Pediatrician
Dr. Shapiro completed his undergraduate education at UC San Diego, earning a B.S. in Biochemistry and Cell Biology, and a B.A. in Political Science. He furthered his education at UCLA where he earned a Masters Degree in Public…
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Circumcision: Is the Pendulum Swinging Back Again?
Posted in Adoption by Dr. Jeremy F. Shapiro on Jun 04, 2009
 

During my meetings with parents-to-be, by far, the most common question I am asked involves vaccines.  But for those who are about to have a son, I am also commonly asked for my perspective regarding neonatal circumcision.  And my response to this point has been pretty standard: if religious/cultural obligations do not exist, I share with parents the American Academy of Pediatrics (AAP) - Circumcision Policy Statement (now about 10 years old but reaffirmed just 4 years ago) which basically states there is not enough scientific evidence to support routine neonatal circumcision.  I do believe the basic premise of "like father, like son" and will often turn to the father-to-be and make sure he understands some questions may arise later in life when his son discovers he is different from his father.  And I may also reference a research article (usually performed in Africa) which demonstrates some reduced risk of acquiring sexually transmitted infections (STIs), but beyond that, I've avoided pointing parents in one direction or another.

 

But I'm wondering if this is about to change as it appears those interesting research articles (again, usually performed in Africa) are growing in number.  Just recently, a report published in the International AIDS Society journal found that circumcising 500,000 males in Botswana by 2012 may prevent up to 70,000 new HIV infections by 2025 as previous studies found uncircumcised men were 2-3 times more likely to acquire HIV when compared to circumcised men.  Furthermore, because the rates of penile cancer vary throughout the world, it does prompt one to consider what risk factors may be in place to explain these differences.  And while I admit the research studies examining the role of circumcision on penile cancer are not the greatest, there is enough theoretical evidence to support that appropriate care of an uncircumcised male (ensuring the foreskin is fully retractable by the time the child is 5 or 6 years of age and cleansed routinely) is important in preventing transmission of certain STIs, particularly ones linked to penile cancer in males and cervical cancer in females (please see my next immunization discussion regarding human papillomavirus (HPV) for further details).

 

So while I cannot speak upon behalf of the AAP regarding any official policy change, I certainly believe it is essential that parents of males have all the information and at this point, if a circumcision is not to be done, appropriate hygiene and care must be undertaken beginning at a young age.

 

 

Dr. Jeremy

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54
Circumcision?
Just curious if any women pregnant with boys are not planning on circumcision.
http://resveratrol-ultra.wetpaint.com
By nirmay  Jun 15, 2009
53
I do want to thank everyone for sharing their viewpoint on this matter. Just as I listen to my patients, I hear all that you are saying.

Dr. Jeremy
By DrJeremy  Jun 12, 2009
52
^^ appropriate care of an uncircumcised male (ensuring the foreskin is fully retractable by the time the child is 5 or 6 years of age and cleansed routinely) ^^

This is horrid advice. The foreskin will be retractable when it IS, and that's the right time. The only person who should ever try to retract a foreskin is its owner. If he's never be discouraged from manipulating it in private, it will get all the help it needs to retract comfortably.

There is no need to clean the intact penis in a special way. Don't go rooting around in there any more than you would in a girl's vagina. Sterile urine leaving the body flushes the foreskin interior to a hygienic state for every mammal on earth, and it's been working pretty well for about 65 million years. The AAP says "clean only what is seen" and also "leave it alone."
By TLCTugger  Jun 11, 2009
51
^^ I do believe the basic premise of "like father, like son" ^^

Of course kids don't match adults in terms of facial and body hair, anatomical proportions, war injuries, etc. It's just dopey and incredible self-centered to think they should match.

If they must match let the father use non-surgical foreskin restoration techniques. Why inflict another mutilation on the child when the adult can be made more whole?
By TLCTugger  Jun 11, 2009
50
This has nothing to do with infant circumcision. Infants aren't at risk for sexually transmitted infection. Any choice about whether to fight HIV by chopping off exquisitely sensitive sexual parts or by using condoms can wait until the OWNER of the penis in question can weigh in.

