Circumcision Controversies

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Introduction

Circumcision, in the simplest terms, is “… the removal of the prepuce of a male.”1 Beyond this basic definition nearly every aspect of circumcision from its origin to its indications, and with whom the responsibility for consent for this operation truly lays, contains some aspect of controversy.

Most newborns in this country are circumcised and there is little disagreement about the technical aspects of this common procedure. There have been volumes written on the potential harms and benefits of circumcision. The American Academy of Pediatrics, to whom many look to for guidance in the treatment of children, have traditionally taken a noncommittal stance on this matter.2 In the modern political environment in the United States, the newest controversies surrounding circumcision exist in the legal and socioeconomic arenas.

Although sober proponents and detractors of circumcision agree that there is no overwhelming medical evidence to support either side, there is considerable disagreement regarding parents consenting to a nonemergency prophylactic procedure in their minor children. Also, at a time when the cost of health care has become a national issue, many question the government funding for these procedures because there is no overwhelming proof that they are beneficial, necessary, or the only method to achieve the desired goals.

Although there are accepted reasons for circumcision in adults, in the United States, most circumcisions are done on neonates, which is the most discussed and controversial procedure. This article examines neonatal circumcision and the difficult problems surrounding this seemingly simple procedure.

Section snippets

History

Adequate knowledge of all aspects of the procedure is essential for the health care providers who advise parents about their child's potential circumcision so they can provide comprehensive information to help with this important decision. Circumcision is one of the oldest and one of the most commonly performed operations, even in contemporary medicine. The origin of this procedure dates back millennia and there is some controversy, along with a fascination, as to where and how it actually

Indications

Patients with true phimosis, balanitis, noniatrogenic paraphimosis, and localized pathologic conditions of the foreskin (warts for example) are accepted as candidates for circumcision, and it is also accepted that these conditions are not present in the newborn. Rickwood11 says a generous estimate would be that less than 2.5% of newborns would require circumcision based on these criteria. Newborn circumcision is motivated by the prevention of these problems during a period when the operation is

Phimosis and urinary tract infection

Phimosis is a pathologic condition in which the patient's foreskin is not retractable. This condition is painful and can cause the foreskin to balloon during urination, hurt during erection, and lead to urinary tract infection (UTI). In adults, this condition is effectively treated with circumcision. Men are born with a physiologic phimosis in that, in most, the foreskin does not easily retract at birth. This condition is usually asymptomatic and resolves as the boy ages, and most boys by

Cost

Medical cost has become an enormous concern in American society. The United States spends between $150 and $200 million per year to perform newborn circumcisions.2 The true measures of costs are difficult to assess because the complications of having foreskin are a small but a life-long risk. Compared with other medical interventions, including circumcision under anesthesia, neonatal circumcision is relatively inexpensive. Schoen and colleagues17 compared the costs of circumcising newborns and

Parental concerns

Although it is laudable to pursue the scientific and economic truths, most parents decide on the newborn circumcision without strong information about its benefits or risks. Bean and Egelhoff26 found that most parents had decided the fate of their child's foreskin before the boy's birth. Most parents and physicians believe that the discussion they have with their physician about the circumcision after birth is unbiased. The reasons parents cite to circumcise their child are their wish that the

Health concerns

Another proffered reason to circumcise newborns is the prevention of penile cancer and other penile maladies. There has been renewed interest in circumcision in places where it has not traditionally been performed because of the research into this particular aspect of circumcision. Cancer of the penis is a rare but serious condition, and in 2011, there were 1360 new reported cases in the United States,31 where most men affected are uncircumcised, and the majority die from the disease.32, 33

Techniques

Although there is considerable discussion about whether circumcision should be performed, there is little controversy as to how. The 3 main methods of circumcision performed in the United States, namely Plastibell, Gomco, and Mogen, all have their proponents. Each method, by a competent operator, has an acceptably low complication rate. The last controversy over technique is the use of anesthesia. There was a belief, now disproven and abandoned, that newborns did not feel pain and that it was

Consent

There is an honest disagreement in the medical community about the medical risks and benefits of circumcision, and there is accumulating evidence that circumcision may benefit the individual over their life time. This growing surety must be tempered by the fact that, barely a century ago, physicians were sure that this same procedure was a cure for a variety of postulated ills, such as masturbation and bedwetting. These views have been discredited. Even in those instances in which contemporary

Parental role

A newborn does not understand the complexities of any procedure and so, as in many decisions that involve children, the duty falls to the parents. There are no valid arguments against a parent's rights to consent to procedures if the operation is life saving, life sustaining, or of undeniable benefit to the patient.39, 40 Parents who make medical decisions for their children are doing so under the concept of substituted judgment; the idea that the person making the decision for the patient will

Health care provider's role

As the technique of circumcision has been refined and made safer, acquiring an informed consent may be the most difficult role for the practitioner in this process. The doctor has to ensure that the parents of the patient understand the reasons why their child should or should not be circumcised, how the procedure will be performed, and what the short-term and long-term consequences might be. Physicians are obligated to ensure that this information is presented in a way the parents can

Summary

The ultimate fate of neonatal circumcision is as obscure as its origin. Despite the exhaustive research on this fascinating subject, the lack of consensus calls for even more unbiased study. If medical research does not answer the outstanding questions about circumcision, clinicians should be aware of the sobering reality that there are legal and socioeconomic forces marshaling eager to answer these questions for us. Competent provision of neonatal circumcision behooves individual clinicians to

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