Circumcision: The Good, the Bad, and American Values

Mary E Buie. American Journal of Health Education. Volume 36, Issue 2. March-April 2005.

Introduction

Male circumcision, an elective procedure, involves the surgical removal of the skin that covers the tip of the penis. Circumcision is uncommon in Asia, South America, Central America and most of Europe, with only 5% to 6% of males circumcised in Great Britain. However, about one-quarter of the world’s male population is circumcised, largely concentrated in the United States, Canada, countries in the Middle East and Asia with Muslim populations, and large portions of Africa.3 National statistics estimate that 1.2 million newborn males are circumcised annually in the United States (70% to 80%). Why do the majority of Americans readily adopt this surgical procedure, whereas other countries do not? This paper will review the procedure, explore values, and delineate the role of health education in relation to neonatal circumcision.

Procedure

In the U.S., health professionals and licensed religious individuals perform circumcisions utilizing one of three instruments: the Gomco clamp, the Plastibell or the Mogen clamp. Physicians often use the Gomco clamp, a metal clamp removed after use. Whereas health professionals report the Plastibell to be easier to use, it often results in inflammation and exudate. This plastic device remains in place until it falls off during healing. The Mogen clamp, or shield, is traditionally used at a bris, or the Judaic circumcision ritual. Its benefits include low blood loss, low incidence of infection and superior cosmetic results.

Circumcision involves the following steps: 1) estimating the amount of skin to be removed, 2) dilating the preputial orifice, 3) freeing the foreskin from the glans of the penis, 4) positioning the device, 5) waiting for hemostasis to occur, and 6) amputating the foreskin. A suture is sometimes needed to ensure hemostasis. Newborns must be stable and healthy to undergo circumcision. This surgery is not performed on premature infants due to their fragile health status.

According to the American Academy of Pediatrics, newborns experience pain and physiologic distress if circumcised without anesthesia. Options for pain reduction, in order of increasing effectiveness, include a eutectic mixture of local anesthetics (EMLA cream), a dorsal penile nerve block (DPNB) or a subcutaneous ring block. Traditional techniques utilizing sucrose and acetaminophen are not recommended as the sole method of pain relief. The American Academy of Pediatrics states that adequate anesthesia should be provided if neonatal circumcision is performed.

Values

Circumcision rates vary across the globe. This may be due to the different values of different cultures, and therefore, values must be taken into consideration in the analysis of circumcision prevalence in the United States. Such values include sanctity, equity, fraternity, paternity and liberty.

Sanctity

Historically, the value of sanctity represented the basis for many newborn circumcisions, as expressed through religion, morality and tradition. This value continues to influence Americans’ decisions to circumcise newborn males.

Religion

According to the book of Genesis in the Bible, around 2000 B.C., Abraham made a covenant with God in which God would give Abraham many descendants, and all of the descendants were to be circumcised as a reminder of the covenant. In the Jewish religion, this developed into the traditional bris milah, or the circumcision ritual performed on the eighth day of life. Generally, this ritual is performed by a mohel, an ordained rabbi licensed by the state to perform circumcision. Judaic rituals still account for a significant portion of circumcisions performed annually in the United States.

Morality

In the past, morality also shaped the practice of circumcision. In the Victorian era, physicians considered circumcision as a cure for impotence, phimosis (a tight or unretractable foreskin), sterility, priapism (painful erection in the absence of sexual interest), masturbation, venereal disease, epilepsy, bed-wetting, night terrors, sexual unrest and homosexuality. Even in the late 19th century, medical professionals continued to accept circumcision as an effective treatment for many medical maladies, such as masturbation, headache, insanity, epilepsy, paralysis, strabismus (a squint), rectal prolapse, hydrocephalus (water on the brain) and clubfoot. The most common basis for circumcision, as documented throughout history, was the prevention of masturbation, a stance encouraged by Christian prohibitionists against non-procreative sex. Today, however, the stigmatization of masturbation is diminishing in America, and morality is rarely cited in reference to the decision to circumcise newborn males.

