© CIRP.org 1996-2024 | Please visit our sponsor and host: IntactiWiki.DO YOU FAVOR . . ROUTINE NEONATAL CIRCUMCISION? Thomas Metcalf, MD Clinical Associate Professor, Department of Pediatrics University of Utah School of Medicine Salt Lake City, Utah Address for correspondence: Thomas Metcalf, MD Willow Creek Pediatrics 7138 S 2000 E., Suite #106 Salt Lake City, Utah 84121 -------------------------------------------------------------- NO WHY? Routine neonatal circumcision has always struck me as a socially motivated surgical procedure looking for a valid medical raison d'etre, not unlike piercing the ears of teenage girls so they will be more acceptable to their peers and then looking for some medical reason for doing so (e.g., hypothesizing that the open wound stimulates the immune system and thereby improves their resistance to infection). We need to continually reexamine our motives for performing circumcision as a prophylactic procedure and use available data to sway the thinking of society and parents. Wallerstein documented circumcision's nonreligious origins as an American and British tradition during the 19th century. The previous century had seen a growing concern about masturbation, perhaps in response to earlier onset of puberty in Western European children and as a product of middleclass sexual concepts. Physicians in English- speaking countries adopted circumcision as cure for masturbation during the latter part of the 19th century. As the list of purported ailments caused by masturbation grew, various authors advanced circumcision of both boys and girls as a cure for masturbatory insanity and other ills. In the United States, the rate of circumcision, according to the best available data, rose from 8% in the 1870s to 56% by 1910 to 75% in 1941 in selected urban hospitals to a high of 90% to 98% during the mid-1970s. Even after the American Academy of Pediatrics and American College of Obstetricians and Gynecologists took a stand against the need for routine neonatal circumcision, no published reports have documented large-scale declines in circumcision rates in the United States, except among dependents of US Army personnel. England, Canada, Australia, and New Zealand all showed rates of circumcision similar to those of the United States until the early 1950s, when rates began to fall, in part because of published findings that questioned a need for the procedures. The rates are now drastically reduced in Britain and are much lower in most of Canada, New Zealand, and Australia than in the United States. Eighty percent of the world's cultures have never circumcised males and still do not. Religious ritual circumcision continues for Muslims, Jews, selected black Africans, nonwhite Australians, and some others, but the United States stands rather alone in its persistently high rates of circumcision for nonreligious reasons. In Norway, with a circumcision rate of 0.02%, foreskin problems are treated medically, not surgically. WHAT ARE THE UNIQUE BENEFITS? While the role of circumcision in prevention of various venereal diseases has never been resolved, the recent spate of literature on the possible link between circumcision and reduction of infant urinary tract infections is perhaps the most significant medical argument for circumcision to be advanced to date. Wiswell and colleagues have produced good data from three retrospective studies of 427,698 infants born in all US Army hospitals from 1974 through 1985, showing a decrease in newborn circumcision rates from 85% to 70.5% and a concomitant increase in urinary tract infections chiefly among uncircumcised male infants. The authors recommended that counseling of parents before circumcision include the data regarding increased risk of urinary tract infection in uncircumcised infants. At the November 1987 annual meeting of the American Academy of Pediatrics, J.A. Roberts, MD, presented results of studies showing that certain Escherichia coli adhere to the mucosal surface of the foreskin removed from newborns, and he believes this is the direct link with increased prevalence of urinary tract infection in uncircumcised male infants. The American Academy of Pediatrics formed a task force to reevaluate the evidence and see if its position on circumcision should be changed. WHAT ARE THE OTHER AREAS OF CONTROVERSY? Controversy has, in general, most recently been directed toward whether circumcision prevents certain types of cancer, contributes to heightened cleanliness, and reduces the incidence of problems with the foreskin or penis when the patient is older. Prevention of Cancer: When penile carcinoma is found, it is nearly always in a patient whose personal hygiene was strikingly minimal. Little protection is afforded by circumcision in men who have a high standard of hygiene. In 1975 the American Academy of Pediatrics stated that optimal hygiene confers as much or nearly as much protection from penile carcinoma as circumcision. An explanation by the physician during the hospital visit with a new parent, plus a comment during physical examination at each well-child visit, will ensure that the parent know how, and can teach the son how, to gently retract and wash the foreskin and glans. Ravich postulated that the incidence of cervical and prostatic