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PubMed2001

Neonatal circumcision.

The merits of neonatal circumcision continue to be debated hotly. Some argue that circumcision is a "uniquely American medical enigma." Most of the world's male population remains uncircumcised; however, most boys born in the United States continue to undergo neonatal circumcision. Review of existing literature supports that most children who are uncircumcised do well from a medical standpoint and, thus, the question of whether US health care practitioners are subjecting neonates to an unnecessary surgical procedure remains. The medical benefits of circumcision are multiple, but most are small. The clearest medical benefit of circumcision is the relative reduction in the risk for a UTI, especially in early infancy. Although this risk [figure: see text] is real, the absolute numbers are small (risk ranges from 1 in 100 to 1 in 1000), and one investigator has estimated that it may take approximately 80 neonatal circumcisions to prevent one UTI. In the case of a patient with known urologic abnormalities that predispose to UTI, neonatal circumcision has a clearer role in terms of medical benefit to the patient. Most of the other medical benefits of circumcision probably can be realized without circumcision as long as access to clean water and proper penile hygiene are achieved. Proper penile hygiene should all but eliminate the risk for foreskin-related medical problems that will require circumcision. Moreover, proper hygiene and access to clean water has been shown to reduce the rate of development of squamous cell carcinoma of the penis in the uncircumcised population. Proper techniques on the care of the foreskin are illustrated in the American Academy of Pediatrics pamphlet titled "How to care for the uncircumcised penis." Regarding the relationship between STDs and circumcision, patient education and the practice of low-risk sexual behavior make a far greater impact than does routine circumcision in hopes of reducing the spread of HIV and other STDs. Nevertheless, in areas where safe sexual practices are poorly adhered to, circumcision can have a relative protective effect against the transmission of HIV and other STDs. The medical harms of circumcision lie mainly in the 1% acute complication rate and the additional patients who require revision of their initial circumcision for cosmetic or medical reasons. Anecdotally, the authors see far fewer complications in the acute and long-term phase when the circumcision has been performed by someone with expertise and experience with the procedure. Thus, the authors routinely recommend to parents that, if they choose to have their newborns circumcised, they should seek out an experienced practitioner. A negative psychologic and sexual impact of circumcision has been argued, but solid, scientific data are lacking. Special interest groups have argued that perhaps the greatest harm of circumcision is in performing an operation without a clear indication. Many of these groups have claimed that performing a routine neonatal circumcision is akin to performing a surgical procedure without a clear medical benefit, and in an infant, that is akin to surgery without informed consent. Although this is an extreme posture, the clinician can understand the emphasis on trying to provide invasive medical services only when a clear medical benefit is expected, especially when treating an infant or child. Deciding whether or not to circumcise an infant continues to challenge many new parents. Clearly, the procedure provides potential medical benefits and potential risks. It is difficult to say whether the benefits outweigh the risks for all male infants. Further complicating the decision for many American parents is that, in some areas of the United States, there exists an unexplained positive cultural connotation with neonatal circumcision. For these reasons, parents who actively choose to keep their sons uncircumcised need to be encouraged to make this decision forthrightly. Parents who choose to have their children circumcised also should be encouraged to actively seek an experienced practitioner who can afford the child adequate local analgesia.

Analgesia↗
PubMed2002

Extraordinarily high rates of male circumcision in South Korea: history and underlying causes.

