Circumcision

There are no absolutes regarding circumcision, and the decision to circumcise a child as a newborn or otherwise must be made after carefully weighing the alternatives to, and risks and benefits of, this common surgical procedure. These alternatives, risks, and benefits must be fully explained to parents considering circumcision, and informed consent must be obtained. In well-trained, experienced hands, circumcision is a safe procedure that effectively eliminates proven problems such as cancer of the penis, and may eliminate the problems of increased risk of urinary tract infection and sexually transmitted diseases.     

Circumcision decision: prominence of social concerns

Despite policy statements against routine circumcision of newborns by the American Academy of Pediatrics and the American College of Obstetrics and Gynecology more than 10 years ago, there has been virtually no change in circumcision practices in the United States. In addition, controlled trials of programs to educate parents about the lack of medical indications for routine newborn circumcision have shown that parental education has little impact on the circumcision decision. We hypothesized that parents based their circumcision decision predominantly on social concerns rather than on medical ones. We prospectively surveyed parents of 124 newborns soon after they made the circumcision decision to learn their reasons for the decision. The strongest factor associated with the circumcision decision was whether or not the father was circumcised (P less than .0001). The survey also showed that concerns about the attitudes of peers and their sons' self concept in the future were prominent among parents deciding to circumcise. The circumcision decision in the United States is emerging as a cultural ritual rather than the result of medical misunderstanding among parents. In counseling parents making the circumcision decision, the health care provider should provide a knowledgeable and honest discussion of the medical aspects of circumcision. Until information is available that addresses parents' social concerns about circumcision, it is unreasonable to expect a significant change in circumcision customs in the United States.     

Male circumcision

Male circumcision consists of the surgical removal of some, or all, of the foreskin (or prepuce) from the penis. It is one of the most common procedures in the world. In the United States, the procedure is commonly performed during the newborn period. In 2007, the American Academy of Pediatrics (AAP) convened a multidisciplinary workgroup of AAP members and other stakeholders to evaluate the evidence regarding male circumcision and update the AAP's 1999 recommendations in this area. The Task Force included AAP representatives from specialty areas as well as members of the AAP Board of Directors and liaisons representing the American Academy of Family Physicians, the American College of Obstetricians and Gynecologists, and the Centers for Disease Control and Prevention. The Task Force members identified selected topics relevant to male circumcision and conducted a critical review of peer-reviewed literature by using the American Heart Association's template for evidence evaluation. Evaluation of current evidence indicates that the health benefits of newborn male circumcision outweigh the risks; furthermore, the benefits of newborn male circumcision justify access to this procedure for families who choose it. Specific benefits from male circumcision were identified for the prevention of urinary tract infections, acquisition of HIV, transmission of some sexually transmitted infections, and penile cancer. Male circumcision does not appear to adversely affect penile sexual function/sensitivity or sexual satisfaction. It is imperative that those providing circumcision are adequately trained and that both sterile techniques and effective pain management are used. Significant acute complications are rare. In general, untrained providers who perform circumcisions have more complications than well-trained providers who perform the procedure, regardless of whether the former are physicians, nurses, or traditional religious providers. Parents are entitled to factually correct, nonbiased information about circumcision and should receive this information from clinicians before conception or early in pregnancy, which is when parents typically make circumcision decisions. Parents should determine what is in the best interest of their child. Physicians who counsel families about this decision should provide assistance by explaining the potential benefits and risks and ensuring that parents understand that circumcision is an elective procedure. The Task Force strongly recommends the creation, revision, and enhancement of educational materials to assist parents of male infants with the care of circumcised and uncircumcised penises. The Task Force also strongly recommends the development of educational materials for providers to enhance practitioners' competency in discussing circumcision's benefits and risks with parents. The Task Force made the following recommendations:Evaluation of current evidence indicates that the health benefits of newborn male circumcision outweigh the risks, and the benefits of newborn male circumcision justify access to this procedure for those families who choose it. Parents are entitled to factually correct, nonbiased information about circumcision that should be provided before conception and early in pregnancy, when parents are most likely to be weighing the option of circumcision of a male child. Physicians counseling families about elective male circumcision should assist parents by explaining, in a nonbiased manner, the potential benefits and risks and by ensuring that they understand the elective nature of the procedure. Parents should weigh the health benefits and risks in light of their own religious, cultural, and personal preferences, as the medical benefits alone may not outweigh these other considerations for individual families. Parents of newborn boys should be instructed in the care of the penis, regardless of whether the newborn has been circumcised or not. Elective circumcision should be performed only if the infant's condition is stable and healthy. Male circumcision should be performed by trained and competent practitioners, by using sterile techniques and effective pain management. Analgesia is safe and effective in reducing the procedural pain associated with newborn circumcision; thus, adequate analgesia should be provided whenever newborn circumcision is performed.Nonpharmacologic techniques (eg, positioning, sucrose pacifiers) alone are insufficient to prevent procedural and postprocedural pain and are not recommended as the sole method of analgesia. They should be used only as analgesic adjuncts to improve infant comfort during circumcision. If used, topical creams may cause a higher incidence of skin irritation in low birth weight infants, compared with infants of normal weight; penile nerve block techniques should therefore be chosen for this group of newborns. Key professional organizations (AAP, the American Academy of Family Physicians, the American College of Obstetricians and Gynecologists, the American Society of Anesthesiologists, the American College of Nurse Midwives, and other midlevel clinicians such as nurse practitioners) should work collaboratively to:Develop standards of trainee proficiency in the performance of anesthetic and procedure techniques, including suturing; Teach the procedure and analgesic techniques during postgraduate training programs; Develop educational materials for clinicians to enhance their own competency in discussing the benefits and risks of circumcision with parents; Offer educational materials to assist parents of male infants with the care of both circumcised and uncircumcised penises. The preventive and public health benefits associated with newborn male circumcision warrant third-party reimbursement of the procedure. The American College of Obstetricians and Gynecologists has endorsed this technical report.     

