Barbara Kay: Review puts to bed activist-inspired case on circumcision

Barbara Kay: Review puts to bed activist-inspired case on circumcision

Barbara Kay
Tuesday, Oct. 18, 2016

Heather Hironimus of Florida spent a week in jail before agreeing to sign a consent form for her 4-year-old son to be circumcised. AP

A new review of circumcision published in the Canadian Journal of Urology is receiving keen attention. The lead author is Dr. Brian Morris, a professor emeritus on the University of Sydney’s school of medical science.

The study finds not only a lower risk for urinary tract infections (UTI) among circumcised males, a benefit long acknowledged that can preclude UTI-caused kidney damage, but a lower lifetime risk for penile cancer, a reduced risk for prostate cancer among black males, lower risk for HIV, genital herpes, the human papilloma virus (HPV), and syphilis. Dr. Morris and his American co-authors state, “We found that up to 65% of uncircumcised males might experience at least one of these [medical conditions] over their lifetime.” Their risk-benefit analysis of the procedure led them to conclude the benefits exceed the risks by about 100 to one. (In another study, published in the Journal of Sexual Medicine, Dr. Morris and colleagues found circumcision produced no adverse affect on sexual function or pleasure, a charge often leveled by anti-circumcision activist groups.)

The report conflicts with the position held by the Canadian Paediatric Society (CPS), namely that the benefits of circumcision do not outweigh the risks, and they therefore do not recommend it for male babies. By contrast, the American Academy of Pediatrics (AAP) is very much onside with the Morris report. Their policy is to recommend education about and access to infant male circumcision, as well as recommending that insurers pay for the procedure (Medicaid does not cover circumcision for the poor in 18 U.S. states). The AAP states: “The new findings show that infant circumcision should be regarded as equivalent to childhood vaccination and that as such it would be unethical not to routinely offer parents circumcision for their baby boy. Delay puts the child’s health at risk and will usually mean it will never happen.”

If this were any other medical intervention, such findings would arouse no debate, and the recommendations would be followed without protest. But circumcision is a social-tension magnet, and the politically correct perspective on foreskins is ‘let it be.’ The current position of the CPS, which used to recommend circumcision, is to all appearances a reflection of the moral power accorded anti-circumcision activists.

For thousands of years of recorded history, in fact until 50 years ago, circumcision was a culturally-rooted practice that aroused no controversy whatsoever. On the contrary, based on hygienic reasoning, the practice spread from cultural groups to the population at large. In the 1960s, 83% of American, and about 70% of Canadian males were circumcised. But these numbers fell dramatically when the issue came under the scrutiny of anti-patriarchal gender activists as (erroneously) an equivalent practice to female genital mutilation (FGM). Today the national Canadian rate is about 32% and the U.S. rate about 77%.

The CPS could not condemn the practice on grounds of increased morbidity. After thousands of years of what is essentially a controlled study with virtually all Jewish men, with a large percentage of Muslim men on one side, and uncircumcised men on the other, it has been unequivocally concluded that circumcision presents no health risks; quite the contrary, as we shall see.

So the lines had to be drawn on moral issues, like pain inflicted, and the lack of consent, or negative medical outcomes such as  bleeding, infection, an “unsatisfactory cosmetic result,” or in rare cases deformation and amputation of the penis or death from haemorrhage or sepsis. The CPS cites a risk figure of 1.5% for such medical complications. Imputing this figure to “sloppy scholarship,” Morris’s team estimates the combined frequency of adverse events at 0.4% overall, arguing that “the cumulative frequency of medical conditions attributable to [having an intact foreskin] was approximately 100-fold higher” than the cumulative risk of circumcision.

As for moral arguments, both the “pain” and “consent” lines of defence are weak. The pain inflicted is so fleeting many babies barely register notice (in any case continuing advances in pain diminution are rendering that argument completely obsolete), and as for “consent,” vaccinations are routinely given to children without their consent. It is true that circumcision is different from vaccinations in that the integrity of the external body is changed by circumcision. But then one might say – and anti-vaxxers do say – that the integrity of the child’s natural internal system is forever changed by vaccinations. As for complications arising from the procedure, they are statistically rare when performed by qualified and experienced surgeons or “mohels,” ritual circumcisionists, as rare as untoward consequences from dental procedures and other medical procedures like tonsillectomies (also performed without consent).

