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Circumcision: The Good, the Bad and American Values

Mary E. Buie

ABSTRACT

National statistics estimate that 1.2 million newborn males are circumcised annually in the United States (70% to 80%). Such values as sanctity, equity, fraternity, paternity and liberty affect circumcision rates in America. The value of sanctity allows freedom of religious beliefs and traditions that often overcome medical impetus in decision- making with regard to circumcision. A lack in the value of equity allows socioeconomic status and cost to impact whether or not babies are circumcised. The value of fraternity allows individual and population benefits through decreased urinary tract infections and decreased sexually transmitted infection transmission. The value of pater- nity allows the attempt to protect newborn males, an effort inherent with risk. Circumcision is an elective surgery, and the value of liberty continues to allow Americans to determine their own stance and action regarding circum- cision. The use of this procedure must be evaluated on an individual basis. Unbiased, comprehensive preoperative information must be provided to ensure informed decisions. Education is the key toward a decision about the value of circumcision, and health educators play a pivotal role in the informed decision-making process.

INTRODUCTION this surgical procedure, whereas other falls off during healing. The Mogen clamp, Male circumcision, an elective proce- countries do not? This paper will review the or shield, is traditionally used at a bris, or dure, involves the surgical removal of the procedure, explore values, and delineate the the Judaic circumcision ritual.4 Its benefits skin that covers the tip of the . Cir- role of health education in relation to neo- include low blood loss, low incidence of cumcision is uncommon in Asia, South natal circumcision. infection and superior cosmetic results.4 America, Central America and most of Eu- Circumcision involves the following rope, with only 5% to 6% of males circum- PROCEDURE steps: 1) estimating the amount of skin to cised in Great Britain.1,2 However, about In the U.S., health professionals and be removed, 2) dilating the preputial ori- one-quarter of the world’s male population licensed religious individuals perform fice, 3) freeing the from the glans is circumcised, largely concentrated in the circumcisions utilizing one of three instru- of the penis, 4) positioning the device, United States, Canada, countries in the ments: the Gomco clamp, the Plastibell or 5) waiting for hemostasis to occur, and and Asia with Muslim popu- the Mogen clamp. Physicians often use the 6) amputating the foreskin. A suture is lations, and large portions of Africa.3 Na- Gomco clamp, a metal clamp removed tional statistics estimate that 1.2 million after use.4 Whereas health professionals newborn males are circumcised annually in report the Plastibell to be easier to use, it Mary E. Buie, MPH, MS, is a USF Doctoral the United States (70% to 80%).1,2 Why do often results in inflammation and exudate.4 Student, 2403 Coventry Avenue, Lakeland, Fl the majority of Americans readily adopt This plastic device remains in place until it 33803; E-mail: [email protected].

