Re: Gross Misnomer of "ROUTINE" Circumcision

Written by Gerald N. Weiss,M.D. on 05. August 1999 at 02:23:58:

In Reply to: ARC Forum Welcome written by Robin on 20. February 1999 at 17:59:07:


>Hello All,

>This forum is primarily intended for unbiased research, to revise our understanding of the ancient tradition of routine circumcision from the perspective of modern medicine. (This means, early monitoring and prevention when possible, accurate diagnosis previous to treatment, information and education).

>In the modern world it seems to me that much of our traditional male identity and values are inappropriate and outmoded.

>I would welcome an open minded exchange of personal experience and ideas, and I would like your help to stimulate and encourage an appropriate modern initiation into manhood.

>Robin Stuart

I heartily endorse this attitude and commend Robin for his outstanding work which
serves to elaborate so well the COMPLICATIONS of those who have not been fortunate
enough to have been PROPHYLACTICALLY circumcised neonatally. The following is
an attempt to explain NEONATAL CIRCUMCISION in the framework of a response to the
American Academy of Pediatrics 1999 discussion of the subject.
Response to the AAP Task Force on Circumcision 1999 Report
by Gerald N. Weiss, M.D.
Manuscript Word Count=1712
As a retired surgeon and sole author copyright transfer is extended to interested party
Address: 5630 Wingfoot Drive Phone: 970-204-0927
Fort Collins, CO 80525 E-mail: gnweiss at frii.com

ABSTRACT
The 1999 American Academy of Pediatrics Task Force on Circumcision bears little
difference from previous reports. The two most stricking differences address cost
factors and procedural analgesia while performing the operation. Though the
current evidence does not substantiate neonatal circumcision as a routine
procedure, the study does indicate potential medical benefits.


