Routine Circumcision of the Newborn Infant: A Reppraisal

Note:

This article, which was printed in the official journal of the American College of Obstetricians and Gynecologists ( ACOG), represents the official policy of ACOG in 1978.

Prompted by the continuing controversy over routine circumcision of the newborn infant, this review of the limited available literature suggests that the operation may facilitate hygiene of the penis and perhaps decrease the risk of carcinoma of the penis. On the other hand the operation frequently features illogical basis for patient selection, neglect of the requirement to obtain informed consent, an inappropriate operator, a needlessly radical technique, disregard for pain, dubious objectives, and unknown cost effectiveness. Long-term prospective studies are needed to evaluate routine circumcision of the newborn infant. However until the benefits of the procedure can be proved worth the risk and cost, medical resources should probably be allocated to heath measures of demonstrated value.
~ (AM. J. OBSTET. GYNECOL 130: 125, 1978)

IN 1975, THE American Academy of Pediatrics reaffirmed its 1971 judgment that routine circumcision of the newborn infant lacks medical justification.¹ Nevertheless, the  American College of Obstetricians and Gynecologists, whose members annually perform hundreds of thousands of circumcisions, declined to endorse this position statement in its present form. This disparity between these viewpoints prompts reconsideration of routine newborn circumcision as a surgical procedure, in terms of: (1) patient selection, (2) informed consent, (3) choice of operator, (4) surgical technique, (5) anesthesia management, (6) objectives, and (7) cost-effectiveness.

Patient Selection

In the absence of a complaint or demonstrable pathology, the selection of candidates for any operation becomes problematic. The foreskins of 96 per cent of newborn infants cannot be fully retracted and, hence phimosis is physiologic in the newborn infant.² The inner surface of the prepuce and the glans share a common epithelium, erroneously termed adhesions, which separates around the time of birth or potentially much later. At birth, determining which children will subsequently develop clinically significant phimosis is impossible.

Thus lacking a rational means of case finding, the physician frequently relegates the decision to the mother, who may base her decision on incomplete or erroneous information. Women's (and men's) understanding of circumcision may be limited. For example, the number of women who do not know the circumcisional status of their marital partner ranges from 10 to 50 per cent.

Surveys of parents to determine the rationale for having their newborn sons circumcised are ever more revealing. Some had their sons circumcised to prevent excessive crying, masturbation or rupture. Others acted on advice from relatives or women's magazines, while still others believed that circumcision is required for admission to the armed forces.³ In another study, mothers based their decision on the belief that circumcision was mandatory hospital policy, that the penis would be rendered more aesthetic, that all male infant are circumcised or that circumcision is required by law.⁴ While fathers tend to be indifferent about circumcision, physicians clearly influence the incidence of circumcisions, ranging in one study from 20 per cent of patients of physicians who opposed circumcision to 100 per cent of patients who supported the procedure.³

Informed consent

Although signed consent is routinely obtained before newborn circumcision, the requirement for informed consent is satisfied far less often. Informed consent, as interpreted by Annas,⁴ denotes two elements: information and consent. The physician contemplating operation ostensibly must relate to the patient (or here, parents) all material facts related to the proposed operation. He must reveal the risks of morbidity and death, the probability of success, and he alternatives to treatment, i. e. non-circumcision or later circumcision. Furthermore, he must describe the attendant risks and probability of success of the alternatives to operation as well.

Physicians often neglect the informational component of informed consent for circumcision. Shaw and Robertson⁴ documented that 57 of 80 mothers (72) per cent denied that a physician had ever discussed circumcision with them. Patel³ reported that parents discussed circumcision with the doctor in only 34 of 100 cases.

Annas⁵ further argues that the more elective the proposed operation, the more crucial is a complete explanation of the material facts. That the parents must consent to elective operation on the genitals of an uncomprehending minor magnifies the importance of this disclosure. Newborn circumcision is not innocuous. While the risk of death from circumcision is small, approximately two deaths per million procedures,⁶ the risks of complications range from 0.06⁶ to 55³ per cent in different studies, reflecting large differences in patient follow-up and in definitions of complications.