The single most irrational argument one often sees is the charge of moral equivalency between circumcision and female genital mutilation. FGM is a phenomenon that is, apart from both affecting the genitals, quite separate from circumcision. Unlike circumcision, which removes an unnecessary piece of skin, in no way prevents natural and satisfying sexual function, FGM is a misogynistic practice created as a means for men to control women, meant to prevent sexual desire and gratification in women to ensure their fidelity, and which removes a portion of the genitals absolutely vital to gratification. It is the very epitome of patriarchy, whereas circumcision is a rite of passage conceived by males for other males, and for thousands of years rooted solely in spiritually contractual language and meaning. Women who have been subjected to FGM invariably come from countries in which extreme misogyny is the norm. Circumcision carries no moral or gender-injustice baggage of this kind whatsoever.

Dr. Morris’s report concludes: “Taken together, the new findings should send a strong message to medical practitioners, professional bodies, educators, policy makers, governments, and insurers to promote this safe, simple procedure, best done in infancy under local anesthesia and to increase access and third party coverage, especially for poor families, who tend to suffer most from foreskin-related diseases. Infant circumcision has, moreover, been shown to be cost saving.”

Parents deserve to be informed of all the evidence, pro and con, when the issue of circumcision arises. It is not necessary for the CPS to actively recommend circumcision to keep to the path of ethics and professional responsibility, but given the accumulation of evidence demonstrating the positive effects of circumcision, it would be unethical of the CPS – or any pediatricians individually – not to present the science available, or worse, to recommend against the procedure.

 

Combined Analgesia and Local Anesthesia to Minimize Pain During Circumcision

Originally published in JAMA Pediatrics, June 2000
Arch Pediatr Adolesc Med. 2000;154(6):620-623. doi:10.1001/archpedi.154.6.620

Anna Taddio, BScPh n, MSc, PhD; Neil Pollock, MD; Cheryl Gilbert-MacLeod, MA, PhD; Kristina Ohlsson; Gideon Koren, MD 

From the Departments of Pharmacy (Dr Taddio and Ms Ohlsson) and Paediatrics (Dr Koren), The Hospital for Sick Children, Toronto, Ontario; the Pollock Clinics, Vancouver, British Columbia (Dr Pollock); and the Department of Psycology, IWK Grace Health Centre, Halifax, Nova Scotia (Dr Gilbert-MacLeod).

Background: Pain of circumcision is only partially relieved by single modalities, such as penile nerve block,lidocaine-prilocaine cream, and sucrose pacifiers.

Objective: To assess the effectiveness of a combination of interventions on the pain response of infants undergoing circumcision.

Methods: Cohort study. Group 1 included infants circumcised using the Mogen clamp and combined analgesics (lidocaine dorsal penile nerve block, lidocaineprilocaine, acetaminophen, and sugar-coated gauze dipped in grape juice). Group 2 included infants circumcised using the Gomco clamp and lidocaine-prilocaine. Infants were videotaped during circumcision, and pain was assessed using facial activity scores and percentage of time spent crying.

Results: There were 57 infants in group 1 and 29 infants in group 2. Birth characteristics did not differ be tween groups. Infants in group 1 were older than infants in group 2 (17 days vs 2 days) (P<.001). The mean duration of the procedure was 55 seconds and 577 seconds for infants in group 1 and 2, respectively (P<.001). Facial action scores and percentage of time spent crying were significantly lower during circumcision for infants in group 1 (P<.001). The percentage of time spent crying was 18% and 40% for infants in groups 1 and 2, respectively. No adverse effects were observed in infants in group 1; 1 infant in group 2 had a local skin infection.

Conclusions: Infants circumcised with the Mogen clamp and combined analgesia have substantially less pain than those circumcised with the Gomco clamp and lidocaineprilocaine cream. Because of the immense pain during circumcision, combined local anesthesia and analgesia using the Mogen clamp should be considered.


