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.

 

Brit Milah on Shabbat or Yom Tov

A very common question that I am asked is ” What happens if my baby is born on Shabbat?”

The mitzvah of Brit Milah is a time bound positive mitzvah that should occur on the 8th day of a baby boy’s life.  So what do we do if this situation arises ?  By calculation a baby boy born on Shabbat should have his Brit Milah on the following Shabbat.

The following criteria must be satisfied in order to have a Brit Milah on Shabbat.

  • The baby must have been born after nightfall Friday night and before nightfall Saturday night.  Nightfall is defined as the time at which three stars are visible in the sky (Tzet Chochavim). If the baby is born after sunset but before nightfall on Friday night, the Brit Milah is delayed until Sunday.
  • The baby must have been born by spontaneous vaginal delivery.  A Caesarian Section disqualifies the baby from having his Brit Milah on Shabbat.
  • The baby must be free of any malady that would otherwise delay the Brit Milah.

If any of these criteria are not met then the Brit Milah would be delayed until Sunday.  The same criteria apply to a baby born on a day that would necessitate his Brit Milah take place on any Yom Tov day, in which case the Brit Milah would be delayed until the first non Yom Tov day following the actual eighth day of his life.

Therefore when attempting to schedule the Brit Milah it is always best practice to consult with me before making any arrangements for the Brit.

Finally, since the mitzvah of Brit Milah is so important that it overrides certain laws of Shabbat/Yom Tov, it is very important that the integrity of the day is preserved.  Therefore, the baby must not be driven to the location of the Brit Milah. Furthermore, all the preparations for the Brit Milah must be concluded prior to the onset of Shabbat including any preparation of food to be served at the Seudat Mitzvah that follows the Brit Milah.

For further information on this topic please feel free to contact me directly.

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

A Modern Pain Free Brit

By Y. Aaron Kaweblum

I have been a “mohel” (person that has a rabbinic certification to perform Jewish ritual circumcisions) since 1980. I am also a Board certified pediatrician in private practice.

Over the last decade I have noticed a trend among Jewish parents to have the baby medically circumcised in the hospital instead of fulfilling the biblical commandment of ritual circumcision or Brith milah. I believe that many parents think that a medical circumcision in the newborn nursery is medically more appropriate and/or that a “Brith Milah” is a barbaric tradition.

The ceremony of “Brith Milah” dates back many thousands of years. It is probably on of the oldest rituals in human history.

According to Jewish law, it takes place on the eight day of life, counting the date of birth as day one, assuming the baby is born before sundown. The Brith-milah could be postponed for health or other religious reasons, but it can never take place before the eight day.

Scientific medical studies have shown that circumcised males have a lower incidence of penile cancer, and are less prone to acquire sexually transmitted diseases.

Recent studies have shown that the baby’s ability to stop bleeding could be decreased during the first week of life. In some cases it is not until the eighth day that the factors required to stop bleeding reach normal level.

Approximately ten years ago, the AAP (American Academy of Pediatrics) demonstrated that a newborn baby feels the SAME level of PAIN as an adult, and strongly condemned the practice of surgery on a baby without using proper pain control. From the religious prospective, Rabbi Tendler from Monds NY, a famous orthodox “posek” (a Rabbi that has gained the trust and respect of the religious community and writes answers to difficult religious issues) wrote that doing a Brith-milah without pain control, is against Jewish principles.

In 1997 a study published in JAMA (Journal of the American Medical Association) showed that only the injection of local anesthesia was effective in controlling pain during newborn circumcision. That same study probed that the user of “EMLA” (topical cream for pain) was useless and even dangerous.

In my personal case, as an orthodox mohel and a pediatrician I have been using local anesthetic on my newborn babies for over 15 years. I even perform Brith-milah ceremonies in babies as old as nine months or 16lb.

In the USA it is against the law to do any kind of surgical procedures on laboratory animals without anesthesia. I still don’t understand why the law allos Rabbis and physicians to do surgery in human newborns without a local anesthetic. Therefor, if you are expecting a baby boy, don’t turn back on the biblical commandment of Brith-milah. The torah and modern science are on your side. Y. Aaron Kaweblum M.D is currently practicing in Miami, Florida.