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sometimes needed to ensure hemostasis.1,4 Morality with slight to moderate increases for the Newborns must be stable and healthy to un- In the past, morality also shaped the midwest region (81.6%), the northeast re- dergo circumcision. This surgery is not per- practice of circumcision. In the Victorian gion (68.3%), and the south (64.5%).10 formed on premature due to their era, physicians considered circumcision as However, the western region (38.0%) de- fragile health status.1 a cure for impotence, (a tight or creased by 25.9%.10 The CDC attributes this According to the American Academy of unretractable foreskin), sterility, priapism decline to the increased birth rate among , newborns experience and (painful erection in the absence of sexual Hispanics in this region, because they are physiologic distress if circumcised without interest), , venereal disease, traditionally less likely to receive circumci- .1 Options for pain reduction, in epilepsy, bed-wetting, night terrors, sexual sions than Caucasian and African-Ameri- order of increasing effectiveness, include a unrest and homosexuality.5 Even in the late can infants.10 Cultural and family traditions eutectic mixture of local anesthetics (EMLA 19th century, medical professionals contin- related to ethnicity continue to influence the cream), a dorsal penile (DPNB) ued to accept circumcision as an effective rate of circumcisions performed annually or a subcutaneous ring block.1 Traditional treatment for many medical maladies, such in the United States. techniques utilizing sucrose and acetami- as masturbation, headache, insanity, epi- Equity nophen are not recommended as the sole lepsy, paralysis, strabismus (a squint), rec- A lack of equity plays a part in the deci- method of pain relief.1 The American Acad- tal prolapse, hydrocephalus (water on the sion to circumcise, since the cost of the pro- emy of Pediatrics states that adequate an- brain) and clubfoot.6,7 The most common cedure remains a barrier to some individu- esthesia should be provided if neonatal cir- basis for circumcision, as documented als. The average charge for circumcision in cumcision is performed.1 throughout history, was the prevention of an office setting between three days and masturbation, a stance encouraged by nine months of age is $196, and the same VALUES Christian prohibitionists against non-pro- procedure performed in the operating room Circumcision rates vary across the globe. creative sex.5 Today, however, the stigmati- costs $1,805.4 Estimated costs of circumci- This may be due to the different values of zation of masturbation is diminishing in sion are between $150 million and $270 different cultures, and therefore, values America, and morality is rarely cited in ref- million in the United States annually.1 Not must be taken into consideration in the erence to the decision to circumcise new- all insurance companies cover circumcision, analysis of circumcision prevalence in the born males. which creates a socioeconomic status dis- United States. Such values include sanctity, Tradition parity in the practice of circumcision. equity, fraternity, paternity and liberty. Tradition continues to influence the Fraternity Sanctity practice of circumcision in the United Fraternity is concerned with maximiz- Historically, the value of sanctity repre- States. Ethnic traditions influence rates of ing the benefit to society. Circumcision, an sented the basis for many newborn circum- circumcision, and reported rates of circum- individual and highly personal procedure, cisions, as expressed through religion, mo- cision vary. In America, some reports indi- does benefit the individual, as well as the rality and tradition. This value continues to cate that Caucasians (81%) are considerably influence Americans’ decisions to circum- more likely to be circumcised than African- general population. Circumcision benefits cise newborn males. Americans (65%) or Hispanics (54%).1,8 include a decreased risk of (UTI) (an individual benefit) and Religion However, the Centers for Disease Control a decreased risk of sexually transmitted According to the in the and Prevention (CDC) reports that this so- diseases (STDs) (an individual and popu- Bible, around 2000 B.C., made a cial disparity does not exist. In the past lation benefit). covenant with God in which God would twenty years, the rate of circumcision give Abraham many descendants, and all among Caucasians remained at 65.8%, with UTI of the descendants were to be circumcised little variation between 1979 and 1997.9 In 1993, a meta-analysis of studies re- as a reminder of the covenant. In the During this same time, the rate of circum- vealed an association between the lack of Jewish religion, this developed into the tra- cision among African-Americans increased male circumcision and risk for urinary tract ditional bris milah, or the circumcision from 57.9% in 1979 to 67.3% in 1997.9 Cir- infection among male infants.3,11 In all of ritual performed on the eighth day of life. cumcision rates vary by geographic region the nine studies identified, uncircumcised Generally, this ritual is performed by a within the United States, as well. In the U.S. infants were more likely to develop UTIs , an ordained rabbi licensed by the in 1979, circumcision rates, in descending than circumcised infants, with risk ratios state to perform circumcision. Judaic ritu- order, were as follows: the midwest region ranging from 5 to 89 infants.3,11 Whereas als still account for a significant portion (74.3%), the northeast region (66.2%), the similar findings have been reported in older of circumcisions performed annually in west (63.9%), and the south (55.8%).10 By children and , the greatest risk for UTI the United States. 1997, these rates remained relatively stable occurs in infants younger than one year of

