THE CIRCUMCISION REFERENCE LIBRARY
From the Department of Pediatrics,
University of Utah Medical Center,
Salt Lake City, Utah.
Lucy M. Osborn. M.D.
Department of Family Medicine,
University of Utah Medical Center,
50 Medical Drive, Salt Lake City, UT 84132.
Received for publication December 1982. revised March 1983, and accepted April 1983.
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 add 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.
THE AMERICAN ACADEMY OF PEDIATRICS Ad Hoc Task Force on Circumcision of the Committee on Fetus and Newborn stated, in 1975, that "there is no absolute medical indication for routine circumcision of the newborn." The Committee further recommended that physicians provide parents with information pertaining to the long-term medical effects of circumcision and non-circumcision, so that they can make a thoughtful decision," that the discussion be a prenatal one, and finally that "a program of education leading to continuing good personal hygiene offers all the advantages of routine circumcision without the attendant surgical risk."1 Review of the literature reveals little change in the 80 to 98 per cent incidence of circumcision in the United States before and after that statement.2-5 The incidence of neonatal circumcision for non-religious reasons in the United States is significantly higher than in other countries.6 The controversy continues regarding the questions of need, risks, benefits, and cost.7-9 Gellis10 has interpreted these data to indicate that physicians "have not been convinced that circumcision is of little benefit" and have, thus, been reluctant to discourage this practice. The purpose of this study was to examine medical and social issues which we felt to be related to our continuing high rate of circumcision. This included assessment of (1) the incidence of circumcision in Utah, (2) perceptions of circumcision by parents, (3) who counsels about and/or performs circumcisions, (4) immediate and later complications resulting from the procedure, and (5) genital problems occurring in circumcised and uncircumcised boys.
The study was divided into four parts:
1. Hospital and Medical Records Survey. Telephone contacts were made with the Medical Records Departments of all 34 hospitals in Utah. Sixteen of these had records which were adequate to determine the rate of circumcision in infants born during 1978. Additionally, since one hospital, Latter Day Saints Hospital in Salt Lake City, accounts for approximately 12 per cent of Utah's births, the records of this hospital were reviewed for the period 1974 to 1979 to detect changes in circumcision rates.
2. Newborn Study. A prospective study was conducted in the normal newborn nursery of the University of Utah Medical Center and in a community hospital in Salt Lake City. Nurses interviewed mothers of 131 consecutive, newly circumcised male infants. The mother was asked the reason for the circumcision, whether she had been counseled about the procedure, and by whom. The nurse then reviewed the child's chart for his race, who performed the circumcision, and whether a complication had occurred following the procedure.
3. Telephone Study. A telephone survey of new mothers was conducted. Contacts were made by reviewing birth announcements of Salt Lake City's two newspapers. The sample consisted of 208 mothers of 6-month-old male infants. The first 108 women were questioned regarding their infants' circumcision status, resultant complications, and hygienic care. The second hundred were questioned regarding circumcision status and the reason for the circumcision.
4. Office Survey. Nursing personnel conducted a survey of parents in the Pediatric Clinic of the University of Utah Medical Center and in a local prepaid office practice. One hundred forty-two boys were included from consecutive office visits, with ages ranging from 4 days to 12 years. Race, circumcision status, and neonatal and later complications of either circumcision or noncircumcision were determined each patient was then examined by a physician who confirmed circumcision status and noted problems such as balanitis or adhesions.
Data were gathered in the four methods described above in order to collect as representative a sample as possible. For each variable of interest, information was garnered from the appropriate surveys and then combined.
Table 1 lists the variables studied, the source of information and the total number of patients in the combined samples.
Statistics for 1977-79 demonstrated an average of 53 per cent males and 47 per cent females born in Utah (Bureau of Vital Statistics). In 1978, 21,355 males were born in the 34 Utah hospitals. Circumcision status was determined for 15,905 males born in 16 of these hospitals. Of these, 13,498 (84.9%) were circumcised. Differences in rates were found between various hospitals and within the surveyed populations. These differences generally reflected ethnic background, with black, Hispanic, Indian, oriental, and other nonwhite children being circumcised less often than Caucasians. Although, in breaking down the incidence of circumcision in the study population (office study), the prevalence of circumcision tended to be somewhat lower among younger children, the incidence of circumcision within Salt Lake City does not appear to have changed. A survey of the Latter-Day Saints' Hospital, which has approximately 5,000 deliveries a year, revealed that for the years 1974 to 1979 the incidence of circumcision remained constant, varying only between 92 and 83 per cent.