This article is being published with the consent of Y. Aaron Kaweblum M.D.

Circumcision Benefits Outweigh Risks, Study Reports

A review of studies has found that the health benefits of infant male circumcision vastly outweigh the risks involved in the procedure.

But the study, published online in Mayo Clinic Proceedings, also found that while the prevalence of circumcision among American men ages 14 to 59 increased to 81 percent from 79 percent over the past decade, the rate of newborn circumcision has declined by 6 percentage points, to 77 percent, since the 1960s.

The authors conclude that the benefits — among them reduced risks of urinary tract infectionprostate cancersexually transmitted diseases and, in female partners, cervical cancer — outweigh the risks of local infection or bleeding. Several studies, including two randomized clinical trials, found no long-term adverse effects of circumcision on sexual performance or pleasure.

One cost-benefit analysis that considered infant urinary tract infections and sexually transmitted diseases found that if circumcision rates were decreased to the 10 percent typical in European countries, the additional direct medical costs over 10 years of births would be more than $4.4 billion.

“Male circumcision is in principle equivalent to childhood vaccination,” said the lead author, Brian J. Morris, emeritus professor of medical sciences at the University of Sydney. “Just as there are opponents of vaccination, there are opponents of circumcision. But their arguments are emotional and unscientific, and should be disregarded.”

A version of this article appears in print on 04/08/2014, on page D6 of the NewYork edition with the headline: Childhood: Benefits From Circumcision.

Circumcision Rates in the United States: Rising or Falling? What Effect Might the New Affirmative Pediatric Policy Statement Have?

Originally published in Mayo Clinic Proceedings, May 2014

 

Brian J. Morris, DSc, PhDStefan A. Bailis, PsyD, Thomas E. Wiswell, MD

Abstract

The objective of this review was to assess the trend in the US male circumcision rate and the impact that the affirmative 2012 American Academy of Pediatrics policy statement might have on neonatal circumcision practice. We searched PubMed for the term circumcision to retrieve relevant articles. This review was prompted by a recent report by the Centers for Disease Control and Prevention that found a slight increase, from 79% to 81%, in the prevalence of circumcision in males aged 14 to 59 years during the past decade. There were racial and ethnic disparities, with prevalence rising to 91% in white, 76% in black, and 44% in Hispanic males. Because data on neonatal circumcision are equivocal, we undertook a critical analysis of hospital discharge data. After correction for underreporting, we found that the percentage had declined from 83% in the 1960s to 77% by 2010. A risk-benefit analysis of conditions that neonatal circumcision protects against revealed that benefits exceed risks by at least 100 to 1 and that over their lifetime, half of uncircumcised males will require treatment for a medical condition associated with retention of the foreskin. Other analyses show that neonatal male circumcision is cost-effective for disease prevention. The benefits of circumcision begin in the neonatal period by protection against infections that can damage the pediatric kidney. Given the substantial risk of adverse conditions and disease, some argue that failure to circumcise a baby boy may be unethical because it diminishes his right to good health. There is no long-term adverse effect of neonatal circumcision on sexual function or pleasure. The affirmative 2012 American Academy of Pediatrics policy supports parental education about, access to, and insurance and Medicaid coverage for elective infant circumcision. As with vaccination, circumcision of newborn boys should be part of public health policies. Campaigns should prioritize population subgroups with lower circumcision prevalence and a higher burden of diseases that can be ameliorated by circumcision.

 

Article Highlights

The present article examines the trend in male circumcision in the United States, contemporary issues, and what these might mean for the future of circumcision practice in this country. The publications referenced were selected for relevance from among the first author’s (B.J.M.) collection of more than 3000 on the topic of male circumcision that had been retrieved using the search term circumcision from weekly PubMed alerts between January 1999 and December 2013 and from Current Contents between January 1988 and December 1998. All the articles were filed under the subcategories of rates, policy, ethics, risks, and each of the medical conditions that male circumcision affects.