Tradition

Tradition continues to influence the practice of circumcision in the United States. Ethnic traditions influence rates of circumcision, and reported rates of circumcision vary. In America, some reports indicate that Caucasians (81%) are considerably more likely to be circumcised than African-Americans (65%) or Hispanics (54%). However, the Centers for Disease Control and Prevention (CDC) reports that this social disparity does not exist. In the past twenty years, the rate of circumcision among Caucasians remained at 65.8%, with little variation between 1979 and 1997. During this same time, the rate of circumcision among African-Americans increased from 57.9% in 1979 to 67.3% in 1997. Circumcision rates vary by geographic region within the United States, as well. In the U.S. in 1979, circumcision rates, in descending order, were as follows: the midwest region (74.3%), the northeast region (66.2%), the west (63.9%), and the south (55.8%). By 1997, these rates remained relatively stable with slight to moderate increases for the midwest region (81.6%), the northeast region (68.3%), and the south (64.5%). However, the western region (38.0%) decreased by 25.9%. The CDC attributes this decline to the increased birth rate among Hispanics in this region, because they are traditionally less likely to receive circumcisions than Caucasian and African-American infants. Cultural and family traditions related to ethnicity continue to influence the rate of circumcisions performed annually in the United States.

Equity

A lack of equity plays a part in the decision to circumcise, since the cost of the procedure remains a barrier to some individuals. The average charge for circumcision in an office setting between three days and nine months of age is $196, and the same procedure performed in the operating room costs $1,805. Estimated costs of circumcision are between $150 million and $270 million in the United States annually. Not all insurance companies cover circumcision, which creates a socioeconomic status disparity in the practice of circumcision.

Fraternity

Fraternity is concerned with maximizing the benefit to society. Circumcision, an individual and highly personal procedure, does benefit the individual, as well as the general population. Circumcision benefits include a decreased risk of urinary tract infection (UTI) (an individual benefit) and a decreased risk of sexually transmitted diseases (STDs) (an individual and population benefit).

(Urinary Tract Infection) UTI

In 1993, a meta-analysis of studies revealed an association between the lack of male circumcision and risk for urinary tract infection among male infants. In all of the nine studies identified, uncircumcised infants were more likely to develop UTIs than circumcised infants, with risk ratios ranging from 5 to 89 infants. Whereas similar findings have been reported in older children and adults, the greatest risk for UTI occurs in infants younger than one year of age. The increased risk associated with uncircumcised infants may be due to preputial colonization of uropathic bacteria, a condition that attenuates over time. UTIs are treatable, but they may lead to expensive, and sometimes invasive, investigations. Renal injury also may result from this condition.

Penile Cancer

In the United States, an estimated 750- 1000 cases of penile cancer occur annually. Uncircumcised males account for almost all of these cases, and the rate of mortality may be as high as 25%. A rare disease in the United States, the age-adjusted annual incidence of penile cancer is 0.9 to 1.0 per 100,000 males. This rate increases in countries in which the majority of males are uncircumcised, such as Brazil (2.9 to 6.8 per 100,000) and India (2.0 to 10.5 per 100,000). Among five published studies examining penile carcinoma, essentially all men with the disease were not circumcised as infants. Circumcision later in life was shown to be ineffective in the prevention of penile cancer. A lack of circumcision also was associated with the development of penile intraepithelial neoplasia, a precursor to penile carcinoma in some males.

Human papillomavirus (HPV) may mediate the increased susceptibility to penile carcinoma among uncircumcised males. There is an association of HPV DNA and genital warts with penile cancer; however, the percentage of penile cancers with HPV DNA is lower than that of four other anogenital tumors (anus, cervix, vulva and vagina). Researchers interpret this outcome to imply that sexual transmission may be less of a factor in the genesis of squamous cell carcinoma of the penis than of these other cancers. Another suggestion is that HPV is a co-factor for penile cancer, requiring the presence of other conditions for progression to malignancy. Regardless, a study conducted by the International Agency for Research on Cancer (IARC) determined that the odds that circumcised men had an HPV infection were about 60% lower than the odds that uncircumcised men had an HPV infection. This same study concluded that the odds of having cervical cancer (almost certainly a sexually transmitted disease, caused by oncogenic strains of HPV) among monogamous women with six or more lifetime sexual partners were reduced by about 60% if the partners were circumcised. Risk factors associated with penile cancer include smoking, genital warts, more than 30 sexual partners and phimosis (a tight or unretractable foreskin).

Human Immunodeficiency Virus (HIV)

In 1994, a review of 30 epidemiological studies revealed a statistically significant association between male circumcision and risk for HIV infection in 18 studies from six countries. Four studies from four countries found a trend towards an association, and four from two countries found no association. A review of 11 studies since that time revealed a statistically significant association among eight studies, a trend towards an association in one study, no association in one study, and an increased risk with circumcision in one study.

