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PubMed1983

Attitudes of Sudanese people to the practice of female circumcision.

This article aims to determine social, religious and traditional attitudes towards the practice of female circumcision and hence to suggested methods for its abolition. A population of 3210 females and 1545 males was chosen by multi-stage random sampling from Northern Sudan. The study was carried out by means of detailed questionnaires. The results showed that the community is still in favour of the continuation of the practice of circumcision. Almost five times as many women and seven times as many men approved of its continuation than opposed it. However, even the majority of those approving circumcision were against the most severe, Pharaonic type. Those who were against circumcision tended to be better educated and/or younger, suggesting that younger generations are initiating a change of attitude in the community. Those respondents who rejected circumcision generally agreed that, because of its multi-factorial nature, a multidisciplinary approach should be used to initiate change; all possible methods should be integrated for the maximum effect. It is thought that educated and influential people should set an example by abandoning circumcision in their own families. Better health education might also be effective because the practice of circumcision is maintained by fear of criticism and ignorance of the after-effects.

Adolescent↗

PubMed2004

Neonatal circumcision: a review of the world's oldest and most controversial operation.

UNLABELLED: Untimely old, circumcision has elicited more controversy and war of words than any surgical procedure in history. Although previous claims of benefits like curing masturbation, gout, epilepsy, and even insanity were no doubt absurd, important research has shed light on real medical benefits of circumcision. In particular, the procedure has consistently shown to result in the decreased risk of debilitating and costly diseases such as HIV, cervical cancer, and infantile urinary tract infection. Because of advances in the understanding of the anatomy of the foreskin and pain conditioning in infants, prevailing attitudes have changed about anesthesia and analgesia during the procedure. This article objectively summarizes the bulk of significant medical literature over the last century to provide an accurate statement about what we know and what we do not know about neonatal circumcision, including its history, epidemiology, medical benefits, complications, contraindications, techniques, management for pain, and current controversies. TARGET AUDIENCE: Obstetricians & Gynecologists, Family Physicians. LEARNING OBJECTIVES: After completion of this article, the reader should be able to describe the evolution of circumcision, to list the potential benefits of circumcision, to outline the various neonatal circumcision techniques, and to summarize the data on the use of analgesia for circumcision.

Circumcision, Male↗

PubMed2001

Fleeting foreskins: the misclassification of male circumcision status.

BACKGROUND: Errors in the classification of male circumcision status could bias studies linking infection to lack of circumcision. GOAL: To determine the frequency and factors associated with the reproducibility of reporting circumcision status. STUDY DESIGN: Secondary analysis of data using logistic regression modeling from a multicenter randomized controlled trial was performed. RESULTS: At follow-up assessment, 15.6% of clinician reports on circumcision status disagreed with baseline reports. Disagreement was more common if both clinicians were women than if both were men (odds ratio [OR], 2.8; 95% CI, 1.9-4.1). As compared with whites reported as circumcised (4%, 19/532 visits), the highest disagreement involved uncircumcised Hispanic (OR, 3.3; 95% CI, 1.7-6.3), white (OR, 12.2; 95% CI, 5.8-25.6), or black (OR, 17.1; 95% CI, 10.4-27.9) men. CONCLUSIONS: This is one study among a small number of studies examining the reproducibility of clinician-reported circumcision status by comparing multiple clinical examinations of the same patient. The magnitude of the misclassification discovered could bias results and indicates the need for greater accuracy in reporting circumcision status in future studies.

Adult↗

PubMed2004

Risk of HIV-1 in rural Kenya: a comparison of circumcised and uncircumcised men.

