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-.