the procedure?
The American Academy of Pediatrics recommends using pain relief measures for the procedure. Types of local anesthesia for reducing pain include topical cream, a nerve block via injection at the base of the penis, and a nerve block via injection under the skin around the penis shaft.
What are the benefits of circumcision?
The American Academy of Pediatrics states that there are not enough benefits from circumcision to recommend it as a routine practice and that it is not medically necessary. As always, it is important to discuss the subject with your doctor.
Circumcision can provide the following benefits:
- Prevention of urinary tract infections in infants
- Prevention of penile cancer in adult men
- A reduction in the risk of sexually transmitted diseases
What are the risks of circumcision?
The risks of circumcision are minimal. However, as with any surgical procedure, there should be careful consideration of the risks. Circumcision should always be performed by a skilled professional and only on a healthy infant, using proven techniques to prevent infections.
The rate of complications ranges from 0.1%-35% with most complications involving infection, bleeding, and the failure to remove enough foreskin.
Bleeding and infection can occur from irritation as a result of friction from the diapers and ammonia in the urine. An application of petroleum jelly can often provide relief from irritation.
More serious complications can include:
- Meatitis (inflammation of the penis opening) and meatal stenosis (disorders related to urination). Some studies report the rate of occurrence of these complications to be as high as 8-21%.
- Injury to the penis such as partial amputation, penis necrosis, and urethral fistulas.
In rare cases, too much skin is removed from the penis, leading to painful erections in adulthood. Some opponents of circumcision believe that removal of the foreskin causes desensitization of the adult glans with reduced sensitivity during sexual intercourse.
After the circumcision procedure
- Clean the area gently with warm water several times a day.
- Replace soiled gauze and apply lubricants as instructed by your care provider.
- Scabbing, light bleeding and some yellow discharge can occur. If you notice any of these symptoms, avoid aggressive rubbing of the affected area.
- Use pain relief methods as instructed by your care provider. These can include increased breastfeeding, use of infant pain medication or topical creams.
When should the doctor be called?
After your son’s circumcision, you will need to contact your doctor if you notice any of the following symptoms:
- Persistent bleeding
- Redness around the tip of the penis that gets worse after three days
- Signs of infection such as the presence of pus-filled blisters or greenish discharge
- Inability to urinate normally within 6 to 8 hours after the circumcision.
- The Plastibell device (a device that may be used during the procedure) does not fall off within 7-10 days.
When should a circumcision procedure not be performed?
Your doctor might want to delay the procedure or chose not to perform it at all if:
- Your baby was born prematurely or is medically unstable
- Your baby was born with physical abnormalities of the penis that require surgical correction. In some cases, the foreskin may be needed as part of a reconstructive operation)
Last Updated: 08/2015
Compiled using information from the following sources:
When it comes to circumcision, earlier is better
Congratulations — you’re having a boy! You’ll be planning the nursery, shopping for a layette and thinking of names. But there’s one other thing you need to consider — circumcision.
Circumcision involves removing the foreskin that covers your baby’s penis when he’s born. The foreskin doesn’t serve a real purpose, so many parents choose to have it removed.
“If you choose to circumcise your baby, I recommend doing it as soon as possible, definitely before the baby is two weeks old,” said Lindsay Baltzer, DO, an HonorHealth family medicine practitioner who sees patients of all ages, including newborn boys. “If you circumcise your baby that young, it can still be done in the office using a local anesthetic. Your baby will tolerate the procedure better because he still has your clotting factors, which aid in blood clotting. An older baby would likely be circumcised in the operating room under anesthesia, usually at six months or after.”
Sometimes the circumcision is done while you and your baby are still in the hospital after delivery. Some parents prefer to wait and have the procedure done in a family medicine or pediatrician’s office.
