CONSENT FOR INFANT CIRCUMCISION

Male circumcision is a procedure where 25-50% of the skin of
penis is removed.  It is important that you understand the well
established risks of the procedure as well as the possible, but
unproven, benefits.


Risks

The following inherent risks are iatrogenic (doctor caused), and
result directly from the neonatal circumcision surgery. 
Significant complications from neonatal circumcision occur in
between 2% to 10% of cases.

1.  Haemorrhage (bleeding): Serious haemorrhage occurs in about
2% of infants, resulting in shock and sometimes death.  While
death is a rare complication of circumcision it does occur.  Boys
with unrecognized bleeding disorders are at risk for serious
haemorrhage.

2.  Infections: Localized or systemic infections (e.g.,
bacteraemia, septicaemia, meningitis, osteomyelitis, lung
abscess, diphtheria, tuberculosis, staphylococcal scalded skin
syndrome, gangrene of the penis and scrotum, scrotal abscess,
impetigo, necrotising fasciitis of the abdominal wall, tetanus
and necrosis of the perineum).  A realistic infection rate is
probably as high as 10%.  Serious infections can cause
irreparable and lifelong harm.  

3.  Urinary Retention: Swelling from the trauma of the surgery,
pain associated with attempts at urination, and sometimes the
Plastibell device (if used) can cause the infant to retain urine,
leading, at times, to acute obstructive uropathy when the bladder
distends to the point of rupture.  

4.  Laceration of penile and scrotal skin: Results in varying
degrees skin tone.

5.  Excessive penile skin loss: Occurs when the prepuce is drawn
forward so that the entire penile skin sheath is removed.  From
puberty on penile bowing (curvature) and pain occurs at the time
of erection.  Pubic hair can be pulled forward onto the penile
shaft with erection and bleeding during sex can occur from shaft
skin tears.  Skin grafts are sometimes required.

6.  Bevelling deformities of the glans (head of the penis):
Varying amounts of the glans are off leaving a scarred bevelled
surface, and at times the entire glans is amputated.

7.  Hypospadias: While this is more frequently a congenital
defect, it can also result from circumcision.  When the frenular
area (underside of the penis) is drawn too far forward, the
crushing bell may injure the urethra at the time the foreskin is
removed, resulting in a urethral opening on the underside of the
shaft.  

8.  Epispadias: When one limb of the crushing clamp inadvertently
is passed into the urethra and closed, it crushes the upper
portion of the urethra and the glans, creating a urethral opening
on the dorsum (top) of the glans.

9.  Retention of the Plastibell Ring: The Plastibell, which
normally falls off in 10 days, may get buried under the skin,
causing ulceration and/or necrosis.  Loss of the glans has also
been reported.

10.  Chordae (permanent bowing of the penis): Often congenital,
this can also result from circumcision.  Dense scarring at the
frenular area causes penile bowing upon erection and may require
plastic surgery to repair.

11.  Keloid Formation: Prominent scars can occur where the
skin-mucous membrane has been incised, crushed or sutured.  

12.  Lymphoedaema: Chronic swelling of the glans due to infection
or surgical trauma which can block lymphatic return.

13.  Concealed Penis: The circumcised penis becomes hidden in the
fat pad of the pubic area, requiring surgery to bring the penis
out again.

14.  Skin Bridges and Penile Adhesions: A common complication
consisting of one or more thick areas of scar tissue that form
bridges between the coronal edge of the raw glans penis (head)
and the raw circumcision wound on the shaft.  For some men these
can be quite painful during erection, restricting the free
movement of shaft skin and pulling on the glans.  

15.  Phimosis of Remaining Foreskin: When only a segment of the
foreskin is removed, the remaining tip sometimes becomes tight
and non-retractable requiring a second surgery.  

16.  Preputial Cysts: Cysts caused by infection or mechanical
distortion blocking the sebaceous glands.  

17.  Skin Tags: Can occur at the circumcision line, representing
an uneven removal of foreskin.  

18.  Loss of Part or All of the Penis: This can be caused by
constricting rings such as the Plastibell or by use of an
electrocautery device.  More frequently the loss is the result
of infection, with the penis becoming increasingly necrotic (dead
tissue) until finally the entire organ falls off.  The proposed
solution in many cases is to raise the child as a girl.