Neonatal circumcision.

The merits of neonatal circumcision continue to be debated hotly. Some argue that circumcision is a "uniquely American medical enigma." Most of the world's male population remains uncircumcised; however, most boys born in the United States continue to undergo neonatal circumcision. Review of existing literature supports that most children who are uncircumcised do well from a medical standpoint and, thus, the question of whether US health care practitioners are subjecting neonates to an unnecessary surgical procedure remains. The medical benefits of circumcision are multiple, but most are small. The clearest medical benefit of circumcision is the relative reduction in the risk for a UTI, especially in early infancy. Although this risk [figure: see text] is real, the absolute numbers are small (risk ranges from 1 in 100 to 1 in 1000), and one investigator has estimated that it may take approximately 80 neonatal circumcisions to prevent one UTI. In the case of a patient with known urologic abnormalities that predispose to UTI, neonatal circumcision has a clearer role in terms of medical benefit to the patient. Most of the other medical benefits of circumcision probably can be realized without circumcision as long as access to clean water and proper penile hygiene are achieved. Proper penile hygiene should all but eliminate the risk for foreskin-related medical problems that will require circumcision. Moreover, proper hygiene and access to clean water has been shown to reduce the rate of development of squamous cell carcinoma of the penis in the uncircumcised population. Proper techniques on the care of the foreskin are illustrated in the American Academy of Pediatrics pamphlet titled "How to care for the uncircumcised penis." Regarding the relationship between STDs and circumcision, patient education and the practice of low-risk sexual behavior make a far greater impact than does routine circumcision in hopes of reducing the spread of HIV and other STDs. Nevertheless, in areas where safe sexual practices are poorly adhered to, circumcision can have a relative protective effect against the transmission of HIV and other STDs. The medical harms of circumcision lie mainly in the 1% acute complication rate and the additional patients who require revision of their initial circumcision for cosmetic or medical reasons. Anecdotally, the authors see far fewer complications in the acute and long-term phase when the circumcision has been performed by someone with expertise and experience with the procedure. Thus, the authors routinely recommend to parents that, if they choose to have their newborns circumcised, they should seek out an experienced practitioner. A negative psychologic and sexual impact of circumcision has been argued, but solid, scientific data are lacking. Special interest groups have argued that perhaps the greatest harm of circumcision is in performing an operation without a clear indication. Many of these groups have claimed that performing a routine neonatal circumcision is akin to performing a surgical procedure without a clear medical benefit, and in an infant, that is akin to surgery without informed consent. Although this is an extreme posture, the clinician can understand the emphasis on trying to provide invasive medical services only when a clear medical benefit is expected, especially when treating an infant or child. Deciding whether or not to circumcise an infant continues to challenge many new parents. Clearly, the procedure provides potential medical benefits and potential risks. It is difficult to say whether the benefits outweigh the risks for all male infants. Further complicating the decision for many American parents is that, in some areas of the United States, there exists an unexplained positive cultural connotation with neonatal circumcision. For these reasons, parents who actively choose to keep their sons uncircumcised need to be encouraged to make this decision forthrightly. Parents who choose to have their children circumcised also should be encouraged to actively seek an experienced practitioner who can afford the child adequate local analgesia.     