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age.1,3,11-13 The increased risk associated with men had an HPV infection.23 This same studies 3 revealed that two studies reported uncircumcised infants may be due to prepu- study concluded that the odds of having statistically significant associations between tial colonization of uropathic bacteria, a (almost certainly a sexually lack of circumcision and genital herpes,45,46 condition that attenuates over time.2,3 UTIs transmitted disease, caused by oncogenic and four studies reported no association.8,47- are treatable, but they may lead to expen- strains of HPV) among monogamous 49 Another study determined that there is an sive, and sometimes invasive, investiga- women with six or more lifetime sexual association in women between HSV-2 in- tions.3 Renal injury also may result from this partners were reduced by about 60% if the fection and a history of intercourse with an condition.3 partners were circumcised.23 Risk factors uncircumcised partner.42 Uncircumcised associated with penile cancer include smok- men appear to be at higher risk for the ac- In the United States, an estimated 750- ing, genital warts, more than 30 sexual part- quisition of genital herpes.42,45,46 Risk fac- 1000 cases of penile cancer occur annu- ners and phimosis (a tight or unretractable tors for genital herpes include race, age, ally.3,14 Uncircumcised males account for foreskin).4 smoking, douching, a greater number of almost all of these cases, and the rate of Human Immunodeficiency Virus (HIV) lifetime sex partners, a history of inter- mortality may be as high as 25%.3,7,14 A rare In 1994, a review of 30 epidemiological course with an uncircumcised partner, the disease in the United States, the age-ad- studies revealed a statistically significant presence of vaginal group B Streptococcus justed annual incidence of penile cancer is association between male circumcision and and abnormal vaginal flora.42 0.9 to 1.0 per 100,000 males.1,15 This rate risk for HIV infection in 18 studies from Other STDs increases in countries in which the major- six countries.3,24 Four studies from four Studies assessing the relationship be- ity of males are uncircumcised, such as Bra- countries found a trend towards an asso- tween and circumcision and the zil (2.9 to 6.8 per 100,000) and India (2.0 to ciation, and four from two countries found relationship between chlamydia and cir- 10.5 per 100,000).1,16,17 Among five pub- no association.3,24 A review of 11 studies3 cumcision present inconclusive results. A lished studies examining penile carcinoma, since that time revealed a statistically statistically significant association between essentially all men with the disease were not significant association among eight stud- circumcision and gonorrhea was reported circumcised as infants.3 Circumcision later ies,25-32 a trend towards an association in in five studies,45,48,50-52 and two studies re- in life was shown to be ineffective in the one study,33 no association in one study,34 ported no association.8,53 For chlamydia, prevention of penile cancer.3,18 A lack of cir- and an increased risk with circumcision in two studies reported significant association cumcision also was associated with the de- one study.35 with lack of circumcision,50,54 three reported velopment of penile intraepithelial neo- Many of these studies were conducted increased risk with circumcision,8,53,55 and plasia, a precursor to penile carcinoma in in Africa, and some argue that this may skew three reported no association.8,48,49 At least some males.3,19 the data in relation to its use in developed 11 studies provide strong evidence indicat- Human papillomavirus (HPV) may countries.6,37 Cultural differences impact ing a significant association between ulcer- mediate the increased susceptibility to pe- circumcision status differently in the United ative STDs, such as and , nile carcinoma among uncircumcised States. In 1997, Marck determined that un- and lack of circumcision.3,29,48,52,55-61 males.3,20,21 There is an association of HPV circumcised males, in circumcising areas Several theories exist as to why circum- DNA and genital warts with penile cancer; of Africa, face discrimination in work, hous- cision lowers the risk of certain STDs like however, the percentage of penile cancers ing, marriage and sexual relations.6 A sig- syphilis, but not others. These include the with HPV DNA is lower than that of four nificant percentage of these men resort to following: 1) trauma of the intact foreskin other anogenital tumors (anus, cervix, vulva prostitutes, increasing their risk of exposure during might produce and vagina).1,22 Researchers interpret this to HIV and other STDs.6,37 Even further, cir- microscopic abrasions that increase the outcome to imply that sexual transmission cumcision causes most tetanus infections,38 susceptibility to STDs, 2) the environment may be less of a factor in the genesis of squa- spreads tuberculosis39 and results in a high under the foreskin might enhance the sur- mous cell carcinoma of the penis than of number of severe complications and death vival of certain infectious agents, prolong- these other cancers.1,22 Another suggestion in Africa.40,41 Therefore, cultural differences ing exposure to them, 3) the epithelium of is that HPV is a co-factor for penile cancer, related to the practice of circumcision in the glans of uncircumcised men may be requiring the presence of other conditions Africa may be inapplicable in the United thinner and less cornified than in circum- for progression to malignancy.1 Regardless, States. cised men, providing less of a physical bar- a study conducted by the International Genital herpes rier to microbes, and 4) non-specific bal- Agency for Research on Cancer (IARC) de- Genital herpes is one of the most preva- anitis, more common in uncircumcised termined that the odds that circumcised lent STDs worldwide, most frequently men, may predispose to certain STDs due men had an HPV infection were about 60% caused by virus type 2 to an inflammatory response.24,48,62 lower than the odds that uncircumcised (HSV-2).42-44 A review of epidemiologic Whereas the studies examining the