What the Latest Rates Data Show

The review was triggered by a recent report by the Centers for Disease Control and Prevention (CDC) on the prevalence of circumcision among males aged 14 to 59 years in the United States.1 The CDC data were obtained from the National Health and Nutrition Examination Surveys (NHANESs) for 2005 to 2010, in which interviews were administered to a nationally representative sample of 6294 males. The CDC researchers estimated total circumcision prevalence to be 80.5% (Table 1).Racial differences were apparent: Prevalence was 90.8% in non-Hispanic white, 75.7% in non-Hispanic black, and 44.0% in Mexican American males. The recent figures are higher than in the CDC’s previous report based on NHANES data for 1999 to 20042 (Table 1).

Table 1Comparison of Total Circumcision Prevalence in Men and Boys Aged 14 to 59 Years in 2005 to 20101 Compared With 1999 to 20042a
Race/ethnicity Prevalence (% [95% CI]) Change (%)
1999-2004 2005-2010
Overall 79 (77-80) 80.5 (78.4-82.5) +2.5
Non-Hispanic white 88 (87-90) 90.8 (89.1-92.6) +3.4
Non-Hispanic black 73 (69-77) 75.7 (72.0-79.4) +4.1
Mexican American 42 (43-57) 44.0 (41.0-46.9) +4.8
aNote that data for 1999 to 2004 were published by the Centers for Disease Control and Prevention as wholenumbers,2 whereas data for 2005 to 2010 were published to 1 decimal point.1

Because these data are for males aged 14 to 59 years—and most circumcisions in the United States take place during the neonatal period—they largely reflect past practice. What happened in the 1950s through the 1990s may not be what is happening today.

Estimates of prevalence of neonatal circumcision generally rely on hospital discharge data.3 Such figures are taken from records of procedures performed during the neonatal hospital stay. However, few studies have investigated the reliability of hospital discharge data as an estimate of neonatal circumcision prevalence; those that have done so have found a substantial discrepancy. A survey in Maryland found that the prevalence was 75.3% based on hospital discharge data but 82.3% based on a postpartum survey.4 An earlier study in Atlanta found that circumcision was recorded for only 84.3% of boys who had received a circumcision.5 In referring to their sample in July 1985, the authors stated, “If we had relied solely on [summary information in the medical record, usually found on the face sheet] we would have estimated that the circumcision rate for that period was 75.3% rather than 89.3%.”5,p.414

These previous comparisons have been of local samples only. To better ascertain recent trends nationally, we considered it instructive to critically compare the new NHANES findings with National Hospital Discharge Survey (NHDS) data for 1979 to 2010 as reported recently by the CDC.3 The present evaluation, therefore, updates the comparison of NHANES and NHDS data by Waskett in 2007.6 That study was limited by having only 1980s births available for comparison. The present analysis is, therefore, more informative.

We show in Table 2 the prevalence of circumcision in the NHANES and NHDS samples for comparable birth years. It is readily apparent that NHANES data show a substantially higher prevalence of circumcision than suggested by the NHDS figures. The recent NHDS analysis did note in the first paragraph, however, that their figures “do not include circumcisions performed outside the hospital setting […] or those performed at any age following discharge from the birthhospitalization.”3 The present article refers to nonhospital and postdischarge circumcisions as “unrecorded circumcisions.” The number of these can be estimated by comparison of NHDS data with NHANES data, where the latter records circumcisions performed at any time and any location.

Table 2Comparison of NHANES1 and NHDS3 Circumcision Prevalence Data for Comparable Birth Years
Birth years Prevalence (%)
NHANES NHDS Unrecorded
1970-1979 82.0 64.5 49.3
1980-1989 79.8 61.2 47.9
1990-1996 76.2 60.9 39.1

NHANES = National Health and Nutrition Examination Survey; NHDS = National Hospital Discharge Survey.

Our calculation involved the following formula: a = i + u(1 – i), where a is the prevalence from NHANES data for men and boys aged 14 to 59 years (which, for convenience, is referred to as “adult circumcisions” for the purpose of this article), i is the prevalence in infancy as captured by NHDS data, and u represents unrecorded circumcisions. Thus, u can be obtained from values for a and i using simple algebra, ie, u = (a – i) / (–i + 1). An explanation of the rationale for this formula appears in the Supplemental Appendix (available online at http://www.mayoclinicproceedings.org). Values for these unrecorded circumcisions are shown in Table 2, alongside the percentage of males deemed by raw NHDS data to be uncircumcised and the percentage who were actually found to be circumcised according to the NHANESs of adults and older boys.

