To the Editor.
The paper by Dr Christakis et al, is informative and important in presenting the risks associated with newborn circumcision. It is essential that parents be fully informed before making a decision whether or not to circumcise their sons, and providing them with all the pertinent information is the responsibility of all health care providers. In discussing with parents the risks associated with circumcision, the focus is heavily weighted on the problems and complications in the immediate post-operative period, with some reference to the benefits of reduced urinary tract infections and penile cancer. I would like to expand the discussion, beyond infancy and adulthood, to the complications of non-circumcision for the elderly dependent male and his caregiver.
As a clinical nurse specialist in an extended care facility caring for an older male population, I would like to address the issue of circumcision from the gerontological perspective. The geriatrics community has had little say and no input into the information that is presented to parents at the time they are deciding whether to circumcise their infant sons, yet the result of this decision is played out daily in nursing homes, long-term care facilities, and in the homes of caregivers. Ultimately, the geriatric community faces care issues when one can no longer meet one's own care needs. Therefore the information pediatricians present must include how this decision will affect the care, well being, and comfort of an older male 70 or 80 years hence.
Good perineal-genital care for an uncircumcised male involves retracting the foreskin to expose the glans or head of the penis, washing and drying the glans, and replacing the foreskin. The procedure of being cleaned is emotionally difficult for the older uncircumcised patient. For the majority of older people who need this hygiene care performed because of a dementing illness the reactions range from personally disturbing to disruptive behavior. Frequently, the patient misinterprets the care and strikes out in terror, kicking and scratching caregivers, whether family or nursing staff.
As the population ages and more families are called on either to provide care or to institutionalize a member of the family, we in the field of health care must consider the effect of noncircumcision on all males and provide information and advice to those making the decision whether to circumcise an infant.
I suggest it is time to look at the decisions of circumcision as a preventative health concern for the later years, with all pediatricians cognizant of how noncircumcision affects the elderly dependent male and his caregiver. I strongly urge my health care colleagues to include information from the gerontological perspective when providing information to parents contemplating circumcision.
- Christakis DA,
- Harvey E
- Copyright © 2000 American Academy of Pediatrics
After reporting that complications potentially associated with circumcision occur 20 times more frequently in circumcised infants than in those who have not been circumcised, Christakis et al conclude that circumcision remains a “relatively safe procedure.” They described its indications as “discretionary.” But they fail to address the important ethical, legal, and human rights issues raised when a “discretionary” (that is, medically unnecessary) surgical operation is carried out on a person who cannot speak for himself. This omission is surprising, in view of America's deep-felt commitment to human dignity and personal freedom
The authors' analysis turns on the assumption that the only downside to circumcision is surgical risk. Such an assumption is hard to justify, since recent anatomical studies1,2 have shown that circumcision removes specialized sexual tissue
The Christakis study appears to confirm that a medically unnecessary surgical intervention is being undertaken in an ethical vacuum on the basis of limited scientific understanding
- Cold CJ,
- Taylor JR
- Copyright © 2000 American Academy of Pediatrics
We appreciate the observations of Mr Harrison and Ms Frank. Each raise important issues that are related to the extraordinarily complex decision that circumcision can pose for parents.
Mr Harrison notes that we failed to consider the ethical, legal, and human rights issues related to circumcision. The goal of our study was to provide the best estimate of the medical complication risk associated with the procedure. Although we did not attempt to tackle the ethical implications of the procedure, those seem in large part to be predicated on the risks and benefits posed. We take Mr Harrison's contention to be that for this procedure the benefits are not sufficient to make the risks morally justifiable. Others might disagree, and he too might feel differently if the benefits were greater or if the complication risk were lower. It is precisely this type of debate that the article was intended to foster.
Ms Frank offers the frequently overlooked gerontological perspective on circumcision. Non-circumcision may pose problems for caregivers of adult uncircumcised males. This is an interesting and important consideration. Our study was limited to medical outcomes and did not deal with the much more complicated and difficult issues related to quality of life. However, to present the risks described by Ms Frank to parents of newborn males, we clearly would need to quantify the population-based magnitude of this problem. Simultaneously, we should collect clinical data on the possibility of diminished sexual sensation suggested by the histological references cited by Mr Harrison.