Male Circumcision A Social And Medical Misconception

Essay, Research Paper

Male Circumcision: A Social and Medical Misconception

University of Johns Hopkins

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, or

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-