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association between lack of circumcision Problems with circumcision the amount of vascularization associated and STDs provide conflicting evidence, cir- Complications may result in 1.5% to 5% with the distal glans tissue, grafting is rec- cumcision appears to have protective effects of circumcisions, and extreme rates range ommended in such injuries.2,67,68 2 against certain STDs.2,63 Therefore, the value from 0.06% to 55%. This variation may be Infection due to geographic and cultural differences of fraternity encourages individual circum- Infection occurs in about 10% of in the literature. One U.S. study compared cisions in the goal of population-wide pre- patients, making it the second most com- the risks from circumcision during the first vention of STDs. mon from circumcision.2 Lo- month of life with those for uncircumcised Paternity cal therapy may attenuate most inflamma- infants.65 For 100,157 circumcised males, Paternity involves protecting children tion cases, but in severe bacterial infections, there were 193 complications (0.19%).65 because they cannot protect themselves. necrotizing fasciitis, staphylococcal ‘scalded These complications included 62 local in- The value of paternity may be viewed from skin’ syndrome, impetigo, osteomyelitis, fections, 8 cases with bacteremia, 83 cases two angles. On one hand, circumcision pro- bronchopneumonia and meningitis may with hemorrhage, 24 cases of surgical tects newborns from possible physiological occur.2 trauma and 20 UTIs.65 The complications problems later in life. On the other hand, in the 35,929 uncircumcised infants were Other complications circumcision itself may induce physiologi- all related to UTIs.65 Another study evalu- Other complications from circumcision cal problems in the newborn male. ated complications from circumcision per- may include urethral injuries, surgical Problems without circumcision formed by medically trained or untrained trauma and operative complications, phi- Neonatal circumcision may prevent operators.66 Traditional, or medically un- mosis after circumcision, skin bridges, physiological problems later in life, includ- trained, circumcisers were responsible for inclusion cysts, and penile lym- ing the following conditions usually seen 2 85% of the complications.66 phoedema. Whereas local anesthesia in adults: , posthitis, phimosis, In the United Kingdom, the Medical should be utilized with neonates undergo- , localized condyloma Defense Union addresses specific issues re- ing circumcision, older children and acuminata and localized carcinoma.2 Bal- garding the complications associated with men are usually circumcised under general anitis (inflammation of the preputial skin) circumcision.2 These include hemorrhage, anesthesia, providing the possibility of and posthitis (inflammation of the glans , amputation of the glans additional complications.2 penis) are often associated with diabetes.2 and infection, among others.2 Balanitis may also result from the lodging Liberty and the Role of Health Educators Hemorrhage of foreign objects under the foreskin of the Americans value liberty and the freedom penis, as seen with the lodging of sand Bleeding, the most common complica- of choice. Health educators are in a posi- under preputial skin in uncircumcised tion from circumcision, accounts for 0.1% tion to ensure that such liberties are main- 2 American soldiers during World War II.64 to 35% of cases. Most cases are minor, re- tained during the decision-making process Phimosis, a tight or unretractable fore- sponding to gentle pressure. Inadequate regarding circumcision. Circumcision is skin, can be treated with topical , hemostasis, blood coagulopathy or anoma- elective surgery. In 1982, McDermott out- but circumcision is often the only treat- lous blood vessels may lead to excessive lined patient-centered counseling objectives 2 ment offered.4 Paraphimosis is retention bleeding. Pressure, electrocautery and, that retain their applicability over twenty of the preputial ring proximal to the coro- infrequently, blood transfusions may be years later. First, health educators must 2 nal sulcus.2 This condition may result in required in these cases. provide unbiased information regarding edema of the prepuce, potentially disturb- Meatitis and meatal stenosis. circumcision and its alternative, noncir- ing perfusion, leading to ischemic pain, Meatitis frequently occurs at a rate of cumcision.64 This information may include cyanosis and, if left untreated, to skin 8% to 20%.2 The removal of the prepuce procedural options, as well as the religious, loss and gangrene.2 After inflammation de- exposes the glans to ammoniacal substances social, traditional and aesthetic origins of creases, circumcision is recommended.2 present in urine-soaked diapers, leading to circumcision.64 Educators must remember, Circumcision is also suggested to treat irritation and injury of the external urethral however, that comprehensive preoperative dermatologic conditions of the foreskin, meatus.2 As a result, the meatus may be information without external medical, such as condyloma acuminata and low- scarred, leading to meatal stenosis which societal or religious pressures is essential 2 stage tumors of malignant basal carcino- predisposes the to UTI. Meatotomy to the informed decision-making process. mas or squamous cell carcinomas.2 Due to may alleviate the symptoms associated with Second, the health educator must detail 2 these indications, circumcision of this complication. the risks and benefits associated with cir- newborns facilitates genital hygiene Glans amputation cumcision and noncircumcision.64 The throughout life under varying environ- Glans amputation is rare, but it may be educator, in conjunction with the physician, mental conditions.2 the most serious complication.2 Because of must clearly explain the indication for

