Neonatal Male Circumcision Research Articles

Parental regret following decision for sons to undergo elective post-neonatal circumcision

The reasons for performing a circumcision among males after the neonatal period are usually cultural or medical. We aimed to evaluate parental regret for providing consent and to identify factors associated with such regret. Included were the parents of males aged 6 months to 18 years who underwent circumcision under general anesthesia at a single center between 2/2017 and 01/2023. Those who underwent additional surgical procedures during the same session were excluded. Parents responded telephonically to the Decision Regret Scale (DRS) questionnaire. Regret was classified as none (0 points), mild (1-25) or moderate-to-strong (26-100). Surgical and demographic data were retrieved for comparison to DRS scores and identification of predictors of parental regret. In total, 201 of the 265 suitable patients met the inclusion criteria. Parents of 130 patients (65% response rate) whose average age was 5.06 (IQR 1.58,7.53) years completed the DRS questionnaire (study group). The average time since surgery was 41.8 (IQR 25.4,59.3) months. Forty surgeries were undertaken for cultural reasons and 90 for medical considerations. Eighteen parents reported regret (15 mild and 3 moderate-to-strong) for their decision to consent to their son's circumcision. The time from responding since surgery was the only significant variable in the DRS scores, with a 33-month gap predicting no regret (p=0.02 compared to shorter gaps). The reasons for circumcision did not significantly differ between the "regret" and "no-regret" groups (p=0.23). Our current investigation revealed a lower incidence of parental regret when compared to previous reports following distal hypospadias repair, likely attributable to the lower complication rate associated with circumcision. Our data reflect the experience of a single center in a country where neonatal male circumcision is routinely performed for cultural and religious reasons, thus precluding the generalization of our findings to places where post-natal circumcision is less commonplace. Consent to their son's post-neonatal circumcision was regretted by 13.8% of parents. Time since surgery significantly influenced the reduction of their negative attitudes.

Clinical and environmental considerations for neonatal, office-based circumcisions compared with operative circumcisions

Neonatal male circumcision is a commonly performed procedure in the United States. Circumcisions are performed at various ages by a variety of clinical providers for multiple reasons, including religious, cultural, personal, and medical indications. In the United States, neonatal circumcision is routinely performed by non-urologic providers in the hospital within the first few days of life or as a religious ceremony on the 8th day of life. If neonatal circumcision is deferred in the hospital and subsequently not performed in the outpatient setting, it is then typically performed in the operating room under general anesthesia after 6 months of life. Neonatal circumcision is supported by both the American Academy of Pediatrics (AAP) and the American College of Obstetricians and Gynecologists (ACOG) due to the belief that the health benefits outweigh the minimal risk of the procedure. Despite this, neonatal circumcision rates have decreased in the United States in recent decades, in part due to access to the procedure, often related to changing insurance coverage. This has led to increased rates of operative circumcisions. Operative circumcisions are more costly to the healthcare system, subject the patient to cardiopulmonary and potentially neurotoxic effects of general anesthesia, and carry an increased environmental footprint, compared to neonatal circumcision. The intention of this paper is not to promote or justify circumcision for all patients, but rather to compare the clinical and environmental impact of neonatal versus operative circumcisions.

Neonatal Male Circumcision: Clearly Beneficial for Public Health or an Ethical Dilemma? A Systematic Review.

Contrasting ethical and legal arguments have been made concerning neonatal male circumcision (NMC) that merit the first systematic review on this topic. We performed PRISMA-compliant keyword searches of PubMed, EMBASE, SCOPUS, LexisNexis, and other databases and identified 61 articles that met the inclusion criteria. In the bibliographies of these articles, we identified 58 more relevant articles and 28 internet items. We found high-quality evidence that NMC is a low-risk procedure that provides immediate and lifetime medical and health benefits and only rarely leads to later adverse effects on sexual function or pleasure. Given this evidence, we conclude that discouraging or denying NMC is unethical from the perspective of the United Nations Convention on the Rights of the Child, which emphasizes the right to health. Further, case law supports the legality of NMC. We found, conversely, that the ethical arguments against NMC rely on distortions of the medical evidence. Thus, NMC, by experienced operators using available safety precautions, appears to be both legal and ethical. Consistent with this conclusion, all of the evidence-based pediatric policies that we reviewed describe NMC as low-risk and beneficial to public health. We calculated that a reduction in NMC in the United States from 80% to 10% would substantially increase the cases of adverse medical conditions. The present findings thus support the evidence-based NMC policy statements and are inconsistent with the non-evidence-based policies that discourage NMC. On balance, the arguments and evidence reviewed here indicate that NMC is a medically beneficial and ethical public health intervention early in life because it reduces suffering, deaths, cases, and costs of treating adverse medical conditions throughout the lifetimes of circumcised individuals.

