ionUniversity of Johns HopkinsIntroductionMale circumcision is defined as a surgical procedure in which the prepuceof the penis is separated from the glands and excised. (Mosby, 1986) Dating asfar back as 2800 BC, circumcision has been performed as a part of religiousceremony, as a puberty or premarital rite, as a disciplinary measure, as areprieve against the toxic effects of vaginal blood, and as a mark of slavery.(Milos & Macris, 1992) In the United States, advocacy of circumcision wasperpetuated amid the Victorian belief that circumcision served as a remedyagainst the ills of masturbation and systemic disease. (Lund, 1990) Thescientific community further reinforced these beliefs by reporting the incidenceof hygiene-related urogenital disorders to be higher in uncircumcised men.
Circumcision is now a societal norm in the United States. Routinecircumcision is the most widely practiced pediatric surgery and an estimated oneto one-and-a-half million newborns, or 80 to 90 percent of the population, arecircumcised. (Lund, 1990) Despite these statistics, circumcision still remains atopic of great debate. The medical community is examining the need for asurgical procedure that is historically based on religious and cultural doctrineand not of medical necessity. Possible complications of circumcision includehemorrhage, infection, surgical trauma, and pain.
(Gelbaum, 1992) Unlessabsolute medical indications exist, why should male infants be exposed to theserisks? In essence, our society has perpetuated an unnecessary surgical procedurethat 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 rolein the circumcision debate.Review of LiteratureMany studies performed worldwide suggest a relationship between lack ofcircumcision and urinary tract infection (UTI). In 1982, Ginsberg and McCrackendescribed a case series of infants five days to eight months of age hospitalizedwith UTI. (Thompson, 1990) Of the total infant population hospitalized with UTI,sixty-two were males and only three were circumcised. (Thompson, 1990) Based onthis information, the researchers speculated that, “the uncircumcised male hasan increased susceptibility to UTI.” Subsequently, Wiswell and associates fromBrooke Army Hospital released a series of papers based upon a retrospectivecohort 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 theuncircumcised male in the first year of life.
(Thompson, 1990) However, Thompson(1990) reports that in these studies analysis of the data was very crude andthere were no controls for the variables of age, race, education level, orincome. The statistical findings from further studies are equally misconstruing.In 1986, Wiswell and Roscelli reported an increase in the number of UTIs as thecircumcision rate declined.
By clearly leaving out “aberrant data”, the resultsof the study are again very misleading. In 1989, Herzog from Boston Children’sHospital reported on a retrospective case-control study on the relationshipbetween the incidence of UTI and circumcision in the male infant under one yearof age. Here too, the results were not adjusted to account for the variables ofage, ethnicity, and drop-out rate of the participants. It is obvious that thisresearch is statistically weak and should not be the criteria on which to decidefor or against neonatal circumcision.
Lund (1990) reports that a study conducted by Parker and associatesestimates the relative risk of uncircumcised males to be double that ofcircumcised males for acquiring herpes genitalis, candidiasis, gonorrhea, andsyphilis. Simonsen and coworkers performed a case-control study on 340 men inKenya, Africa in an attempt to explain the different pattern for acquired immunedeficiency syndrome (AIDS) virus in Africa as compared to the United States.(Thompson, 1990) The authors conclude that the relative risk for AIDS was higherfor uncircumcised men. Results from similar studies in the United States remainconflicting. Although most of the existing studies do associate a relationshipbetween the incidence of venereal disease and circumcision, the American Academyof Pediatrics found existing reports inconclusive and conflicting in results.
(Lund, 1990) There is an overwhelming incidence of STD and AIDS in the UnitedStates, where a majority of the men are circumcised.It is imperative that we look at ways of altering our risk of exposure tothese agents than at altering the sexual anatomy of the healthy male. Thesedisease states are caused by specific pathogens and high-risk behavior, not bythe uncircumcised penis.Clinical research clearly supports the idea that circumcision performed inthe neonate has many characteristics associated with pain. There is an increasein heart rate, crying, blood pressure, and in serum cortisol levels.