Circumcision is performed in millions of male newborns worldwide. Despite evidence that circumcision is painful, the procedure continues to be performed without adequate analgesia.1 Analgesics are not administered routinely by physicians because of concerns regarding the side effects of drugs and perceived lack of importance of pain.2

Dorsal penile nerve block (DPNB) was demonstrated previously to be effective for this procedure.3-5 We showed that lidocaine-prilocaine cream (eutectic mixture of local anesthetics [ EMLA ]) can decrease the pain from circumcision.2 In a recent study that compared EMLA with DPNB and ring block with lidocaine, both infiltration methods were superior to EMLA.6 Sucrose given with a pacifier was shown to have some benefits7,8 and acetaminophen may be helpful for postoperative pain.9

Combination interventions are more effective than single interventions. Stang et al10 found that DPNB and a pacifier dipped in sucrose were more effective than DPNB and a pacifier dipped in water. Mohan et al11 found that sucrose and EMLA together were better than either sucrose or EMLA alone. Using EMLA prior to DPNB decreased needle penetration pain but did not improve overall analgesia achieved by DPNB in older children.12

A recent study demonstrated that pain from circumcision is affected by the technique used to perform the procedure. In that study, the Mogen clamp was associated with less pain than the Gomco clamp.13 This may have been at least in part caused by the shorter procedure time associated with the Mogen clamp technique. In addition, infants premeditated with the DPNB during circumcision with the Mogen clamp had less pain than infants circumcised using the same method who were not given an analgesic.

The ultimate goal of pain management during circumcision is to prevent pain. We hypothesized that we could approach this goal if a combination of analgesic interventions and the Mogen clamp technique were employed together. The objectives of this study were to assess the effectiveness and safety of a combination of interventions including EMLA cream, DPNB, acetaminophen, and sugarcoated gauze on the pain response of infants undergoing circumcision using the Mogen clamp technique.

 

SUBJECTS AND METHODS
The study underwent ethical review in our institution, and written consent was obtained by the parents of infants that participated. The study was a cohort design with 2 study groups. The first group included infants circumcised using the Mogen clamp and combined analgesics (group 1). The analgesics administered before the circumcision included 0.5 mL of 80-mg/mL acetaminophen (administered orally 45 minutes before the clinic appointment); 1 or 2 g of EMLA on the foreskin and abdomen (applied 60 minutes prior to the procedure); and 2 subcutaneous injections of 1.1 mL of 0.5% lidocaine at the 10:30 and 1:30 positions (i.e., DPNB) after EMLA was removed and 10 minutes before the circumcision.The acetaminophen was administered to infants by their parents at home. They were given an information pamphlet and spoke to an office nurse before the scheduled appointment. Infants were last fed at home before the procedure. On arrival to the clinic, EMLA was applied by an office nurse. Part of the dose was placed on the penis and the remainder on a Tegaderm dressing. Then the penis was extended upward and gently pressed on the abdomen and the dressing was placed over the penis and taped to the abdomen. The cream and dressing were removed after 1 hour. During the infant’s stay in the waiting room, a 3 X 3-cm folded gauze embedded with three fourths of a teaspoon of sugar and dipped in grape juice was placed in his mouth. The gauze was replaced by a fresh one 3 different times: while in the waiting room, before the DPNB injection, and before the circumcision.This integrated approach was developed by one of us (N.P.) and is currently in use in the clinical setting. All infants in group 1 were restrained on a circumcision board and circumcised using the analgesics and surgical technique described above (referred to as the Pollock procedure) by one of us (N.P.).The second group included infants circumcised using the Gomco clamp and EMLA (group 2). One gram of EMLA was applied for 60 to 80 minutes prior to the procedure. The EMLA was applied using a similar technique as for group 1. Infants were not offered anything to suck on. Group 2 was taken from our previous double-blind, randomized clinical trial of EMLA.2 Infants were fed I to 3 hours before the circumcision. All of the infants were restrained on a circumcision board and were circumcised by another single operator (P.R.).2Since the results of our randomized controlled trial were published, EMLA has been considered the minimum standard for analgesia during routine circumcision in our institution. We chose not to perform a randomized controlled trial because these data were available for comparison and it was considered unethical to prospectively enroll infants into a group that was expected to experience more pain during a circumcision.We included healthy full-term infants without jaundice and methemoglobinemia and not receiving analgesic or sedative drugs outside of the study protocol. Infants in group 2 were circumcised in the first week of life. However, infants in group 1 also included older infants, to assess the effect of postnatal age on pain response.Infants in both groups were videotaped during the procedure. Pain was scored from the videotape by a research assistant using the same techniques as our previous study (ie, Neonatal Facial Coding System [NFCS] and infant cry duration).2 The circumcision procedure was divided into phases. The analyses included the baseline phase and the circumcision phase (ie, forceps application, lysis of adhesions, application of clamp, cutting foreskin, and removal of clamp).The primary outcome was facial activity score. The facial activity score was composed of the sum of the percentage of time that 3 discrete facial actions from the NFCS (ie, brow bulge, eyes squeezed shut, and nasolabial furrow) were observed for each phase of the procedure. These facial actions are considered the most sensitive and specific to pain. As in our clinical trial, each facial action was coded as present or absent every 2 seconds for a maximum of 20 seconds per phase.2 Then, the percentage of time that each of the 3 facial actions was observed was calculated. The 3 percentage scores were weighted equally using a ratio of 1:3 and added together for an overall facial activity score that could range from 0 to 1. The percentage of time spent crying per phase of the procedure was calculated by dividing the duration of time spent crying by the duration of time of the phase.