carcinoma was decreased by circumcision but noted that where penile hygiene increased, cervical carcinoma in partners decreased. Thorough review by Preston of the data of Ravich and Apt laid to rest concerns about both cervical and prostatic carcinoma. Circumcision has not been shown to be a determinant, but studies of truly comparable populations are lacking. In the meantime, we should not perpetuate a painful surgical procedures if soap, water and a brief education will suffice. Hygiene: American parents and even their physicians are only slowly learning about the care of the foreskin and the normal progression of retraction as the infant matures. Many American physicians have continued either to circumcise or to forcibly retract the foreskin of newborns to make it easier to keep clean. Boyce and the American Academy of Pediatrics have published guidelines on caring for the uncircumcised penis, which may also be applied to care of the circumcised penis, since many circumcisions are incomplete. The foreskin does retract with time, but the parent needs instruction in its care before and after it does so. If poor hygiene is a risk for the uncircumcised penis, it is also a risk for the circumcised put partially hooded penis. Prevention of Later Problems: Physicians' reasons for recommending routine circumcision have included prevention of balanitis, posthitis, balanoposthitis, phimosis, and foreskin adhesions. Herzog and Alvarez reported a retrospective study of 273 circumcised and 272 uncircumcised infants, aged 4 months to 12 years. Balanitis occurred in 5.9% of uncircumcised and 2.9% of circumcised boys; phimosis with accompanying symptoms (as determined by a physician) in 2.6% of uncircumcised and 0.4% of circumcised boys; and foreskin adhesions in 4% of each group. Paraphimosis occurred in two uncircumcised boys. They reported that the boy's ethnic group was as important a feature in determining the frequency of complications as was circumcision (Hispanics reported more complications in both groups) and that although the overall frequency of complications was higher among uncircumcised boys, most of the problems were minor. Ferguson and colleagues more recently reported a longitudinal study of 500 boys in New Zealand. During infancy, circumcised boys had more problems. Later, uncircumcised boys had more problems. The authors stated that "it is unclear whether good hygiene can offer the alleged benefits of neonatal circumcision." It appears that foreskin problems in uncircumcised children are minor and no more frequent than problems with other body parts. The problems that do occur can be treated medically instead of surgically. i believe that until a prospective study is carried out in two comparable populations, the usually minor problems of uncircumcised children can be adequately prevented or treated through education. WHAT ARE THE DRAWBACKS? Circumcision hurts, whether it is done during the newborn period or later in life. This has been well researched in documenting the efficacy of the penile dorsal nerve block for newborn circumcision. Although it hurts less with use of a lidocaine (Xylocaine) block, even then it could not be described as painless because the block itself hurts and is not always fully effective. A few physicians defend not using the block by saying that they perform the circumcision so quickly the child feels less pain from the procedure than he would from the block. I believe that either these physicians do not want to spend the time involved in using the block or have not read the documentation on the issue. I find that waiting five minutes after injection of the block increases anesthetic efficacy to essentially 100%. Even so, circumcision causes needless pain: better it were not performed at all. WHAT ARE THE COST RAMIFICATIONS? The three issues involved in routine neonatal circumcision are (1) the cost to the public, insurance industry, and Medicaid, (2) the profit physicians make from doing the procedure, and (3) the cost versus profit of having a urologist do a therapeutic circumcision later in the person's life if problems arise. A urologist in Salt Lake City (A.W. Middleton, Jr., personal communication, 1984) described the following scenario: In one year in his practice, he performed circumcisions on 55 adults. Since 80% of American men at that time were circumcised, he figured that the 55 represented some of the initially uncircumcised 20% who later required therapeutic circumcision. he predicted that if we were to stop circumcising newborns, up to five times this 55, or 275 adults, might well need circumcision later. Thus he said, "I advocate you all stop circumcising infants, because we'll get them later on." He cited a Canadian study, in which the cost of circumcision on 34,000 newborns in one year in Ontario was about $1 million. During the same year, 4,600 therapeutic circumcisions performed on children and adults cost $2.4 million, plus lost wages, which added perhaps another $1 million. The cost, if all infants had been circumcised, would be about $2 million; if none were, the cost for subsequent procedures would be $6.8 million. Thus, there would be a saving of more than $4 million if all infants were circumcised as newborns. Recent circumcision rates in