The percentage of unrecorded circumcisions is similar across the 3 groups of birth years. The figure is somewhat smaller for the most recent birth years (1990-1996). This finding may be the result of a random fluctuation or a downward trend, or it may reflect the fact that this cohort includes males as young as 14 years, who have had less time in which to be circumcised, although circumcision later in childhood is much less common than during the neonatal period. Using data from the local studies in Maryland4 and Atlanta5 discussed previously herein, we calculate that unrecorded circumcisions in these studies were 28.3% and 56.7%, respectively, ie, they were comparable with those in Table 2 for national data.

We found the mean percentage of unrecorded circumcisions in Table 2 to be 45.4%. On the basis of this figure, we provide in Table 3 predictions for the prevalence of adult circumcision in males born between 1997 and 2010. Although we found that there has been a decline in the prevalence of circumcision from the peak of 83.3% in 1960 to 1969,1 the decline is comparatively small, having fallen only 6.1 percentage points from the 1960 to 1969 birth cohort to the 2010 birth cohort (ie, 83.3 – 77.2 = 6.1).

Table 3Projected Adult Prevalence of Circumcision
Birth years Prevalence (%)
NHDS Adult
1997-1999 62.5 79.5
2000-2009 58.0 77.1
2010 58.3 77.2

NHDS = National Hospital Discharge Survey.

Based on the information previously herein, we show in the Figure the overall prevalence of circumcision in the United States from the late 1940s to 2010.

 

Thumbnail image of Figure. Opens large image

Figure

Prevalence of adult circumcision in the United States during the past 6 decades (1948-2010).1278 The solid line represents documented prevalence among adults; dashed line, our predictions (see the text for how this was derived).

 

Earlier NHDS data to the year 2000 found an increase in neonatal circumcision from 48.3% of newborns in 1988 to 1991 to 61.1% in 1997 to 2000 (P<.0001).9 These rates came from a study of 4,657,402 newborn male hospitalizations from the Nationwide Inpatient Sample that identified newborns who underwent circumcision during a 13-year period usingInternational Classification of Diseases, Ninth Revision procedure codes. A 2011 CDC report based on NHDS statistics found, however, a decrease from 62.5% in 1999 to 56.9% in 2008.10

Thus, despite the 2013 CDC report based on NHANES data for 2005 to 2010 having shown that circumcision prevalence has risen marginally in all racial groups, the present analysis reveals a 6 percentage point fall in the overall prevalence of newborn circumcision in recent times. The main reason is most likely the much faster increase in the Hispanic population,11the ethnic group having the lowest circumcision prevalence. The burgeoning Hispanic population in the West accounts for most of the decrease in national prevalence.3 Because Hispanic and black individuals are overrepresented in poorer demographics, the withdrawal of Medicaid funding for elective circumcision in 18 states is of concern to public health,1213as was also expressed by the authors of the CDC’s recent report.1 After controlling for other factors, states with Medicaid coverage had hospital circumcision rates 24 percentage points higher than states without such coverage.12

Pediatric Recommendation

Circumcision rates may have been influenced, in part, by the periodic reports from the American Academy of Pediatrics (AAP). These reports have changed slowly from negative in the 1970s to neutral in 1999 to positive in 2012.14 It will be interesting to see what impact the recent change in recommendations by the AAP will have on national circumcision rates. The AAP report found (1) that the benefits of infant male circumcision exceed the risks; (2) that parents are entitled to factually correct, nonbiased information about benefits and risks; (3) that access to circumcision should be provided for families who choose it; (4) that effective pain management and sterile technique should be used; and (5) that third-party reimbursement is warranted. The AAP’s policy was developed by ethicists, epidemiologists, and clinical experts, assisted by the CDC, the American Academy of Family Physicians, and the American College of Obstetrics and Gynecology. The AAP policy graded the quality of the research that the Task Force cited and concluded, “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.”14,p.e756,e757,e778 It is not prescriptive. Instead, it states, “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.” Thus, it retains the balance of rights and responsibilities between the individual child, the child’s parents, and society at large. The AAP’s 2012 report might be regarded as close to a recommendation as might be possible in the present era of autonomy, where even vaccinations can be refused by parents for their children.

