Circumcision again? No, once is enough

Physicians should be informed about the risks and benefits of circumcision.

Issue: July 2007

Philip A. Brunell

I take pen in hand with trepidation, as nothing seems to invoke as much response as does circumcision.

We usually get enough letters to fill our next issue; in this case, they have arrived from as far away as Australia.

When I was living in England and returning from a meeting, I got into a conversation with one of the attendees during the subway ride home. After he learned that I was a pediatrician, the man started screaming about how we were encouraging circumcision and how this has left him impotent.

The man also proclaimed that women prefer uncircumcised men. I was not sure how they could tell on first introduction, but I decided this would be a good topic for cocktail party conversation. Although not quite a valid survey, the consensus seemed to be that who and how made more difference than the presence or absence of a foreskin.

Study data have been cited that demonstrated greater satisfaction in female partners of circumcised men because of improved genital hygiene (Pediatrics. 2003;111:490). In another review, researchers cited several papers’ indication that circumcision in adults did not seem to have an adverse effect on men’s sexual pleasure (Pediatrics. 2007;118:385). Thus, my informal survey does not seem to be far from the mark.

The requirement for circumcision of Hebrew infants on the eighth day of life is mentioned in Genesis 4:10 and again in Exodus 4:23. It is believed to have been a common practice in the region among a number of other groups at that time.

One wonders if the original practice was to prevent the problem of managing an uncircumcised penis in tropical climates, as Schoen quotes a urologist as stating that almost 150,000 hospitalizations related to uncircumcised penises might have been prevented by circumcision during the North African campaign of World War II (Pediatrics. 2007:118:385).

Adult circumcision was sometimes practiced in the 19th century to improve men’s sexual satisfaction. Among the Maasi, every boy must undergo Emorata, or the circumcision ceremony, at about the time of puberty. This is performed without anesthesia, and they are disgraced if they cry out. One can see colorful groups of these young men wandering the countryside in their red garments with their faces painted white.

Circumcision continues to be a common practice among diverse populations today.

Benefits

The change in the AAP position from “recommended” to “talk to your pediatrician” has led some parents to believe that evidence indicating this procedure is not desirable had become available. If anything, the contrary seems to be true.

Schoen (Pediatrics. 2007;118:385) presents a plethora of evidence of the beneficial effects of circumcision.

There is recent evidence that the risk for ulcerative genital disease (eg, syphilis and chancroid) and HPV in men who had been circumcised is reduced (Pediatrics. 2007;119:1006).

Schoen is frustrated that the AAP committee has ignored these findings and reiterated its position: “Existing scientific evidence demonstrates the potential medical benefits of newborn male circumcision; however, these data are not sufficient to recommend routine neonatal circumcision. In circumstances in which there are potential benefits and risks, yet the procedure is not essential to the child’s current well-being, parents should determine what is in the best interest of the child. To make an informed choice, parents of all infant boys should be given accurate and unbiased information and be provided the opportunity to discuss this decision. If a decision for circumcision is made, procedural analgesia should be provided.” One should certainly provide anesthesia and assure the parents of this.

Discussion with parents

On the surface, these recommendations appear to be balanced as well as noncommittal, but what do health care providers tell parents?

In a revealing paper titled “We have heard from the experts. Now let’s hear from the parents,” we are told that almost 40% of parents believed they had not gotten enough information from their obstetrician or pediatrician. What is most disconcerting is that 15% of the parents of those infants who were circumcised claimed that a medical provider had not discussed the procedure with them, which would imply that these were done without informed consent.

For the uncircumcised infants, 46% of their parents reported that the procedure was not discussed with a medical provider, and 27% of these later regretted their decision. A small number subjected their children to postnatal circumcision (Pediatrics. 2001107:20e).

Some parents in the survey did not have their infants circumcised because their insurance carrier would not pay for it. With the change in AAP policy, many insurance companies have elected to no longer cover this procedure.

In a quick survey of the parenting books, I found the discussion of circumcision generally inadequate. Both pediatricians and obstetricians should be familiar enough with the advantages and disadvantages of circumcision and be sensitive to their own biases. We all have our own biases, and mine quite frankly is from observing some boys in agony from paraphimosis, in which the foreskin becomes trapped behind the corona and forms a tight band of constricting tissue.

It is also important to recognize that if one is uncomfortable with this discussion, it should be deferred to someone else.

Downside to circumcision

The downside of circumcision, in addition to the immediate care, is best described in a large study of hospital records from the State of Washington in which more than 350,000 records were reviewed (Pediatrics. 2000;105:246). There was one complication for every 476 circumcisions — mainly minor infections or bleeding.

In trying to provide some perspective, the researchers calculated a rate of 1.14 complications for every six urinary tract infections prevented and 1.9 complications for every penile cancer prevented. They cautioned that one should not interpret these data strictly on numerical grounds, as the seriousness of UTI or penile cancer far exceeds those of the complications.

It should be pointed out that only one complication of 350,000 necessitated a prolonged hospital stay. Additionally, it is important to realize that significant complications can occur when circumcision is performed beyond the newborn period (Pediatrics. 1976;68:824) and that adult circumcision is usually associated with a recovery period of weeks, during which time all sexual activity is suspended (Am Fam Physician. 2000;62:2623-2628).

We have a duty to our patients to be informed about the risks and benefits of circumcision and be certain that we do not have biases that will compromise our ability to present this information. There are issues in the immediate postnatal period with care of the circumcision.

We also must present the need for care of the uncircumcised penis initially by the parents and later by the boy or man. Finally, we should be able to present the long-term benefits of this procedure.