This file contains the original 1975 policy statement of the Canadian Paediatric Society regarding male neonatal circumcision and two supplements which were issued in 1982 and 1989. These policy statements have been superseded by the 1996 policy statement, Neonatal Circumcision Revisited. These statements, however, are retained as reference material.]
Statement
CIRCUMCISION IN THE NEWBORN PERIOD
It may be expected that local customs will influence any decision for or against routine circumcision of male infants during the first few days of life, For instance. this is rarely done in Britain, whereas in parts of California it is quite common, perhaps as an index of social status or virtually as universal policy in some large hospitals.
Nevertheless, there is no medical indication for circumcision during the neonatal period.*
Any claim for the presence of phimosis as a reason for circumcision during the first four years fails to acknowledge the natural history of tissue differentiation in the region destined to develop the cleavage between the prepuce on the outside and the glans deep to it, or of the range of variation in the rate of atrophy or redundant foreskin within that age group.
Any assertion that a policy against routine circumcision has predisposed infants to phimosis or paraphimosis cannot be valid without first ruling out the possibility that the infants in question had experienced the common practice of forceful retraction of the prepuce just after birth, using the fingers alone or aided by a probe to break down the "adhesions"—really the undifferentiated tissue, and perhaps a haemostat to stretch the preputial orifice. The scarring effects of such a manipulation, usually an unrecorded procedure, are more hazardous than either circumcision itself or unmolested non-circumcision.
Such unrecorded manipulations and subsequent fibrosis have not been exonerated as the initiating cause of troublesome collections of smegma which are sometimes found in children considered prone to the complications of neglected personal hygiene.
The more immediate hazards of circumcision include infection which may be minor, or which could lead to gangrene or general sepsis, severe haemorrhage, mutilative deformity of the penis, or rarely, a procedural misadventure requiring partial amputation of the penis.
Later complications include the excoriation of the exposed edges of the glans from a diaper dermatitis, or a similar lesion at the urethral meatus, resulting in stenosis in some cases. The narrowed passage may produce obstructive uropathy and its more serious consequences.
There seems to be little basis for prescribing routine circumcision because of a fear of cancer of the uncircumcised prepuce developing in a septuagenarian. It is an infrequently encountered lesion, easy to detect and unlikely to spread. This remote possibility of a curable condition of very old age stands in sharp contrast to the established hazards of neonatal circumcision.
There is no foundation to the belief that in adult life, circumcision adds or reduces tactile sensation in the adult penis during intercourse. [CIRP note: This statement has been disproved. See The Ridged Band: Specialized Sexual Tissue.]
The claim that circumcision is associated with a reduced prevalence of venereal diseases in the adult male, or a decreased frequency of cervical carcinoma in the sexual partner, has not been established as a cause-and-effect relationship.
Although the desire for conformity has sometimes influenced a parent's or doctor's decision, intended to ensure that the newborn infant in question will grow up to have genital resemblance with his father and brothers, any important conformity must now be considered in relation with the peer group in a society with a rapidly diminishing demand for circumcision.
Because a decision to circumcise in the newborn period must be ascribed to social rather than medical reasons, it would be even more inappropriate in an infant who is destined for adoption or other placement to impose the operation before the transition into the new family setting has been completed. A natural parent giving up a child for such placement should not be empowered to authorize circumcision, nor should a social agency be responsible for such a decision on behalf of the infant. Such an agency would be overstepping any mandate provided by its Provincial Protection of Children Act.
Certainly, no circumcision should be performed on an infant with a hypospadias, or any other genital abnormality no matter how slight, until a careful diagnosis has been made, together with an assignment of sex if necessary, and a detailed plan of management has been developed.
Although there is some unresolved contention about the propriety of performing circumcision during the first few days of life, there is no disagreement in condemning the practice of carrying out this procedure while the infant is still in the delivery room. During his first few hours, he must be protected against the stress of pain and the possible exposure to cold, each of which may interfere with the success of the cardiovascular and pulmonary adjustments necessary for adequate respiratory function after birth. Also, so soon after birth, there is a greater chance of inadequate awareness, should there be a familial bleeding tendency that would have been a positive contra-indication for circumcision.
If circumcision is to be carried out later during the first few days, it should be performed by the person most adept at the procedure, and most readily available and capable to deal with any early complications. If paediatricians are showing leadership in curtailing the numbers of mutilative operations of questionable benefit, it is likely that uninformed parents may turn to their family physician or obstetrician to perpetuate such an obsolete operation. Therefore, discussion of this subject should be encouraged among all who may deal with parents, both among the medical and nursing professions.