Risk-Benefit

The AAP Task Force did not conduct a risk-benefit analysis. Because it considered the literature only to 2010, it did not capture risk-benefit analyses published in 2012.1516 Table 4 provides an updated risk-benefit analysis drawing on literature cited in the latter studies and in the AAP report14 and on data in more recent reviews and meta-analyses. This analysis shows that over the lifetime, benefits exceed risks by at least 100 to 1. If one considers the seriousness of some conditions that circumcision protects against, the benefit would actually be much greater. Based on risk-benefit considerations, neonatal circumcision might rationally be considered in the same light as childhood vaccination.

Table 4Comprehensive Risk-Benefit Analysis of Infant Male Circumcisiona
Condition Fold increase in risk (95% CI) Rating ofevidenceb Percentage affected Reference, year
Risks of not circumcisingc
 Urinary tract infection: age 0-1 y 9.9 (7.5-13) 1++ 1.3d Morris and Wiswell,17 2013
 Urinary tract infection: age l-16 y 6.6 (3.3-13) 1++ 2.7d Morris and Wiswell,17 2013
 Urinary tract infection: age >16 y 3.4 (0.92-50) 1+ 28d Morris and Wiswell,17 2013
 Urinary tract infection: lifetime 3.6 (1.8-5.7) 1+ 32d Morris and Wiswell,17 2013
 Pyelonephritis (infants) 10 2+ 0.6d Zorc et al,18 2005; Rushton andMajd,19 1992; Rushton,20 1997;Elder,21 2007
With concurrent bacteremia 20 2+ 0.1d Zorc et al,18 2005; Rushton andMajd,19 1992; Rushton,20 1997;Elder,21 2007
Hypertension in early adulthood 2– 0.1d Jacobson et al,22 1989
End-stage renal disease in early adult 2– 0.06d Jacobson et al,22 1989
 Candidiasis 2.5 (1.7-3.7) 2+ 10d Richters et al,23 2006
 Prostate cancer 1.2-2 2+ 2-10d Wright et al,24 2012; Morris et al,252007; Morris et al,26 2011; Morris and Waskett,27 2012
 Balanitis 3.1 (1.9-5.0) 1+ 10d Morris et al,16 2012
 Phimosis 100 1++ 10d Morris,28 2007
 High-risk HPV infection 1.5 (1.1-2.0) 1++ 6d Tobian et al,29 2009; Auvert et al,302009
2.7 (1.2-6.3) 1+ 10d Morris et al,26 2012; Castellsaguéet al,31 2002; Miralles-Guri et al,322009; Albero et al,33 2012
 Herpes simplex virus type 2 1.4 (1.0-2.5) 1++ 4d Tobian et al,29 2009; Sobngwi-Tambekou et al,34 2009; Tobianet al,35 2009
1.1 (1.0-1.3) 1– 1d Weiss et al,36 2006
 Genital ulcer disease 2.0 (1.4-2.3) 1+ 2d Gray et al,37 2009
Trichomonas vaginalis 1.9 (1.0-3.6) 1+ 0.5d Sobngwi-Tambekou et al,38 2009
Mycoplasma genitalium 1.8 (1.0-3.4) 1++ 1d Mehta et al,39 2012
 Chancroid 0.1-1.1 1++ Lowd Weiss et al,36 2006
 Syphilis 1.9 (1.2-2.9) 2+ Lowd Weiss et al,36 2006
 HIV (acquired heterosexually) 2.4 (1.8-3.2) 1++ 0.3d Siegfried et al,40 2009; Weiss et al,412008; Sansom et al,42 2010; Morriset al,43 2012
 Penile cancer (lifetime) >20 1++ 0.1d American Academy of Pediatrics,142012; Morris et al,26 2011
 In female partner
Cervical cancer 2.4 (1.3-4.3) 2++ NA Castellsagué et al,31 2002; Boschet al,44 2009
Chlamydia trachomatis 5.6 (1.7-20) 2+ NA Castellsagué et al,45 2005
Herpes simplex virus type 2 2.2 (1.4-3.6) 2+ NA Cherpes et al,46 2003
Trichomonas vaginalis 1.9 (1.0-10) 1++ NA Gray et al,47 2009
Bacterial vaginosis 1.7 (1.1-2.6) 1++ NA Gray et al,47 2009
Risks associated with neonatal circumcisione
 Local bruising at the site of injection of local anesthetic (if dorsal penile nerve block used) NA NA 25f NA
 Infection, local NA NA 0.2f NA
 Infection, systemic NA NA 0.02f NA
 Excessive bleeding NA NA 0.1f NA
 Need for repeat surgery (if skin bridges or too little prepuce is removed) NA NA 0.1f NA