How could a parent's best guess now ever be a better be a better answer to what the owner of the penis would prefer for his sex life than that owner's own reasoned opinion? If you cut your child you are saying that you not only don't trust him to practice safe sex, you don't trust him to be able to make decisions about himself. He will be a rational adult one day, as you are now, except by then he will have more and better information about whatever AIDS counter-measures are available THEN.

In the meantime it's HIS body and only HE has the moral right to decide to have healthy normal body parts amputated.

Most of the US men who have died of AIDS were circumcised at birth.

Foreskin feels REALLY good.
By TLCTugger  Jun 11, 2009
49
Nirmay,
Thanks for quoting me but I wanted to tell you that the link you posted goes to a site about anti-aging cream. :? Maybe you accidentally posted the wrong link or something.

Anyway, yes only the boy himself manipulates his foreskin. Trying to encourage retraction would be like trying to retract a girl's clitoral hood and trying to widen her vaginal opening. Not only is it unnecessary and potentially harmful but it is molestation! The genitals develop fine on their very own. This is how they develop naturally in mammals and humans for as long as we have walked the earth. Foreskins of boys and girls do NOT need any help or encouragement to reach maturity. The tight foreskin deserves just as much respect as a tight hymen of a girl. This kind of misinformation is what causes problems for so many of our intact boys here in America. Parents get overly concerned about their son's intact penis simply b/c many doctors don't respect the normal developmental process. That process isn't complete on most boys until after puberty.
By latinalonestar  Jun 11, 2009
48
his is why it is dangerous to go tugging at pre-pubescent boys' foreskins!!! I will never understand doctors have an obsession with hurrying the retraction process. The penis is pretty well self-cleaning throughout childhood. If you are concerned, soak your child in a warm tub (no soap please) but don't go tugging on his foreskin. The golden rule is that the ONLY person to retract a foreskin is the boy HIMSELF. If you want further information contact Doctor's Opposing Circumcision. They have courses and literature about the development of the intact boy and have done extensive research regarding this issue. Here are a few good links:
http://ezinearticles.com/?Best-Anti...
By nirmay  Jun 11, 2009
47
I also want to add that in a very small percent of men (less than 3%), the foreskin never retracts. As long as it does not impede sex or masturbation there is no need to seek treatment. This can be a normal variation for some men (and women alike). If it does impede sex then the man can use a steroidal cream and stretching exercises. Note this treatment is for grown men ONLY, as some boys take until after puberty to have a fully retractable foreskin.

Really it's not that hard folks. Just treat your sons like you treat your daughters. Only clean what is seen.
By latinalonestar  Jun 10, 2009
46
Dr. Jeremy,
You are incorrect. NO GENTLE TUGGING, NO MANIPULATION. More recent studies report that only 50% of boys are retractable by age 10. There is absolutely no reason to encourage retraction on young boys. Retraction is a SEXUAL function and is just plain not necessary. Even gentle tugging can cause micro-tears to the delicate opening. The hormones of puberty replace the fiberous tissue with more elasticy tissue. This is why it is dangerous to go tugging at pre-pubescent boys' foreskins!!! I will never understand doctors have an obsession with hurrying the retraction process. The penis is pretty well self-cleaning throughout childhood. If you are concerned, soak your child in a warm tub (no soap please) but don't go tugging on his foreskin. The golden rule is that the ONLY person to retract a foreskin is the boy HIMSELF. If you want further information contact Doctor's Opposing Circumcision. They have courses and literature about the development of the intact boy and have done extensive research regarding this issue. Here are a few good links:

Development of a Retractable Foreskin in Child/Adolescent:
http://www.doctorsopposingcircumcis...

Avoiding Circumcision After the Neo-natal Period:
http://www.nocirc.org/publish/pamph...

Answers to Your Questions About Forcible Retraction:
http://www.nocirc.org/publish/pamph...

Expert Medical Advice, How to Protect Your Intact Son (from doctors):
http://www.mothering.com/protect-yo...

And some more:
Retraction:

http://www.cirp.org/library/normal/

http://www.cirp.org/library/normal/...

http://churchofjesuschrist.net/circ...