Adverse events (skin reactions, bleeding, and infection) were noted during the circumcision and during follow-up telephone interviews with the parents at 24 hours and 1 week after the circumcision.

SAMPLE SIZE CALCULATION
A sample size of 60 infants (30 per group) was considered sufficient based on the ability to detect a difference in pain scores between infants that was 0.8 SD, with 80% power and 95% confidence (ie, large effect size). We recruited an additional 30 infants in group 1 to account for the effects of age on pain response.

STATISTICAL ANALYSES
Infant responses during circumcision were compared between groups using repeated-measures analysis of variance, with the baseline value as the covariate. Regression analysis were used to compare responses of infants of different ages. Demographic data and adverse effects were analyzed using X2 test and t test as appropriate.

 

RESULTS

Eighty-six infants participated in the study: 57 infants in group 1 and 29 in group 2. There were no dropouts in either group. For 1 infant in group 1, the quality of the video recording was poor and facial action coding could not be performed. Demographic data are shown in the Table. Other than postnatal age, there were no significant differences between the groups.

The duration of the procedure was significantly shorter for infants circumcised using the Mogen clamp compared with those circumcised with the Gomco clamp (mean [SD], 55.0 seconds [12.6] vs 576.6 seconds [64.11])(P<.001).

The facial activity scores recorded during circumcision are shown in Figure 1. The scores were significantly lower (P<.001) for infants in group 1. Group 1 had significantly lower pain scores (P<.05) during forceps application, lysis of adhesions, and application and removal of clamp.

Infants in group 1 cried for proportionately less time than infants in group 2 during the entire procedure (Figure 2) (P<.001). The percentage of time spent crying was shorter (P<.01) for infants in group 1 during forceps application, lysis of adhesions, and application and removal of clamp. Twenty-six infants (46%) in group 1 did not cry at all during the procedure and 7 (12%) cried for less than 10% of the time; the mean percentage of time spent crying during the circumcision was 18% compared with 6% during baseline (P<.05).

Postnatal age and percentage of time crying during the entire procedure were not correlated (r=0.07; P=.61). Similar results were obtained when each phase of the procedure was analyzed separately, using either facial activity scores or percentage of time crying as outcome variables.

There were no adverse effects reported in infants in group 1. One infant in group 2 had an infection at the surgical site that was treated with a topical antibiotic.

 

COMMENT

In this study, we evaluated pain in infants during circumcision with the Mogen clamp and a combination of local anesthetics and analgesics. The rationale for this study was that treatment strategies studied to date have not been shown to completely eliminate pain in all infants; we previously demonstrated that neonatal circumcision has long-term effects on infant pain response to routine 4- and 6-month vaccination.14 We postulated that decreasing the duration of circumcision and providing maximal analgesia would minimize pain for the infants and thus prevent potential long-term sequelae. Our results demonstrated that this “holistic” approach was associated with a significantly shorter procedure time and less pain than circumcision using the Gomco clamp and EMLA. However, infants continued to exhibit some pain responses during the procedure. It is unclear how much of their responses are caused by pain from the procedure vs discomfort from being restrained. Furthermore, it is not known whether the approach used in this study prevents changes in future infant pain behaviors at routine vaccination.