(Myron &Maguire, 1991) Researchers are also in agreement that the neural pathways forpain perception are present in the newborn and that the intraneuronal distancesin infants compensate for the incomplete myelinization of the nerve. (Myron &Maguire, 1991) Although the use of a local anesthetic may reduce the neonatalphysiologic response to pain, this has not become a routine procedure for mostphysicians. Beliefs that the risks outweigh the benefits, that anesthesiaproduces additional pain, and that the immature neuroanatomy of the neonaterenders a minimal pain response help to explain why physicians do not administeranesthesia during circumcision. (Myron & Maguire, 1991)Thompson (1990) reports that the exact incidence of post-operativecomplication remains unknown. Errors such as the removal of too much or toolittle skin, formation of skin bridges or chordee, urethrocutaneous fistula, andnecrosis of the glands or entire penis can occur following circumcision.
Thereported incidence of excessive bleeding ranges from 0.1% to as high as 35%.(Snyder, 1991) Infection can also occur resulting in staphylococcal scalded skinsyndrome, gangrene, generalized sepsis, or meningitis. (Snyder, 1991) Almost allof these complications can be avoided in practice.
However, many problems aredue to the fact that circumcision is viewed as a minor surgery and is oftendelegated to the new physician with little direct supervision or priorinstruction. Snyder (1991) refers to the Wiswell study on the risks ofcircumcision. The total complication rate after circumcision was .19%, however,the risk of severe complications following noncircumcision remained extremelylow, .019%.
(Snyder, 1991). Assuming that circumcision is not performed in sucha meticulous manner worldwide, it is possible that the risks of circumcision arefar greater that the current research in this country suggests.DiscussionClinical evidence cited from the literature confirms that circumcision inthe neonate can result in unnecessary trauma and pain. There is no unequivocalproof that lack of circumcision is directly related to the incidence of UTI andSTDs. Despite these facts, circumcision is still performed as a routineprocedure.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 nursingpractice, changing issues and concerns, and ethical concepts and principles. Itis the responsibility of the nurse to educate and provide the patient withchoices.
As health care professionals, we are responsible for providing unbiasedcounseling. Nurse’s must disregard their own personal biases when discussingcircumcision with the patient. According to the doctrine of informed consent, wemust present all of the known facts to the patient. The patient needs to beinformed that circumcision is an elective surgery, and to the best of theirability the nurse must present what constitutes the benefits, risks, andalternatives available.
(Gelbaum, 1992)According to the ANA Standards of Clinical Nursing Practice, (1991) thenurse shares knowledge with colleagues and acts as a client advocate. Therefore,it is imperative in light of the current research that the nurse disclose thesefindings to associates in the health care profession and continue to lobbyagainst the use of unnecessary surgical interventions in the neonate.Summary In summary, there is no statistical evidence in the literature thatcircumcision is directly related to a decrease in urinary tract infection,sexually transmitted disease, or AIDS in this country. There is evidence thatcircumcision evokes a pain response and carries the post-operative risks ofinfection, trauma, and disformity. Although circumcision is highly performedwithin our medical community, it still cannot be recommended without undeniableproof of benefit to the patient. According to the ANA, it is the nurse’sresponsibility to read the literature, obtain the facts, and share theirknowledge with patients and colleagues.
ConclusionCircumcision evolved out of a cultural and religious ritual and has beenmaintained over the decades despite the risks associated with this nonessential,surgical procedure. The current literature does not reveal a need forcircumcision in the neonate. However, circumcision in the male neonate willcontinue to be a topic of wide debate until the risks can be shown, without adoubt, to outweigh the benefits. Circumcision has truly become a social norm inour country that the medical community attempts to justify with weak andinaccurate research.
According to the ANA, it is not the role of the nurse to decide for theparent on the need for circumcision in the infant. Rather, it is the nurse’srole to present all of the information in an unbiased manner and remain anadvocate of the rights of the patient. Nurse’s need to realistically analyze thedata available and decide if they truly are an advocate, or are merely followingin the steps of their colleagues.ReferencesAmerican 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-Category: Science