Factors Affecting the Practice of Circumcision

In 1975 the American Academy of Pediatrics (AAP) stated that there is no medical indication for routine circumcision of the newborn.¹ This conclusion followed a review of the pros and cons of circumcision. The AAP also stressed that the final decision should be left to the parents, and that their decision should be based on true informed consent.¹

Grimes² estimated that more than 1 million circumcisions are performed each year in the United States; it is the second most common surgical procedure performed on American males.² Kaplan⁴ estimated that about $60 million are spent annually on routine circumcision.

This procedure is not totally innocuous.^2,4-7 Patel⁸ reported that 55% of the children in his series had some complication, varying from slight oozing of blood to phimosis requiring recircumcision. Complications include hemorrhage, infection, and trauma, including loss of penile skin and mutilation. Meatal ulcers and meatal stenosis may occur as late complications.^6,9 Horwitz et al¹⁰ and Kirkpatrick and Eitzman¹¹ described infants with sepsis, and Berman¹² reported two cases of urinary retention secondary to ritual circumcision.

Since physicians advise parents regarding circumcision, the purpose of this study was two fold: (1) to determine the physicians attitude toward circumcision and what factor's influence those attitudes, and (2) to determine what impact the AAP's recommendations had on these attitudes and on the practice of circumcision in the Chicago area.

METHODS

Questionnaires were sent to all pediatricians, obstetricians, and family practitioners who were listed in the Directory of Medical Specialists.¹³

The survey was directed at those particular physicians because they are the groups most likely to give advice to the family about circumcision of the newborn. Another questionnnaire was sent to the head nurses of perinatal services in the Chicago region to determine whether there was any change in the rate of circumcision of area hospitals between 1976 and 1978. This survey was completed between January 1979 and June 1979. Two hundred seventy six physicians (69% of those solicited) and 18 hospitals (45%) participated in the survey.

RESULTS

Demographic Data

Of the 276 physicians participating in the study, 30% were pediatricians, 21% were obstetricians, 47% were family practitioners, and 2% were other. Twenty-seven percent of the physicians were aged 25 to 40 years; 49% were in the 41 to 55-year age group; and 24% were over the age of 55. More of the pediatricians (38%) were under age 40 than were the other specialists.

The physicians represented a variety of ethic and religious backgrounds. Eighty-seven percent were white, 4% were black, 2% were Hispanic, and 7% listed as other, including Moslem and Hindu. The family practitioners were predominantly Protestant; however, the pediatricians and obstetricians were distributed more or less equally among the Catholic, Protestant, and Jewish faiths.

Physicians' Recommendations

When asked what recommendation they made to mothers, more physicians (41%) recommended that circumcisions be done routinely than recommend that it not be done (15%). However, 38% did not make any recommendation, and 5% did not answer the question. Thus, of 156 physicians who mad a recommendation about circumcision, 76% recommended routine circumcision.

Demographic Factors Affecting the Physicians' Recommendation

Age, specialty, and religion appeared to influence the physicians' approach. Pediatricians (28.9%) were significantly mare likely than the obstetricians (13.0%) and family practitioners (10.2) to recommend against routine circumcision (P<.001). The older physicians more commonly recommended routine circumcision, whereas younger physicians were more likely to recommend against it. Protestant physicians were in favor of routine circumcision more often than the other religious groups, and Jewish physicians were more likely to make no recommendation.

Physicians' Reasons for Recommending Circumcision

The physicians gave as their major reason for recommending circumcision that it was better for hygiene; 90% offered this reason. Thirty percent said it was consistent with their religious or cultural traditions. Twenty-seven percent recommended routine circumcision because they believed it would prevent certain forms of cancer.

The physicians' attitudes about a possible link between circumcision and cancer were specifically assessed. They were asked their opinion about any possible relationship between penile cancer and lack of circumcision. The largest percentage (38%) stated that, in their opinion, the medical literature shows no relationship between the two. A sizeable number (32%) had either no opinion or no answer. The pediatricians (54%) were most likely to take a stand and say no such relationship exists.