Care of the intact penis-

http://www.cirp.org/pages/parents/p...

http://www.nocirc.org/publish/4pam.pdf

http://www.medem.com/MedLB/article_...

http://www.aap.org/publiced/BR_Unci...
By latinalonestar  Jun 10, 2009
45
LOL ya know with all this back and forth and where I stand and where everyone else does. Just reading the number 43 and 44 it still seems less complicated for circumsized. But its our own decisions granted as parents we all makes decisions hubby's little brother who is 4 and his nephew who is 2 are not circumsized which is My in laws choices, but me and hubby decided this is what we want to do. I believe by the way there are connections in all things and there were purposes for why the circumcision was started, I am not asking anyone to agree, but dont discredit me for the way I believe and choices I am making for my son.
By CayleeBugsMom  Jun 10, 2009
44
Latinalonestar, Thank you for your input but please note your 1990 copyright date. Although it may still be normal at age 5 or 6 to not have fully retractable foreskin, most boys will be near full retraction at this age. What I should stress (and maybe I didn't) is-if it is not, gentle tugging at this age is fine. But you are correct in never any forceful separation...just some gentle tugging.
Dr. Jeremy
By DrJeremy  Jun 10, 2009
43
EEEEEK!!!! NO, NO, NO. As stated by the American Academy of Pediatrics you do not need to retract a boy for "cleaning" infant and childhood smegma is self-cleaning. Only 50% of boys are retractable by age 10 and the other 50% become retractable between age 10 and puberty. Only AFTER puberty does a boy need to retract his foreskin, rinse with water, and replace the foreskin over the glans. This doctor clearly doe not know about the development of the intact boy:

Guidelines for Parents and Doctors:

by American Academy
of Pediatrics

At birth, the penis consists of a cylindrical shaft with a rounded end called the glans. The shaft and glans are separated by a groove called the sulcus. The entire penis - shaft and glans - is covered by a continuous layer of skin. The section of the penile skin that covers the glans is called the foreskin or prepuce. The foreskin consists of two layers, the outer foreskin and an inner lining similar to a mucous membrane.

Before birth, the foreskin and glans develop as one tissue. The foreskin is firmly attached - really fused - to the glans. Over time, this fusion of the inner surface of the prepuce with the glans skin begins to separate by shedding the cells from the surface of each layer. Epithelial layers of the glans and the inner foreskin lining are regularly replaced, not only in infancy but throughout life. The discarded cells accumulate as whitish, cheesy ``pearls'' which gradually work their way out via the tip of the foreskin.

Eventually, sometimes as long as 5, 10, or MORE years after birth, full separation occurs and the foreskin may then be pushed back away from the glans toward the abdomen. This is called foreskin retraction. The foreskin may retract spontaneously with erections which occur normally from birth on and even occur in fetal life. Also, all children ``discover'' their genitals as they become more aware of their bodies and may retract the foreskin themselves. If the foreskin does not seem to retract easily early in life, it is important to realize that this is NOT abnormal and that it should eventually do so.

(Diagram here)

Drawing reprinted with permission of Edward Wallerstein, author of Circumcision: An American Health Fallacy. [CIRP note: The drawing is presented only in the older (1984) edition of the pamphlet.]

[The Function of the Foreskin: The glans at birth is delicate and easily irritated by urine and feces. The foreskin shields the glans; with circumcision this protection is lost. In such cases, the glans and especially the urinary opening (meatus) may become irritated or infected, causing ulcers, meatitis (inflammation of the meatus), and meatal stenosis (a narrowing of the urinary opening). Such problems virtually never occur in uncircumcised penises. The foreskin protects the glans throughout life.] [CIRP Note: This important paragraph, and the drawing, were printed in the 1984 edition of this pamphlet; but were removed in the 1990 version!]

Infant Smegma: Skin cells from the glans of the penis and the inner foreskin are shed throughout life. This is especially true in childhood; natural skin shedding serves to separate the foreskin from the glans. Since this shedding takes place in a relatively closed space - with the foreskin covering the glans - the shed skin cells cannot escape in the usual manner. They escape by working their way to the tip of the foreskin. These escaping discarded skin cells constitute infant smegma, which may appear as white ``pearls'' under the skin.