 Loss of penis NA NA 0.0001f NA
 Death NA NA 0.00001f NA
 Loss of penile sensitivity NA NA 0f NA
aHIV = human immunodeficiency virus; HPV = human papillomavirus; NA = not applicable.
bRating of evidence was based on the Scottish Intercollegiate Guidelines Network grading system for evidence-basedguidelines48: high-quality meta-analyses, systematic reviews of randomized controlled trials (RCTs), or RCTs with very low risk of bias (1++); well-conducted meta-analyses, systematic reviews of RCTs, or RCTs with low risk of bias (1+); meta-analyses, systematic reviews of RCTs, or RCTs with high risk of bias (1–); high-quality systematic reviews of case-control or cohort studies or high-quality case-control or cohort studies with a very low risk of confounding, bias, or chance and a high probability that the relationship is causal (2++); well-conducted case-control or cohort studies with a low risk of confounding, bias, or chance and a moderate probability that the relationship is causal (2+); and case-control or cohort studies with a high risk of confounding, bias, or chance and a significant risk that the relationship is not causal (2–); reports with lower ratings, such as case reports and case series (3) and expert opinion (4), were not considered.
cThese data show that the risk to an uncircumcised male of developing a condition requiring medical attention during their lifetime is approximately 1 in 2. Values shown are mostly based on statistics for the United States unless RCT data were available from other countries. State-of-the-art reviews are shown where possible rather than individual studies. Information on sexually transmitted infections applies to those acquired in heterosexual males.
dThe percentage of uncircumcised affected is the inverse of the number needed to treat value, which is the approximate number of males who need to be circumcised to prevent 1 case of each condition associated with lack of circumcision.
eThese data show that risk of an easily treatable condition is approximately 1 in 200 and of a serious complication is 1 in 5000. Estimates are taken from American Academy of Pediatrics,14 2012; Wiswell and Geschke,49 1989; and Ben Chaim et al,50 2005.
fPercentage affected is the inverse of the number needed to harm value, which is the approximate number of males who need to be circumcised to see one of each particular (mostly minor) adverse effect. The item “local bruising” is not included in the overall calculation of easily treatable risks because this phenomenon disappears naturally without any medical intervention.

Access and Funding

In most states, Medicaid covers infant male circumcision for the poor. The CDC report criticized the lack of Medicaid coverage for elective circumcision in 18 states.1 The CDC authors estimated that there were 3.5 million uncircumcised men and boys potentially at risk for heterosexually acquired human immunodeficiency virus (HIV), 48.3% of whom lacked health insurance. It is the poor within minorities, principally black and Hispanic, who present the highest disease burden from lack of circumcision. With this and private health insurance coverage in mind, the AAP guidelines state that the preventive and public health benefits associated with newborn male circumcision warrant third-party reimbursement of the procedure.14Their statement reinforces calls for a reevaluation by these 18 states of parental access to and funding for elective circumcision, which has been regarded as a “health parity right of the poor.”121351