Immediate complications of circumcision have been classified into three categories: hemorrhage, infection, and surgical trauma.² Hemorrhage is the most frequent complication and may require sutures, pressure dressings, or transfusion.^2,3 In Patel's³ recent study of 100 patients, 31 had minimal bleeding and four had moderate bleeding. One infant required suturing.

Infection of the wound can lead to scarring, deformity, and phimosis. Seven of the same 100 patients had mild wound infections, and one had a severe infection requiring antibiotics.³ Exposed to irritation caused by the ammonia of wet diapers, the unprotected glans may develop meatal ulceration or meatitis, predisposing to meatal stenosis.^1,2 Thirty of 100 patients sustained mild meatal ulcerations, while one child had a severe ulceration.³

Surgical mishaps continue to occur, particularly in inexperienced hands. A partial inventory of operative accidents and their sequalae includes denuding of the penis shaft; incomplete circumcision with residual deformity; lacerated scrotum; subglanular fistula; bivalved, grooved or amputated glans; concealed penis; and cautery burns.² Most case reports lack denominator data, and the incidence of surgical trauma remains unknown.

Three neonatal cases of urine retention due to circumcision, with one child presenting with septic shock, have recently been described. In addition, the complication of septicemia has led to osteomyelitis, pulmonary abscesses, and death.

As outlined by Annas,⁵ informed consent for circumcision necessitates an explanation of its hazards. If the incidence of immediate complications were as low as 0.06 per cent,⁶ the immediate risk from nontreatment would probably still be lower. Delayed complications of circumcision are allegedly more frequent,² although their incidence is unknown. The long term consequences on non-circumcision likewise are not well documented. Prospective studies are needed to resolve these questions. Nevertheless, millions of uncircumcised male subjects in Western nations tolerate their foreskins with minimal disability.²

However, if the need for circumcision arises in later life, the procedure can then be done with the full understanding and informed consent of the patient himself, as well as with the benefits of anesthesia and analgesia. While circumcision of an adult requires more time and costs more than does circumcision of a newborn infant, the ratio of the risks of the operation at these ages is unknown.

Choice of operator

Why do obstetricians-gynecologists perform circumcisions? The requisite skills can certainly be acquired, if needed, by the infant's primary care physician. Performance of the circumcision by the child's rather than by the mother's physician might foster better postoperative care of the wound and prevent complications. The child's physician routinely counsels the mother about infant care; wound management could easily be included in these discussions. Obstetrician-gynecologists seldom see the circumcision patient for follow-up; however the child's physician will be examining him at regular intervals during immunization. and well baby visits beginning at six to 12 weeks of age.

Moreover, routine performance of newborn circumcisions ostensibly should threaten an obstetrician-gynecologist's specialty certification. Commenting on limitations of practice for candidates, the  American Board of Obstetrics and Gynecology, Inc.,⁷ warns that physicians who assume responsibility for the health of male patients for operative or other care, will not be regarded as specialists in obstetrics-gynecology, except as this practice is related to governmental services, the investigation and management of on infertility problem, or care in an emergency.

Surgical technique

Since the goals of circumcision are diverse, critical evaluation of available techniques is difficult. For example, what constitutes adequate circumcision? Judging from amounts of foreskin excised, one infers that there is no consensus at all. Surgical outcomes of circumcision reveal striking latitude, ranging from the glans being completely covered by prepuce to being completely uncovered.³

However if one assumes that the immediate objective is to enable retraction of the foreskin (a nonphysiologic maneuver), less drastic operative techniques will suffice. The dorsal slit represents an established urologic position, and Diaz and Kantor⁸ have proposed the dorsal slit as an alternative to circumferential circumcision in newborn infants. The advantages of this technique may include the elimination of tissue excision as well as reductions in operating time and surgical risk.