The physicians were also asked whether in their opinion the medical literature shows a positive correlation between carcinoma of the cervix and the absence of circumcision in the male partner. Twenty-three percent responded yes, while 48% said there was no correlation between the two. A large number (29%) either gave no answer or stated that they had no opinion. A greater number of pediatricians believed there was no correlation. However, 14% of the pediatricians, 25% of the family practitioners, and 33% of the obstetricians believed there was an association between the two. The differences were significant at the P=.002 level.

Impact of Parents' Wishes on Physician's Recommendation

When physicians who recommended against circumcision were asked, if the parents wanted it done should it be done anyway, 80% replied yes. Forty-three percent of the physicians said that, in their practice parents did have their newborns circumcised despite their recommendation.

Impact of the AAP's Statement on Physicians' Attitudes

The influence of the AAP's position on routine circumcision was then assessed by first determining the level of the physicians' knowledge regarding the recommendations. Only 49% of the physicians were aware of the Academy's recommendations. Age did not influence the response to this question. Pediatricians and obstetricians were equally knowledgeable about the AAP's recommendation. Sixty-two percent of each group knew the AAP did not recommend routine circumcision, whereas only 39% of the family practitioners were aware of the AAP's current recommendations.

Those 128 physicians who knew the AAP's recommendations regarding circumcision were asked if they explained those recommendations to the mothers. Sixty-two percent replied they did. Significantly more pediatricians (75%) discussed these recommendations with the parents, while only 53% of the obstetricians and family practitioners advised the families. Only 24% of these physicians said that they recommended against routine circumcision in their practice. A large number (31%) continued to recommend that circumcision be done, and 45% made no recommendation at all.

Educational Programs

Only 8% of the physicians reported that their hospitals have educational programs informing members of the current recommendations about circumcision. Eighty-two percent of the physicians stated that their hospital did not have such a program, while the other 10% did not answer the question.

The physicians were asked if they had noted a change in the incidence of circumcision in their practice during the last three years (1975 to 1978). The majority of physicians said they had not seen any change. Another 21% reported that the number of circumcisions had decreased.

The hospitals responding to the survey reported an incidence of circumcision varying from 70% to 95%. Three of the hospitals in which more than 1,500 neonates were born per year mentioned that they do not have information easily available; however, most male neonates are circumcised. Only two hospitals had educational programs about circumcision for mothers. Only three hospitals had seen a decline in the incidence of circumcision between 1976 and 1978, and two hospitals were the hospitals that had educational programs. In all of the hospitals, the obstetricians performed the procedure.

COMMENT

Although this survey was conducted in the Chicago area, these results are likely to be representative of other large urban areas since the participating physicians and their patients represented diverse religious and ethnic backgrounds.

The results of this survey emphasize that circumcision is an extremely complex issue influenced by many variables. Despite the AAP's recommendation that there is no medical indication for routine circumcision, a substantial number of physicians continue to recommend routine circumcision of the neonate.

Age, ethnic background, and religion all appeared to have some effect on the physicians' attitudes. Interestingly, Protestant physicians were more likely to recommend routine circumcision, while Jewish physicians, for whom circumcision is a religious ritual, were more likely to make no recommendation.

The most common reason given by the physician for recommending routine circumcision was better hygiene. Good hygiene, however, can be maintained in the non-circumcised male if the parent and later the child are properly educated.