Cost-benefit

A cost-effectiveness study that considered only infant urinary tract infections and sexually transmitted infections (STIs) found that if male circumcision rates were to decrease to the levels of 10% typically seen in Europe, the additional direct medical costs in infancy and later for treatment of these among 10 annual birth cohorts would exceed $4.4 billion, even after accounting for the cost of the procedure (average, $291; range, $146-$437) and treatment of complications (average cost, $185 each [range, $130-$235]; prevalence, 0.4% [range, 0.2%-0.6%]).52 Each forgone infant circumcision procedure was estimated to lead to an average of $407 in increased direct medical expenses per male and $43 per female.52 This analysis did not consider other conditions, and neither did it consider the indirect costs. It seems logical then that this analysis might have greatly underestimated the true cost. The study adds to one by the CDC that found that neonatal male circumcision was cost-saving for HIV prevention, at least in black and Hispanic males, in whom HIV prevalence is highest.42 An Australian analysis of genital cancer prevention found that neonatal circumcision provides at least partial cost savings for these.53

A study of a Medicaid birth cohort of 29,316 found that for every year of decreased circumcision due to Medicaid defunding there would be more than 100 additional HIV cases and $30 million in net medical costs as a result of these.54 The cost to circumcise males in this birth cohort was $4,856,000. Modeling has found that cost savings initially generated by noncoverage of elective circumcisions by Medicaid in Louisiana55 and Florida56 was mitigated by increases in the rate and expense of medically indicated circumcisions. The Louisiana study considered only the costs of these for boys aged 0 to 5 years. Lifetime costs would represent a much greater financial impact on health care systems. The Florida study involved males aged 1 to 17 years undergoing circumcision between 2003 and 2008 and found that Medicaid defunding was followed by a 6-fold rise in publicly funded circumcisions (cost = $111.8 million).56

Ethical and Legal Issues

Parents can legally authorize surgical procedures in the best interests of their children.1457585960 The AAP’s ethics committee and others support this contention,6162 as does Article 14(2) of the United Nations Convention on the Rights of the Child (UNCRC) 44/25 of November 20, 1989.63 Exceptions include failing to act in the interests of children and situations in which a medical procedure or withholding a medical procedure might cause serious harm. Because infant male circumcision is not prejudicial to the health of children but instead is beneficial, it also does not violate Article 24(3) of the UNCRC. This document does not refer to childhood male circumcision. If it did, then it is unlikely that the UNCRC would have as signatories almost all the Islamic states and Israel.64 Article 24(1) of the UNCRC calls on parties to agree to “recognize the right of the child to the enjoyment of the highest attainable standard of health and to facilities for the treatment of illness and rehabilitation of health. States Parties shall strive to ensure that no child is deprived of his or her right of access to such health care services.”63

Although some argue that a child has a right to “bodily integrity” and, thus, that circumcision of boys should be banned, discouraged, or at least delayed until he can decide for himself,656667 others disagree6468697071 based on several reasons, some of which are discussed later herein. One author argues that being circumcised boosts autonomy more than constraining it.72 Article 24(3) of the UNCRC seeks to abolish traditional practices prejudicial to the health of children.63Because infant male circumcision is not prejudicial to the health of children but rather is beneficial, it does not violate Article24(3).64 In fact, one commentator construed Article 24(3) as requiring circumcision.64 He pointed out that the tradition in countries that abstain from circumcision can, in fact, be judged as being prejudicial to the health of children.64 He used as an example the increased risk in sexually active minors of acquisition and transmission of potentially fatal oncogenic human papillomavirus genotypes and HIV.

Most parents care deeply for their children and try to do what is best for them. The AAP recommended development of unbiased educational material and that physicians routinely discuss the circumcision decision with parents early in a pregnancy. Fully informed parents might likely choose to have their baby boy circumcised.73 It has been argued that parents who are opposed—even after being fully informed—would seem to place greater value on preserving the foreskin than in protecting their child against the harms, to the boy and his future sexual partners, of the uncircumcised state.64Nevertheless, some parents may refrain out of respect for cultural traditions or perhaps religion; others out of a philosophical position of opposing anything other than the natural state or the acceptance of the alternative views of opponents. Regardless, the decision of parents who refuse should be respected and accepted.