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circumcision in the individual case, the sur- mary goals of health educators, but we must Immunological functions of the human gical technique, the potential hazards (with also look beyond these avenues, and beyond prepuce. Sex Transm Infect. 1998; 74: 364-367. the procedure and with local anesthesia), solely prospective parent education. 7. Hodges F. A short history of the insti- and the plan of action in the case of com- Society must be educated about circum- tutionalization of involuntary sexual muti- plications.3 Thirdly, the health educator cision. Health educators know the impor- lation in the United States. In Denniston must allow and encourage a free choice tance of education prior to presentation of GC, Milos MF, eds. Sexual : a between the two alternatives.64 Through the the problem. There is a lack of common human tragedy. New York: Plenum, 1997; use of these measures, health educators may knowledge regarding circumcision, not only 17-40. ensure an informed decision regarding cir- by John Q. Public, but also by health edu- 8. Laumann EO, Masi CM, Zuckerman cumcision, as well as a fair and just exercise cators. Ask your colleagues, friends and EW. Circumcision in the United States. of the value of liberty. family about circumcision. How much do JAMA. 1997; 277: 1052-1057. Informed decision-making begins with they know? How much do you know? It is 9. Percent of newborn males with cir- the health educator/prospective parent dis- ironic that the topic of circumcision is di- cumcision performed in short-stay hospi- cussion. These discussion sessions have tra- minishing in health education, even as the tals by race: United States, 1999. Available ditionally taken place in one of three ways: procedure becomes increasingly accepted at: http://www.cdc.gov/nchs. Accessed during prenatal visits, during hospital- and performed in American society. Com- March 28, 2004. based prenatal classes, or during hospital- prehensive discussions of circumcision in 10. Percent of newborn males with cir- based postpartum visits.64 Such avenues re- public health classes, cumcision performed in short-stay hospi- main vital pathways toward educating and classes, community classes, clinics, through tals by region: United States, 1999. Avail- informing prospective parents about pre- public health campaigns, and especially by able at: http://www.cdc.gov/nchs. Accessed natal and birthing issues; however, they may word-of-mouth are vital to a renewed health March 28, 2004. not be as effective in the dissemination of education effort regarding circumcision. 11. Wiswell TE, Hachey WE. Urinary circumcision information. Health educators This effort will increase the public awareness tract infections and the uncircumcised state. miss opportunities during prenatal visits, of circumcision, as well as its implications Clin Pediatr. 1993; 32: 130-134. which often occur between physicians and for society, which affect the values of sanc- 12. Craig JC, Knight JF, Sureshkumar P, prospective parents only, with no health tity, fraternity, paternity and liberty. The et al. Effect of circumcision on incidence of educator involved. This generally results American population must be knowledge- urinary tract infection in preschool boys. J from the absence of health educators on able about the pros and cons of circumci- Pediatr. 1996; 128: 23-27. staff at the physician office/clinic, yet it sion, and it is the responsibility of health 13. Spach DH, Stapleton AE, Stamm WE. yields another missed educational oppor- educators to bring this issue to the forefront Lack of circumcision increases the risk of tunity. 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HealthTeacher.com is an original curriculum created for teachers that • Is comprehensive and sequential. • Covers nine core topic areas, including the top six risk factors identified by CDC. • Meets National Health Education Standards. Compare HealthTeacher’s curriculum align ment with the Assessment Framework Descriptors. • Is based on the Assessment Framework.

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108 American Journal of Health Education — March/April 2005, Volume 36, No. 2