CIRCUMCISION PROCEDURE

This index contains information about the practical aspects of male circumcision, including:

Introduction

Male neonatal circumcision is a radical invasive non-therapeutic procedure, that removes and destroys a body part having important physiological functions. Rosemary Romberg's classic book, "Circumcision: the Painful Dilemma," is probably the best reference. It shows a circumcision procedure illustrated step-by-step with photographs and drawings (p. 162ff.)

There are illustrations of the circumcision procedure in Edward Wallerstein's classic, "Circumcision: An American Health Fallacy", with a discussion starting on page 204. These pictures have been reproduced in other places, including Jim Bigelow's book "The Joy of Uncircumcising", and "Say No to Circumcision: 40 Compelling Reasons" by Thomas J Ritter MD and George Denniston MD (both from Hourglass, PO Box 171, Aptos CA 95001).

There are documents describing the circumcision procedure:

Other known devices for infant circumcision are: The Ross circumcision ring (similar to Plastibell, but made of metal); the Yellen clamp (looks like a woodworking C-clamp, and works similarly to the Gomco); the Sheldon clamp ("..looks like a nail clipper on steroids..."). Some circumcisions are done with a scalpel by a freehand method. Anaesthesia is rarely used, and the pain is intense with all of these methods (see the section on Pain).

The Mogen clamp reportedly is favored by Jewish mohels because it is said to use the traditional method of ritual circumcision. It is also claimed to be "faster and less painful" by those who advocate its use.

If you would like to read more about the surgical risks of circumcision, the books of Wallerstein, and particularly Romberg (mentioned above) are very helpful. Both of these are unfortunately out of print, but should be available in a good University library. See also Complications.

Doctors: Please review this proposed consent form for infant male circumcision.


Articles

Parent Directory

Child Circumcision

Circumcision Instruments

  1. Gomco clamp Patient Care Magazine 1978; March 15:82-85.
    [CIRP Note: The following reference dicusses the use of anesthesia with the Gomco clamp circumcision. CIRP cautions that the anesthesia used reduces but does not eliminate pain.]
  2. Peleg D, Steiner A. The gomco circumcision: common problems and solutions. Am Fam Physician 1998; September 15:891. (link to www.aafp.org)
  3. Plastibell device CIRP special presentation. (1997)
  4. Kaweblum A. et al. Circumcision using the Mogen clamp. Clinical Pediatrics 1984; 23:679-682.
  5. Reynolds RD. Use of the Mogen clamp for neonatal circumcision. Amer Fam Physician 1996; 54:177-82.
  6. picture of a Sheldon circumcision clamp [CIRP Note: The Sheldon clamp is reported to have been withdrawn from the market by the manufacturer because of lawsuits.]
  7. Tara KLamp disposable circumcision device (manufacturer's literature)
  8. Hill G. "Grandfathered" circumcision devices should be tested for safety and efficacy. BMJ 2002; Rapid response: Oct 18.

Reimbursement and Costs

The Reimbursement Advisor gives advice to medical doctors on how to make claims for reimbursement9 while the Survey of Fees and Practices, reports a survey of the charges for a circumcision by obstetricians from around the United States.10 Mansfield reports on the additional cost of the hospital stay for circumcision.11 Mansfield et al. estimate that in hospital circumcisions result in increased hospital charges for services of $234 million to $527 million in 1990-91. Van Howe reported the cost of a post neonatal circumcision to be $3009 to $3241 per case.12 Bollinger reports data from HCIA-Sachs.15 HCIA-Sachs reports that the total cost of an in-hospital non-therapeutic neonatal circumcision in the United States has risen from $1154 in 1992 to $1869 in 1999, an increase of 62%. The total cost of all in hospital neonatal circumcisions in the United States is reported to be $2.1 billion in 1999. Wayne points out that circumcision fails to meet the HCFA requirements for reimbursement so may be fraudulent.14

  1. Reimbursement advisor: How to get paid for circumcision. OBG Mgmt (Oct 1993), p 25
  2. Garry T. Circumcision: A survey of fees and practices. OBG Mgmt (Oct 1994), pp. 34-36.
  3. Mansfield CJ, Hueston WJ, Rudy M. Neonatal circumcision: associated factors and length of hospital stay. J Fam Pract 1995;41(4):370-376.
  4. Van Howe RS. Neonatal circumcision: associated factors and length of hospital stay (letter). J Fam Pract 1996;43(5):431.
  5. Van Howe RS. Cost effective treatment of phimosis. Pediatrics 1998;102(4):e43.
  6. Wayne EM. Focus on the foreskin, not its destruction. Clin Pediatr 2000; 39(1): 65.
  7. Bollinger D. Intact Versus Circumcised: Male Neonatal Genital Ratio in the United States. Circumcision Reference Library, 22 April 2003.