Unless there’s a cultural or religious reason for keeping the foreskin intact, Dr. Baltzer recommends considering circumcision due to the higher risk of infection if it’s left in place. Benefits of circumcision include:
- Decreased risk of urinary tract infections
- Less home care to keep dead skin cells from accumulating under the foreskin
Although you likely don’t want to think about this when looking at your newborn — ultimately circumcision may protect him from sexually transmitted diseases and from penile cancer.
Numbing the surgical site
The circumcision appointment with a physician takes about 40 minutes. Your baby’s penis will be numbed, and he will be given some “sweeties” — a sugar solution that acts as a relaxant. Your baby will be soothed and swaddled as the doctor performs the circumcision with an assistant whose primary purpose is to keep your baby comfortable. The procedure itself is quick, but you’ll stay a bit longer to discuss home care.
In recent years, there’s been an overall decline in circumcision rates, possibly because the procedure is sometimes not covered by insurance. If you do need to pay out of pocket, call your doctor’s office, ideally before your son is born, to get a cost.
You may assume you’ll be asked about circumcision after your baby’s birth, while you’re still in the hospital. But you may not be, so be prepared to ask. You’ll also want to find out whether the doctor you’ve chosen to care for your baby performs circumcision. Some do, and some don’t.
If you choose not to circumcise, you’ll want to be sure to discuss proper care with your baby’s doctor. By three to five years, the foreskin should be retracted so the penis can be properly cleaned. Obviously, you’ll be providing this care in the early years, but you’ll want to teach your son how to do the same, so he continues to clean appropriately as part of his hygiene routine.
“If you do choose to circumcise, you should know that babies do very well with this procedure,” Dr. Baltzer said. “We take great care to decrease pain and to keep your little one comfortable. Not to worry — he will be well cared for.”
Adult male circumcision in Nyanza, Kenya at scale: the cost and efficiency of alternative service delivery modes
Cost differences between program approaches
The most important finding of this study is that the unit cost differences between the horizontal and diagonal program approaches are modest, $38.62 for APHIA II and $44.62 for NRHS. Ninety percent of the adult MCs conducted during the study period were through the NRHS diagonal approach and 10% through the APHIA II horizontal approach. NRHS’ greater share of the total is due to the use of dedicated (full-time) MC teams that contrasts with non-dedicated (part-time) MoH teams providing MCs during only 12–38% of their time in the APHIA II approach. NRHS also deployed 2–9 dedicated teams per district, compared with 2–3 non-dedicated teams deployed by the MoH with APHIA II support. When the surgery sessions are underway, the teams work at capacity, but staff wait times, particularly before the start of the surgical sessions, are substantial. The unit cost figures we report include the cost of all MC-related staff time including wait time, and thus capture these inefficiencies.
The larger NRHS service volume may suggest that the diagonal NRHS approach can be scaled up more quickly in the short term and can increase service volumes over time. However, long-term operational challenges may emerge as it seeks to achieve fuller integration with existing MoH adult MC services. The horizontal APHIA II approach, while producing consistently lower service volumes, has also demonstrated rising service volume. The NRHS strategy may be more suited for rapid clearing of the unmet demand for MC, whereas the APHIA II strategy, since it has been more thoroughly integrated with the Kenyan health care system, may be more suited to serving the smaller volume of ongoing new cases. Of Kenya’s provinces, Nyanza experienced the highest increase in male circumcision rates, between the 2007 and 2012 Kenya AIDS Indicator Surveys from 48% in 2007 to 66% in 2012, and thus may approach this more routine caseload demand over the next few years.
Given the shortage of health workers in Nyanza across all cadres , shifting resources in the direction of either approach in the short term is no substitute for long-term investments to increase the health care workforce. Hiring should be done in a way that ensures the right balance of non-dedicated and dedicated MC workers. Disparities in health worker wages can potentially contribute to inequities through internal migration of health workers to MC from other important health services and from one geographic area to another. Disparities in wages may also contribute to a lack of motivation among existing MoH staff in the absence of MC-specific incentives. Decisions regarding which MC program approaches to emphasize should consider human resource shortages, cost, and long-term sustainability within the aims of national health policies and strategies.