Arguments by opponents start with the premise that circumcision of males has no benefits, only harms, or that the benefits only apply later in life when the male can make the circumcision decision for himself.6674 Table 4 shows that benefits apply in the early pediatric period and extend all the way through life to the geriatric period. Problems in uncircumcised elderly men, especially in nursing homes, are underrecognized and need more attention and research. Another claim is that circumcision diminishes sexual function, sensitivity, and pleasure.677475 A recent exhaustive systematic literature review76and a meta-analysis77 found either no adverse effect or an improvement in these parameters as a result of circumcision.

Parents and physicians each have an ethical duty to the child to attempt to secure the child’s best interest and well-being.78Because the benefits outweigh the risks and the procedure is safe (Table 4), circumcision might be seen in the same light as other interventions that parents must choose for their child. It is the duty of states to create conditions necessary for the fulfillment of rights to good health by facilitating the availability of interventions that are beneficial. Logically it can be argued that should include male circumcision.79 Ethically, infant male circumcision seems to fall within the prerogative of parental decision making.71 A landmark review a decade ago noted that most decisions made by parents for their children will likely have a more profound effect on them than the presence or absence of a foreskin.80

The timing of circumcision is crucial. Medical and practical considerations strongly favor the neonatal period (Table 4).16Surgical risk is, thereby, minimized and the accumulated health benefits are maximized.1416 If circumcision is not performed, one of the benefits potentially lost is protection against urinary tract infections that in infancy may lead to kidney damage (see the recent review by Morris and Wiswell17). Those who argue that circumcision can be delayed so that the boy can make up his own mind when older might not have considered that the operation on mature genitalia is not as simple as the surgery on a baby boy’s penis. Delay may result in increased cost, a higher risk of complications, anesthesia risk if a general anesthetic is used (as is more likely), a longer healing time, a poorer cosmetic outcome should sutures be used, a requirement for temporary sexual abstinence, interference with education or employment, and loss of opportunity for, or delay in, the achievement of protection from STIs for those who become sexually active early and for those who ignore advice on abstinence, thereby exposing them to increased risk of STIs during the 6-week healing period.1416 Thus, it is disingenuous to suggest that the procedure is comparable at both ages.64 Furthermore, an adult cannot consent to his own infant circumcision.64

Many nations that condemn childhood male circumcision are not as quick to condemn other comparably invasive and dangerous procedures that have no medical benefit,64 eg, cosmetic orthodontia, correction of harelip, surgery for tongue-tie, growth hormone injections for treatment of dwarfism, and removal of supernumerary digits.64 Thus, as stated byJacobs,64 it seems odd that neonatal male circumcision is regarded by some as controversial.

As far as the law is concerned, there is a view that the legal system has no place interfering in medical practice when it is based on evidence except to ensure that professionals always act responsibly.

Conclusion

The latest data on male circumcision in the United States show a 2.5% overall increase in prevalence in males aged 14 to 59 years between 2000 and 2010. In contrast, there has been a downward trend in neonatal circumcisions, with the present analyses finding that the true extent of this decline is 6 percentage points. Given (1) the wide-ranging protection that neonatal circumcision affords against a diversity of medical conditions, some of which can be fatal; (2) the high benefit to risk ratio; (3) the data on cost-effectiveness; and (4) the affirmative AAP policy in 2012, in our view, it might be an appropriate time for governments, insurers, and the medical profession to act. When considered together with ethical and human rights arguments, neonatal circumcision should logically be strongly supported and encouraged as an important evidence-based intervention akin to childhood vaccination. We predict that states that currently no longer cover elective circumcision under Medicaid will restore provision of this procedure for those unable to afford it, especially because it will lead to considerable short- and long-term savings to government health budgets by reducing more expensive circumcisions for medical need later, where these often involve costly general anesthesia; it will also reduce the cost of treatment of the many foreskin-mediated conditions, infections, and cancers in males and their sexual partners that male circumcision affords varying degrees of protection against. We predict that future CDC surveys will find significant ongoing increases in the prevalence of circumcision in the United States.

Supplemental Online Material

 

© 2014 Mayo Foundation for Medical Education and Research. Published by Elsevier Inc. User rights governed by an Open Access license.

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