Chapter 36 / Primary Care of the Newborn: The First 6 Weeks 601

The Circumcision Decision

In the United States, circumcising male newborns became prevalent in the 1950s. A complex web of religious, cultural, and family traditions surrounds each family in this decision. Certain religious traditions (Jewish, Muslim) have practiced male circumcision for centuries. [ - but not as a medical procedure. Articles about brain surgery do not usually begin by citing as a close precedent the ancient custom of drilling a hole in the skull to release evil spirits.]

The procedure of circumcision involves the cutting of adhesions [a misnomer for the normal union of the newborn foreskin and glans] and retraction of the foreskin covering the glans of the penis. [It is astonishing that Ms Varney does not mention at this point that the foreskin is then cut off.] This procedure is customarily done in the hospital or during the first month of life as a religious ceremony. Complications from circumcision are unusual but can be serious. The most frequent complications are local infection and bleeding, seen in only 0.2 to 0.6 percent of infants [16]. [The higher figure is lower than that cited in Chapter 73, and much lower than those cited in one of its own references.] Although the foreskin of newborns is rarely able to be retracted, by age 3 the foreskin can be retracted on 80 to 90 percent of male children. [This neutral statement differs from the prescriptive one in Chapter 73.]

The contemporary medical rationale for circumcision is a source of controversy. Proponents of circumcision maintain that because the circumcised penis can be kept clean more easily, circumcised males experience lower incidence of urinary tract infection and cancer. Routinely circumcising newborns prevents the small percentage of men with phimosis (inability to retract the foreskin) from developing problems with edema and inflammation of the glans. [ - problems that can, as everywhere else on the body, be treated non-surgically] Opponents of circumcision maintain that modern sanitarv conditions in the United States eliminate the need for this procedure. [No, we deny there ever was a need for it.] They believe that the procedure is a painful violation of an unconsenting infant to get rid of a functional body part. [Correct! Not just unconsenting (of course) but someone who may decide later he would rather his penis had been left alone. This is the closest this book comes to considering circumcision as a human rights issue. And it is a pity Ms Varney says nothing more about the foreskin's various functions.]

Parents choosing not to circumcise should be taught the normal anatomy of the penis and its development.[ - to prevent them being alarmed by perfectly normal events, such as "ballooning"] As the child matures, he should be taught to retract the foreskin gently while bathing in order to clear any collection of smegma. Parents must be urged not to retract a foreskin forcefully, since the resultant irritation and edema may cause further adhesions. [This is a misunderstanding. Forcible retraction tears the synechia, leaving the surfaces of the foreskin and glans raw. They then heal together, creating not "further" but true adhesions. It may also tear the mucosal surface of the foreskin creating scar tissue and preputial stenosis.]

In some areas, nurse-midwives have added circumcision to their practices [17]. This is a procedure that must [...if it must be performed....] be carefully taught by an experienced preceptor with many demonstrations. The technique of circumcision is described in Chapter 73. Whether a midwife can add this skill to his or her clinical practice depends on state regulation in midwifery practice. [Whether s/he should is highly debatable.] All midwives, regardless of their personal position on the subject must be prepared to present the pros and cons of circumcision to parents. [...in the US, while parents continue to ask about it. In most of the rest of the English-speaking world, it is no longer offered, or even discussed. Contrast the approach of Mayes' Midwifery.]

Circumcision

Vivian H. Lowenstein, CNM, CRNP, MSN, Certified Mohelet

...

Midwives who have determined that there is a need for providing this procedure [a demand is not the same as a need] to the clientele they serve should learn the skill with high regard to the [unnecessary] surgical procedure that is being done to a healthy newborn. ...

Midwives performing newborn circumcision need to be aware of current state legislation in this area and attempt to change it where it restricts midwives from providing this service. [ ! ] Additionally, midwives should review the process of credentialling within institutitional clinical guidelines. [The meaning of this is unclear. Does she mean midwives who can not - or will not - circumcise, should not be licenced to deliver babies in particular jurisdictions?]