The actual technique of circumcision, whether by the classical method with scalpel and sutures, or using the Gomco clamp, seems less important than the individual choice according to the individual operator's skill and preference. Care should be taken, however, to ensure that the bell in socket of the clamp has not worn to such a degree as to allow less than total crushing force evenly distributed along the circumference of the prepuce. The reported misadventure in the literature, and the lack of any impressive review, should make one reluctant to recommend the disposable Plastibell device for this operation.
Although the neonatal infant is given only a sugar ball to suck on as a soother against the pain, no one would perform a circumcision on a two-month old infant without first administering anaesthesia. This seems incongruous in the absence of any known neurophysiological difference between these two age groups that would justify such a discrepancy in approach. If there is validity in this consideration, the alternatives would have to be an acceptance of the added risk of anaesthesia for each newborn infant undergoing circumcision, or else the conclusion that such a risk or the vagal and psychological consequences of withholding pain relief should remove any remaining defence of the circumcision routine.
The appropriate time in which to enlighten prospective parents about contemporary concepts of circumcision is during prenatal care. Therefore, family physicians. obstetricians and nurses should be invited to consider these facts and opinions.
In the search for ways in which to stem the rising cost of health care, the removal of such an unnecessary procedure as a routine practice can be calculated as a major saving in terms of direct charges - professional fees, nursing and other hospital services and supplies, and sometimes the length of hospital stay - and secondary costs resulting from any recognized clinical complications.
Adoption of the foregoing concepts should result in a sharper decrease in the percentage of infants circumcised, and thus a reason to convert a hospital circumcision room to a more useful function, e.g. a parents' room for privacy with their baby, a breast feeding room for the mother discharged before the infant, or if in an appropriate area, a laboratory supporting foetal and neonatal intensive care. The greatly reduced numbers of circumcisions may be performed in facilities used for other procedures requiring aseptic control, e.g. exchange transfusion and lumbar puncture in the infant. Facilities in a maternity unit should not be expected to serve the requirements of an infant already sent home from his place of birth.
Ritual circumcisions are performed for religious reasons and are therefore outside the category of medical or social indications. Because these ritual rites are performed on the eight day, beyond the usual length of newborn infant stay, it seems unlikely that any special facility will be required for this purpose in any new construction of maternity facilities.
Foetus and Newborn Committee Members:
Dr. P. R. Swyer - Chairman
Dr. R. W. Boston
Dr. A. Murdock
Dr. C. Paré
Dr. E. Rees
Dr. S. Segal - Editor
Dr. J. C. Sinclair
------------------------------------------------------------
------------------------------------------------------------
Courtesy of:
Canadian Paediatric Society
c/o Children's Hospital of Eastern Ontario
Smythe Road
Ottawa, Ontario
Citation:
Foetus and Newborn Committee. FN 75-01 Circumcision in the Newborn Period. CPS News Bull Suppl 1975; 8(2):1-2.
1982 Supplemental Statement by the CPS.
CANADIAN MEDICAL ASSOCIATION JOURNAL, Volume 126: Page 1399,
15 June 1982.
BENEFITS AND RISKS OF CIRCUMCISION: ANOTHER VIEW
Platform of the Fetus and Newborn Committee of the Canadian Paediatric Society
The review by Warner and Strashin(1)
clearly presented the arguments for and against
circumcision and the contraindications. However, the most
important reason for favouring circumcision - that is,
preventing carcinoma of the penis - is not completely
established. In addition, Warner and Strashin overly
minimized the risks of circumcision. They also did not
include the cost of complications of neonatal circumcision
in their cost benefit analysis.
While the literature suggests that
circumcision may protect against carcinoma of the penis,
the case is not entirely proven. There are, for example,
wide differences in the incidence of penile carcinoma among
African tribes that do not practise circumcision.(2) In
Sweden, where circumcision is rare, the incidence of penile
carcinoma is low.(3) It is possible that there are genetic
or environmental factors that influence the incidence of
this carcinoma and, by coincidence, are associated with
circumcision. Warner and Strashin do recognize that the
protective role of circumcision is not completely
established. In their conclusions they stated that "cancer
of the penis may be prevented by circumcision", but in the
abstract of the article the crucial word "may" is
omitted.