Circumcision policy statement

Male circumcision is a common procedure, generally performed during the newborn period in the United States. In 2007, the American Academy of Pediatrics (AAP) formed a multidisciplinary task force of AAP members and other stakeholders to evaluate the recent evidence on male circumcision and update the Academy's 1999 recommendations in this area. Evaluation of current evidence indicates that the health benefits of newborn male circumcision outweigh the risks and that the procedure's benefits justify access to this procedure for families who choose it. Specific benefits identified included prevention of urinary tract infections, penile cancer, and transmission of some sexually transmitted infections, including HIV. The American College of Obstetricians and Gynecologists has endorsed this statement.     

Attitudes and decision making about neonatal male circumcision in a Hispanic population in new york city

Objective. To understand attitudes and decision making regarding neonatal male circumcision. Methods. Parents (n = 150) with a son 3 years old were interviewed regarding demographics, communication with a medical provider, attitudes, and process by which the neonatal circumcision decision was made. Results. Thirty-three percent of sons were circumcised. In univariate analyses, choosing male circumcision was associated with parents being interviewed in English, the father being circumcised, positive attitudes, being informed of the advantages of circumcision, making a decision before birth, and being offered a choice. In the final model, parents who came from a culture and family that believed in circumcision and who believed that it was not too risky were more likely to circumcise their sons. Conclusions. Decisions regarding circumcision appear to be influenced by values, risk perceptions, and medical providers. Future research should address ways of ensuring that families have the opportunity to make an informed decision.     

Circumcision for prevention of penis and cervix cancer? Results of a parent survey]

Results of questioning young parents--582 by direct questioning and 624 by questionnaires--about their knowledge of male circumcision are presented. 61% of those directly questioned and 24% of parents polled by questionnaire did not know what circumcision means. The older the parent and the higher their professional qualifications, the greater their knowledge. Reasons for circumcision were divided into four categories: surgical, hygienic, prophylaxis of cancer and cosmetic. Health education about genital hygiene and circumcision is necessary.     

Circumcision: is the risk of urinary tract infection really the pivotal issue?

Recent information regarding the increased risk of urinary tract infections in the first year of life for uncircumcised boys has created confusion regarding the appropriate guidance to be given to parents confronting the circumcision issue. A decision model was built that addressed the question of whether or not to circumcise a newborn male considering the probability of a non-circumcised boy having a UTI in the first year of life (0.041), the probability of a circumcised boy having a UTI in the first year of life (0.002), and the likelihood of renal scarring from a UTI (0.075). After considering the morbidity associated with the procedure, all possible outcomes were ranked from worst to best (circumcised-renal pathology to uncircumcised-no infection) and given a value on a 0 to 1 scale. For the set of values assigned to the outcomes, the choice of no circumcision yielded the highest expected utility. For the set of assigned utilities, sensitivity analysis showed that unless the probability of a UTI in the first year of life for an uncircumcised male was greater than or equal to 0.29, then non-circumcision was still the preferred choice. The decision was most sensitive to the degree of aversion to the morbidity associated with the procedure (pain, bleeding, inflammation).     

Circumcision. A study of current practices

The purpose of this study was to investigate the current incidence of circumcision, the reasons governing parental decisions regarding circumcision, the immediate and later complications from the procedure, as well as genital problems occurring in uncircumcised boys. The incidence of circumcision was found not to have changed over the past five years despite the recommendations of the American Academy of Pediatrics Task Force on Circumcision. The reasons given for circumcision reflected mostly the strength of tradition, rather than a medical approach. Four per cent of newborns experienced early complications from the procedure, whereas 13 per cent experienced later, minor complications. Problems reported in uncircumcised infants were probably variants of normal. While the results of this study and evidence for discontinuing neonatal circumcision, we strongly recommend that, if physicians dissuade parents from having their infants circumcised, they must give adequate information concerning hygiene and the slow, natural separation of the foreskin from the glans.     