Reasons for Circumcision
Reasons given by mothers for having their sons circumcised are summarized in Table 2. Many parents gave more than one reason for having had their sons circumcised. Cleanliness and "health" were cited most frequently, while social custom was the second leading reason given by mothers. This category included those who stated it was routine, "normal," family tradition, recommended by grandparents, or that the father was circumcised. Physical appearance was frequently cited by mothers in the newborn period, while it was given much less in the telephone interviews of older infants' mothers. These data are quite similar to those obtain Lovell and Cox.4
Our results also support the observations of these investigators, who found that clearly medical reasons (e.g., decreased infection or cancer) were given much less frequently than were socially related ones. Finally, while only 5 per cent of parents of newborns give no reason for having their child circumcised, 26 per cent of parents of 6-month-olds gave none.
Counseling of Parents
Of parents participating in the newborn study, interviewed immediately after their infant's circumcision, 67 per cent stated they had been counseled regarding the procedure while only 7 per cent of the mothers of 6-month-olds interviewed during the telephone survey recalled such counseling. Those who had received advice were counseled more often by obstetricians (73%) than pediatricians (16%).
Performance of Circumcision
Obstetricians performed 115 of 131 (87.7%) of the circumcisions at the two hospitals surveyed. Circumcisions were occasionally performed by family practitioners (3%), and rarely by pediatricians (2%) or rabbis (1%).
Complications of Circumcision
Neonatal complications were determined (Table 3); only problems requiring treatment were considered to be significant. Complications were reported in 14 of 361 (4%) circumcisions, including six hemorrhages, three surgical problems requiring later revision of circumcisions, four infections, and one instance in which a Plastibell ring had been used which was too small. All complications were treated successfully, with resolution of symptoms. One child required overnight hospitalization for treatment of hemorrhage. The other 13 infants were treated either as outpatients or during their initial hospitalization without delay in discharge.
Of 230 circumcised children, studied after the neonatal period (Table 3), 13 per cent (30 of 230 children) had experienced later complications. The most common complaint was foreskin adhesions (18) which generally occurred in infants less than one year of age. Other complaints were smegma accumulation, phimosis, meatitis (ranging from irritation to actual infection), and concerns about general cleanliness. Three children required circumcision revision. Only 17 (12%) of the 142 boys in the office study were uncircumcised. Of these, nine were less than 6 months of age, and four were between 6 and 12 months. Mothers of two children reported the complication of foreskin adhesions (11%). These adhesions were lysed in one child at 4.5 years of age, while the second was circumcised for this complaint when he was 3. No mothers complained of hygienic problems or infection in their children. One mother requested circumcision for her 1-year-old who had no apparent problems. No reason was given.
Variable Data Source Number Incidence of circumcision Medical record 15,905 Telephone office surveys 250 Reasons for circumcision Newborn 231 Counseling of parents Newborn, telephone survey 339 Performance of circumcision Newborn 131 Neonatal complications Newborn, telephone survey 361 Later complications Telephone office survey 230 Problems of uncircumcised Office survey 17
Reason Number* Per Cent Hygiene 159 69 Social custom, routine 48 21 Circumcised father 39 17 Physical appearance 33 14 No reason 32 14 Decreased infection 14 6 Religion 12 5 Doctor's advice 7 3 Decreased cancer 6 3
Neonatal (n = 361) Later (n = 230) No. % No. % Hemorrhage 6 (2) Foreskin adhesions 18 (8) Infection 4 (1) Poor hygiene 6 (3) Surgical 3 (1) Meatitis 3 (1) Bell too small 1 (0.3) Surgical revision 3 (1) TOTAL 14 (4) TOTAL 30 (13)
The current incidence of circumcision in the United States is between 80 and 97 per cent and has remained unchanged since the Ad Hoc Task Force statement.5,10 Circumcision ranks as the most common surgery in children.11 Our data confirm that the incidence of newborn circumcision has changed little in the past five years, indicating that, in Utah, the AAP statement has had no effect on circumcision rates. One reason for this may be that most circumcisions in our community are performed by obstetricians. The American College of Obstetrics and Gynecology has declined endorsement of the AAP statement.7 Because the frequency of prenatal visits to pediatricians in Utah is still relatively low, pediatricians have little opportunity to advise parents concerning the procedure. Only seven per cent of the parents of 6-month-olds, interviewed during the telephone survey, recalled any counseling regarding circumcision. But 67 per cent of parents in the newborn study did, mostly by obstetricians. All parents received information prior to the procedure in order to give consent. During the telephone study, parents were specifically asked whether or not they had received advice about the necessity or advisability of circumcision. The information given in the newborn period may not have involved true "counseling" on the need or advisability, or it may have been so brief as to have been forgotten in six months. Reasons given for circumcision reflected the strength of tradition rather than a medical approach. Mothers stated circumcision was "healthier" or "cleaner," or favored it because family or social custom dictated it.