...
The corona is the upper portion of the glans [This is ambiguous -"upper" compared to the underside or the tip? - the corona is the "flange" encircling the distal end of the glans] The correct excision of foreskin is at the level of the coronal sulcus. [Correct according to whom? A circumcision may be high or low, loose or tight.]

...If an anomaly is noted the circumcision is not done. The dorsal slit can be approximated and sutured since the foreskin my be required for reconstructive surgery. [It would be microsurgery to suture the two layers separately: the one-layered suturing that a midwife would do would greatly reduce the area available for reconstructive surgery, and permanently prevent the foreskin from retracting properly in the event that reconstructive surgery is decided against. Is there a certain gay abandon about the way the baby's penis may be cut open, looked inside, and then closed again - like a mechanic with a new car?]...The disadvantages of the Gomco are that it involves more parts, requires more steps in the procedure, and takes more time.

...The Plastibell has a higher incidence of infection.

...Using the Mogen clamp has the distinct disadvantage of making the circumcision a "blind" procedure. The glans of the penis cannot be seen (so anomalies may not be discovered until after the circumcision) and is thus at risk of being cut. The midwife should observe the use of different clamps in order to be able to provide accurate information to parents and to choose the method that appears most safe and comfortable to use. [That should be "...least unsafe and painful for the baby to have used on him."] ...

Neonatal circumcision is usually performed with no anesthesia. [And while the rest of this passage compares different kinds, the instructions that follow make no mention of how, when, or where to apply any.] It is apparent through observation and clinical research that the procedure is painful to the newborn. The research has shown that the baby has increased cortisol levels during the procedure [6, 7] [Taddio found that the effects of the trauma last for months afterwards. They also hinder the successful establishment of breastfeeding.]. ... The difficulty with providing pain relief to the neonate is that the risk of the method itself must be considered [and factored-in among reasons not to circumcise]...

Preparation

Counselling should begin during prenatal care, when parents should be provided with the information and resources to make a decision about circumcision if the child should be male. Informed consent is [if they decide in favour of circumcision] then required postpartum. The midwife should assess the parents' need for information and provide it and assess the parents' commitment to their decision to circumcise the newborn. [And if they show signs of wavering...? And if they decide to leave his penis alone?]
The practitioner performing the circumcision is responsible for obtaining the informed consent. Counselling should cover
[the functions of the foreskin; the benefits to the baby, the boy and the man of being intact; the baby's right to physical integrity and freedom from unnecessary surgery;]
what male circumcision is; medical research and recommendations [9] [The reference is to the 1989 AAP Task Force on Circumcision report. There have been two more since then: the latest, in 1999, says "Existing scientific ... data are not sufficient to recommend routine neonatal circumcision."]; religious and cultural beliefs; possible complications and risks, care of the uncircumcised and circumcised penis: signs and symptoms of complications; and whom to contact with questions and concerns. (See Information for Parents.)

The decision [whether or not] to circumcise a newborn son requires information on cultural beliefs [on the functions and benefits of the normal, intact penis] and medical benefits and risks and clarification of any misconceptions. The time available during prenatal care offers the parents the opportunity to consider their feelings and beliefs regarding circumcision. The midwife should be supportive of the parents and help them to communicate with one another to decide what is best for their child. ...

[This whole section is based on the assumption that the baby will be circumcised. The counselling stage should not be built around that assumption.]

Before the procedure is done [implying that it will be done], talk to the parents about how long the procedure will take and when it will be done and give them the option of being present. [Many practitioners discourage them from being present, rightly thinking that seeing the surgery will put them off having it done to future sons. If parents want part of the genitals cut off their newborn child but don't want to see it happen, that is certainly a contradiction of interest.] Plan to do the circumcision before a feeding [Lander found one of 12 babies circumcised without anaesthetic vomited projectilely] and tell the mother that after the circumcision the baby will feed well. [When this is true, it is because the poor mite is desperate for some consolation. But there is growing evidence that circumcision interferes with the establishment of breastfeeding.]

Parents are very concerned about the safety of their son. Acknowledging their feelings and concerns and telling them what to expect helps to comfort them. [...implying that the problem is theirs. Their concerns are valid; their baby is not completely safe.]

The circumcision can be performed 12 to 24 hours after the birth. ...