Many of these studies were conducted in Africa, and some argue that this may skew the data in relation to its use in developed countries. Cultural differences impact circumcision status differently in the United States. In 1997, Marck determined that uncircumcised males, in circumcising areas of Africa, face discrimination in work, housing, marriage and sexual relations. A significant percentage of these men resort to prostitutes, increasing their risk of exposure to HIV and other STDs. Even further, circumcision causes most tetanus infections, spreads tuberculosis and results in a high number of severe complications and death in Africa. Therefore, cultural differences related to the practice of circumcision in Africa may be inapplicable in the United States.

Genital Herpes

Genital herpes is one of the most prevalent STDs worldwide, most frequently caused by herpes simplex virus type 2 (HSV-2). A review of epidemiologic studies revealed that two studies reported statistically significant associations between lack of circumcision and genital herpes, and four studies reported no association. Another study determined that there is an association in women between HSV-2 infection and a history of intercourse with an uncircumcised partner. Uncircumcised men appear to be at higher risk for the acquisition of genital herpes. Risk factors for genital herpes include race, age, smoking, douching, a greater number of lifetime sex partners, a history of intercourse with an uncircumcised partner, the presence of vaginal group B Streptococcus and abnormal vaginal flora.

Other STDs

Studies assessing the relationship between gonorrhea and circumcision and the relationship between chlamydia and circumcision present inconclusive results. A statistically significant association between circumcision and gonorrhea was reported in five studies, and two studies reported no association. For chlamydia, two studies reported significant association with lack of circumcision, three reported increased risk with circumcision, and three reported no association. At least 11 studies provide strong evidence indicating a significant association between ulcerative STDs, such as syphilis and chancroid, and lack of circumcision.

Several theories exist as to why circumcision lowers the risk of certain STDs like syphilis, but not others. These include the following: 1) trauma of the intact foreskin during sexual intercourse might produce microscopic abrasions that increase the susceptibility to STDs, 2) the environment under the foreskin might enhance the survival of certain infectious agents, prolonging exposure to them, 3) the epithelium of the glans of uncircumcised men may be thinner and less cornified than in circumcised men, providing less of a physical barrier to microbes, and 4) non-specific balanitis, more common in uncircumcised men, may predispose to certain STDs due to an inflammatory response.

Whereas the studies examining the association between lack of circumcision and STDs provide conflicting evidence, circumcision appears to have protective effects against certain STDs. Therefore, the value of fraternity encourages individual circumcisions in the goal of population-wide prevention of STDs.

Paternity

Paternity involves protecting children because they cannot protect themselves. The value of paternity may be viewed from two angles. On one hand, circumcision protects newborns from possible physiological problems later in life. On the other hand, circumcision itself may induce physiological problems in the newborn male.

Problems without circumcision

Neonatal circumcision may prevent physiological problems later in life, including the following conditions usually seen in adults: balanitis, posthitis, phimosis, paraphimosis, localized condyloma acuminata and localized carcinoma. Balanitis (inflammation of the preputial skin) and posthitis (inflammation of the glans penis) are often associated with diabetes. Balanitis may also result from the lodging of foreign objects under the foreskin of the penis, as seen with the lodging of sand under preputial skin in uncircumcised American soldiers during World War II. Phimosis, a tight or unretractable foreskin, can be treated with topical steroids, but circumcision is often the only treatment offered. Paraphimosis is retention of the preputial ring proximal to the coronal sulcus. This condition may result in edema of the prepuce, potentially disturbing perfusion, leading to ischemic pain, cyanosis and, if left untreated, to skin loss and gangrene. After inflammation decreases, circumcision is recommended. Circumcision is also suggested to treat dermatologic conditions of the foreskin, such as condyloma acuminata and lowstage tumors of malignant basal carcinomas or squamous cell carcinomas. Due to these indications, circumcision of newborns facilitates genital hygiene throughout life under varying environmental conditions.

Problems with circumcision

Complications may result in 1.5% to 5% of circumcisions, and extreme rates range from 0.06% to 55%. This variation may be due to geographic and cultural differences in the literature. One U.S. study compared the risks from circumcision during the first month of life with those for uncircumcised infants. For 100,157 circumcised males, there were 193 complications (0.19%). These complications included 62 local infections, 8 cases with bacteremia, 83 cases with hemorrhage, 24 cases of surgical trauma and 20 UTIs. The complications in the 35,929 uncircumcised infants were all related to UTIs. Another study evaluated complications from circumcision performed by medically trained or untrained operators. Traditional, or medically untrained, circumcisers were responsible for 85% of the complications.

In the United Kingdom, the Medical Defense Union addresses specific issues regarding the complications associated with circumcision. These include hemorrhage, meatal stenosis, amputation of the glans and infection, among others.