Our study was designed to examine the overall effectiveness of combined analgesia and anesthesia on infant pain response rather than the effectiveness of each specific analgesic. In comparison with a study of the Mogen clamp and DPNB plus pacifier analgesia,13infants in this study cried for proportionately less time (18% vs 31%), suggesting that the additional analgesics (EMLA, sucrose, and acetaminophen) helped minimize pain. In the previous study, however, 56% of infants did not cry during the procedure13compared with 46% in this study. In another study of the Mogen clamp and DPNB analgesia, more infants cried during the procedure (73%)15 than in this study.

We used a larger volume of lidocaine for anesthesia (at half the concentration) compared with other published studies in the literature. We did this to facilitate diffusion of the drug to the target site of action. We observed no complications in infants treated with combination analgesia. Our data are consistent with previously published safety data on DPNB and EMLA for use in neonates.16,17Concurrent use of EMLA, DPNB, and acetaminophen did not lead to a clinically significant risk of methemoglobinemia. These data add to a recently published study demonstrating no additive effect of acetaminophen on methemoglobin concentrations in 10 neonates treated with acetaminophen 12 hours before receiving EMLA.18

We evaluated the effect of postnatal age on infant pain response to determine if the analgesic regimen was appropriate for newborns after the first few days of life. We found no differences in infant responses between newly born and older infants up to 72 days of age. These results suggest that the analgesic regimen evaluated is equally effective in newborn and older infants. It also demonstrates that the different mean gestational ages between the study groups did not contribute to the differences in pain response detected by us.

Provisions were made to maintain similar conditions in the environments of infants in both groups while they were undergoing the procedure. It is possible that some differences in infant responses may be because of differences between the surgeons. However, both physicians perform circumcisions on a daily basis and are skilled in the technique they use. The results obtained in this study for infants circumcised with EMLA and the Gomco clamp are sufficiently similar to previous studies using EMLA and the Gomco clamp19

to suggest that the skill of the surgeon did not explain differences between groups. Similarly, the results obtained for the infants circumcised with combined analgesia and the Mogen clamp are somewhat similar to previous studies of DPNB and the Mogen clamp.13

We believe that if circumcision is to be performed, it should be done using the least painful method. We have demonstrated that circumcision with the Mogen clamp and combined analgesia is safe and minimizes pain from this procedure. Accepted for publication November 11, 1999.

 

CONCLUSION

We believe that if circumcision is to be performed, it should be done using the least painful method. We have demonstrated that circumcision with the Mogen clamp and combined analgesia is safe and minimizes pain from this procedure.

Accepted for publication November 11, 1999. Corresponding author: Anna Taddio, BScPhm, MSc, PhD, Department of Pharmacy, The Hospital for Sick Children, 555 University Ave, Toronto M5GIX8, Ontario, Canada (e-mail: anna.taddio@sickkids.on.ca).

 