OBJECTIVE: To investigate the high circumcision rate in South Korea and its rapid increase in the short period since its introduction. SUBJECTS AND METHODS: From January to December 2000, 5434 South Korean males (or their parents) aged 0-92 years were interviewed in detail about their circumcision status, their age at circumcision, and the possible effect of circumcision on their sexuality. In addition, 267 practising medical doctors were surveyed about their basic understanding of circumcision and phimosis. RESULTS: Currently the circumcision rate for high-school boys is > 90% and for those > 70 years old is < 10%. The circumcision rate in 1945 was < 0.1%. When averaged over the whole population, the present South Korean circumcision rate is approximately 60%; the rate has increased dramatically with time and particularly in the past 20 years, when the estimated number of male circumcisions has exceeded the number of male births. Although circumcision in South Korea has been strongly influenced by American culture, it has never been predominantly neonatal. The age at circumcision has continued to decrease and boys are now circumcised at approximately 12 years old. Of those who were circumcised long after they had been sexually active, > 80% reported no noticeable difference in sexuality, but a man was twice as likely to have experienced diminished sexuality than improved sexuality. Of the doctors who were surveyed, 41% carried out circumcision but, unlike in America, gynaecologists and paediatricians rarely did so. Among the doctors, basic knowledge on circumcision and phimosis was generally lacking, regardless of whether they practised circumcision or not. Amongst the factors contributing to the high circumcision rate was the mistaken notion held by both doctors and the general public that circumcision is directly correlated with industrialization and general progress of living standards. Many doctors believe the out-dated and sometimes controversial benefits of circumcision, i.e. prevention of cervical cancer and sexually transmitted diseases, and improved sexuality. Thus the vast majority of doctors recommend circumcision regardless of the patient's age. Peer pressure was also an important contributing factor. CONCLUSION: South Korea has an unusual history of circumcision. The mistaken and out-dated notions about circumcision and lack of knowledge of phimosis by physicians seem to be a leading contributory factor to the extraordinarily high circumcision rate.

Adolescent↗
PubMed1999

Age of male circumcision and risk of prevalent HIV infection in rural Uganda.

OBJECTIVE: To assess whether circumcision performed on postpubertal men affords the same level of protection from HIV-1 acquisition as circumcisions earlier in childhood. DESIGN: Cross-sectional study of a population-based cohort. SETTING: Rakai district, rural Uganda. METHODS: A total of 6821 men aged 15-59 years were surveyed and venous blood samples were tested for HIV-1 and syphilis. Age at circumcision was dichotomized into men who were circumcised before or at age 12 years (prepubertal) and men circumcised after age 12 years (postpubertal). Postpubertal circumcised men were also subdivided into those reporting circumcision at ages 13-20 years and > or = 21 years. RESULTS: HIV-1 prevalence was 14.1% in uncircumcised men, compared with 16.2% for men circumcised at age > or = 21 years, 10.0% for men circumcised at age 13-20 years, and 6.9% in men circumcised at age < or = 12 years. On bivariate analysis, lower prevalence of HIV-1 associated with prepubertal circumcision was observed in all age, education, ethnic and religious groups. Multivariate adjusted odds ratio of prevalent HIV-1 infection associated with prepubertal circumcision was 0.39 [95% confidence interval (CI), 0.29-0.53]. In the postpubertal group, the adjusted odds ratio for men circumcised at ages 13-20 years was 0.46 (95% CI, 0.28-0.77), and 0.78 (95% CI, 0.43-1.43) for men circumcised after age 20 years. CONCLUSIONS: Prepubertal circumcision is associated with reduced HIV risk, whereas circumcision after age 20 years is not significantly protective against HIV-1 infection. Age at circumcision and reasons for circumcision need to be considered in future studies of circumcision and HIV risk.

Adolescent↗
PubMed2003

Male circumcision for prevention of heterosexual acquisition of HIV in men.