BACKGROUND: Most studies that have found an association between uncircumcised status and infection with human immunodeficiency virus type 1 (HIV-1) have compared participants from various demographic backgrounds, among which the prevalence of other risk factors might have varied. We report findings from a study conducted among men within a single ethnic community in which circumcision was dictated by the religious denomination to which the men belonged. METHODS: Of the 1217 eligible men, we included in the analysis 845 who gave blood samples for HIV-1 testing and who were confirmed as either fully circumcised (n = 398) or uncircumcised (n = 447). The seroprevalence of HIV-1 was compared between the 2 groups. RESULTS: All correlates of HIV-1 prevalence that we measured were distributed similarly between circumcised and uncircumcised men. The seroprevalence of HIV-1 was 30% among the uncircumcised men and 20% among the circumcised men. Among uncircumcised men, HIV-1 seroprevalence was similar between men from circumcising denominations (31%; n = 111) and noncircumcising denominations (30%; n = 336). The crude prevalence ratio for HIV infection associated with not being circumcised was 1.5 (95% confidence interval = 1.2-2.0); and adjustment for other measured risk factors for HIV-1 infection had little impact on this result. CONCLUSION: Our study provides evidence that circumcision is associated with a reduced risk of HIV-1 infection.

Adult↗

PubMed2005

Adult male circumcision: results of a standardized procedure in Kisumu District, Kenya.

OBJECTIVE: To develop a standard procedure for male circumcision in a resource-poor medical setting and prospectively evaluate the outcome in a randomized, controlled trial with the incidence of human immunodeficiency virus (HIV) as the main outcome, as studies suggest that circumcision is associated with a lower incidence of HIV and other sexually transmitted infections in high-risk populations. SUBJECTS AND METHODS: Healthy, uncircumcised, HIV-seronegative men aged 18-24 years from Kisumu District, Kenya, were offered participation in a clinical trial using a standard circumcision procedure based on "usual" medical procedures in Western Kenya. The follow-up included visits at 3, 8 and 30 days after circumcision, with additional visits if necessary. Healing, satisfaction and resumption of activities were assessed at these visits and 3 months from randomization. RESULTS: Overall, 17 (3.5%) of the 479 circumcisions were associated with adverse events judged definitely, probably or possibly related to the procedure. The most common adverse events were wound infections (1.3%), bleeding (0.8%), and delayed wound healing or suture line disruption (0.8%). After 30 days, 99% of participants reported being very satisfied with the procedure; approximately 23% reported having had sex and 15% reported that their partners had expressed an opinion, all of whom were very satisfied with the outcome. About 96% of the men resumed normal general activities within the first week after the procedure. CONCLUSION: Safe and acceptable adult male circumcision services can be delivered in developing countries should male circumcision ultimately be advocated as a public-health measure.

Adolescent↗

PubMed1993

Clinical presentation of genital warts among circumcised and uncircumcised heterosexual men attending an urban STD clinic.

INTRODUCTION: A recent study comparing heterosexual men with and without confirmed sexually transmitted diseases (STDs) in an urban STD clinic showed that uncircumcised men were less likely than circumcised men to have genital warts detectable by clinical examination (adjusted odds ratio 0.7, 95% confidence interval 0.4, 0.9). Based on these initial findings we hypothesised that the appearance and anatomic distribution of genital warts, and possibly treatment response, may be different for circumcised and uncircumcised men. METHODS: The anatomic location, appearance, number of warts, and response to treatment was investigated through review of medical records of 459 heterosexual men with genital warts detected in 1988. RESULTS: Age- and race-adjusted estimates indicated that among men with genital warts, warts were detected much more commonly on the distal penis--that is, the corona, frenulum, glans or urethral meatus-, among uncircumcised men (26%) than among circumcised men (3%) (OR 10.0, 95% CI 3.9, 25.7). Where the appearance was specified, warts were more often described as condylomatous in uncircumcised men and slightly more often as papular in circumcised men. No significant difference between circumcised and uncircumcised men was seen in the number of return visits to the clinic for persistent warts after treatment with liquid nitrogen: 2.2 visits for 19 uncircumcised men and 2.3 visits for 149 circumcised men. CONCLUSION: Circumcised men were more likely than uncircumcised men to have genital warts, but when present, warts were more often located on the distal portion of the penis among uncircumcised men. This paradox is not understood, but could reflect either nonspecific resistance to proximal penile warts conferred by the foreskin, or heightened susceptibility to various HPV types in uncircumcised men, some of which may confer subsequent immunity to genital warts.

Adolescent↗

PubMedDate not supplied

Incidence of meatal stenosis following neonatal circumcision in a primary care setting.

