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 penis. 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 foreskin 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 Middle East 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]. 102 American Journal of Health Education — March/April 2005, Volume 36, No. 2 Mary E. Buie 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 infants due to their era, physicians considered circumcision as However, the western region (38.0%) de- fragile health status.1 a cure for impotence, phimosis (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 Pediatrics, newborns experience pain and (painful erection in the absence of sexual Hispanics in this region, because they are physiologic distress if circumcised without interest), masturbation, venereal disease, traditionally less likely to receive circumci- anesthesia.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 nerve block (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 urinary tract infection (UTI) (an individual benefit) and Religion However, the Centers for Disease Control a decreased risk of sexually transmitted According to the book of Genesis in the and Prevention (CDC) reports that this so- diseases (STDs) (an individual and popu- Bible, around 2000 B.C., Abraham 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 mohel, 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 adults, the greatest risk for UTI the United States. 1997, these rates remained relatively stable occurs in infants younger than one year of American Journal of Health Education — March/April 2005, Volume 36, No. 2 103 Mary E. Buie 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