Circumcision: The Pros and Cons

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Circumcision The Pros and Cons

• A snip in time, saves nine.

Christopher R. Leon-Guerrero MS III
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History of Circumcision

• -Dates back as early as the bible if not earlier
• Genesis 1711 And you shall circumcise the flesh
  of your foreskin, that it may be for a sign of
  the covenant between me and you.

Et circumcidetis carnem praeputii vestri ut sit
in signum foederis inter me et vos
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Historical Reasons for Circumcision

• Religious
• e.g. Judaism and Islamism
• - Culture and Tradition
• e.g. rite of passage to adulthood, tribal
  identification, fertility offering
• Hygiene
• Physical and spiritual cleansing

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Circumcisions and Medicine

• -Circumcision became a common medical practice in
  the 19th century
• -Originally indicated for the prevention of
  masturbation

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Epidemiology of Circumcisions

• Circumcisions increased dramatically after World
  War II and peaked in the mid-1970s
• 5th most common procedure performed in the
  United States
• estimated close to 1.2 million circumcisions are
  performed annually in the United States
• - 1/6 of men are circumcised worldwide

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American Academy of Pediatrics Guidelines

- Originally circumcision was a medically
accepted procedure - In the mid 1970s the AAP
deemed circumcision as an unnecessary medical
procedure - In 1989 the AAP switched its stance
back to pro-circumcision because of data
suggesting protection against UTIs and STIs
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The Economics of Circumcision

• - Estimated 150-270 million dollars is spent
  annually on circumcisions in the United States
• Average Inpatient Cost 195
• - Physician Reimbursement 107

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Circumcision Procedure

• There is more than one way to skin a cat
• Gomco clamp
• Plastibell device
• Mogen clamp

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The Pros of Circumcision

• (1) Protection against UTI
• - All studies show an increase risk of UTI in
  uncircumcised males
• - 7-14 of 1000 uncircumcised male infants will
  develop a UTI during the first year of life
• - Only 1-2 of 1000 circumcised male infants will
  develop a UTI during the first year of life
• - Lies, lies and statistics!! The absolute risk
  of developing a UTI in an uncircumcised male
  infant is low
• - Poor methodology of studies

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The Pros of Circumcision (continued)

• (2) Protection against penile cancer
• - Neonatal circumcision confers some protection
  from penile cancer however, circumcision at a
  later age does not seem to confer the same level
  of protection
• - Threefold increased risk of penile cancer in
  uncircumcised men (phimosis)

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The Pros of Circumcision (continued)

• (3) Hygiene??
• -Remains controversial! Evidence-based medicine
  shows no proof to affirm the association
• -However it is biologically plausible ?
  increased periurethral bacterial colonization
  may be a risk factor

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The Pros of Circumcision (continued)

• (4) Enhanced Sexual Function??
• -aesthetically pleasing
• -less sexual dysfunction in males who are
  circumcised?
• - studies show no difference in exteroceptive
  and light tactile stimulation

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The Pros of Circumcision (continued)

• (5) Decreased risk of HIV infection!!
• The US National Institutes of Healths (NIH)
  data safety and monitoring board has halted
  clinical trials in Kenya and Uganda after data
  showed that the rate of HIV infection for
  circumcised heterosexual men declined by half.
• Male circumcision for HIV prevention in young
  men in Kisumu, Kenya a randomized controlled
  trial. Bailey RC, Moses S, Parker CB, Agot K,
  Maclean I, Krieger JN, Williams CF, Campbell RT,
  Ndinya-Achola JO. The Lancet - Vol. 369, Issue
  9562, 24 Feb. 2007, 643-656.
• Circumcision in the Time of HIV When Is There
  Enough Evidence to Revise the American Academy of
  Pediatrics' Policy on Circumcision? Dickerman JD.
  Pediatrics Vol. 119 No. 5 May 2007, pp. 1006-1007.

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The Cons of Circumcision
(1) Medical Complications -rate of complications
0.2 - 0.6 -the majority of complications are
minor e.g. bleeding and minor infections - 0.1
of all circumcisions will have bleeding
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The Cons of Circumcision(continued)

• (2) Pain for the Infant
• evidence supporting pain experienced by the
  newborn
• complete innervation at birth
• anesthesia is indicated!

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The Cons of Circumcision

• (3) Social Implications
• - a slippery slope

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The Cons of Circumcision

• (4) The Cost
• - 150-270 million dollars annually
• - not covered by insurance

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Current AAP Guidelines and Ethical Considerations

• - Patients should be given informed consent
• - Patients should be informed of the benefits
  and risks
• - Anesthesia should be used
• Only on stable and healthy infants
• AAP reaffirmed 1999 policy statement in 2005

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Final Note

• - Physicians should be knowledgeable about
  current changes in benefits and risks for
  circumcisions to better inform their patients
• - Physicians should provide equal access to
  care

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References

• Male circumcision for HIV prevention in young
  men in Kisumu, Kenya a randomized controlled
  trial. Bailey RC, Moses S, Parker CB, Agot K,
  Maclean I, Krieger JN, Williams CF, Campbell RT,
  Ndinya-Achola JO. The Lancet - Vol. 369, Issue
  9562, 24 Feb. 2007, 643-656.
• Circumcision in the Time of HIV When Is There
  Enough Evidence to Revise the American Academy of
  Pediatrics' Policy on Circumcision? Dickerman JD.
  Pediatrics Vol. 119 No. 5 May 2007, pp. 1006-1007
  (doi10.1542/peds.2007-0739)
• Male neonatal circumcision indications,
  controversies and complications. Hutcheson JC.
  Urol Clin North Am. 2004 Aug31(3)461-7, viii.
  Review.
• American Academy of Pediatrics Circumcision
  Policy Statement. Task Force on Circumcision.
  Pediatrics. Vol. 103 No. 3 March 1999, pp.
  686-693