There have been numerous studies in the literature attempting to prove or disprove that circumcision protects against various cancers. There is a growing body of evidence that circumcision does not protect against cancer of the cervix or cancer of the prostate. Handley¹⁴ in 1936 was the first to suggest a link between cervical cancer and non-circumcision. He found that cervical cancer was less common among women whose husbands were circumcised. Khanolkar,¹⁵ however, found just the opposite result in a different population. He showed that there was more cervical cancer in one group of women whose husbands were circumcised when compared with another whose husbands were not. Here, hygiene may have been an important factor. Herpesvirus type 2 has been more recently implicated as playing a major role in causing cervical cancer.¹⁶ Women who have had multiple sex partners, who began having sexual intercourse at an early age, and who have had other venereal diseases are all at an increased risk for cervical cancer. Noncircumcision appears to play no primary role in the etiology of cervical cancer.

Ravich¹⁷ tried to link prostatic cancer to noncircumcision by showing a higher rate of cancer in his non-Jewish patients than in his Jewish patients. However, he failed to match these two groups for age. This is especially important since prostatic cancer becomes more common with advancing age. There are no other studies that convincingly show a relationship between noncircumcision and prostatic cancer.

There is an association, however, between lack of circumcision and carcinoma of the penis. Penile cancer is rare in circumcised men. It is also rare in cultures where men practice good hygiene, for example in Sweden. Hygiene appears to offer as much protection against this cancer as circumcision does.  [ Note: This article is from 1982. For a more recent view on the etiology of penile cancer see: Cold CJ, Storms MR, Van Howe RS. Carcinoma in situ of the penis in a 76-year-old circumcised man. J Fam Pract 1997;44(4) 407-409] 

Despite this evidence, a substantial number of physicians in our survey recommended circumcision to prevent cancer. There are several possible explanations: the physicians may be poorly informed; they may not have found the data convincing; or they were swayed by the beliefs of the population they serve.

Only half of the physicians were aware of the AAP's recommendation, which may account for the position of some. Since this recommendation is more likely to appear in the pediatric and obstetric literature, it is not surprising that this group is more knowledgeable. However, knowledge of the AAP's recommendation did not appear to affect a large number of physicians. About one third of those who knew of the recommendation still recommended circumcision routinely.

Also, a number of physicians did not discuss the AAP's recommendation with the parents. This raises the question as to how many of the physicians, in compliance with current practice, discussed the risks and possible complications of circumcision with the parents. Lovell and Cox¹⁸ found that 80% of the mothers they surveyed had not had the risks of circumcision explained to them. Is, then, the AAP's intent of an educationally informed consent being fulfilled? In our study, certainly most of the hospitals had no educational programs. The two hospitals that did have such a program showed a decrease in the incidence of circumcision. These statistics are interesting, but represent two few hospitals to draw any real conclusions.

It would appear from this study that if the AAP wishes to make an impact on the circumcision decision, they will have to organize educational programs aimed at pediatricians, obstetricians, and family practitioners. Educational material should be made available to pregnant women. Parents-to-be should have the opportunity to discuss their decision in advance of delivery. Only then can a properly informed decision be made by the family.

CONCLUSION

The AAP's 1975 statement that there is no medical indication for circumcision has had little impact on the practice of circumcision in the Chicago area. This is because many factors other than strict medical opinions govern pediatricians', obstetricians', and family practitioners' attitudes about circumcision. Educational programs aimed at primary care physicians, expectant parents, and the public at large should be established to allow for decisions based on informed consent.

From the Department of Pediatrics and Obstetrics, Columbus-Cuneo- Cabrini Medical Center (Drs. Patel and Flaherty), and the  Department of Preventive Medicine,  Northwestern University (Dr. Dunn), Chicago.

Reprint requests to Department of Pediatrics, Columbus Hospital, 2520 N Lakeview, Chicago, IL 60614 (Dr. Patel).

The Circumcision Information and Resource Pages are a not-for-profit educational resource and library. IntactiWiki hosts this website but is not responsible for the content of this site. CIRP makes documents available without charge, for informational purposes only. The contents of this site are not intended to replace the professional medical or legal advice of a licensed practitioner.

  © CIRP.org 1996-2024 | Filetree | Please visit our sponsor and host:  IntactiWiki.