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 than1% 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.



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Child's mother


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Child's father


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Witness

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


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