Cost-Utility Analyses

Cadman et al. (1984) studied the benefits and costs of neonatal circumcision. They concluded that the benefit (alleged prevention of penile cancer) was insufficient to justify the cost, so public health insurance programs should not cover neonatal circumcision.16 Lawler et al.17 (1991) and Ganiats et al.18 (1991) independently concluded that the health effect of circumcision was essentially neutral, that they could not medically justify non-therapeutic neonatal circumcision, and that other factors must be used to support a decision to circumcise an infant. Lawler et al. and Ganiats et al., however, overlooked certain adverse consequences that have now come to the forefront. Chessare (1992) reported that non-circumcision has the highest medical-utility.19 A more recent study by Van Howe (2004) concludes that circumcision has an adverse effect on health, is not good health policy, and that it cannot be justified financially or medically.20

  1. Cadman D, Gafni A, McNamee J. Newborn circumcision: An economic perspective. Can Med Assoc J, 1984;131:1353-5.
  2. Lawler FH. Bisonni RS. Holtgrave DR. Circumcision: a decision analysis of its medical value. Family Medicine. 23(8):587-93, 1991 Nov-Dec. (abstract)
  3. Ganiats TG. Humphrey JB. Taras HL. Kaplan RM. Routine neonatal circumcision: a cost-utility analysis. Med Decis Making. 11(4):282-93, 1991 Oct-Dec. (abstract)
  4. Chessare JB. Circumcision: Is the risk of urinary tract infection really the pivotal issue? Clin Pediatr 1992;31(2):100-4.
  5. Van Howe RS. A cost-utility analysis of neonatal circumcision. Med Decis Making 2004;24:584-601.

Factors Affecting the Circumcision Decision

The following journal articles contain information about the factors that affect the circumcision decision. Hawa Patel (1966) may have been the first to formally study the reasons parents give for making the decision. 21 He found that the decisions are usually based on misinformation or medical myths.22 Daksha A. Patel (1982) reported low levels of physician information.22 He recommended establishment of educational programs.22 Taylor (1983) reported the factors associated with circumcision are a circumcised older brother, and prenatal health care delivered by an obstetrician. Factors associated with no circumcision are the fact that this male is the first born, prenatal health care by a general practitioner, and maternal age of less than 20.23 Metcalf's study (1983) in Salt Lake City found that the three most popular reasons for circumcision were hygiene, social custom, and a circumcised father.24 He also reported that one fourth of the mothers could not remember after six months why they had their son circumcised.24 Enzenauer (1986) found that videotaped counseling is much more successful than oral counseling in reducing the incidence of circumcision.25 Brown & Brown (1987) report that social reasons, including a circumcised father, are the most important reasons that parents choose circumcision.26 Parental education will have little effect according to this study.26 Tiemstra (1999) reported that conditions have not improved much in the fifteen years since earlier studies.27 Tiemstra studied the timing of the parental decision about circumcision. He found that parents tend to make up their mind before they have received circumcision counseling.27 He believes that counseling about circumcision should begin at first patient contact.27 This is much earlier than is commonly practiced in the United States.27

  1. Patel H. The problem of routine circumcision. Canadian Medical Association Journal 95 (Sept 10, 1966): 576-581.
  2. Patel DA, Flaherty EG, Dunn J. Factors affecting the practice of circumcision. Arch J Dis Child 1982;136:634-636.
  3. Taylor PG. Case-control study of counselling against neonatal circumcision. Can. Med. Assoc. J 1983;128:814-7.
  4. Metcalf TJ, Osborn LM, Mariani EM: Circumcision: A study of current practices. Clin Pediatr 1983;22:575-9.
  5. Enzenauer RW, Powell JM, Wiswell TE, et al. Decreased circumcision rate with videotaped counseling. South Med J 1986;79(6):717-720.
  6. Brown MS, Brown CA. Circumcision decision: prominence of social concerns. Pediatrics 1987;80:215-9.
  7. Tiemstra JD. Factors affecting the circumcision decision. J Am Board Fam Pract 1999;12(1):16-20.

Other Information on Male Circumcision Procedure

  1. Spence GR. Chilling of newborn infants: its relation to circumcision immediately following birth. South Med J 1970; 63(3):309-11.
  2. Redmond R. Circumcision variations. Foreskin Quarterly 13, March 1990.
  3. Griffiths D, Frank JD. "Inappropriate circumcision referrals by GPs." J R Soc Med 1992; 85: 324-325.
  4. Childs ND. Many Pediatricians Performing Circumcisions: Survey Tells Who Is Making the Cuts. Pediatric News Vol 31, No 7, Page 34. July 1997.
  5. Stang H, Snellman LW. Circumcision Practice Patterns in the United States. Pediatrics Vol. 101 No. 6 June 1998, p. e5. (Link to AAP Website)
  6. Farshi Z, Atkinson KR, Squire R. A study of clinical opinion and practice regarding circumcision. Arch Dis Child 2000;83:393-396.
  7. Dritsas LS. Below the belt: doctors, debate, and the ongoing American discussion of routine neonatal circumcision. Bulletin of Science, Technology & Society 2001;21(4):297-311.
  8. Spilsbury K, Semmons JB, Wisniewski ZS, Holman CD. Routine circumcision practice in Western Australia. ANZ J Surg 2003;73(8):610-4.
  9. Cathcart P, Nuttall M, van der Meulen J, et al. Trends in paediatric circumcision and its complications in England between 1997 and 2003. Br J Surg 2006;93:885–90.


Adult Circumcision

Procedure

The following article illustrates the adult circumcision procedure. It is a radical, invasive, traumatic procedure with a long painful recovery time. It destroys the physiological functions of the prepuce; it is the most expensive treatment option; and it is the one procedure still promoted by many American doctors for almost any penile problem, even though newer treatment modalities are available. For information on newer effective, conservative, non-invasive, non-traumatic treatment options, see Conservative Treatment of Penile Problems.

  1. Holman JR, Stuessi KA. Adult circumcision. American Family Physician 1999; March 15: 1514. (Link to www.aafp.org)


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(File last revised 7 August 2006)

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