Essay/Term paper: Male circumcision: a social and medical misconception

Essay, term paper, research paper:  Science Reports

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-