19.  Meatitis: Inflammation of the urethral opening, from loss
of protective foreskin, which can lead to ulceration and meatal
stenosis (narrowing).  Many infants and children suffer this
after their loss of the protective foreskin.

20 Meatal Ulceration: Caused by meatitis and/or abrasions from
dry nappies and from nappies soiled with urine and faeces. 
Meatal ulceration does not occur in the intact male and occurs
in up to 50% of circumcised infants.

21.  Meatal Stenosis: In advanced meatal ulceration, scar tissue
can constrict the urethral opening causing urinary obstruction. 
Meatal stenosis is usually not apparent for several years,
occurring in about 10% of all circumcised infants and not at all
in intact males.  

22.  Progressive loss of glans sensitivity: This is the most
common complaint of adult circumcised men, whereby some men
report stimulation needed to the point of pain to achieve orgasm.

23.  Sexual dysfunction: Including impotence and premature
ejaculation.  

24.  Nonspecific Urethritis: This venereal disease is more common
in circumcised adults.

25.  Gastric rupture: Has been reported associated with prolonged
crying during a
circumcision.

26.  Glans necrosis: The head of the penis can lose it's blood
supply and begin to rot from the scarring that follows
circumcision.

27.  Tachycardia, Heart Failure and Myocardial Injury have been
reported associated with the procedure.

28.  Psychological Trauma: Boys who are circumcised shortly after
birth cry longer and louder when given their primary series of
immunisations.

29.  Death: Occurs at a rate of 1 in 500,000.

Complications From Anaesthesia (if used)

1) Bleeding: Usually consists of small ecchymoses (bruises) at
injection sites at a rate of
around 1.2%.

2) Loss of Blood Supply to the Genitals: This has been reported
following a dorsal penile nerve block where the wrong local
anaesthetic was used.

3) Anaesthetic Failure: The local anaesthetic does not always
work.

4) Methaemoglobinaemia ("blue baby syndrome")


Presumed (but Unproven) Benefits

The American Academy of Pediatrics Task Force on Circumcision in
1975 proclaimed that there is no medical indication for routine
circumcision of the newborn.  The Task Force met again in 1989
and concluded that the procedure may have some potential medical
benefits.  To date, none of these benefits have been conclusively
proven.  

1) Urinary tract infections: A few studies have suggested that
boys who are not circumcised may have a 1% chance of developing
a urinary tract infection.  These studies have all been done
either in military or inner-city hospitals and suffer from
serious methodological flaws.  The one study that has not been
done in military or inner-city hospitals showed a urinary tract
infection rate of 0.12%, which was the same as for boys who were
circumcised.  The risk of urinary tract infections in Sweden
(where none of the boys are circumcised) is 0.5%.  There is also
some evidence that circumcision may help mask the symptoms of
serious urinary tract abnormalities.  At least two studies has
shown that boys circumcised shortly after birth are at higher
risk for urinary tract infections.

2) Penile cancer: There is an association in the United States
between not being circumcised and penile cancer, but now it is
known that most cases of penile cancer are caused by human
papillomavirus which is acquired through sexual intercourse.  In
Denmark and Japan (where none of the boys are circumcised) the
rate of penile cancer is the same as the United States.  More
baby boys die from circumcision than men die of penile cancer. 

3) Phimosis (a narrowing of the foreskin): Occurs in less than
1% of boys.  Of these 80% can be successfully treated with
steroid cream.  The remaining 20% can be treated with plastic
surgery that preserves the foreskin.

4) AIDS: Several studies out of Africa suggest that HIV
infections are more common in men with foreskins, while several
studies have demonstrated that circumcised men are at higher
risk.  The United States has one of the highest rates of
circumcision as well as one of the most rapid increases in HIV
infections in the world.  What is clear is that HIV is most
related to the number of sexual partners and condom use.  

5) Hygiene: A recent study showed no significant difference
between the number of penile problems experienced by boys who
were or were not circumcised.  The boys who were circumcised had
more problems early in life, while the boys who were not
circumcised had more problems later on.  None of the problems
encountered in the studied population were considered serious.


I have read and understand the risks involved in circumcising my
son.  



_____________________________________
Child's mother


_____________________________________
Child's father


_____________________________________
Witness




[Robert S. Van Howe MD; adapted by John D. Dalton]