Ontario have been noted as 60% in 1974 and 53% in 1979. While this rate is lower than that in the United States, it may still be that Canadians are not yet as used to dealing appropriately with the uncircumcised foreskin as are Europeans and thus have a higher rate of later therapeutic circumcisions than might be expected in a society more used to being uncircumcised. In his landmark study of 1968, Oster stated that phimosis has a diminishing incidence as childhood and adolescence progresses. he went on to say that physiologic phimosis is rare and tends to regress spontaneously; surgery is rarely indicated, he wrote. However, "clumsy attempts at retraction probably cause secondary phimosis, which requires operation." These findings were gathered in Denmark, where "the prepuces had not been the object of interest or of manipulation by doctors or parents, because in Denmark such a tradition has never existed." Perhaps if physicians in the United States spent more time reading the literature from societies that are accustomed to caring for the uncircumcised penis, both prophylactic circumcision of the newborn and later therapeutic circumcision could be eliminated, thereby saving costs at both ends of the spectrum. Would I give up the $55 I charge parents or insurance companies for each neonatal circumcision? To be fair, only 65% of this fee is returned to our practice from three of the eight health maintenance organizations with which we deal and from Medicaid. Circumcision is nevertheless a source of income. however, I would gladly let it pass the way of routine rectal dilation and clipping of the lingual frenulum in newborns. If circumcision is required later in a small number of adolescents or adults, I would be pleased to have it performed by a urologist. WHAT ARE YOUR RECOMMENDATIONS? Parents continue to want to have their infant sons circumcised, and their reasons differ little from those of ten year ago. Reasons most often given for wanting circumcision for their child include cleanliness; prevention of later problems; prevention of infection or cancer; appearance similar to father, brother, or other boys; and custom or personal preference. Reasons most often given for not having circumcision done include "I just don't think it should be done" (highest percentage), that it is not medically important, it hurts too much, the baby's father is not circumcised, and the choice is being left to the child when he is older. I find that the parents have usually made their decision by the time I discuss the issue with them. Of course, I can refuse to do the procedure, but the ideal is that the attitude of American parents change. This will likely result from organized advocacy of lay groups (as has happened with breast-feeding and family-centered care) and from counseling by physicians. Insurance carriers' decisions to pay or not pay for the procedure may also play a role. When parents ask me if they should circumcised their child, I reply that I advise against it, given the present data. I believe the penis is delivered in its natural state and that with proper hygiene it will do just fine as it is. I tell them I do not believe that circumcision is necessary to prevent cancer of the penis or cervix, and that later phimosis and balanitis are very unlikely if good hygiene is maintained. If a son is uncircumcised and his father is circumcised, the father can explain that his parents decided to have him circumcised when he was a baby, but that it is more natural not to be circumcised. I tell parents that the junior high and high school boys I have talked to in my practice claim to have no idea of which kids in their gym classes are circumcised and which are not, that they usually do not shower after class (to my surprise!), and say they would not notice anyway. I tell parents to leave the baby's uncircumcised penis alone until the two-week visit, and at that time I describe how to retract the foreskin gently with each bath, wash it with soap, and rinse it well. I tell them to teach the boy this same technique as he begins to wash himself. I tell them that there are some apparently good data indicating that uncircumcised infant boys may have a higher risk of urinary tract infection, and that although the risk is small and the data need to be confirmed, they should figure this into their decision. If they seem unsure at the prenatal or newborn hospital visit, I give them a handout to read and ask them to think about it. I assure them that the circumcision can be done, with lidocaine block, with no more pain at the two-week visit than immediately after birth. WHAT FUTURE DEVELOPMENTS ARE LIKELY? I maintain that for the present, there is no justifiable role for prophylactic newborn circumcision. The vast majority of men worldwide seem to be doing just fine without being circumcised, and I think the United States would do well to emulate other societies. The risk of urinary tract infection may be significantly increased in uncircumcised infant boys; if this is confirmed, I will change my thinking and my advice to parents. If not, physicians should speak out against routine circumcision, and encourage lay advocacy groups to use their influence to change American habits.
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