Bleeding, the most common complication from circumcision, accounts for 0.1% to 35% of cases. Most cases are minor, responding to gentle pressure. Inadequate hemostasis, blood coagulopathy or anomalous blood vessels may lead to excessive bleeding. Pressure, electrocautery and, infrequently, blood transfusions may be required in these cases.

Meatitis frequently occurs at a rate of 8% to 20%. The removal of the prepuce exposes the glans to ammoniacal substances present in urine-soaked diapers, leading to irritation and injury of the external urethral meatus. As a result, the meatus may be scarred, leading to meatal stenosis which predisposes the infant to UTI. Meatotomy may alleviate the symptoms associated with this complication.

Glans amputation is rare, but it may be the most serious complication. Because of the amount of vascularization associated with the distal glans tissue, grafting is recommended in such amputation injuries.

Infection occurs in about 10% of patients, making it the second most common complication from circumcision. Local therapy may attenuate most inflammation cases, but in severe bacterial infections, necrotizing fasciitis, staphylococcal ‘scalded skin’ syndrome, impetigo, osteomyelitis, bronchopneumonia and meningitis may occur.

Other complications from circumcision may include urethral injuries, surgical trauma and operative complications, phimosis after circumcision, skin bridges, inclusion cysts, chordee and penile lymphoedema. Whereas local anesthesia should be utilized with neonates undergoing circumcision, older children and adult men are usually circumcised under general anesthesia, providing the possibility of additional complications.

Liberty and the Role of Health Educators

Americans value liberty and the freedom of choice. Health educators are in a position to ensure that such liberties are maintained during the decision-making process regarding circumcision. Circumcision is elective surgery. In 1982, McDermott outlined patient-centered counseling objectives that retain their applicability over twenty years later. First, health educators must provide unbiased information regarding circumcision and its alternative, noncircumcision. This information may include procedural options, as well as the religious, social, traditional and aesthetic origins of circumcision. Educators must remember, however, that comprehensive preoperative information without external medical, societal or religious pressures is essential to the informed decision-making process. Second, the health educator must detail the risks and benefits associated with circumcision and noncircumcision. The educator, in conjunction with the physician, must clearly explain the indication for circumcision in the individual case, the surgical technique, the potential hazards (with the procedure and with local anesthesia), and the plan of action in the case of complications. Thirdly, the health educator must allow and encourage a free choice between the two alternatives. Through the use of these measures, health educators may ensure an informed decision regarding circumcision, as well as a fair and just exercise of the value of liberty.

Informed decision-making begins with the health educator/prospective parent discussion. These discussion sessions have traditionally taken place in one of three ways: during prenatal visits, during hospital-based prenatal classes, or during hospital-based postpartum visits. Such avenues remain vital pathways toward educating and informing prospective parents about prenatal and birthing issues; however, they may not be as effective in the dissemination of circumcision information. Health educators miss opportunities during prenatal visits, which often occur between physicians and prospective parents only, with no health educator involved. This generally results from the absence of health educators on staff at the physician office/clinic, yet it yields another missed educational opportunity. Health educators also miss opportunities during hospital-based prenatal classes. The number of women enrolled in hospital-based prenatal classes is declining, possibly due to the increased prevalence of epidurals used during delivery (C. Wachdorf, PhD, CNM, oral communication, September, 2004). Regardless of the reason, fewer women in these classes mean greater missed opportunity to inform. Finally, health educators miss opportunities during hospital-based postpartum visits. The parental decision to circumcise is often made before or early in pregnancy. If health educators wait until after delivery to discuss the issues related to circumcision, generally the parental decision has already been made, whether it is an informed decision or not. This lack of timeliness results in additional missed opportunities. These methods of communication are still primary goals of health educators, but we must also look beyond these avenues, and beyond solely prospective parent education.

Society must be educated about circumcision. Health educators know the importance of education prior to presentation of the problem. There is a lack of common knowledge regarding circumcision, not only by John Q. Public, but also by health educators. Ask your colleagues, friends and family about circumcision. How much do they know? How much do you know? It is ironic that the topic of circumcision is diminishing in health education, even as the procedure becomes increasingly accepted and performed in American society. Comprehensive discussions of circumcision in public health classes, human sexuality classes, community classes, clinics, through public health campaigns, and especially by word-of-mouth are vital to a renewed health education effort regarding circumcision. This effort will increase the public awareness of circumcision, as well as its implications for society, which affect the values of sanctity, fraternity, paternity and liberty. The American population must be knowledgeable about the pros and cons of circumcision, and it is the responsibility of health educators to bring this issue to the forefront of public health and health education.