With the recent assertion that neonatal circumcision rates have suddenly and dramatically fallen in the US at a time that it is being feverishly pushed in Africa to "prevent" HIV, it is worth looking deeper to see what is behind this claim.
The paper, entitled "Rates of selected neonatal male circumcision-associated severe adverse events in the United States, 2007-2009," first presented at the AIDS 2010 conference in Vienna (abstract here), and detailed online on mdconsult.com, seems to be concerned first with the rates of complication. The mdconsult.com article (full article available here in pdf) reports the authors' claim that the complication rate is small within the first 90 days post surgery. They go on to claim that the complication rate is considerably higher for older children, but is still very low. (Hint, hint: cut 'em early!)
image (left) / flickr / nats / Circumcision Services
The first concern here is that 90 days is not long enough to follow a cohort after circumcision. Complications of this surgery are varied and myriad, often unacknowledged and denied, and frequently result in familial embarrassment and a reluctance to come forward unless there is an immediate need for correction. Moreover, the psychological fallout, also very much a complication, may be suppressed for years or decades. Complications often do not always get treated right away due to parental ignorance and because many American parents may not have the means to get follow up medical care.
A better way to measure complications is to survey not birth statistics or hospital admissions alone, but rather to look at the data comprehensively from all sources, such as from the private practices of pediatric urologists. One such pediatric urologist, M. David Gibbons, commented not too long ago following a poorly researched Mens Health article (2/2009) sternly and tursely entitled, Should all males be circumcised?
His comment:
Neonatal circumcision is totally unnecessary, and there is no current role for preventative or prophylactic neonatal circumcision. Unfortunately, 70-80% of neonatal circumcisions are performed by obstetricians, who can neither manage their complications (2-5% incidence) nor obtain proper informed consent (defined as outlining risks and benefits of a procedure, as well as alternatives-including nothing) for neonatal circumcision. Currently, the American College of OB-GYN (ACOG) have no parameters for training (learning and performing neonatal circumcision, managing complications) of residents, who then go out and continue this practice.
In my practice, as a pediatric urologist, I manage the complications of neonatal circumcision. For example, in a two year period, I was referred >275 newborns and toddlers with complications of neonatal circumcision. None of these were 'revisions' because of appearance, which I do not do. 45% required corrective surgery (minor as well as major, especially for amputative injury), whereupon some could be treated locally without surgery. Complications of this unnecessary procedure are often not reported, but of 300 pediatric urologists in this country who have practices similar to mine...well, one can do the math, to understand the scope of this problem...let alone, to understand the adverse cost-benefit aspect of complications (>$750,000) in this unfortunate group of infants and young children.
Fortunately, neonatal circumcision is on the decline as parents become educated...but the complications still continue. Until the time that the USA falls in step with the rest of the planet who does not submit newborns to neonatal circumcision, ACOG should assure that the training of obstetricians to perform this procedure is adequate, particularly in avoiding and managing complications of a procedure that is unnecessary, and that obstetricians learn to obtain proper informed consent from parents who have no idea of the problems that can ensue.
M.David Gibbons, MD
Associate Professor, Pediatric Urology, Georgetown University School of
Medicine and George Washington School of Medicine.
Attending Pediatric Urologist, Childrens National Medical Center,
Washington, DC.
Director, Pediatric Urology, Georgetown University Hospital,
Washington, DC.
Head, Pediatric Urology, Inova Fairfax Hospital For Children, Falls Church,
Virginia.
It doesn't take a math major to see that 275 complications in two years multiplied by 300 pediatric urologists, as the good doctor suggests we do, comes to 82,500 incidents. While that is a relatively small percentage of all infants circumcised in the US (>1.6 million per year - see below), for an unnecessary and painful operation that robs the patient of erogenous tissue under circumstances where he cannot voice his preference for or against ... and holy effing cow, that's a lot! Now, multiply the incident cost (>$750,000) by 300 as the good doctor suggests, and we have a financial burden approaching $62 billion over two years.
Now frankly, that sounds rather high until you realize that the costs vary greatly by region and likely include by extrapolation thousands who never get treated for lack of insurance or an understanding that a painful penis or weird appearance is not normal and needs corrective medical attention. Therefore, the cost is probably lower because complications are likely undertreated.
Now what about that sudden and dramatic drop in American circumcision rates? Well, it is probably mere hyperbole. According to the mdconsult.com article, there were some 6,571,500 US neonatal circumcisions during the years beginning in 2006 and ending in 2009. That works out to 1,642,875 US neonatal circumcisions per year if you accept the number of yearly male births at 2,170,000, calculated by taking <14 live births per 1000 people divided by 2 with an estimated current population of 310 million (CIA Factbook). Hence, we get a neonatal circumcision rate of about 76% on their numbers.
Where's the drop? I call bullshit.