Warner and Strashin discussed the
literature on the incidence of early complications,
including the report by Gee and Ansell(4), which noted one
life-threatening hemorrhage, four cases of septicemia and
one case of complete penile denudation, as well as
circumcision in eight cases of hypospadias among 5000
circumcised boys. Then they concluded that "hemorrhage,
infection and other immediate complications..... are easily
treated; those that are not are very rare". The potential
for meningeal spread from septicemia and the hospital costs
for these complications were ignored. Neither did they
discuss problems resulting from inappropriate management of
the prepuce that can result in the need for later
circumcision. Phimosis commonly follows infantile
balanitis, which occurs when premature and energetic
attempts are made to break down the incorrectly named
"preputial adhesions" the epithelial tissue that has not
yet separated into planes. This lack of separation is
normal in newborns and may not be completed until the age
of 16 or 17 years.(5) Øster(5) reported that among
1968 schoolboys examined annually for 8 years the incidence
of phimosis was 8% at age 6 to 7 years but only 1% by the
age of 16 to 17 years. How many physicians recommending and
carrying out circumcision in schoolboys know this? A survey
of 60 pediatricians in the United States revealed that 78%
did not know at what age the prepuce might normally be
retracted.(6) Øster(5) found
that only 3 (0.15%) of the 1968 boys required circumcision.
Thus, the true need for later circumcision may be greatly
exaggerated.
McKim's editorial on circumcision also
minimized the risks of this operation in the newborn
period.(7) The risks should indeed be minimal; however,
because circumcision is not always carried out by
"experienced, skilful surgeons", surgical complications are
regularly seen and are not "extremely rare", as McKim
stated.
Certainly the good teaching and
supervision of neonatal circumcision McKim pleaded for are
vital.
In the past we made many errors when
therapeutic approaches were developed in the absence of
adequate proof of efficacy.(8) Silverman(8) has emphasized
our need not only to learn from past experiences but also
to ensure that we use the correct methods to evaluate our
interventions.
Several years ago the fetus and newborn
committee of the Canadian Paediatric Society carefully
reviewed the pros and cons of circumcision; the conclusions
were published in a statement in 1975.(9) The intentions of
this statement was to reduce the number of unnecessary
circumcisions and the complications that might result.
(Incidentally, Warner and Strashin did not refer to this
review.) The present fetus and newborn committee sees no
reason for modifying the statement of the
previous committee and is concerned that a completely
balanced view be available to the physician asked to decide
upon the necessity for circumcision.
References:
Warner E. Strashin E: Benefits and risks of circumcision. Can Med Assoc J 1981; 125: 967-976, 992
Burkitt DP: Distribution of cancer in Africa. Proc R Soc Med 1973; 66: 312-314
Klauber GT: Circumcision and phallic fallacies or the case against routine circumcision. Conn Med 1973; 37: 445-448
Gee WF, Ansell JS: Neonatal circumcision: a ten-year overview: with comparison of the Gomco clamp and the Plastibell device. Pediatrics 1976; 58: 824-827
In 1975, the CPS Foetus and Newborn
Committee carefully reviewed the pros and cons of
circumcision and published the conclusion that routine
circumcision was not necessary.
In 1982, the Committee saw no reason to
modify the previous statement. However, they advocated that
a completely balanced view be available from the physician
in order to make a decision regarding the necessity for
circumcision.
In 1988, a growing concern arose due to
a report by T.E. Wiswell (see 1 and 2 below) which showed a
decreased incidence of urinary tract infections in
circumcised male infants. Due to these concerns the Board
asked the Foetus and Newborn and the Infectious Diseases
and Immunization Committees to study the report.
As the present
information available concerning the risks of urinary tract
infections and transmission of sexually transmitted
diseases in relation to circumcision are not sufficiently
compelling to justify a change in policy, the
Committees maintain that no change should be made to the CPS recommendations concerning routine
circumcision.
We will continue to monitor the
situation.
Wiswell TE, Smith FR, Bass JW: Decreased
incidence of urinary tract infections in circumcised male
infants. Pediatrics 1985;75:901-903.
------------------------------------------------------------
------------------------------------------------------------
Courtesy of:
Canadian Paediatric Society
c/o Children's Hospital of Eastern Ontario
Smythe Road
Ottawa, Ontario
The Circumcision Information and Resource Pages are a not-for-profit educational resource and library. IntactiWiki hosts this website but is not responsible for the content of this site. CIRP makes documents available without charge, for informational purposes only. The contents of this site are not intended to replace the professional medical or legal advice of a licensed practitioner.
Note:
© CIRP.org 1996-2024 | Please visit our sponsor and host: IntactiWiki.