Anesthesia management

That an adult can physically restrain an infant in order to perform genital surgery on him is unquestioned; that to do so is compassionate is less apparent. Physicians apply different standards of pain tolerance to newborn infants, perhaps because these patients cannot articulate their anguish. If the physician were requested to circumcise a one-year-old child, would he rely on physical restraints in lieu of anesthesia? Operation without anesthesia indeed obviates risks associated with anesthesia but recalls a more primitive area of medicine.

The frequent rejoinder that the tiny patient does not feel pain defies both experimental evidence and common experience. Although thresholds of stimulation vary, newborn infants are capable of responding not only to pain but also to visual, auditory, tactile. gustatory, and olfactory stimuli. Reciprocally, at least four physiologic systems in the neonate may reflect stress or tension: the gastrointestinal tract, cardiovascular system, respiratory system, and skin.

Marked flushing frequently occurs during circumcision, and the propensity of newborn infants to vomit under the stress of circumcision is well appreciated by nursery personnel. The alteration in pitch and intensity of cry when the first crushing clamp is applied to the foreskin is unmistakable. Endocrine and other physiologic responses of the infant to the stress of circumcision have not been well documented in the existing literature.²

Nevertheless, plasma cortisol increased significantly in newborn infants circumcised in the first six hours of life in one study.⁹ In addition, newborn circumcision has led to immediate and significant increases in wakefulness and fussy crying of these infants, as well as alterations in sleep patterns, attributed to the stress of operation.

In contrast to the sometimes dramatic somatic responses of the neonate to operation without anesthesia, the psychological consequences of this trauma are conjectural. Psychoanalyst Erik Erickson has described the first of eight stages of man as the development of basic trust versus basic mistrust. For the baby to be plucked from his bed, strapped in a spread eagle position, and doused with chilling antiseptic is perhaps consistent with other new-found discomforts of extrauterine existence. The application of crushing clamps and excision of penile tissue, however, probably do little to engender a trusting, congenial, relationship with the infants new surroundings.

Surgical objectives

Physicians' reasons for advocating routine circumcision include cleanliness; prevention of balanoposthitis, future phimosis, or cancer (in men and women); failure of the foreskin to retract; and custom.⁴ Welch¹⁰ has has classified surgery as follows: repair of wounds, extirpation of diseased organs or tissue, reconstructive surgery, and physiologic surgery (e. g. sympathectomy). Predictably routine newborn circumcision eludes classification. Contemporary surgery has yet to embrace the philosophy of purely prophylactic surgery. If, however, the scope of surgery broadens to encompass preventive operations, the prepuce of the neonate will likely rank low on a list of bodily parts requiring ablation.

As noted by the American Academy of Pediatrics and others,^1,2 medical justification for routine circumcision of the newborn is wanting. However, some, dissenting with the Academy's findings, claim that the Academy's report failed to emphasize adequately the preventive and hygienic advantages of circumcision.

Newborn circumcision usually prevents later circumcision but at an expense of hundreds of thousands of needless operations per year. Moreover, since phimosis is a potential complication of circumcision, some infants have to be circumcised more than once. (1 per cent of patients in one study).³

While circumcision may be protective against the development of cancer of the penis, good hygiene afford an equal degree of protection.^1,2 Studies from diverse cultures indicate that carcinoma of the penis is rare among men with good hygiene, regardless of circumcisional status. Among men with poor hygiene, circumcision offers little protection.² Gee and Ansell¹¹ estimated the risk of developing cancer of the penis as less than that of suffering a major complication of circumcision (0.2 per cent); one occurs in adulthood and the other at a few days of age. No reliable data support a correlation between lack of circumcision and carcinoma of the prostate,² and the postulated association between lack of circumcision now appears groundless.²

Circumcision may facilitate cleaning of the distal penis, but is operation a legitimate means of improving hygiene? To advocate newborn circumcision because small boys go camping for three weeks without ever bathing raises other possibilities of operation in lieu of soap, water and instruction in cleanliness. One author has postulated excision of the external ears to eliminate these reservoirs of dirt. Simple vulvectomies of newborn female infants might facilitate cleanliness and reduce risks of vulvitis in young girls as well as carcinoma of the vulva in older women. Fingernails loom as yet another respository of filth and potential disease vector.