Unit costs by service delivery mode
In assessing unit costs by mode, a more complex picture emerges. Unit costs for adult MCs delivered at base facilities are very similar, $38.33 and $39.58 at APHIA II and NRHS, respectively. This is likely due to the fact that the majority of NRHS-supported base sites are MoH sites. The difference between outreach at APHIA II and combined outreach/mobile at NRHS sites is also modest, $40.51 vs. $46.20, a difference of 14.1%. However, the difference in unit cost between mobile MCs supported by APHIA II and outreach/mobile services supported by NRHS is more substantial, 36.5% higher in the latter. Part of this difference can be explained simply: Compensation for direct service providers at the APHIA II-supported sites is 45% of the level of equivalent staff compensation at NRHS. If the cost of direct service personnel at NRHS were reduced accordingly, the difference in unit costs for this portion of field activities drops to 22.1%, and the direction reverses: $40.51 at APHIA II–supported sites versus $37.61 at NRHS sites. Thus, it is hard to explain differences in unit costs by factors that are inherent in the relative virtues of a horizontal versus diagonal approach. On balance, we believe that higher efficiencies are more likely to be attained by adjusting the way MC activities are implemented within service delivery modes in either approach, than by attempting to select one broad approach as generally more efficient than the other.
Placing the results reported here in a broader context, the unit costs are of the same general magnitude as those reported elsewhere in the MC cost literature. The Futures Group has empirically estimated the unit cost of MCs in various African settings at $35–$50 . Other modeling of adult MC scale-up in 16 geographic areas estimated an average of $168 per HIA and 5.6 MCs per HIA, thus implicitly $30 per MC . Finally, a study of high-volume circumcision surgery at a fixed facility in Orange Farm, South Africa found that the procedure could be performed for an average of US$40, and that the procedure required 20 minutes (versus 29.5 for combined APHIA and NRHS at base facilities) including 7.5 minutes of the surgeon’s time (versus 16.3 for combined APHIA and NRHS). The reported cost was similar to the $38.33 and $39.58 per procedure we found for APHIA-II and NRHS, respectively . However, these costs are not directly comparable since the Orange Farm estimate includes direct services and the rental and maintenance of the surgical space only. It excludes the cost of training, outreach and of overhead and administration. On the other hand, medical personnel salaries are higher in South Africa than in Kenya, and adjusting for this difference would move the unit cost estimates toward convergence. The shorter periods of total time for the procedure and for the surgeon’s time in the Orange Farm facility may be due to the different organization of the surgery including the use of disposable kits, and electrocautery which saves suturing time, the single most time-intensive part of the procedure. Another important study of MC costs in Zambia was used as the basis of an MC scale-up modeling exercise carried out by the Futures Institute . The data from Zambia suggests a unit cost of US$46.82, somewhat higher than the findings we report for Nyanza.
The observed variation in unit costs for these MC programs in Nyanza must also be considered in the context of far wider unit cost variation observed previously in HIV prevention programs. In our five-country study of 215 HIV prevention programs (the Prevent AIDS Network for Cost-Effectiveness Analysis Project), we found variations in unit cost of 10- to 100-fold within a range of prevention strategies and countries . These differences mainly represented variations in the number of delivered units of service, accompanied by some variation in the intensity of service per client, with relatively fixed personnel and other input costs. By comparison, the differences between adult MC approaches in Nyanza are small and are largely explained by variations in salaries. The roughly similar cost may reflect multiple homogenizing factors, including standardization of the service content; communication and coordination among the MC partners; and similar motivations by both APHIA II and NRHS program managers to try to optimize performance.