The objective of this study was to prospectively document the incidence of meatal stenosis in boys. The study included a consecutive sample of boys whose visit with the physician included a genital examination in a private primary care pediatric practice in rural northern Wisconsin. Meatal stenosis was diagnosed in boys from 1.94 to 12.34 years of age. The diagnosis was made in 24 of 329 circumcised boys who were Tanner I development and older than 3 years of age (7.29%, 95%CI=4.48-10.10%). Nearly all required meatotomy to resolve their symptoms. All of the boys with meatal stenosis were circumcised neonatally (exact OR=3.54, 95%CI=0.62-infinity). The ratio of circumcised boys to noncircumcised boys in this study provided 80% power to demonstrate a 21.4% difference in the incidence of meatal stenosis between circumcised and noncircumcised Tanner I boys 3 years and older. Meatal stenosis may be the most common complication following neonatal circumcision. The frequency of this complication and the need for surgical correction need to be disclosed as part of the informed consent for neonatal circumcision. A careful meatal examination is indicted in any circumcised boy with abdominal or urinary complaints.

Adolescent↗

PubMed1983

Circumcision. A study of current practices.

The purpose of this study was to investigate the current incidence of circumcision, the reasons governing parental decisions regarding circumcision, the immediate and later complications from the procedure, as well as genital problems occurring in uncircumcised boys. The incidence of circumcision was found not to have changed over the past five years despite the recommendations of the American Academy of Pediatrics Task Force on Circumcision. The reasons given for circumcision reflected mostly the strength of tradition, rather than a medical approach. Four per cent of newborns experienced early complications from the procedure, whereas 13 per cent experienced later, minor complications. Problems reported in uncircumcised infants were probably variants of normal. While the results of this study and evidence for discontinuing neonatal circumcision, we strongly recommend that, if physicians dissuade parents from having their infants circumcised, they must give adequate information concerning hygiene and the slow, natural separation of the foreskin from the glans.

Child↗

PubMed1992

Circumcision: is the risk of urinary tract infection really the pivotal issue?

Recent information regarding the increased risk of urinary tract infections in the first year of life for uncircumcised boys has created confusion regarding the appropriate guidance to be given to parents confronting the circumcision issue. A decision model was built that addressed the question of whether or not to circumcise a newborn male considering the probability of a non-circumcised boy having a UTI in the first year of life (0.041), the probability of a circumcised boy having a UTI in the first year of life (0.002), and the likelihood of renal scarring from a UTI (0.075). After considering the morbidity associated with the procedure, all possible outcomes were ranked from worst to best (circumcised-renal pathology to uncircumcised-no infection) and given a value on a 0 to 1 scale. For the set of values assigned to the outcomes, the choice of no circumcision yielded the highest expected utility. For the set of assigned utilities, sensitivity analysis showed that unless the probability of a UTI in the first year of life for an uncircumcised male was greater than or equal to 0.29, then non-circumcision was still the preferred choice. The decision was most sensitive to the degree of aversion to the morbidity associated with the procedure (pain, bleeding, inflammation).

Circumcision, Male↗

PubMedDate not supplied

A cost-utility analysis of neonatal circumcision.

A cost-utility analysis, based on published data from multiple observational studies, comparing boys circumcised at birth and those not circumcised was undertaken using the Quality of Well-being Scale, a Markov analysis, the standard reference case, and a societal perspective. Neonatal circumcision increased incremental costs by $828.42 per patient and resulted in an incremental 15.30 well-years lost per 1000 males. If neonatal circumcision was cost-free, pain-free, and had no immediate complications, it was still more costly than not circumcising. Using sensitivity analysis, it was impossible to arrange a scenario that made neonatal circumcision cost-effective. Neonatal circumcision is not good health policy, and support for it as a medical procedure cannot be justified financially or medically.

Circumcision, Male↗

PubMed2005

HIV infection and circumcision: cutting through the hyperbole.

