Friday, 15 April 2011

Considerations for the best age of circumcision

Overview
The age at which male circumcision is done differs in different cultures and countries. In Malaysia and Singapore Muslim parents usually have their male children circumcised when they are from 7 to 12 years of age. The peak period for circumcisions is usually the school term holidays. A minority have it done during infancy or at the age of puberty. Whilst it used to be done traditionally by non-medical persons who specialize in it, the norm now is to have it done by doctors or surgeons. There is no requirement for it to be done by a Muslim, though most parents would prefer it if they have the choice.

In Turkey the age of 5 to 9 years is considered best. Most parents feel that boys must be able to remember the occasion, which they would not if they had it done as babies. In Pakistan, circumcision within the first week of life is increasingly being practiced and is done before the baby leaves the hospital where he was delivered.

In the Philippines it is customarily done at around the age of puberty. Filipino parents often bring their sons to me at the age of 11-14 years for circumcision and I am told that this is the norm in the their home country as well. In America where the majority of circumcisions are done for non-religious reasons, the operation is usually done in infancy, within the first few days after birth and before discharge from the maternity hospital.

Amongst the Jews, circumcision is traditionally done on the 8th day after birth, in a religious ceremony called Brit Millah or Bris Millah which includes the child naming ceremony. It is done by a Mohel, a Jew who besides being trained in the art of circumcision is also well versed in Jewish laws and tradition. The circumcision used to be so strictly observed that the bodies of stillborn or babies dying soon after birth are circumcised before they are buried.

Medical Considerations
I wish to share some thoughts on the best age of circumcision for boys. I had already elaborated on the benefits and risks of circumcision in an earlier post. The overall incidence of urinary tract infection (UTI) is about 1-2 % in male infants. This is higher that the incidence in boys and young adults. Thus if a boy is to be circumcised anyway, why not do it earlier so that the protection is assured during this period. Circumcision results in an approximately 12-fold reduction in the incidence of UTI in infancy

With regard to penile cancer, much of the protective benefit may be lost if circumcision is not performed in early infancy. In a case controlled study (reported in J Natl Cancer Inst 1993 85(1):19) it was found that the relative risks of penile cancer did not differ between uncircumcised men and those circumcised after infancy, and were three times more than babies circumcised a few days after birth. Thus it would seem that circumcision done after infancy had no protective effect as far as penile cancer was concerned.

Possible mechanisms by which circumcision may decrease the incidence of penile cancer include avoiding the development of phimosis (tightness of the foreskin) and preventing the retention of smegma (an oily secretion under the folds of the foreskin). Phimosis which prevents the foreskin from being retracted is one of the most common predisposing causes of penile cancer. Smegma begins to form in the first few days of life, and I have personally found that some infants have lots of it when I retract their skin prior to the circumcision operation. Removing these two predisposing factors early in infancy is crucial to realizing the medical benefits of circumcision. Cancer of the penis (and cervical cancer in their partners) is almost nonexistent in Jews and in Muslims who circumcise soon after birth (Gillenwater: Adult and Pediatric Urology). Similarly the protective effect against aids and Human Papilloma virus infection is only effected if circumcision is done in early infancy.

The consensus of medical opinion is that circumcision is best done as early as possible (between 24 and 72 hours old) to derive its maximum benefits. There are other advantages apart from those outlined above. In the first few days after birth, babies tend to bleed less and fuss less during a circumcision. The longer the wait, the higher the risk that the child will require stitches to stop bleeding. In older boys there is much anxious anticipation of circumcision and they are often apprehensive, cry out more and are more difficult to hold down. This may be traumatic also for the parents and difficult for the doctor. In my own experience of doing circumcision at various ages over the past 25 years, babies heal and recover fastest after the operation and also have the least complications. Older boys are more likely to complain of pain in the days following the operation, and may refuse to walk or pass urine. They may also refuse to have it cleaned or handled.

Religious Considerations
What about the views of Islamic scholars on the timing of circumcision? As-Shawkani says (Nayl al-Awtar 1/32): "There is nothing that states explicitly about its time … the majority of Fuqaha hold that there is no time limit defined for circumcision."

Imam Nawawi (Al-Majmu 1/303) states that “circumcision is recommended to be performed on the seventh day of infancy on the same day as Aqiqah.”

According to the Maliki school, it is better to delay the circumcision until the age when he is taught how to pray, ie between the ages of 7 and 10. (Fiqh al-Islam Adillathi 3/742)

Abdullah ibn Jabir (r.a.) and Aisha (r.a.) related: “The Prophet (s.a.w.) performed the Aqiqah of al-Hasan and al-Hussein and circumcised them on the 7th day.” (Related by al-Bayhaq & Tabarani)

When Wahb ibn Munabbih (a Tabiin) was asked about the wisdom of circumcising on the 7th day, he said: “To make it easier for the child.” (Tuhufatul Mawdud)

Conclusion
The medical benefits that accrue to circumcision are maximized if it is done early within the first week after birth. The operation is also easier and has less incidence of complications at that age. Whilst circumcision in infancy is not specifically enjoined in Islam, the fact that the Prophet (s.a.w) himself had his grandsons circumcised on the seventh day at the same time as Aqiqah makes a very strong case indeed for us to follow his example.

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