Further refinements in the staffing and logistical organization of the adult MC procedure itself may yield only modest gains in efficiency. This is because the marginal cost of supplies and personnel for each procedure is a small portion of the total unit cost. Yet, a dollar deducted from costs represents resources that can be freed to expand services, whatever the source of that savings. We therefore support further operations research into the possibility of streamlining the surgical procedure and immediately proximate activities. However, our data suggest that once programs have trained lower-cost surgical staff, large further reductions in costs must be sought elsewhere. The areas described in the accompanying Additional file 5 (Five Areas of Possible Efficiency Improvements for MC Delivery) include reduced staff wait times, trimmed overhead and more efficient scheduling of surgery days. Of these, scheduling and administrative efficiencies appeared most likely to yield a substantial reduction in cost per MC and thus per HIA. Operational efficiency (reducing start-up time on MC days) appears to offer smaller gains. Gains in technical efficiency through the Shang Ring and electro-cautery appear unavailable given their current costs and the relatively low cost of the labor and supplies they displace.
The measure of increased efficiency should be placed in this broader context of cost-effectiveness, using the cost per HIA metric, as it takes into account the possible trade-offs between potential economies and the number of MCs delivered.
This report is limited to retrospective data from 222 MC service delivery sites over an 18-month period and prospective T&M data from 246 procedures. While these are sufficient to document unit costs and their variations, they are insufficient to support a robust multivariate analytic approach that might more definitively identifies the correlates of efficiency. Further, NRHS costing data for outreach and mobile services were unavailable in a disaggregated form, making only rough comparisons between the NRHS and APHIA approaches for outreach and mobile service delivery modes possible. The results might be quite different if mobile and outreach modes were separated for the NRHS approach. The T&M data were limited to a two-month period, and it is possible that seasonal variations in caseload or other factors captured by longer data collection period could affect the estimates of incremental per-case costs. The unit costs we reported are associated with the caseload shown in Figure 5. Since HIV intervention programs display economies of scale , if demand declines, unit costs could rise. This could occur if, for example, the most willing clients having already been served, and more money is needed for outreach to maintain the caseload size. Finally, we did not have data on the incidence of adverse events, though the cost of treating adverse events is implicitly captured in the personnel time and cost calculations.
The observed unit costs for adult MC programs in Nyanza, while likely to be similar in other provinces in Kenya, must also be considered in the context of far wider unit cost variation observed previously in the region. In particular the reported personnel costs are most relevant to other countries in which there is a clinical officer cadre. Personnel costs will be different in countries in which medical officers are required to be part of MC surgery. Moreover, MC programs using techniques other than the forceps-guided method may have different unit costs. The findings of this study, while not directly generalizable to other countries where MC programs are being implemented, offer insights into expected efficiencies and cost-effectiveness where similar types of program approaches and service delivery modes are being implemented.
Circumcision is the most common surgery among males. It is the removal of the foreskin (the sheath of tissue covering the head of the penis). In most cases, circumcision is performed on newborns. Circumcision is ancient practice that had its beginnings in religious rites. Today, it is done for both religious and medical reasons.
Who gets a circumcision?
In the United States, five or six of every 10 boys are circumcised. The world’s highest rates for circumcision are in the U.S., the Middle East, and South Korea. Worldwide, about one in three males is circumcised. The surgery is rare in Europe, Asia, and South America. Circumcision is a part of both Jewish and Muslim religious customs. In the Jewish faith, circumcisions are performed on the eighth day of a life.
When are most circumcisions performed?
In general, circumcisions in the U.S. are done a day or two after birth. The longer the procedure is delayed, the more risky it becomes. Even so, circumcisions can be done on older boys and adult males.
Who performs a circumcision?
Depending on when a circumcision is performed, it can be done by an urologist or pediatrician in the hospital in the days right after birth. It also can be done later in a doctor’s office.
Jewish newborns usually are circumcised by a rabbi in a religious ceremony called a bris.
Do healthcare professionals recommend circumcision?
The American Academy of Pediatrics (AAP) and the American Urological Association (AUA) both believe that circumcising newborns has benefits as well as risks. Both groups suggest that the decision be left to parents. The AAP also recommends the use of pain medicines in babies undergoing circumcision.
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