Adult Smegma: Specialized sebaceous glands - Tyson's Glands - which are located on the glans under the foreskin, are largely inactive in childhood. At puberty, Tyson's Glands produce an oily substance, which, when mixed with shed skin cells, constitute adult smegma. Adult smegma serves a protective, lubricating function for the glans.

Foreskin Hygiene: The foreskin is easy to care for. The infant should be bathed or sponged frequently, and all parts should be washed including the genitals. The uncircumcised penis is easy to keep clean. No special care is required! No attempt should be made to forcibly retract the foreskin. No manipulation is necessary. There is no need for special cleansing with Q-tips, irrigation, or antiseptics; water externally will suffice.

Foreskin Retraction: As noted, the foreskin and glans develop as one tissue. Separation will evolve over time. It should not be forced. When will separation occur? Each child is different. Separation may occur before birth; this is rare. It may take a days, weeks, months, or even many years. This is normal. Although many foreskins will retract by age 5, there is no need for concern even after a longer period. [1984 version only: No harm will come in leaving the foreskin alone.] Some boys do not attain full retractability of the foreskin until adolescence. THIS IS NORMAL!

Hygiene of the Fully Retracted Foreskin: For the first few years, an occasional retraction with cleansing beneath is sufficient.

Penile hygiene will later become a part of a child's total body hygiene, including hair shampooing, cleansing the folds of the ear, and brushing teeth. At puberty, the male should be taught the importance of retracting the foreskin and cleaning beneath during his daily bath.

Summary: Care of the uncircumcised boy is quite easy. ``Leave it alone'' is good advice. External rinsing on a daily basis is all that is required. Do NOT retract the foreskin in an infant or child, as it is almost always attached to the glans. Forcing the foreskin back may harm the penis, causing pain, bleeding, and possibly adhesions. The natural separation of the foreskin from the glans may take many years. After puberty, the adult male learns to retract the foreskin and cleanse under it on a daily basis.

Copyright © 1984, 1990. American Academy of Pediatrics
By latinalonestar  Jun 10, 2009
42
tadlem,
"one last thing, the vagina has protective secretions that the penis does not. the penis relies more on personal cleanliness where, tho women should also be clean, of course, the natural secrections of the vaginal provide a 'coating' to diminish infections and aid in lubrication.
"
Please do dome research about the foreskin, its role is to protect the glans and many other things. The fact that vagina has protective secretion or not doesn't matter, what matters is girls still have more infections than boys. And they are cured with antibotics, circumcision isn't required. The same should be applied for boys.


"my personal stance has always been for the parents to talk to their DOCTOR, find other sources of information and educate themselves as much as possible on all aspects and make a decision based on that education and on their personal beliefs. i can only state MY personal beliefs for the sake of conversation, to stimulate rhetoric for us all to consider, and to take a stand for my religious beliefs as is appropriate to the topic.
no offense taken, none meant."

Also don't forget that circumcision is a decision you are not forced to make. It's not a life/death issue. Considering it will have impact on your son's sexual life and not yours, don't you think it's up to him to make this decision ?
It's not because a baby/young child can't give consent that you have consequently the responsability to make this decision. So if I follow your logic, you could also choose his future wife just because he can't give consent and you think you make the best decision for him ?