REFERENCES

1. Howard CR, Howard FM, Garfunkel LC, de Blieck EA, Weitzman M. Neonatal circumcision and pain relief: current training practices. Pediatrics. 1998;101:423428.
2. Taddio A, Stevens B. Craig K, et al. Efficacy and safety of lidocaine-prilocaine cream for pain during neonatal circumcision. N Eng/ J Med. 1997;336:1197-1201.
3. Kirya C, Werthmann MW Jr. Neonatal circumcision and penile dorsal nerve block: a painless procedure. J Pediatr. 1978;92:998-1000.
4. Holve RL, Bromberger PJ, Groveman HD, Klauber MR, Dixon SD, Snyder JM. Regional anesthesia during newborn circumcision. Clin Pediatr. 1983;22:813-818.
5. Stang HJ, Gunnar MR, Snellman L, Condon LM, Kestenbaum R. Local anesthesia for neonatal circumcision: effects on distress and cortisol response. JAMA. 1988:259:1507-1511.
6. Lander J, Brady-Fryer B, Metcalfe JB, Nazarali S, Muttitt S. Comparison of ring block, dorsal penile nerve block, and topical anesthesia for neonatal circumcision: a randomized controlled trial. JAMA. 1997;278:2157-2162.
7. Blass EM. Hoffmeyer LB. Sucrose as an analgesic for newborn infants. Pediatrics. 1991,87:215-218.
8. Herschel M, Khoshnood B, Ellman C. Maydew N, Mittendorf R. Neonatal circumcision: randomized trial of a sucrose pacifier for pain control. Arch PediatrAdolesc Med. 1998,152:279-284.
9. Howard CR, Howard FM, Weitzman ML. Acetaminophen analgesia in neonatal circumcision: the effect on pain. Pediatrics. 1994;93:641-646.
10. Stang HJ, Snellman LW, Condon LM, et al. Beyond dorsal penile nerve block: a more humane circumcision. Pediatrics. 1997:100:e3. Available at: www .pediatrics.org/cgi/content/full/100/2/e3. 11. Mohan CG, Risucci DA, Casimir M, Gulrajani-LaCorte M. Comparison of analgesics in ameliorating the pain of circumcision. J Perinatol. 1998:18:13-19.
12. Serour F, Mandelberg A, Zabeeda D, Mori J. Ezra S. Efficacy of EMLA cream prior to dorsal penile nerve block for circumcision in children. ActaAnaesthesiol Scand 1998:42:260-263.
13. Kurtis PS. DeSilva HN, Bernstein BA. Malakh L, Schechter NL. A comparison of the Mogen and Gomco clamps in combination with dorsal penile nerve block in minimizing the pain of neonatal circumcision. Pediatrics. 1999:103:e23. Available at: http://www.pediatrics.org/cgi/content/full/103/2/e23.
14. Taddio A. Katz J, Ilersich AL, Koren G. Effect of neonatal circumcision on pain response during subsequent routine vaccination. Lancet. 1997;349:599-603.
15. Newton CW, Mulnix N, Baer L, Bovee T. Plain and buffered lidocaine for neonatal circumcision. Obstet Gynecol. 1999;93:350-352.
16. Snellman LW, Stang HJ. Prospective evaluation of complications of dorsal penile nerve block for neonatal circumcision. Pediatrics. 1995;95:705-708.
17. Taddio A, Ohlsson A, Einarson TR, Stevens B, Koren G. A systematic review of lidocaine-prilocaine cream (EMLA) in the treatment of acute pain in neonates. Pediatrics. 1998:101(2):el. Available at: http://www.pediatrics.org/cgi/content/ full/101/2/el.
18. Brisman M, Llung BM. Otterbom I, Larsson LE, Andreasson SE. Methaemoglobin formation after the use of EMLA cream in term neonates. Acta Paediatr.1998. 87:1191-1194.
19. Taddio A, Ohlsson K. Ohlsson A. Lidocaine-prilocaine cream for analgesia during circumcision of newborn boys [Cochrane Review on CD-ROM]. Oxford, England: Cochrane Library, Update Software, 1999:issue 3.

 

Male Circumcision

Male circumcision consists of the surgical removal of some, or all, of the foreskin (or prepuce) from the penis. It is one of the most common procedures in the world. In the United States, the procedure is commonly performed during the newborn period. In 2007, the American Academy of Pediatrics (AAP) convened a multidisciplinary workgroup of AAP members and other stakeholders to evaluate the evidence regarding male circumcision and update the AAP’s 1999 recommendations in this area. The Task Force included AAP representatives from specialty areas as well as members of the AAP Board of Directors and liaisons representing the American Academy of Family Physicians, the American College of Obstetricians and Gynecologists, and the Centers for Disease Control and Prevention. The Task Force members identified selected topics relevant to male circumcision and conducted a critical review of peer-reviewed literature by using the American Heart Association’s template for evidence evaluation.