Critical evaluation of unscientific arguments disparaging affirmative infant male circumcision policy

We evaluate recent claims opposing infant male circumcision, a procedure now supported by the evidence-based policy of the American Academy of Pediatrics. We find those criticisms depend on speculative claims about the foreskin and obfuscation of the strong scientific evidence supporting pediatric policy development. An argument that circumcision should be delayed to allow a boy to make up his own mind as an adult fails to appreciate the psychological, scheduling and financial burdens later circumcision entails, so reducing the likelihood that it will occur. In contrast, early infant circumcision is convenient, safer, quicker, lower risk, healing is faster, cosmetic outcome is routinely good and the lifetime benefits accrue immediately. Benefits include reduction in urinary tract infections, inflammatory skin conditions, foreskin problems, and, when older, substantial protection against sexually transmitted infections and genital cancers in the male and his female sexual partners. Some authorities regard the failure to offer parents early infant circumcision as unethical, just as it would be unethical to fail to encourage the vaccination of children. In conclusion, the criticisms of evidence-based infant male circumcision policy are seriously flawed and should be dismissed as unhelpful to evidence-based development and implementation of pediatric policy intended to improve public health and individual wellbeing.     

Circumcision controversies

Despite its long history and common practice, circumcision remains a controversial procedure. This article reviews the history of this operation, examines the controversy that surrounds it, and emphasizes the performing practitioner's responsibility to the patient and his family in guiding them through the complicated decision making surrounding newborn circumcision.     

Circumcision policy: A psychosocial perspective

The debate about the advisability of circumcision in English-speaking countries has typically focused on the potential health factors. The position statements of committees from national medical organizations are expected to be evidence-based; however, the contentiousness of the ongoing debate suggests that other factors are involved. Various potential factors related to psychology, sociology, religion and culture may also underlie policy decisions. These factors could affect the values and attitudes of medical committee members, the process of evaluating the medical literature and the medical literature itself. Although medical professionals highly value rationality, it can be difficult to conduct a rational and objective evaluation of an emotional and controversial topic such as circumcision. A negotiated compromise between polarized committee factions could introduce additional psychosocial factors. These possibilities are speculative, not conclusive. It is recommended that an open discussion of psychosocial factors take place and that the potential biases of committee members be recognized.     

Circumcision for phimosis--indications and results

A follow-up study including all boys (n = 117) operated with circumcision for phimosis during 1976 was performed. Most patients were operated on an outpatient basis. Early complications like bleeding or infection were few and mild. In 13 cases there was a postoperative stricture of the urethral orifice which had to be widened. Five patients had complaints about the cosmetic result. Eight boys expressed shyness and unwillingness to undress in school gym. In no instance were there any signs of a more serious psychological disorder. The operative indications are discussed and it is concluded that worried parents of boys with phimosis can be safely advised to have their boys circumcised if the prepuce is scarred or there has been recurrent balanitis, or if the boy has reached school age and the foreskin is still unretractable.     

Circumcision for Phimosis–Indications and Results

ABSTRACT. A follow-up study including all boys ( n = 117) operated with circumcision for phimosis during 1976 was performed. Most patients were operated on an outpatient basis. Early complications like bleeding or infection were few and mild. In 13 cases there was a postoperative stricture of the urethral orifice which had to be widened. Five patients had complaints about the cosmetic result. Eight boys expressed shyness and unwillingness to undress in school-gym. In no instance were there any signs of a more serious psychological disorder. The operative indications are discussed and it is concluded that worried parents of boys with phimosis can be safely advised to have their boys circumcised if the prepuce is scarred or there has been recurrent balanitis, or if the boy has reached school age and the foreskin is still nnretractable.     