Soory, but I don't get it
By puzo  Jun 09, 2009
41
momof3mn ..this is not an attack, just a response. first, just because we believe that "God said so", as you put it, doesn't mean we condone non-monogamous, unprotected sex. quite the opposite. our opinions are based on Biblical statement, not on medical science and thus can't be 'compared'.
second, Jorge started the European thing and the statement was something like, 'if you don't like it here, go there'.. not a blatant invitation for him to move, just a comment that if he thinks things are so great there, he has that option. and, no one said anything about anyone supporting legislation about anything. this is a discussion about CHOICE and we are simply stating our beliefs about those choices.
just because someone can cite research articles, doesn't make them an expert and (as anyone in the medical or scientific field knows), research studies can .. CAN.. be manipulated to give you the desirable outcome for which you are searching. the closest we can come to otherwise, are controlled, double-blind studies, and OPINION has nothing to do with it.
not to attack Jorge, but the comments requesting him to be a bit more subduded were because of his inability or choice to not listen to anyone else's point of view, but rather that we should all drop our beliefs for his because he is so 'knowledgeable'. well, on an opinion forum, we all have the rights to our opinions and to voice them and should do so with respect to the others.
as i told him, i admire his passion for this topic, but said simply that he might be more convincing if he was a bit more 'humble' in his presentation. that is not to berate him, or anyone, in any way, just an observation.
one last thing, the vagina has protective secretions that the penis does not. the penis relies more on personal cleanliness where, tho women should also be clean, of course, the natural secrections of the vaginal provide a 'coating' to diminish infections and aid in lubrication.
my personal stance has always been for the parents to talk to their DOCTOR, find other sources of information and educate themselves as much as possible on all aspects and make a decision based on that education and on their personal beliefs. i can only state MY personal beliefs for the sake of conversation, to stimulate rhetoric for us all to consider, and to take a stand for my religious beliefs as is appropriate to the topic.
no offense taken, none meant.
By tadlem  Jun 09, 2009
40
sja,
I wasn't trying to attack you personally, but I clearly disagree with some of your reasons. I mean if my parents told me they circumcised me because I would be a bad/dirty boy later, I'd feel pissed off. How would you react if your parents circumcised you for this same reason?
I can't blame my parents cause at that time their consent was hardly required for circumcision and my father was Jew. I used to be proud of being cut because during my education I was told that foreskin was birthdefect and cause severe damages later in life and I thought that was right. My parents used the same thought process as yours and thought they made the best decision for me. But the reality is, the fact they thought it was best for me doesn't mean it was. It wasn't at all when I discover foreskin restoration recently.
After travelling to Europe and do more research, my point of view cleary changed. Most men are uncut and do very well. All I was told were just myths. The fact your husband has a penis doesn't matter. He clearly doesn't know what he's missing. Contrary to some anti-circ websites, I don't think circumcision destroys all pleasures (at least not for me). Sex was clearly good for me being cut. After 18 months of foreskin restoration, I can swear you that sex is now awesome.
Also there is an increasing number of Jews refusing circumcision and circumcision they used to practice isn't the same as today (they used to just cut the top of the foreskin, now to prevent any restoration they cut all the foreskin and do very tight circumcision).

"but ultimately I will be making the decision for my son, not anyone else on this site." Of course you're not making this decision for someone, I'd become crazy if someone was trying to remove my new foreskin :-)
By puzo  Jun 09, 2009
39
(ATTENTION: THIS IS NOT AN ATTACK - JUST A COMMENT - YOU CAN TAKE OFFENSE IF YOU CHOOSE - BUT NONE IS INTENTED.)

So I find it interesting that the religious argument and the medical argument are coupled as a justification for circumcision. Even the AAP, as Dr. Jeremy points out, can't find a true medical justification for routine circumcision - not even increased risk of non-hiv infection. So at this point the primary scientifically-based justification is that some studies show that uncircumcised men may be infected more easily, and therefore more easily spread HIV. The medical justification then is that circumcision makes unprotected, non-monogamous, sex safer. To this is added the religious argument – which is condensed down to “because God said so”. Hmmm? Put the two together and…..

I would like to say a few words in Jorge’s defense – although he hardly needs my help – imo he does a pretty good job of defending himself. But….

I may have missed it, but I didn’t see the place where Jorge was trying to stop anyone from making the decision they felt was best for their son. Jorge has an opinion, one he feels he rationally arrived at through research. I have not researched the citations he notes, so I’m not saying he is right or wrong – it is just his opinion. His research makes it difficult for him to understand why anyone would choose circumcision for their son, but unless I’m missing something, I don’t see where he is supporting legislation to make it illegal, which is the only way Jorge could influence any parent’s ability to choose circumcision. Someone having a different opinion, no matter how strongly held, well presented or succinctly supported by scientific fact and case study, does not negate someone else’s right to make a different choice for their own family. I can’t see where Jorge is being a bully and I certainly don’t see where he should leave the country because he holds a different opinion than some posters. He is simply presenting his opinion along with his assessment of the facts supporting it.

