Male Circumcision: A Social and Medical Misconception
Introduction
Male circumcision is defined as a surgical procedure in which the prepuce of the
penis is separated from the glands and excised. (Mosby, 1986) Dating as far back as 2800
BC, circumcision has been performed as a part of religious ceremony, as a puberty or
premarital rite, as a disciplinary measure, as a reprieve against the toxic effects of
vaginal blood, and as a mark of slavery. (Milos & Macris, 1992) In the United States,
advocacy of circumcision was perpetuated amid the Victorian belief that circumcision
served as a remedy against the ills of masturbation and systemic disease. (Lund, 1990)
The scientific community further reinforced these beliefs by reporting the incidence of
hygiene-related urogenital disorders to be higher in uncircumcised men.
Circumcision is now a societal norm in the United States. Routine circumcision is
the most widely practiced pediatric surgery and an estimated one to one-and-a-half
million newborns, or 80 to 90 percent of the population, are circumcised. (Lund, 1990)
Despite these statistics, circumcision still remains a topic of great debate. The medical
community is examining the need for a surgical procedure that is historically based on
religious and cultural doctrine and not of medical necessity. Possible complications of
circumcision include hemorrhage, infection, surgical trauma, and pain. (Gelbaum, 1992)
Unless absolute medical indications exist, why should male infants be exposed to these
risks? In essence, our society has perpetuated an unnecessary surgical procedure that
permanently alters a normal, healthy body part.
This paper examines the literature surrounding the debate over circumcision,
delineates the flaws that exist in the research, and discusses the nurse's role in the
circumcision debate.
Review of Literature
Many studies performed worldwide suggest a relationship between lack of circumcision
and urinary tract infection (UTI). In 1982, Ginsberg and McCracken described a case
series of infants five days to eight months of age hospitalized with UTI. (Thompson,
1990) Of the total infant population hospitalized with UTI, sixty-two were males and only
three were circumcised. (Thompson, 1990) Based on this information, the researchers
speculated that, "the uncircumcised male has an increased susceptibility to UTI."
Subsequently, Wiswell and associates from Brooke Army Hospital released a series of
papers based upon a retrospective cohort study design of children hospitalized with UTI
in the first year of life. The authors conclusions suggest a 10 to 20-fold increase in
risk for UTI in the uncircumcised male in the first year of life. (Thompson, 1990)
However, Thompson (1990) reports that in these studies analysis of the data was very
crude and there were no controls for the variables of age, race, education level, o
r income. The statistical findings from further studies are equally misconstruing. In
1986, Wiswell and Roscelli reported an increase in the number of UTIs as the circumcision
rate declined. By clearly leaving out "aberrant data", the results of the study are again
very misleading. In 1989, Herzog from Boston Children's Hospital reported on a
retrospective case-control study on the relationship between the incidence of UTI and
circumcision in the male infant under one year of age. Here too, the results were not
adjusted to account for the variables of age, ethnicity, and drop-out rate of the
participants. It is obvious that this research is statistically weak and should not be
the criteria on which to decide for or against neonatal circumcision.
Lund (1990) reports that a study conducted by Parker and associates estimates the
relative risk of uncircumcised males to be double that of circumcised males for acquiring
herpes genitalis, candidiasis, gonorrhea, and syphilis. Simonsen and coworkers performed
a case-control study on 340 men in Kenya, Africa in an attempt to explain the different
pattern for acquired immune deficiency syndrome (AIDS) virus in Africa as compared to the
United States. (Thompson, 1990) The authors conclude that the relative risk for AIDS was
higher for uncircumcised men. Results from similar studies in the United States remain
conflicting. Although most of the existing studies do associate a relationship between
the incidence of venereal disease and circumcision, the American Academy of Pediatrics
found existing reports inconclusive and conflicting in results. (Lund, 1990) There is an
overwhelming incidence of STD and AIDS in the United States, where a majority of the men
are circumcised.
It is imperative that we look at ways of altering our risk of exposure to these
agents than at altering the sexual anatomy of the healthy male. These disease states are
caused by specific pathogens and high-risk behavior, not by the uncircumcised penis.