BACKGROUND: The findings from observational studies, reviews and meta-analyses, supported by biological theories, that circumcised men appear less likely to acquire human immunodeficiency virus (HIV) has contributed to the recent ground swell of support for considering male circumcision as a strategy for preventing sexually acquired infection. We sought to elucidate and appraise the global evidence from published and unpublished studies that circumcision can be used as an intervention to prevent HIV infection. OBJECTIVES: 1) To assess the evidence of an interventional effect of male circumcision for preventing acquisition of HIV-1 and HIV-2 by men through heterosexual intercourse 2) To examine the feasibility and value of performing individual person data (IPD) meta-analysis SEARCH STRATEGY: We searched online for published and unpublished studies in The Cochrane Library (issue 2, 2002), MEDLINE (April 2002), EMBASE (February 2002) and AIDSLINE (August 2001). We also searched databases listing conference abstracts, scanned reference lists of articles and contacted authors of included studies. SELECTION CRITERIA: We searched for randomized and quasi-randomized controlled trials of male circumcision or, in their absence, observational studies that compare acquisition rates of HIV-1 and HIV-2 infection in circumcised and uncircumcised heterosexual men. DATA COLLECTION AND ANALYSIS: Independent reviewers selected studies, assessed study quality and extracted data. We stratified studies based on study design and on whether they included participants from the general population or high-risk groups (such as patients treated for sexually transmitted infections). We expressed findings as crude and adjusted odds ratios (OR) together with their 95% confidence intervals (CI) and conducted a sensitivity analysis to explore the effect of adjustment on study results. We investigated whether the method of circumcision ascertainment influenced study outcomes. MAIN RESULTS: We identified no completed randomized controlled trials. Three randomized controlled trials are currently underway or commencing shortly. We found 34 observational studies: 16 conducted in the general population and 18 in high-risk populations. It seems unlikely that potential confounding factors were completely accounted for in any of the included studies. In particular, important risk factors, such as religion and sexual practices, were not adequately accounted for in many of the included studies. General population study results:The single cohort study (N = 5516) showed a significant difference in HIV transmission rates between circumcised and uncircumcised men [OR = 0.58; 95% CI: 0.36 to 0.96]. Results for the 14 cross-sectional studies were inconsistent, with point estimates for unadjusted odds ratios varying between 0.28 and 1.73. Six studies had statistically significant results, four in the direction of benefit and two in the direction of harm. The test for heterogeneity between the cross-sectional studies was highly significant (chi-square = 77.59; df = 13; P-value < 0.00001). Nine studies reported adjusted odds ratios with eight in the direction of benefit, ranging from 0.26 to 0.80. Use of adjusted results tended to show stronger evidence of an association although they remained heterogenous (chi-square = 75.2; df = 13; P-value < 0.00001). Only one case-control study was found (N = 51) which had a non-significant result [OR = 1.90; 95% CI: 0.50 to 7.20]. High-risk group study results:The four cohort studies identified found a protective effect from circumcision with point estimates for unadjusted odds ratios varying from 0.10 to 0.39. Two of these studies had statistically significant results. Two studies reported adjusted odds ratios, both protective with one being significant. The chi-square test for between-study heterogeneity was not significant (chi-square = 5.21; df = 3; P-value = 0.16). All eleven cross-sectional studies reporting unadjusted results found benefit from circumcision, eight of which had statistically significant results. Estimates of effnal studies reporting unadjusted results found benefit from circumcision, eight of which had statistically significant results. Estimates of effect varied from an unadjusted odds ratio of 0.10 to 0.66. Between-study heterogeneity was significant with the chi-square = 29.77; df = 10; P-value = 0.0009. Four of these studies reported adjusted odds ratios ranging from 0.20 to 0.59 and all were significant. One additional cross-sectional study only reported an adjusted odds ratio in the direction of benefit which was statistically significant. All three case-control studies found a protective effect of circumcision on HIV status, two being statistically significant. Point estimates varied from unadjusted odds ratios of 0.37 to 0.88. One reported an adjusted odds ratio showing a significant protective effect. Adverse effects:No studies reported on the adverse effects of circumcision. In most studies, circumcision had taken place during childhood or adolescence before the studies commenced. REVIEWER'S CONCLUSIONS: We found insufficient evidence to support an interventional effect of male circumcision on HIV acquisition in heterosexual men. The results from existing observational studies show a strong epidemiological association between male circumcision and prevention of HIV, especially among high-risk groups. However, observational studies are inherently limited by confounding which is unlikely to be fully adjusted for. In the light of forthcoming results from RCTs, the value of IPD analysis of the included studies is doubtful. The results of these trials will need to be carefully considered before circumcision is implemented as a public health intervention for prevention of sexually transmitted HIV.

Circumcision, Male↗
PubMed2002

Knowledge and attitudes of Korean parents towards their son's circumcision: a nationwide questionnaire study.

