THE CIRCUMCISION REFERENCE LIBRARY
A physician, opposed to routine
circumcision for newborns,
explains why he believes the
risks of this procedure
outweigh the benefits.
By David A. Grimes
Routine circumcision of the newborn, a controversial procedure, has ethical, medical, economic, and psychological significance for all Americans. No other operation today is performed so often for such poorly understood reasons on such unwilling patients in such unlikely settings.
Questioning the value of any routine procedure that is accepted unquestioningly is both prudent and healthy(1). This is particularly true for routine circumcisions because of our lack of knowledge about prevention of penile ailments.
Clinical impressions and untested hypotheses have governed the practice of nontherapeutic circumcision since its emergence in Africa over 5,000 years ago(2). Even today, little scientific knowledge is available. Since nurses play a critical role in caring for newborns, they need to be aware of the controversy regarding circumcision in order to counsel families more effectively about potential benefits and risks of this operation.
Which newborns should undergo circumcision and why? It is difficult to identify candidates for circumcision since the foreskin of 96 percent of newborn males cannot be retracted(3). Thus, phimosis - inability to retract the foreskin, which protects the glans, shares a common epithelium with the latter. As boys get older, separation of this epithelium gradually and progressively occurs, so that by age 16 to 17, phimosis occurs in only one percent of uncircumcised males(4).
Selection of candidates for surgery is based primarily on the mother's wishes. Fathers generally take little interest in the circumcision decision(1,5). The reasons mothers give for deciding to have their sons circumcised suggest that the decision is often irrational. In one study, parents' reason for circumcision included prevention of "rupture," masturbation, or excessive crying(5). In another study, mothers had their sons circumcised because they believed that all males are circumcised, that the circumcision is required by law, that circumcision is mandatory hospital policy, or the the penis would be rendered more aesthetic(6). Other reasons include advice from women's magazines and the belief that circumcision is required for admission to the armed forces.
Circumcision probably facilitates cleaning the penis. But is cleanliness a legitimate indication for surgery? Less drastic measures can usually suffice. Children are customarily taught the use of toilets toothbrushes, soap and water, and instructions in cleaning the genitals may be an effective alternative to surgery(7).
Circumcision may decrease the risk of cancer of the penis, a rare disease in the U.S. Lack of circumcision has been associated with cancer of the penis, but more importantly, so has lack of hygiene(7,8). Carcinoma of the penis is uncommon in men with good hygiene, but circumcision affords little protection where hygiene is poor. No good data support a relationship between lack of circumcision and cancer of the prostate or cancer of the cervix in females.(7).
Circumcision may help boys feel "regular," since most American males are circumcised(9). That male with normal body anatomy should be embarrassed in a locker room suggests that the cultural norms may be distorted, rather than the genitalia in question.
Circumcision of the newborn takes less time and costs less than circumcision of adults, and it avoids the risk of anesthesia associated with the latter. The relative safety of circumcision at these times, however, is unknown.
Is routine circumcision of the newborn economically wise? Assuming that 83 percent of the 1,613,000 boys born in the United States in 1975, approximately 1,339,000 newborn's foreskins were removed that year (10,11). If only one percent of those newborns would have subsequently developed clinically significant phimosis, then 16,000 might have required circumcision later in life(4).
Circumcisions on newborns are done without any anesthesia. Obviously this eliminates the risks of anesthesia, but this practice recalls a more primitive era of medicine. Extending this practice to other procedures, we might envision patients being denied anesthesia during biopsies, vasectomies, or dental extractions.
Some babies die from circumcision, although the risk is small - approximately two deaths per million procedures.(12). Many more babies suffer complications. Estimates of morbidity range form 0.06 percent to 55 percent, reflecting wide differences in definitions and followups(5,12). One study reported an incidence of significant complications, such as life threatening hemorrhage, or completed denudation of the penile shaft of one per 500 circumcisions.(13).
Three types of complications predominate: hemorrhage, infection, and surgical trauma(14). Bleeding may require suturing or transfusion. Wound infection can lead to scarring, deformity, and phimosis. Exposed to the ammonia of wet diapers, the unprotected glans may develop a meatal ulceration, which can lead to meatal stenosis. Surgical mishaps remain a problem often because the operation is referred to the least qualified surgeons - medical students and junior house staff.(15)
Other complications include iatrogenic microphallus (concealed penis), denudation of the shaft, incomplete circumcision with subsequent deformity, lacerated scrotum, subglanular fistula, bivalved, grooved or amputated glans, and cautery burns(14). A tragic example of the last complication led to sloughing of most of the penis of a four-month-old. After two years and a number of unsuccessful attempts to reconstruct the penis, the patient was surgically changed to a female.(13).
Circumcision also affects infant behavior and psychobiology. One group of researchers documented changes in newborns' sleep patterns after circumcision(16). This may be due to the stress of the experience. Others observed an immediate and significant increase in wakefulness, especially fussy crying after the procedure(17). In addition, the responses of circumcised males to auditory stimulation are different from those on noncircumcised males or females. These responses include more time awake and agitated(18). The endocrine response of newborns to circumcision supports the behavioral evidence that the operation is stressful; significant increases in plasma cortisol have been noted 20 minutes and 40 minutes after circumcision(19).
Potential long-term psychological consequences are not known. This lack of information is particularly troubling since the human brain is especially vulnerable to both exogenous and endogenous influences during the interval from the latter part of pregnancy to about 18 months of age. Since animal studies reveal long-term behavioral, physiological, anatomical, and neuro-phamacological effects of minor events in early life, the effects of circumcision on newborns should not be considered short-lived in the absence of evidence to the contrary. Even if the effects were short-lived, they might alter early parent-child interactions and hence later development(10).
In 1975, the American Academy of Pediatrics reaffirmed its position that there are no valid medical indication for circumcision of newborns. "A program of education leading to good personal hygiene would offer all the advantages of circumcision without the attendant surgical risk"(20).
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