The Value of Neonatal Circumcision: An Unanswered and Perhaps Unanswerable Question

For almost two decades, there has been an ongoing dispute among physicians, particularly pediatricians, as to the justification for neonatal circumcision, especially on a routine basis. Neonatalogists have regarded the operation as without merit.¹ Physicians in all fields agree on the necessity for careful explanation to the parents, preferably before the infant is born. They deplore the occasional grave complications that are largely produced by poor technique and inexperienced operators. One major reason formerly used to justify neonatal circumcision—prevention or correction of phimosis—has been shown to be untenable by serial studies frombirth to adulthood.

The major indications now proposed as justifying the procedure are prevention of penile cancer and balanitis and a reduction in herpes genitalis and, possibly, cancer of the uterine cervix. These diseases are decades removed from the neonatal period, and opponents of circumcision regarding them as lacking incontrovertible proof or as inconsequential. They say that inadequate hygiene would serve aswell as circumcision.

On the other hand, proponents say that risks to the infant can be almost eliminated by recognition of contraindications and good technique by well-trained operators. They say adequate lifelong penile hygiene is unlikely in large sections of the population, especially since one study found that 50 of 69 14 to 15-year-old uncircumcised British schoolboys with totally retractable foreskins practiced no hygiene.² Furthermore, in populations where hygiene is poor, cancer of the penis is a common male malignant neoplasm.³ While this cancer is rare in the United States, patients often do not seek help until the disease is well advanced and devastating in its effect.⁴ Estimates of the relative frequency of deaths caused by cancer of the penis and neonatal circumcision vary from 200 caused by cancer to one caused by circumcision in Australia⁵ to the subsequently retracted statement that there are more deaths caused by circumcision complications than cancer of the penis.⁶

The increased incidence of uncircumcised men among Canadian Army recruits with venereal disease (VD) in 1947,⁷ as well as the earlier requirement of the US Navy that their personnel be circumcised, shows that the incidence of VD was indeed greater among uncircumcised men. This indication was thought to be long outmoded until the frequency of herpes genitalis infection was recognized. In a British study, the occurrence of herpes was found to be greater among uncircumcised men.⁸ Certainly, this question is still not definitely answered, nor is the possibility that cancer of the uterine cervix is more common among uncircumcised men. The investigators of a recent study, which failed to show a statistical significance among 1,148 patients with cervical cancer whose husbands were physically examined, concluded that the role of circumcision in the epidemiology of cancer of the cervix remains uncertain and that further carefully controlled studies are needed.⁹

Historically, the critical attention of physicians caring for newborns was directed toward circumcision at a time when that procedure and exchange tranfusion were the only services to newborns paid for by certain Blue Shield plans. The obvious injustice of this rankled, as the value of circumcision seemed questionable, and sophicated care of premature infants was emerging. In an attempt to provide an objective answer after the American Academy of Pediatrics (AAP) Committee on Fetus and Newborn had stated, There is no medical indication for circumcision in the neonatal period,¹ the AAP appointed an ad hoc committee consisting of a neonatalogist, a pediatric urologist, an obstretrician, and this author (H.C.T). The ad hoc committee was sharply divided in its opinions, and the resulting statement was a compromise that stated there was no absolute indication for routine circumcision of the newborn.,¹⁰ The words absolute and routine were meant to convey a different impression from the conclusion of the AAP Committee on the Fetus and Newborn, but this has not always been the interpretation of readers.

The argument continues to rage, and there are at least 100 listings on circumcision from the English-speaking literature referenced in the Index Medicus from 1975 through 1982. The journal Pediatrics alone accounted for 19. Some are case reports of serious complications. Others are statements of personal convictions, some with emotional overtones. There are a few careful studies and several review articles. They are in obstetric, surgical, urologic, psychiatric, family practice, and nursing journals and from at least eight countries.

What should be the posture of pediatricians at this time, especially since the physicians attitude could be a major factor in parental decisions? First, neonatal circumcision is not a routine procedure to be accomplished on all newborns. If performed, it should be preceded by careful explanation to the parents of both the pros and cons. Adequate lifelong penile hygiene should be defined. The value of such counseling is, however, dubious.¹¹ To reduce risks to a minimum, the procedure should be performed on stabilized normal infants with meticulous surgical technique by well trained personnel.

In 1983, it is impossible to say how great or little is the value of neonatal circumcision over the entire period of a mans life. A well-documented article by Warner and Strashin¹² reviews in detail many aspects of the subject. If it is not performed, it is variously estimated that 5% to 10% of males will subsequently need circumcision when the risks, costs, and emotional trauma will be much greater.^12,13

To determine definitely the prophylactic value of neonatal circumcision would require large prospective studies throughout decades in several countries with different climates and involving all socioeconomic-educational strata. The multiple variables encountered might well prevent valid conclusions, even if the heavy expertise and longtime commitment of investigators could be obtained. It may well be that, depending on climate, nationality, and education, neonatal circumcision will be of great value in certain populations and unnecessary for others. Physicians have always had to deal with these uncertainties. Pediatricians will rarely see the diseases that are, or may be, more common in the uncircumcised. Therefore, they must try to maintain their objectivity and admit that they do not know the definitive answers.

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