OBJECTIVE: To evaluate knowledge about the foreskin and circumcision, and to understand the attitudes of parents to circumcision in Korea, where circumcision in childhood is widely practised with no particular religious or medical background. SUBJECTS AND METHODS: A nationwide study involving questionnaires was conducted on 5500 parents with at least one son attending elementary school. Responses were obtained from one of the parents. RESULTS: The response rate was 76.1% (4183); circumcision was most common in boys when aged 11 years, followed by neonatal circumcision. Of the parents, 91.3% believed that circumcision is necessary, while 2.1% believed it to be unnecessary. The principal reasons given for circumcision were 'to improve penile hygiene' (82.4%), followed by 'to improve future sexual potency' (7.5%). Among those who did not believe circumcision to be necessary, the most common reason was the expectation of spontaneous retraction of the prepuce with age (55.1%). Most (88.4%) of the parents believed that smegma is not a clean material, and is infected by microorganisms. Most parents (80.6%) thought that circumcision would prevent genital tract infection of the future spouse. Peer pressure was one of the most influential factors in deciding upon circumcision; 41.9% of the parents were anxious that their child might be ridiculed by his peer group unless he was circumcised, while 27.4% of the parents believed that their child might be ridiculed if he was circumcised. Mothers were more positive about circumcision than fathers (P < 0.05). Parents with a higher education and higher socio-economic status were also more positive about circumcision (P < 0.05). Mothers were prone to emphasize improved sexual potency (P < 0.05). There was no significant difference in response between urban and rural areas. CONCLUSION: This study indicates that common beliefs held by parents about the prepuce or circumcision differ significantly from current medical knowledge, and these beliefs have a major influence on the practice of circumcision in Korea. More clinical research on the natural history of the foreskin is needed, and it is critical that both children and parents are informed about the potential benefits and disadvantages of circumcision.

Adolescent↗
PubMed2003

Potential for an intervention based on male circumcision in a South African town with high levels of HIV infection.

The study aims to investigate the potential for an intervention based on male circumcision in a South African town with a high level of HIV infection. It draws on two cross-sectional studies conducted in August 2000 among a sample of 606 male adults aged 13-59 years, and in August 1999 among a sample of 723 male youth aged 14-24 years. A qualitative study was further conducted on perceptions and attitudes towards male circumcision using focus group discussions and in-depth interview. Among men aged 25-59 years, 36% reported being circumcised The median reported age at circumcision was 20. A total of 42% of 14-24-year-old circumcised men reported having been circumcised in a medical setting. Circumcised and uncircumcised men did not differ in their sexual behaviour or in sociodemographic characteristics, apart from their age and ethnic group. Among 467 uncircumcised adult men, 59% said that they would be circumcised if circumcision reduced the chances of getting HIV and STDs. Focus group discussions showed that circumcision is still important to many people, and is seen as an essential part of the transition into adulthood Reluctance to be circumcised was mainly related to the possibility of adverse outcomes of circumcision performed in non-medical settings, although initiation schools remain attractive for education and transmission of cultural values. Some misconceptions remain, however, especially about the preventative nature of circumcision for STD transmission. The cultural importance of male circumcision has weakened over the last century and when it is done it is often by a medical practitioner. An intervention that would include male circumcision seems feasible in communities such as the one where this study was conducted but needs to be carefully planned in order to ensure that participants understand that circumcision probably reduces, but certainly does not eliminate, the risk of HIV infection.

Adolescent↗
PubMed2003

The effect of health care coverage on circumcision rates among newborns.