The objective of this study was to determine whether the justifications given for promoting mass circumcision as a preventive measure for HIV infection are reasonable and whether mass circumcision is a feasible preventive measure for HIV infection in developing countries. The medical literature concerning the practice of circumcision in the absence of medical indication was reviewed regarding its impact on HIV infection and related issues. The literature was analysed with careful attention to historical perspective. Our results show that the medical literature supporting mass circumcision for the prevention of HIV infection is inconsistent and based on observation studies. Even if the two ongoing randomised controlled trials in Africa show a protective benefit of circumcision, factors such as the unknown complication rate of the procedure, the permanent injury to the penis, human rights violations and the potential for veiled colonialism need to be taken into account. Based on the best estimates, mass circumcision would not be as cost-effective as other interventions that have been demonstrated to be effective. Even if effective, mass circumcision as a preventive measure for HIV in developed countries is difficult to justify.

Circumcision, Male↗

PubMedDate not supplied

Neonatal circumcisions performed by pediatric residents: implementation of a training program.

OBJECTIVE: To implement a pilot training program on neonatal circumcisions for pediatric residents in a residency training program, and to evaluate the effectiveness of the program in improving knowledge and skills in performing circumcisions. DESIGN: Educational curriculum. SETTING: The mother-baby unit of a tertiary care university medical center. PARTICIPANTS: Nineteen pediatric residents in training. INTERVENTION: A 1-month circumcision-training program. OUTCOME MEASURES: Successful completion of the training program, change in mean knowledge scores, and change in attitudes regarding circumcision. RESULTS: All 19 residents successfully completed the pilot program. Residents were enthusiastic about the opportunity to train in performing circumcisions. The mean test scores on the content items increased significantly from 5.0 (SD, 1.8) before training to 8.3 (SD, 1.0) after training (P <.003). After training, there were significant changes in residents' attitudes regarding giving anesthesia for the procedure and the medical indications for performing routine circumcisions. CONCLUSIONS: Given a structured curriculum, pediatric residents can be taught to safely and successfully perform neonatal circumcisions with adequate technical competency and pain relief skills. Training results in increased knowledge and increased level of comfort in performing this routine procedure.

Adult↗

PubMedDate not supplied

Circumcision revision in male children.

OBJECTIVE: To determine indications for circumcision revision and to identify the specialty of the person who performed unsatisfactory primary circumcision. MATERIALS AND METHODS: The authors reviewed medical records of 52 cases that underwent circumcision revision over a 6-year period (1998 to 2004). Sleeve surgical technique was used for revision in patients with redundant foreskin or concealed penis, penoplasty for partial or complete degloving of the penis and meatotomy for external meatal stenosis. The mean age of children was 32 months (range 6 months to 9 years). RESULTS: Most of unsatisfactory primary circumcisions (86.7%) were performed by laymen. All patients who underwent circumcision revision had good to excellent cosmetic results. CONCLUSION: Primary circumcision performed by laymen carry a high complication rate and serious complications may occur. A period of training and direct supervision by physicians is required before allowing laymen to perform circumcision independently.

Child↗

PubMed2002

[Experiences with ritual circumcision in Norway].

BACKGROUND: We wanted to provide a survey of the extent and practice of locally performed ritual circumcision of boys born to Muslim parents in Norway. MATERIAL AND METHODS: Newborn boys with Muslim parents in two counties in Norway (Rogaland and Troms) were registered. 56 ritual circumcisions were performed in outpatient departments in the local hospitals during the period under investigation, 11 on newborns, 33 on boys between one and ten, and 12 on boys above ten. RESULTS: The number of circumcised boys in 1999 was 24% of the total number of boys born to Muslim parents that year; in 2000, 48%. Circumcision of boys between one and ten is ten times more time-consuming than circumcision of newborns or boys above ten. INTERPRETATION: An estimated 672 boys are born to Muslim parents in Norway each year. Less than 50% of newborns with Muslim parents are circumcised in local outpatient departments. We recommend that ritual circumcision is restricted to newborns or to boys above ten, and that informed written consent is obtained from boys above ten.

Age Distribution↗

PubMed1990

Current trends in routine newborn male circumcision in New York State.