Evaluation of current evidence indicates that the health benefits of newborn male circumcision outweigh the risks; furthermore, the benefits of newborn male circumcision justify access to this procedure for families who choose it. Specific benefits from male circumcision were identified for the prevention of urinary tract infections, acquisition of HIV, transmission of some sexually transmitted infections, and penile cancer. Male circumcision does not appear to adversely affect penile sexual function/sensitivity or sexual satisfaction. It is imperative that those providing circumcision are adequately trained and that both sterile techniques and effective pain management are used. Significant acute complications are rare. In general, untrained providers who perform circumcisions have more complications than well-trained providers who perform the procedure, regardless of whether the former are physicians, nurses, or traditional religious providers.

Parents are entitled to factually correct, nonbiased information about circumcision and should receive this information from clinicians before conception or early in pregnancy, which is when parents typically make circumcision decisions. Parents should determine what is in the best interest of their child. Physicians who counsel families about this decision should provide assistance by explaining the potential benefits and risks and ensuring that parents understand that circumcision is an elective procedure. The Task Force strongly recommends the creation, revision, and enhancement of educational materials to assist parents of male infants with the care of circumcised and uncircumcised penises. The Task Force also strongly recommends the development of educational materials for providers to enhance practitioners’ competency in discussing circumcision’s benefits and risks with parents.

The Task Force made the following recommendations:

  • Evaluation of current evidence indicates that the health benefits of newborn male circumcision outweigh the risks, and the benefits of newborn male circumcision justify access to this procedure for those families who choose it.
  • Parents are entitled to factually correct, nonbiased information about circumcision that should be provided before conception and early in pregnancy, when parents are most likely to be weighing the option of circumcision of a male child.
  • Physicians counseling families about elective male circumcision should assist parents by explaining, in a nonbiased manner, the potential benefits and risks and by ensuring that they understand the elective nature of the procedure.
  • Parents should weigh the health benefits and risks in light of their own religious, cultural, and personal preferences, as the medical benefits alone may not outweigh these other considerations for individual families.
  • Parents of newborn boys should be instructed in the care of the penis, regardless of whether the newborn has been circumcised or not.
  • Elective circumcision should be performed only if the infant’s condition is stable and healthy.
  • Male circumcision should be performed by trained and competent practitioners, by using sterile techniques and effective pain management.
  • Analgesia is safe and effective in reducing the procedural pain associated with newborn circumcision; thus, adequate analgesia should be provided whenever newborn circumcision is performed.
    • Nonpharmacologic techniques (eg, positioning, sucrose pacifiers) alone are insufficient to prevent procedural and postprocedural pain and are not recommended as the sole method of analgesia. They should be used only as analgesic adjuncts to improve infant comfort during circumcision.
    • If used, topical creams may cause a higher incidence of skin irritation in low birth weight infants, compared with infants of normal weight; penile nerve block techniques should therefore be chosen for this group of newborns.
  • Key professional organizations (AAP, the American Academy of Family Physicians, the American College of Obstetricians and Gynecologists, the American Society of Anesthesiologists, the American College of Nurse Midwives, and other midlevel clinicians such as nurse practitioners) should work collaboratively to:
    • Develop standards of trainee proficiency in the performance of anesthetic and procedure techniques, including suturing;
    • Teach the procedure and analgesic techniques during postgraduate training programs;
    • Develop educational materials for clinicians to enhance their own competency in discussing the benefits and risks of circumcision with parents;
    • Offer educational materials to assist parents of male infants with the care of both circumcised and uncircumcised penises.
  • The preventive and public health benefits associated with newborn male circumcision warrant third-party reimbursement of the procedure.

The American College of Obstetricians and Gynecologists has endorsed this technical report.

KEY WORDS

AAFP — American Academy of Family Physicians
AAP — American Academy of Pediatrics
ACOG — American College of Obstetricians and Gynecologists
BV — bacterial vaginosis
CB — caudal block
CDC — Centers for Disease Control and Prevention
CDM — Charge Data Master
CI — confidence interval
DPNB — dorsal penile nerve block
HPV — human papillomavirus
HSV — herpes simplex virus
IELT — Intravaginal Ejaculatory Latency Times
MSM — men who have sex with men
NHDS — National Hospital Discharge Survey
NIS — National Inpatient Sample
OR — odds ratio
RCT — randomized controlled trial
STI — sexually transmitted infection
UTI — urinary tract infection

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