Clinical research clearly supports the idea that circumcision performed in the
neonate has many characteristics associated with pain. There is an increase in heart
rate, crying, blood pressure, and in serum cortisol levels. (Myron & Maguire, 1991)
Researchers are also in agreement that the neural pathways for pain perception are
present in the newborn and that the intraneuronal distances in infants compensate for the
incomplete myelinization of the nerve. (Myron & Maguire, 1991) Although the use of a
local anesthetic may reduce the neonatal physiologic response to pain, this has not
become a routine procedure for most physicians. Beliefs that the risks outweigh the
benefits, that anesthesia produces additional pain, and that the immature neuroanatomy of
the neonate renders a minimal pain response help to explain why physicians do not
administer anesthesia during circumcision. (Myron & Maguire, 1991)
Thompson (1990) reports that the exact incidence of post-operative complication
remains unknown. Errors such as the removal of too much or too little skin, formation of
skin bridges or chordee, urethrocutaneous fistula, and necrosis of the glands or entire
penis can occur following circumcision. The reported incidence of excessive bleeding
ranges from 0.1% to as high as 35%. (Snyder, 1991) Infection can also occur resulting in
staphylococcal scalded skin syndrome, gangrene, generalized sepsis, or meningitis.
(Snyder, 1991) Almost all of these complications can be avoided in practice. However,
many problems are due to the fact that circumcision is viewed as a minor surgery and is
often delegated to the new physician with little direct supervision or prior instruction.
Snyder (1991) refers to the Wiswell study on the risks of circumcision. The total
complication rate after circumcision was .19%, however, the risk of severe complications
following noncircumcision remained extremely low, .019%. (Snyder, 1991)
Assuming that circumcision is not performed in such a meticulous manner worldwide, it is
possible that the risks of circumcision are far greater that the current research in this
country suggests.
Discussion
Clinical evidence cited from the literature confirms that circumcision in the
neonate can result in unnecessary trauma and pain. There is no unequivocal proof that
lack of circumcision is directly related to the incidence of UTI and STDs. Despite these
facts, circumcision is still performed as a routine procedure.
As stated in the American Nurses' Association (ANA) Code of Ethics (1985), nurse's
are required to have knowledge relevant to the current scope of nursing practice,
changing issues and concerns, and ethical concepts and principles. It is the
responsibility of the nurse to educate and provide the patient with choices. As health
care professionals, we are responsible for providing unbiased counseling. Nurse's must
disregard their own personal biases when discussing circumcision with the patient.
According to the doctrine of informed consent, we must present all of the known facts to
the patient. The patient needs to be informed that circumcision is an elective surgery,
and to the best of their ability the nurse must present what constitutes the benefits,
risks, and alternatives available. (Gelbaum, 1992)
According to the ANA Standards of Clinical Nursing Practice, (1991) the nurse shares
knowledge with colleagues and acts as a client advocate. Therefore, it is imperative in
light of the current research that the nurse disclose these findings to associates in the
health care profession and continue to lobby against the use of unnecessary surgical
interventions in the neonate.
Summary
In summary, there is no statistical evidence in the
literature that circumcision is directly related to a decrease in
urinary tract infection, sexually transmitted disease, or AIDS
in this country. There is evidence that circumcision evokes a pain
response and carries the post-operative risks of infection,
trauma, and disformity. Although circumcision is highly performed
within our medical community, it still cannot be recommended
without undeniable proof of benefit to the patient. According to
the ANA, it is the nurse's responsibility to read the literature,
obtain the facts, and share their knowledge with patients and
colleagues.
Conclusion
Circumcision evolved out of a cultural and religious ritual and has been maintained
over the decades despite the risks associated with this nonessential, surgical procedure.
The current literature does not reveal a need for circumcision in the neonate. However,
circumcision in the male neonate will continue to be a topic of wide debate until the
risks can be shown, without a doubt, to outweigh the benefits. Circumcision has truly
become a social norm in our country that the medical community attempts to justify with
weak and inaccurate research.
According to the ANA, it is not the role of the nurse to decide for the parent on
the need for circumcision in the infant. Rather, it is the nurse's role to present all of
the information in an unbiased manner and remain an advocate of the rights of the
patient. Nurse's need to realistically analyze the data available and decide if they
truly are an advocate, or are merely following in the steps of their colleagues.
References
American Nurses Association (1991). Standards of clinical nursing
practice. Washington, D.C.: American Nurses Association.
Gelbaum, I. (1992). Circumcision to educate not indoctrinate-a
mandate for certified nurse-midwives. Journal of Nurse-
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