The first 12 hr of life are transitional and provide the opportunity for observation of the newborn....

Set up and check all equipment...

When the midwife is systematic in setting up the equipment and knows that everythng is in working order, the procedure can be done quickly, smoothly, and safely.
[The operative word is "can":  you get no guarantee.]

...

...

Push the foreskin back gently to identify the opening of the urinary meatus and to assess the degree of adhesions that may be present.
...

An ininital assessment of the adhesions...

Removing adhesions

...
The baby will probably be crying at this time if he hasn't already started.

...

Gomco Clamp Technique

...

...

[The rest of the details of how to circumcise a baby are - so far as someone who would rather eat broken glass than circumcise one can tell - pretty complete. The sketches illustrating the surgery are clear, but fail to convey its bloodiness as photographs do.]

Application of the Dressing

...

...The midwife should emphasis that handwashing before and after changing the diaper is necessary to decrease the risk of infection.

[That will protect the mother against infection from the baby's faeces. As for the baby, perhaps he should be instructed not to defecate for the first week after circumcision...?]

What is male circumcision?

Male circumcision is the [surgical] removal of the foreskin of the penis. [No mention of the functions of the foreskin, of how it works, of how big it grows to be, or of the human rights issue involved (who it belongs to).]

Medical Research and Recommendations

[This section mentions only research and recommendations in support of circumcision.]

Past reports on circumcision (1975 and 1983) by the American Acaedmy of Pediatrics (AAP) concluded that there is no absolute medical indication for routine circumcision of the newborn." [...as the healthy life of billions of intact men worldwide demonstrates better than any study.] Since that time research has shown that circumcised males may [or may not] have fewer [by how many?] infections. [Of what seriousness? But note how this vague statement is used as if it were a clear and powerful indication.]

In 1989 the AAP Task Force on Circumcision reported that "new evidence has suggested possible medical benefits from newborn circumcision. Preliminary data suggest the incidence of urinary tract infection in male infants may be reduced when the procedure is performed during the newborn period. There is also additional published information concerning the relationship of circumcision to sexually transmitted diseases and, in turn, the relationship of viral sexually transmitted diseases to cancer of the penis and cervix." (American Academy of Pediatrics Task Force on Circumcision, Report of the Task Force on Circumcision, Pediatrics, 84, (4), 388-391, August 1989).

Religious and Cultural Beliefs

[This section focuses on religions and cultures that practice circumcision.] ... People in other cultures believe circumcision should be done for hygienic purposes; [people in most cultures do not circumcise, without having any strong opinion about it] people in some cultures do not believe circumcision should be done. [... and it is strongly contrary to some cultures to do it. The United States is the only country left in the English-speaking world that still promotes routine infant circumcision.]

Possible Complications and Risks

The rate of complications from circumcision is less than 1 percent. [It is not clear where this figure comes from. Even if it were accurate, that means a baby suffers complications of circumcision every 45 minutes in the United States. Kaplan, cited in the references, says:

The most common complications are bleeding and infection [either of which can lead to death]. Risks include [but are not confined to] cutting to much or too little of the foreskin, injury to the top of the penis, or side effects caused by local anesthesia (if it is used).

Care of the Uncircumcised Penis
[The intact penis is not "uncircumcised" any more than the intact hand is not "unamputated".]

There is no special care required for the penis of a child that is not circumcised. [Correct!] The penis should be washed without forcibly retracting the foreskin. [Correct!] The foreskin should retract by the time the child is 3 years of age [Says who? Helen Varney in Chapter 36 says 10-20% will not. Failure to retract by some arbitrary age is often an excuse for circumcision, yet many adult men have non-retractile foreskins that give them no trouble.], when he should be taught to push the foreskin back, wash the glans of the penis with soap [only very mild soap, if any] and water, then pull the foreskin up again. [He should be taught to do that only when his penis is good and ready.]

Care of the Circumcised Penis

Signs and Symptons of Complications
...

Whom to contact with Questions or Concerns
...

[The bibliography includes papers by arch-circumcisionists Schoen, Weiss and Wiswell, but not the books by Romberg or Wallerstein.]