MAYO: Many physicians no longer advise routine circumcision of male infants

MANY PHYSICIANS NO LONGER ADVISE ROUTINE CIRCUMCISION OF MALE
INFANTS

Circumcision is one of the most frequent types of elective
surgery performed in the United States.  Yet most patients have
no say in the decision to undergo the operation, and sometimes
the person performing the procedure has not attended medical
school.

Many physicians are skeptical about the potential health benefits
of routine circumcision in newborns.  The American Academy of
Pediatrics, the American College of Obstetrics and Gynecology,
and the Pediatric Urologists Association all say routine
circumcision is unnecessary.  Still, every year, 80 to 90 percent
of all males in this country are circumcised.  The practice
continues to be strongly favored by American parents.

HOW IS CIRCUMCISION DONE?

The procedure removes the foreskin (prepuce) that surrounds and
covers the tip (glans) of the penis.  A special instrument is
used to stretch the skin and pull it away from the end of the
penis.  With a scalpel, the operator removes a sleeve of skin,
leaving the glans uncovered.  In infants, the entire operation
takes only a few minutes to complete.

When done by a skilled physician, complications are infrequent
and rarely serious.  Nevertheless, circumcision is not a minor
procedure.  Meticulous technique is required to avoid problems.

Hemorrhage at the site of the incision is the most common
complication.  A local infection also may occur.  (Infections
nearly always can be remedied by use of an antibiotic ointment). 
Significant injury to the penis itself is rare.

WHY IS IT DONE?

Through the years, circumcision has been performed in many parts
of the world for religious as well as medical purposes, and for
social and cultural reasons.  For example, male infants
circumcision has been and is practiced by people of all the
Semitic races, Jews and Arabs alike.  For the orthodox Jew,
circumcision symbolizes a unique relationship with God.  The
procedure usually is performed by a nonmedical mohel (a ritual
circumciser) on the eighth day of life.  Devout Muslims also
circumcise their sons for religious reasons.

Circumcision is common in parts of Africa and the South Pacific. 
The origin of circumcision in these regions is unknown. 
Sometimes it is performed as a ritual; part of the passage from
puberty to manhood.

In contrast, circumcision never has been common in Europe and
even today is infrequently performed on newborn infants. 
(Perhaps this is why Michelangelo's famous statue depicts Jewish
King David as uncircumcised.)

Still, in our country, circumcision remains popular, even though
responsible medical organizations representing American
pediatricians, obstetricians and urologic surgeons state that
routine circumcision of male infants is neither medically
necessary nor desirable.

ADVANTAGES AND DISADVANTAGES:

Why, then, are we Americans still circumcising our infant sons? 
Advocates of routine circumcision believe the procedure might
serve to prevent cancer of the penis.  They reason that a
circumcised penis is easier to keep clean throughout a lifetime,
and they point to statistics that reveal a lower incidence of
penile cancer among men who were circumcised as infants.

Supporters of circumcision also point out that about 5 percent of
all uncircumcised infants will require the operation later in
life at a time when the surgery is more complex and risky (the
operation sometimes requires a general anesthetic when performed
later in life).

Physicians who oppose routine infant circumcision (they are in
the majority) believe the procedure is of dubious medical value
and point to the small, but definite, risk of complications. 
These physicians say good hygiene offsets the potential for
penile cancer, which is rare in the United States even among
those not circumcised.

CIRCUMCISION LATER IN LIFE:

Although routine circumcision of infants now is discouraged by
many physicians, the procedure still is occasionally appropriate
in adults under certain conditions.  For example, circumcision
may be appropriate:

-if the foreskin cannot be pulled back from the glans (a
condition called phimosis);

-if the foreskin, once pulled back from the glans, cannot be
replaced in its normal position; this may cause swelling and pain
in the glans (paraphimosis); or

-if an infection occurs under the foreskin (balanitis).

MAKING THE DECISION:

Throughout the world, every hour of every day, parents are faced
with the decision of whether to proceed with circumcision.  Today
in America, the decision to circumcise rarely is based on medical
opinion.

For example, in a study done a few years ago at a Baltimore,
Maryland hospital, two groups of parents were evaluated.  One
group had the circumcision procedure explained prior to the
baby's delivery.  They also received a brochure explaining the
medical facts (which indicated little medical need for the
operation in the vast majority of infants).  The other group did
not receive this special instruction.  A follow-up investigation
showed that more than 95 percent of male infants in both groups
were circumcised.

OUR CONCLUSIONS:

In view of the fact that physicians maintain there are few valid
medical indications for the routine use of this surgical
procedure among male infants, why do parents persist in favoring
it?  There is no precise answer.  But tradition and former
physician support probably play a role.  Parents perhaps are
concerned that their son will "look different" from most of his
peers.

Most likely, we will see a gradual shift in opinion and practice
as people throughout our land become more aware of medical facts
about routine circumcision of infants.

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From:
Mayo Clinic Health Letter (Volume 3, Number 10, October 1985)
a publication of the Mayo Clinic
Rochester, Minnesota
U.S.A.  55905

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