Knowledge of and attitude towards circumcision of adult Korean males by age

AIM: Circumcision is widely practised in Korea, but little is known regarding the public's attitude towards circumcision. This study was designed to evaluate the knowledge and the general opinion of Korean adult males towards circumcision. METHODS: Fifteen hundred self-completion questionnaires were distributed to adult males in five decadal age groups ranging from 10 to 59 y old. Questions concerning opinions regarding the necessity, reasons, potential benefits and disadvantages of circumcision, as well as the role of peer pressure upon the decision to circumcise were included. Completed questionnaires were collected and analysed statistically. RESULTS: The achieved response rate was 62.7%. 73.1% believed that circumcision is necessary, while 7.1% believed it is not necessary. The principal reason for circumcision was to improve penile hygiene (77.9%). 68.7% did not prefer neonatal circumcision regardless of the respondent's age. The major reason was fear of pain (36.9%). Peer pressure was one of the most influential factors when deciding upon circumcision: 60.8% believed that they might be ridiculed by their peer group unless circumcised, and the younger the age of the respondent, the more frequently this opinion was held (p < 0.05). 62.7% thought that circumcision would prevent genital tract infection of the sexual partner. Respondents with older age tended to emphasize improved sexual potency (p < 0.05). CONCLUSIONS: This study indicates that common beliefs of adult males about circumcision in Korea are relatively homogeneous. Tailored education about circumcision is needed.     

Circumcision — Maternal attitudes

The medical profession is basically opposed to newborn circumcision. The practice is still common, however, and in an attempt to find out why this is so, a survey to determine maternal attitudes towards circumcision was carried out. In addition, the whole practice of circumcision is reviewed in an attempt to rationalize the arguments and to put the problem into perspective. Offprint requests to: P. A. King     

The ethics of cardiopulmonary resuscitation. I. Background to decision making.

Futile cardiopulmonary resuscitation (CPR) may prevent humane care of the dying child and deprive parents of the opportunity to express their love, grief, and dedication at a critical moment, while appropriate and successful CPR may restore intact their child. Attempted resuscitation of corpses or children with terminal illness indicates inadequate knowledge, discrimination, and decision making. CPR is a medical procedure applicable to certain medical problems; weighing up the risks and benefits in each individual case is a medical function that is constrained by the law and must take full note of patient and family preferences, but cannot be governed by them and should not be over-ruled by laws based on complex but different cases. Time limits on occasions may curtail the full process of consultation and decision making. Applications of skills and resources in the right time and place requires understanding of the medical logistics and study of the potential for good outcome.     

Circumcision of the young infant in a developing country using the Plastibell

Circumcision of the male infant by conventional methods is common practice in Tanzania. This study reports the use of the Plastibell to circumcise 386 young infants between 1992 and 1998 and shows differences in age at circumcision between African and Asian infants. The Plastibell has been found to be cheap and easy to use and was associated with minor, remediable complications in less than 3% of infants.     

Circumcision for the prevention of urinary tract infection in boys: a systematic review of randomised trials and observational studies.

OBJECTIVE: To undertake a meta-analysis of published data on the effect of circumcision on the risk of urinary tract infection (UTI) in boys. DATA SOURCES: Randomised controlled trials and observational studies comparing the frequency of UTI in circumcised and uncircumcised boys were identified from the Cochrane controlled trials register, MEDLINE, EMBASE, reference lists of retrieved articles, and contact with known investigators. METHODS: Two of the authors independently assessed study quality using the guidelines provided by the MOOSE statement for quality of observational studies. A random effects model was used to estimate a summary odds ratio (OR) with 95% confidence intervals (CI). RESULTS: Data on 402,908 children were identified from 12 studies (one randomised controlled trial, four cohort studies, and seven case-control studies). Circumcision was associated with a significantly reduced risk of UTI (OR = 0.13; 95% CI, 0.08 to 0.20; p<0.001) with the same odds ratio (0.13) for all three types of study design. CONCLUSIONS: Circumcision reduces the risk of UTI. Given a risk in normal boys of about 1%, the number-needed-to-treat to prevent one UTI is 111. In boys with recurrent UTI or high grade vesicoureteric reflux, the risk of UTI recurrence is 10% and 30% and the numbers-needed-to-treat are 11 and 4, respectively. Haemorrhage and infection are the commonest complications of circumcision, occurring at rate of about 2%. Assuming equal utility of benefits and harms, net clinical benefit is likely only in boys at high risk of UTI.