PURPOSE: Social and personal biases are thought to have a role in the decision to circumcise newborns. However, economic factors such as the type of health care coverage may determine which parents are offered circumcision during the newborn period. Therefore, we examined the rates of newborn circumcision among patients with and without insurance at a midwestern community hospital and tertiary care center. MATERIALS AND METHODS: A retrospective analysis of all patients undergoing circumcision at 2 different labor and delivery facilities between January 1997 and December 2001 was performed. Female gender, prematurity and all congenital anomalies comprised exclusion criteria. Circumcision rates were stratified by health care coverage and race. To assess characteristics of patients who did not undergo circumcision during the newborn period the indications for circumcision and insurance status were examined at a children's hospital. RESULTS: Health care coverage differed significantly between the 2 labor and delivery facilities. Medicaid or uninsured patients comprised approximately 72% of the population at the tertiary care facility and slightly less than 10% of the total deliveries at the community hospital. Despite the difference in health care coverage status, there was no statistically significant difference between the rates of circumcision among newborns. The circumcision rates were 81% (4,021 of 4,992 cases) and 82% (8,059 of 9,859) at the community and tertiary care facilities respectively. Similarly, there was no difference between circumcision rates when stratified by health care status or race. At the children's hospital there were 2 distinct populations seeking circumcision. Of Medicaid patients 87% younger than 3 years sought circumcision because they were denied circumcision during the newborn period. In contrast, adoption was cited 90% of the time as the reason for seeking circumcision in the privately insured patients. CONCLUSIONS: Although health care coverage may influence the indications for circumcision in older children, health care coverage does not appear to influence newborn circumcision rates in the Midwest.

Child, Preschool↗
PubMed2003

Routine circumcision practice in Western Australia 1981-1999.

BACKGROUND: Routine neonatal circumcision has declined in most English-speaking countries. The purpose of the present study was to investigate the trends in incidence of routine circumcision in Western Australia and current patterns of the procedure according to sociodemographic factors. METHODS: Hospital morbidity data were used to conduct a population-based study of all circumcisions performed in Western -Australian hospitals during 1981-1999. Medicare insurance rebate statistics were used to estimate the numbers of circumcisions performed outside of hospital on boys <6 months of age between 1994 and 1999. RESULTS: In 1994, 9.8% of boys were circumcised before reaching 6 months of age, falling to 7.9% by 1999. Boys <6 months of age were 3.3 times more likely to undergo a hospital-performed circumcision if they lived in country areas compared with metropolitan Perth. Middle socioeconomic class families were twice as likely to circumcise a son than those in the higher and lower socioeconomic groups. The decreasing circumcision rate in boys <6 months of age was partly offset by an increase in routine circumcisions in boys older than 6 months of age during 1981-1999. CONCLUSION: Circumcision remains a relatively common procedure in Western Australia. Based on total routine circumcision rates in 1999, 10.2% of boys will be circumcised by the time they reach 15 years of age. The routine circumcision rate in boys <6 months is falling in contrast to a rising routine circumcision rate in older boys. Risk factors for a circumcision before 6 months of age include living in country areas and a middle socioeconomic status.

Adolescent↗
PubMed2002

Revision of circumcision in children: Report of 56 cases.

BACKGROUND/PURPOSE: Circumcision is the most commonly performed surgical procedure in the United States today. Despite the large number of specialists who perform this procedure, only occasionally are the results unsatisfactory. The purpose of this study is to review the indications for circumcision revision, attempt to identify the specialists who are performing unsatisfactory circumcisions, describe the authors' surgical technique for circumcision revision, and review current coding and billing issues related to this procedure. METHODS: The authors reviewed the charts of 56 consecutive children who underwent circumcision revision over a 4-year period (1995 to 1999). They also reviewed their current coding and billing practices for this procedure. RESULTS: Children undergoing revision of circumcision ranged in age from 6 weeks to 11 years with a mean of 26.7 months. Redundant foreskin was the most common indication for circumcision revision. In 38 patients (68%) the authors were able to identify the specialist who performed the procedure. Pediatricians were most commonly identified (n = 26), followed by residents in training (n = 10) family physician (1), and nurse midwife (1). The authors were unable to identify the type of neonatal circumcision originally performed. Their surgical procedure was the conventional sleeve technique without variation in 55 cases. A gomco clamp was utilized in one patient under local anesthesia and resulted in significant difficulty in the performance of the revision. All patients had a satisfactory cosmetic outcome. There was one complication in a child who required a return to the operating room for postoperative bleeding and hematoma. In review of the authors coding practices they found that there was an appropriate diagnosis code available for redundant foreskin but a specific procedure code was lacking before 2002. The authors also found that midwives perform circumcisions throughout the United States. CONCLUSIONS: Considering the number of neonatal circumcisions performed in the United States, revision of circumcision uncommonly is required. The most common indication for circumcision revision is redundant foreskin. Although pediatricians were most commonly implicated in this study as the source of unsatisfactory circumcisions, that finding probably is more a reflection of local practices and referral patterns. Our recommended surgical procedure, the conventional sleeve technique, is familiar to pediatric surgeons, produces a satisfactory cosmetic result, and is easy to teach to residents and fellows. The authors do not recommend the use of a gomco clamp for circumcision revision. The authors do not feel that a circumcision revision should be delayed expecting that the child will grow into the redundant foreskin. Appropriate diagnosis codes have been available, but a new and more specific procedure code has just been introduced in 2002.