Despite the fact that circumcision of the new-born male has been practiced for at least 6,000 years, the procedure remains controversial. Circumcision rates in the United States remain among the highest of any nation in the industrialized world, yet there is little descriptive data on the demographic characteristics of newborns who are circumcised. New York State's hospital discharge data were used to examine demographic patterns for the procedure for the period 1980-1986. Circumcision was less common in New York City than in other areas of New York State, and was more common in private hospitals than in public hospitals. Whites had the highest rate of circumcision (70%), while Hispanics had the lowest (25%). Newborns under Medicaid coverage were more likely to be circumcised in voluntary hospitals than in public hospitals (45% vs 33%). We conclude that circumcision rates vary depending on a variety of factors, some of which may be attributable to the physician and others to family and society.

Circumcision, Male↗

PubMed1989

American Academy of Pediatrics: Report of the Task Force on Circumcision.

Properly performed newborn circumcision prevents phimosis, paraphimosis, and balanoposthitis and has been shown to decrease the incidence of cancer of the penis among US men. It may result in a decreased incidence of urinary tract infection. However, in the absence of well-designed prospective studies, conclusions regarding the relationship of urinary tract infection to circumcision are tentative. An increased incidence of cancer of the cervix has been found in sexual partners of uncircumcised men infected with human papillomavirus. Evidence concerning the association of sexually transmitted diseases and circumcision is conflicting. Newborn circumcision is a rapid and generally safe procedure when performed by an experienced operator. It is an elective procedure to be performed only if an infant is stable and healthy. Infants respond to the procedure with transient behavioral and physiologic changes. Local anesthesia (dorsal penile nerve block) may reduce the observed physiologic response to newborn circumcision. It also has its own inherent risks. However, reports of extensive experience or follow-up with the technique in newborns are lacking. Newborn circumcision has potential medical benefits and advantages as well as disadvantages and risks. When circumcision is being considered, the benefits and risks should be explained to the parents and informed consent obtained.

Circumcision, Male↗

PubMed1983

The effect of an educational intervention on the rate of neonatal circumcision.

Despite the absence of verifiable indications, routine circumcision of the male neonate remains one of the most common surgical procedures in the United States. A sample of obstetric clinic patients in a large urban hospital was tested to determine whether spoken educational intervention would reduce the rate of circumcision. The results showed that the rate was lowered significantly (94.4% circumcised in the control group versus 72% circumcised in the study group). Nevertheless, the majority of the study mothers requested circumcision for their sons despite the educational intervention, suggesting the presence of strong social motives. The authors conclude that many mothers in this population chose circumcision because of inadequate medical information or strong social motives. Both must be addressed if the rate of elective circumcision is to be reduced.

Adult↗

PubMed1994

Acetaminophen analgesia in neonatal circumcision: the effect on pain.

OBJECTIVE: Recognizing the concerns about the use of local anesthesia in neonatal circumcision, a painful procedure usually performed without analgesia or anesthesia, we undertook a study of acetaminophen for pain management of this procedure. DESIGN: A prospective, randomized, double-blind, placebo-controlled, clinical trial of acetaminophen analgesia in 44 healthy full-term neonates undergoing circumcision was conducted. Beginning 2 hours before Gomco circumcision, neonates received either acetaminophen (15 mg/kg per dose, 0.15 mL/kg per dose) or placebo (0.15 mL/kg per dose) every 6 hours for 24 hours. Neonates were monitored intraoperatively for changes in heart rate, respiratory rate, and crying time. Postoperative pain was assessed at 30, 60, 90, 120, 360 minutes, and 24 hours using a standardized postoperative comfort scoring system. Feeding behavior was also assessed before and after circumcision by nursing observation. RESULTS: Neonates in both groups showed significant increases in heart rate, respiratory rate, and crying during circumcision with no clinically significant differences observed between the groups. Postoperative comfort scores showed no significant differences between the groups until the 360-minute postoperative assessment, at which time the acetaminophen group had significantly improved scores (P < .05). Feeding behavior deteriorated in breast- and bottle-fed neonates in both groups, and acetaminophen did not seem to influence this deterioration. CONCLUSIONS: This study confirms that circumcision of the newborn causes severe and persistent pain. Acetaminophen was not found to ameliorate either the intraoperative or the immediate postoperative pain of circumcision, although it seems that it may provide some benefit after the immediate postoperative period.

Acetaminophen↗