Circumcision — Are You With us or Against us?

In the United States most pediatric urologists are involved with a significant number of circumcision issues, such as a request for circumcision by parents, concerns over penile adhesions in uncircumcised and circumcised boys, hidden penis, trapped penis, phimosis, suspected balanitis and incomplete circumcision. In this country more than 60% of newborns are circumcised, although the rate varies based on ethnic background, geographic region and insurance status.^1,2 In contrast, European men generally are circumcised only for religious reasons. Furthermore, when hypospadias repair is performed, often the foreskin is preserved. Recently we published an article in The Journal of Urology® by Schoen et al describing the higher costs associated with postneonatal circumcision compared with neonatal circumcision.³ In short order, numerous letters to the editor were submitted, some of which were critical of the analysis, while others indicated that the analysis did not consider potential benefits in adulthood for men and their sexual partners. Several of these letters are published in this issue of The Journal, and provide a flavor of the controversy.

Few pediatric urological topics generate as much passion among nonurologist physicians (and some pediatric urologists) and lay people as newborn circumcision. Several years ago an outspoken proponent of circumcision who was invited to speak at a national conference on the topic in San Francisco made his hotel reservation under a different name because of concerns regarding anti-circumcision activists.

Newborn circumcision is the most common operation performed in the United States but it is done primarily for cosmetic reasons or because the parents think that it will afford better hygiene. There is also a perception that circumcision in adulthood is much more painful than in the newborn period. A tour through the newborn nursery when babies are lined up for circumcision might change this opinion, although penile blocks are helpful. The risk for circumcision complications is significant, and most parents seem unaware about those risks when signing the consent form. There are potential health benefits to circumcision, including reduction in the risk of pyelonephritis in infancy, penile cancer in adulthood and HIV in sub-Saharan Africa.⁴ Do these potential health benefits mean that all boys should be circumcised? No. In fact, the health benefits and risks of circumcision are evenly balanced by the advantages and risks of beinguncircumcised.

Some argue that circumcision violates medical ethics,⁵ and medical practitioners who perform circumcision should be aware of these ideas. There is another ethical issue with regard to newborn circumcision and the practice of surgery. A principle of surgery is that the surgeon is responsible for postoperative care, and identifies and manages surgical complications, calling in consultants as necessary. In most communities newborn circumcision is performed by nonurologists, most commonly obstetricians, although it also is performed by pediatricians and family physicians. When obstetricians perform the procedure, generally they do not see the child at followup to assess healing, and they assume that the primary care physician will manage the postoperative care. If there is a complication such as infection, trapped penis or incomplete circumcision, usually the problem is identified by the pediatrician or family physician and the urologist is asked to take care of the problem. Typically the obstetrician is unaware of the complication. I have also encountered obstetricians who have refused to place sutures to control bleeding following Gomco circumcision because they were uncomfortable suturing such a small structure.

The arguments will continue and, unfortunately, there is little room for compromise. It is important that families be aware of the risks of circumcision and practitioners be aware of the ethical arguments against routine circumcision. Furthermore, since it is a cosmetic procedure, the cost of circumcision should be paid out of pocket rather than by the insurance company or by the public in cases of Medicaid.

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