Child↗
PubMed2005

The increasing incidence of newborn circumcision: data from the nationwide inpatient sample.

PURPOSE: Newborn circumcision is the most common surgical procedure in the United States, yet there are few contemporary data regarding circumcision rates or the factors that affect these rates. The goal of this study was to determine trends in the national rate of newborn circumcision between 1988 and 2000, and to evaluate patient and hospital factors associated with newborn circumcision. MATERIALS AND METHODS: The Nationwide Inpatient Sample provides information on 5 million to 7 million inpatient stays per year. Newborn male hospitalizations were selected, and those newborns who underwent circumcision were identified using International Classification of Disease-9 procedure codes. Weighted national estimates of circumcision rates were calculated, and patient and hospital characteristics were examined to identify factors associated with newborn circumcision. RESULTS: We identified 4,657,402 newborn male hospitalizations during a 13-year period. Circumcision rates increased significantly with time-48.3% of newborn males underwent circumcision in 1988 to 1991 vs 61.1% in 1997 to 2000 (p <0.0001). In multivariate regression analysis the odds of circumcision increased by 6.8% per year during the study period (p <0.0001). Patient characteristics associated with increased odds of circumcision in the multivariate model included private insurance (p <0.0001), higher socioeconomic status (p <0.0001), fewer co-morbid diagnoses (p <0.0001) and black race (p <0.0001). Hospital factors associated with increased odds of circumcision included Northeast or Midwest geographic region and rural location. CONCLUSIONS: There was a significant increase in the rate of newborn circumcision between 1988 and 2000. The increase may be related to increased recognition of the potential medical benefits of circumcision. However, the increase may also result in a higher incidence of surgical complications of circumcision.

Circumcision, Male↗
PubMed2003

Attitudes and practices regarding circumcision in Turkey.

BACKGROUND: In Turkey, circumcision is a necessity for boys to gain a masculine identity. In contrast to Western societies, where circumcision is performed in the neonatal period, it is performed at older ages in our population, and the timing may affect the psychosocial well-being of males. The person who performs the operation, a physician or a traditional circumciser, may affect their health as well. OBJECTIVE: To provide some information about the practice of circumcision in Turkey, such as timing, by whom and why it is performed in our country, and relation of their fathers' past emotions about their own circumcision to this current practice. METHODS: Questionnaires were filled out in face-to-face interviews with parents of 1235 male children under 16 years of age who attended well-child clinics of Gazi University Hospital and 10 different primary health care centres throughout Ankara, Turkey. RESULTS: Median age of circumcision was found to be 6 years. Only 14.8% of children were circumcised before 1 year of age. The main reasons for circumcision were religious and traditional. The medical benefits of the procedure outweighed the traditional reasons for only 15.2% of the families. The operation was carried out by a traditional circumciser in 13.3% of the children. Most of the fathers who could remember their own emotions about circumcision confessed that they had been frightened. They remembered the procedure as painful. Indeed, the mean age of their sons' circumcision was close to their own circumcision age. CONCLUSIONS: Traditions still play an important role in the timing of circumcision and by whom and why it is performed in Turkey. Changing times and educational levels do not seem to affect the traditional approach to circumcision.

Adolescent↗