Cost-effectiveness

No health program should be evaluated in a vacuum; instead, the benefits of the program should be compared with the benefits that would have accrued had the same funds and energies be expended in alternate programs.¹² Although the health value of newborn circumcision has been alleged, its cost-effectiveness ration remainsto be established.

Routine newborn circumcision constitutes a health program of large proportions, for newborn circumcision is probably the most frequently performed operation in the United States.

With the assumption that 80 per cent of the 1,608,326 males born in 1973 were circumcised, approximately 1,287,000 newborn foreskins were excised during that year. When newborn infants and patients in federal hospitals are excluded, in 1973, the most frequent operation in the United States was diagnostic curettage (934,000 cases).

The cost in dollars of excising 1,287,000 foreskins is substantial. Demetrakopoulos¹³ estimated that circumcising 100 percent of the 1,822,910 born in 1971 would have cost 200 million dollars. A lower figure is probably more accurate. With a physician's fee of $25 and an instrument fee of $15 per case, the cost of circumcising 1,287,000 would be approximately 51 million dollars.

Discussing protection of the medical commons from overgrazing by medical practices of no value or of undetermined value, Hiatt¹⁴ cited numerous procedures once widely practiced in the United States that have now virtually disappeared. Examples include colectomy for epilepsy, gastric freezing for peptic ulcer, wiring of aortic aneurysms, and renal capsule stripping for acute renal failure. Most such practices fell into disuse not because they were supplanted by better procedures but because they were eventually found to be of no medical value. Because they remained on the medical commons too long, valuable heath resources were squandered. Mass campaigns, such as wholesale circumcision, draw money and personnel away from other areas of medicine; if these other areas are more important, then the campaign has a negative effect on the public's health.¹²

Where else might preventive health resources for newborn infants be directed? Immunization programs are health measures of established cost-effectiveness, yet vaccination rates are far too low. The application each year of thousands of medical personnel hours and 51 million dollars toward improving immunization rates for children would result in substantial health benefits. Screening newborn infants for phenylketonuria is another health program with a scientific foundation, clear objectives, measurable outcomes, and demonstrated cost-effectiveness. At a time when health care resources are limited and demands are great, investment each decade of half a billion dollars to trim foreskins appears injudicious.

Hiatt¹⁴ lamented that once a medical practice has been adopted and disseminated it is not quickly abandoned, even when it is shown to be of no benefit. When asked to comment on a medical practice of questionable benefit, however, Pritchard and associates¹⁵ responded emphatically that clinicians ought to use techniques only when certain that they do good; in clinical practice physicians should not have to prove that techniques are not dangerous. Commenting on the Australian Paediatric Society's resolution that newborn male infants should not routinely be circumcised, an editor¹⁶ observed that some subjects die hard, and of all the hardy perennials routine newborn circumcision is amongst the most stubborn.

Comment

The existing literature is inadequate to evaluate appropriately routine circumcision of the newborn infant. On the basis of limited data, however, circumcision of neonates appears to lack sufficient justification. Potential benefits may include facilitation of hygiene and diminution in the risk of cancer of the penis. Lying outside the province of modern surgery, however, the procedure frequently features illogical bases for patient selection, neglect of the requirement to obtain informed consent, an inappropriate operator, needlessly radical technique, disregard for pain, dubious objectives, and unknown cost-effectiveness. Long-term randomized trials will be required to evaluate adequately newborn circumcision and its alternatives. However, until the benefits of routine circumcision of the neonate can be proved worth the risk and cost, medical resources probably should be allocated to measures of demonstrated value.

Reprint requests: Dr. David A. Grimes, Family Planning Evaluation Division, Bureau of Epidemiology, Center for Disease Control, Atlanta Georgia 30333.

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