Do you favor ... routine neonatal circumcision?


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

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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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