Neonatal Circumcision: A Dispassionate Analysis

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“The existing literature is inadequate to evaluate appropriately routine circumcision of the newborn infant… until benefits of routine circumcision of the neonate can be proved worth the risk and cost, medical resources probably should be allocated to measures of demonstratable value.”David Grimes, MD 1Circumcision of male infants is among the most common operations in the United States and is perhaps the most controversial. Although precise estimates have been elusive, rates vary according to racial, ethnic, and socioeconomic factors and range as high as 89% in certain metropolitan regions of the United States. 2 Because of its widespread use, circumcision has come under the same scrutiny as other preventive health measures. In 1978 David Grimes argued that the efficacy of circumcision be unequivocally established before allowing its routine use. 1 During the subsequent two decades, nearly 700 articles on circumcision were published in the scientific medical literature, yet relatively few reported new data to better inform parents and clinicians. 3 Many pages in journals of pediatrics, urology, obstetrics and gynecology, and family medicine have been filled with editorials and narrative reviews supporting the philosophic positions of their authors. 4–6 In contradistinction, this review will provide a dispassionate analysis of the evidence on the benefits and risks of neonatal circumcision. This review is not a quantitative meta-analysis. Few outcomes of circumcision have been studied rigorously enough to warrant such an approach. Rather, I will describe the best available data and the clinical recommendations they support. The evidence will be considered within a clinically relevant framework in which decision-making relies on three interrelated factors: 1) clinical experience, 2) scientific evidence, and 3) patient preference.Evidence in PerspectiveIdeally, clinicians’ recommendations to patients are based on sound clinical reasoning and relevant scientific evidence. Patients’ preferences are elicited, and their active participation in decision-making is encouraged. For preventive measures of proven benefit and limited risk, such as cervical cancer screening, clinical experience and patient preference play a minimal role. Conversely, when virtually no evidence exists to inform decision-making, or if the evidence is mixed, clinical decisions rely primarily on clinical experience and informed patient preference. Is there overwhelming evidence that circumcision is beneficial or harmful, or should proscriptive recommendations be avoided in favor of informed parental choice? After considering briefly the roles of patient preference and clinical experience, I will spend the remainder of the article reviewing the scientific evidence on the potential health benefits, risks, and economic costs of circumcision and the evidence on optimal technique and anesthesia.PATIENT (PARENTAL) PREFERENCESIn the case of neonatal circumcision, parents decide on behalf of their sons to accept or decline circumcision. There is compelling evidence that parents’ decisions are based on religious, cultural, or personal beliefs and are not calculated according to potential health benefits and risks. 7 Recent guidelines by the American Academy of Pediatrics and the Canadian Paediatric Society recognize the important role of cultural and personal factors in parents’ circumcision decisions. 2,3Several randomized and nonrandomized trials comprising parents of nearly 300 boys have not shown any difference in circumcision rates among parents who did and did not receive written and verbal information and group education during their prenatal care. 8,9 This finding is consistent across socioeconomic strata. 9 In clinical practice, however, information is not always shared with patients in an unbiased fashion. A cross-sectional survey of patients and their perinatal care providers showed that clinicians’ opinions can influence parental choices and interfere with the process of informed consent.

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