A newspaper headline reporting on the American Academy of Pediatrics’
(AAP) Task Force on Circumcision stated “PEDIATRICIANS NOT PROMOTING
CIRCUMCISION, NOT AGAINST IT”. This is a fair analysis and actually differs
little from the 1989 conclusions reported by this same organization. The opening
statements reflect the Committee’s opinion:
“Existing scientific evidence demonstrates potential medical benefits of newborn
male circumcision; however, these data are not sufficient to recommend routine
neonatal circumcision.”
An accompanying footnote clearly states:
“The recommendations in this statement do not indicate an exclusive course of
treatment or serve as a standard of medical care.”
Two aspects in the 1999 Report are emphasized that were not in the earlier
Task Force conclusions. As would be expected the cost factor is addressed in the
opening paragraph and then concludes with the recommendation for procedural
analgesia when performing the operation. Both of these considerations are of major
public concern and controversy.
Although for years the cost factors from an over all monetary point of view
have favored prophylactic neonatal circumcision (Warner E & Strashin E 1981;
CMAJ: 125;973 and Wiswell, T 1990;AFP:41;862), there are other cost
considerations. The real costs to patient and public involve aspects that to a large
extent remain unresolved. Until such time as data becomes available including
longitudinal studies of penile problems over a male’s lifetime and costs of neonatal to
late circumcision surgery, it is not possible to debate this issue scientifically. A study
by Lawler, FH et al (FM 1991:23;587-593) concluded:
“... that there is no medical indication for or against circumcision.
...The decision regarding circumcision may most reasonably be made on
non-medical factors such as parent preference or religious convictions.”
Cost considerations from the pediatric and surgical viewpoints are revealing.
In the 1970s it became apparent that the power of insurance payments was directing
health care. LR King, a member of the 1975 AAP Task Force on Circumcision
reported that the reason for the statement “there is no absolute medical indication
for circumcision of the newborn” was due to two factors (Weiss GN Int Surg
1986:71;62):
“1) a concern about needless surgery causing pain and suffering, and
2) the thought that insurance dollars spent on neonatal surgery would cover the
cost of neonatal intensive care .”
The advances and expenses of the Neonatal Intensive Care Units have now been
taken to task by insurers, government and general public. Survival of the afflicted
“one-pounders” has become an ethical issue. Furthermore, expenses for genito-
urinary care of the uncircumcised infant, child and young adults (not to mention
later life penile problems), contrasted to the circumcised neonate, presents a
pediatric, as well as adult, cost dilemma. The 1999 AAP Task Force Report
conclusion only adds to the confusion:
“Although the relative risk of UTI (Urinary Tract Infection) in uncircumcised
male infants is increased from 4- to as much as 10-fold during the first year of
life, the absolute risk of developing a UTI in an uncircumcised male infant is low
(at most, ~1%). “
Compounding a scientific cost analysis is data availability and manner of
presentation. The Report acknowledges the greater frequency of STD, AIDS and
penile cancer in the uncircumcised. The low frequency of penile cancer and
significance of other considerations leads the Task Force to state:
“Nevertheless, in a developed country such as the United States, penile cancer is a
rare disease and the risk of penile cancer developing in an uncircumcised man,
although increased compared with a circumcised man, is low., and
“However, behavioral factors appear to be far more important risk factors in the
acquisition of HIV than circumcision status.”
And, of course, the real “bottom line” to all such statements is the fact that:
“The true frequency of these problems [penile] is unknown.”
The other consideration as to cost is the surgical one. As a retired surgeon I
can speak with experience and more objective critical analysis. As late as the 1980s,
when serving in the US military, neonatal circumcision was not even listed as a
surgical procedure. It was performed but not recorded as “surgery” on our Report
of Operations. Even to this day, this attitude may be reinforced by current
malpractice insurance companies. Pediatricians and Family Practitioners,
approved as qualified and performing circumcisions in the first year of a child’s life
may do so with no special increase in rates. However, if performed after the first
year of life, circumcision falls in the category of major surgery and thus premium
rates increase!
It is recognized that the majority of American neonatal procedures of this
type are done by nurses, medical students, physician assistants, interns or residents
who have little or no surgical expertise, training and often no supervision. The most
common neonate and male surgery is often performed by non-surgeons!! There is
an explanation.
In the United States of America our country was founded on the distinct
separation of State and Church. Following this direction, surgeons as a group
attributed the procedure to the Hebrew ritual. As the advantage of the secular
prophylactic surgical measure reached a height, prompted by military conflicts and
scientific confirmations (Weiss, GN and Harter, AW, Circumcision: Frankly
Speaking, 1998, Wiser Publications, Fort Collins, CO), neonatal circumcision
became a norm for 80% to 90% of newborns during mid century in the U.S. The
simplicity and safety of a surgical procedure, not basically considered surgery but
ritual, was enhanced with new metal and plastic gadgetry. The Gomco Clamp and
Plastibell devices for neonatal circumcision substituted for the trained surgeons’
hands. Hebrew Mohels (i.e., ritual circumcisers), who for centuries were guided by
compassion and procedural speed for the eight day old Jewish infant, were rigidly
trained for the delicate procedure. They were relegated to the ritual category.
Others meantime were to be assured of a safe circumcision, by virtue of technology,
even though the operators lacked or had minimal training. Surgeons of the time felt
the common and important procedure to be in a ritual and safe category. As for
safety of those in the non-ritual group, it depended more on technological safeguards
than on trained operators. The warnings of a prominent English surgeon, P.
Bousfield (St Bartholomew’s Hospital Journal 1916:24;5) almost a century ago went
unheeded:
“The newly qualified surgeon or the advanced student who is called upon to
perform some minor operation has in very many instances never seen that
operation performed by any member of the senior staff; often his only
experience of it may have been a textbook. ... One is inclined to approach
circumcision in a somewhat light-hearted manner; it is simple, with but little
danger and appears to be very easy. ...this simple little operation is in reality
a delicate and by no means to be despised work of art...”
Failing to learn the lessons of the past, cited by this Member of the Royal College of
Surgeons, the rare complications can be attributed to those inexperienced operators.
Known to me personally is one outspoken anti-circumcision advocate who suffered
at the hands of someone apparently untrained for the operation. Slowly, very slowly,
others than those in the surgical sphere (Stang, HJ et al PEDIATRICS 1997:100;6)
have come to recognize the need that:
“Further study of the procedures utilized in the Jewish brit is warranted.”
The above author is recognized by the AAP 1999 Task Force report relative
to his neurologic research pointing toward “a more humane circumcision”. It seems
reasonable and incumbent upon members of the surgical profession to recognize the
extreme importance of this neonatal surgery and to begin education of medical
students. An E-mail message received from a medical student in Germany this past
month illustrates the point:
“Congratulations on your research on circumcision! I find it really deplorable that
this uncomplicated but thus so beneficial operation is losing population so rapidly
in our days. I am a 24 year old medical student from Germany and I have spent 18
years of my life with a foreskin...and with it with a great many problems. I am
circumcised now and more than happy about it. I wish circumcision was the norm
here in Germany, because it is - as you might know - very unpopular here. In my
med school here circumcision is not even taught. Wish you all the best for your
research, Signed”
It is distressing and depressing for me as one who spent a lifetime in surgical
care of many thousands of patients while in medical training, private and clinic
practice, military and governmental service to see a secular prophylactic health
measure be so neglected by my surgical colleagues. Neonatal circumcision is safe
preventive surgery that is a viable option in maintaining and promoting quality
genital health for males of all ages.
In the meantime, the AAP 1999 Task Force conclusion is justified:
“Existing scientific evidence demonstrates potential medical benefits of newborn
male circumcision; however, these data are not sufficient to recommend routine
neonatal circumcision.”
Long term scientific research will confirm the evidence of hygienic, aesthetic,
health preventive and perhaps sociologic aspects of neonatal circumcision. Only by
adequate training of pediatricians, family practitioners, urologists, obstetricians --
for that matter ALL in the medical community--in the positive and negative
concerns of this preventive neonatal surgery will the benefits be fully realized by the
American public. It is then that the newborn’s parents will be equipped to give an
unqualified informed consent on scientific grounds and not for religious reasons
only. Of even greater significance is the need of the surgical profession to take on the
responsibility of so vital and delicate an operation that is not below an American
surgeon in spite of its simplicity and safety. Rather, “this simple little operation is in
reality a delicate and by no means to be despised work of art.”

AGAIN, Robin and others are to be congratulated on revealing the degree of COMPLICATIONS and
outright misery and discomfort so many males suffer as a result of penile problems
related to phimosis, paraphimosis and an entity few physicians are even aware of-- frenulum
brevae. Continue your signal, outstanding and promising studies. I intent to learn with
you and contribute as my 50+ years of surgical experience has taught me.
With best wishes for continued success of this project, GN Weiss, MD




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