Further, while only five per cent of mothers of newborns gave no reason for having their sons circumcised, full one-fourth of mothers of 6-month-olds could not recall the reason for having their sons circumcised. Perhaps by then, their original reasons were not significant enough to be remembered.
This entrenched tradition of custom is probably the greatest obstacle faced by those who would decrease the number of circumcisions done in this country.
The most recent surveys of complications of circumcision range from 0.2 to 28 per cent,2,11 depending upon whether one includes all minor complications, only those requiring treatment, or simply those which are life threatening. The number of early complications requiring treatment in this study was four per cent of 361 circumcisions. None was life-threatening. Later complications were experienced by 13 per cent of 230 children. Only three children suffered both early and late complications. Six children required circumcision revision, exposing them to repeated surgical and anesthetic risks. Foreskin adhesion was the most common complication, with the higher frequency in children less than one year of age. These were usually lysed in the pediatrician's office. These adhesions probably result from the apposition of the cut edge of the foreskin with the denuded glans surface and may lead to actual skin-bridging, as described by Klauber and Boyle.12 Many parents do not recognize that the foreskin has been adherent to the glans until sufficient smegma has accumulated to make the penis appear infected because of the visible smegma under the adhesion.
When later complications of uncircumcised infants were sought, two of 17 children were said to have had problems with foreskin adhesions. These "complications" actually may not have been complications but rather variants of normal.13,14 As we have reported previously, the majority of pediatricians do not know the natural history of the foreskin, and frequently, may give parents of uncircumcised infants and children inappropriate advice, as in the two cases described here.15
The arguments concerning circumcision continue. Gairdner13 and Oster14 made a strong case for leaving boys uncircumcised, allowing the natural separation of the foreskin from the glans to take place gradually, and instructing boys in proper hygiene. This obviates the need for "preventive" circumcision. 13,14 St. John-Hunt et al.9 disagreed, stating that a large number of British school boys suffered balanitis secondary to poor hygiene of the uncircumcised penis. Their data, however, were much less rigorously collected than that of Gairdner and Oster. No study similar to Oster's has been done in the United States to investigate how well uncircumcised boys care for themselves. We found, in a previous study,15 that mothers of uncircumcised infants are given little information regarding the maintenance of good hygiene and that pediatricians' advice varied greatly. This is a crucial issue, since the AAP recommendations concerning the lack of medical need for circumcision are dependent upon lifelong personal hygiene.
Finally, the amount of pain and the psychological implications for the infant undergoing circumcision are simply unknown.7,16 The use of the penile dorsal nerve block, while introducing a minimal anesthetic risk, seems a possible alternative for preventing the pain the infant may endure during the procedure.16 In summary, in the five years since the AAP statement, we have seen no change in the frequency of circumcision, possibly because those who most often perform circumcisions, the obstetricians, have not taken a similar stand. Parents are not adequately counseled concerning the necessity for the procedure, and for traditional reasons continue to ask that it be done. Complications of circumcision, while seldom serious, do occur. In our small series of uncircumcised boys, true complications were not encountered.
While most of the results of this study give evidence for support of the AAP statement, we feel that the issue of adequate personal hygiene in uncircumcised children and adults needs further investigation.
We strongly recommend that, if physicians dissuade parents from having their infants circumcised, they must give those parents the information concerning hygiene and the slow natural separation of the foreskin from the glans.
The authors thank Barbara J. Edelman for technical assistance in the preparation of this manuscript.
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