Circumcision

Dr. Grahame SmithThe Childrens

Hospital at Westmead

Undertaken for many thousands of years

History

Originally a hygiene measure

A ritual, religious Enhance/

decrease sexual performance

Prevent masturbation (Brigman)

Why

RACP/RACS 2010 Not recommended routinely

American Academy of Pediatrics 2012 Not recommended routinely Justified for families that choose it

Canadian Pediatric Society 1989 Not recommended

None recommend routine circumcision

Current position statements

Finland In February 2010, a Jewish couple were fined for causing bodily

harm to their then infant son who was circumcised in 2008 by a mohel brought in from the UK. Normal procedure for persons of Jewish faith in Finland is to have a locally certified mohel who works in Finnish healthcare perform the operation. In the 2008 case, the infant was not anesthetized and developed complications that required immediate hospital care. The parents were ordered to pay 1500 euros in damages to their child

Netherlands Germany

Dec 2012; law passed explicitly permitting non-therapeutic circumcision to be performed under certain conditions (religious)

Strongly opposed

Risk & cognitive error 1

Risk & cognitive error 2

We fear snakes and not cars We fear spectacular, unlikely events

Plane crash versus car crash We underestimate our risk of disease We don’t interpret statistics well

Risk & cognitive error summary

Thought Hats Religious - faith * Science* - evidence

Thought processes

Religious, social, “cultural freedom” Prevent

Penile cancer HIV Other STDs UTIs

Arguments for

Recurrent UTIs – 1% children Foreskin increases UTI risk 5 – 10 times

Phimosis (pathological) – 1% children Recurrent balanitis – 1% children

Medical indications

Reduced sexually transmitted disease HIV, Herpes, HPV etc.

Safe sex practices cheaper & more effective May be valid in areas with high HIV incidence HPV vaccine a better alternative

Penile cancer (1: 100,000) too rare to worry about

UTIs – example to follow

Invalid reasons

Assume complication rate 2% (1% - 10%) 1000 well children circumcised

=> 8 less UTIs, 20 complications 1000 Children with UTIs

=> 250 UTIs prevented, 20 complications

Risk benefit analysis for UTIs

Circumcision may decrease female pleasure during intercourse

O’Hara & O’Hara - surveyed 138 women. Of that group 20 (14.5%) preferred non-intact circumcised sexual partners while 118 or (85.5%) preferred intact non-circumcised sexual partners. This means that about 6 out of 7 women preferred intact non-circumcised partners while about 1 out of seven preferred non-intact circumcised partners

And further risk

Abnormal penis Hypospadias Epispadias Buried penis

Systemic Coagulopathy Increased anesthetic

risk

Contra indications

Early Pain Infection Bleeding Fistula Glans amputation Loss of penis Death

Risks

Late Meatal stenosis Poor cosmetic result Skin tags, suture sinuses Buried penis

Risks

Theoretical Sued or prosecuted

Legally, parents may not consent for an operation for a child when such a decision is not in the child’s best interest.

Risks

Care of the normal foreskin

Nothing required

Forceful retraction may cause injury and phimosis

Infancy and childhood

Retract and clean each day

After puberty

Treatment not needed

Responds well to Betnovate ½ cream

Phimosis - physiological

Responds to Betnovate ½ cream – rarely

Tacrolimus May be

carcinogenic Circumcision

usually curative

Phimosis – pathological

Phimosis and buried penis

Megaprepuce

Paraphimosis

Tight frenulum

Foreskin adhesions

Foreskin lumps

Smegma

Smegma - more

Multiple Happen even in the best of hands Incidence = 5 to 10%

Circumcision complications

Buried penis

Shaft to glans

adhesions

Meatal stenosis

Shortage of skin

Amputation glans

Don’t circumcise unless there is a medical indication (benefits outweigh the risk)

If there is an indication, it’s a good operation

Conclusion

https://www.racp.edu.au/page/paed-policy http://www.cps.ca/documents/position/circumcision http://pediatrics.aappublications.org/content/early/2012/08/22/

peds.2012-1989 http://www.cirp.org/library/legal/brigman/ http://www.circumcision.org/ (against) http://www.circinfo.net/ (pro) O’Hara K, O’Hara J. The effect of male circumcision on the

sexual enjoyment of the female partner. BJU Int 1999;83 Suppl 1:79–84.

References