Just for the record, my husband is circumcised and our son is not. I have been sexually intimate with both circumcised and uncircumcised men and found the experience lovely with both. I believe that natural selection would have eliminated foreskin long ago if it were a true detriment to human health and procreation. I do not understand how an intact penis could be considered any more “filthy” or “disgusting” than a vagina (I find both naturally and wonderfully well suited to their respective purposes). And finally, I think the perfect response to locker room teasing is “what the hell are you doing looking at my penis?”.
By momof3mn  Jun 09, 2009
38
I am engaged to an intact man, but three years ago, we were rather strictly physical (i.e. this is not just because I love him).

Foreskin is better. It is a topic of conversation with the women I know...and there seems to be a consensus that foreskin is gentler on a woman and permits for more frequent, more vigorous and longer sex (more orgasms). More intimacy = healthier relationships.

Have a little faith in your boys. Teach hygiene. Encourage strong positive self image and acceptance of who they are on the inside.
By alyssum  Jun 08, 2009
37
Puzo, there really is no need to attack me. I have had a very informative conversation with JorgeM on here, that enabled me to ask questions and get answers from a man. If you took the time to read all of my responses, you would note that before we knew what we were having, my husband and I did discuss this, and I left the final decision up to him. Before you attack me for that, my reasons for letting him make the final decision are 1) I don't have a penis, obviously he does, he has had the experiences with his penis, I will never have, 2) when it comes down to it, if my son has issues regarding his reproductive system, he is going to go to his father, along with when he is given the "sex talk" it would come from his father, and 3) being we are religious people, I believe PERSONALLY that God told the Israelites to circumcize their men for a reason, same as tadlem and CayleeBugsMom. There is no reason to attack me for a decision I may have to make some day, that will IN NO WAY affect you. Please try and control yourself when you respond to me.

NervousP, thanks for a woman's perspective on sex with and uncircumcized man. It was VERY helpful to me to get some insite about the other side of the coin!

I do want to say, I don't understand why people are insulting eachother over this topic. What it comes down to is what each parent feels is right for THEIR child, and no one on here should be telling another parent what to do. Yeah, information is power, and I am again greatful to JorgeM and others on here who were able to provide me with information that was unknown to me, but ultimately I will be making the decision for my son, not anyone else on this site.
By sja  Jun 08, 2009
36
I am married to an uncircumcised man and neither he or I have EVER had an infection!! We have been together for 4 years! As far as any future sons we have, they will also be uncircumcised, we both believe my husbands skin provides GREAT pleasure to each of us and would NEVER want to deny our child this pleasure someday. I personally do not believe an optional procedure which can never be truly reversed should ever be preformed on any child... An adult would have memories of the pain where a baby MAY not but at least the adult had a say in his own permanent elective surgery. And as for the tight foreskin my husband had this until his early 20s... (never got an infection from being unable to wash under the foreskin for 20 years) but he still would not choose to circumcise our son. The discomfort of stretching the skin was well worth the pleasure according to him. As far as satisfying a woman, well that is not a foreskin issue I PROMISE. And for the oral sex on my husband, well, he is the first man i enjoy oral sex with, which is entirely due to his foreskin.
By NervousP  Jun 08, 2009
35
"I think that irregardless of what the fad is, my husband and I would still have our son circumsized. I have never heard my husband, brothers (I have 4), dad, stepdad, or past boyfriends complain of any regrets,"

Of course circumcision doesn't completly kill pleasure. Most cut men don't know what they are missing. If they really do (considering the results of cut men after foreskin restoration) they probably feel different.

"also, I just think it is far cleaner, and once the circumcision heals, require less care."

There's no special care about an intact penis. There's no need to retract. You just wash it the same way as a finger.


"I also think I would have him circumcized, because let's face it, pre-teen and teenage boys are not the cleanest people."

So if your son isn't happy about circumcision or just ask you about what happened to him, you are going to tell him you decided to cut a piece of his penis because he is dirty boy, right?
Also girls are far more likely to get infections, would you consider circumcising your daughter also ?
By puzo  Jun 07, 2009

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