Factors influencing neonatal male circumcision uptake among expecting couples in Zambia: formative findings

ABSTRACT Male circumcision is a protective HIV prevention strategy. However, uncircumcised Zambian men are reluctant to undergo voluntary medical male circumcision (VMMC). Tailored interventions are necessary to stimulate the uptake of early infant male circumcision (EIMC) and VMMC in Zambia. This feasibility study presents the formative process of utilising the PRECEDE framework in the development of a family-centred EIMC/VMMC intervention, Like Father Like Son, and its application in an existing VMMC intervention, Spear & Shield. We found that fear of the pain associated with EIMC procedures, foreskin disposal, beliefs in children’s autonomy and rights, and men’s dominance in health decision-making were factors affecting EIMC uptake. Perceived benefits for infants included improved hygiene, protection from HIV infection, and faster recovery. Reinforcing factors included female partners and fathers’ MC status. The availability and access to EIMC services and information, skill and experience of health workers, and engagement and belief in traditional circumcision practices were factors enabling EIMC uptake. These individual, interpersonal, and structural factors positively and negatively influencing EIMC uptake in the Zambian clinic context were integrated into the intervention for expecting parents. Feedback from community advisory boards suggested the process was effective in developing a culturally tailored and acceptable EIMC/VMMC promotion intervention.

From Private Practice to Academia: The Experience of a General Academic Pediatrician.

After pediatric residency, the author worked in a rural community where he was able to immediately practice skills acquired during training such as intubations, bag-mask ventilation, IV placement, ear irrigation, foreign body removal from eyes and ears, abscess incision and drainage, intraosseous placement for rapid hydration of a severely dehydrated infant, EKG, X-ray readings, and ear-irrigations to cite but a few examples. Furthermore, the writer acquired other high-valued procedural skills such as neonatal male circumcision, frenotomy, ligation of supernumerary digits, and manual separation of labial adhesions. The author feels that he could only have acquired and maintained these skills by working in a busy rural pediatric practice. When the writer later became a faculty member, he was able to effectively train medical students and pediatric residents to acquire these same skills. Even though there is a paucity of research information on procedural skills acquisition among general pediatric residents, the writer proposes that the recruitment of full-time general academic pediatricians with real-world experience may be potentially beneficial for the training of medical students and pediatric residents.

Snip the Tip

Abstract Male circumcision originated as a covenant of God with Abraham in biblical times. This practice is rooted in the Jewish and Islamic religions as both claim ancestry with Abraham. Although neonatal male circumcision was mostly performed in these cultures, it became a common practice in the United States in the 1800s. As this is not medically necessary, the frequency of male circumcision is decreasing in some parts of the world, although circumcision in older men is increasing because of the health benefits reported. Although there are several techniques to perform the procedure, pain management during and after the procedure is important. The nurse must ensure that the infant is the right candidate for the procedure, support the parental decision, and monitor the infant for any complications. Research around male circumcision on the long-term effects, reduction of complications, and economic and health benefits earlier in life may be important.

Exploring opposition to ritual female genital cutting since the first U.S. federal prosecution: the 2017 Detroit case.

In the U.S., the 1996 federal law banning medically unnecessary female genital cutting (FGC) of minors was rendered unconstitutional in 2018 in the Nagarwala case. This paper highlights legal developments at the federal and state levels in the U.S. since this trial. It looks at anti-FGC frameworks in other Western countries such as Australia, the UK, France, and Switzerland for comparison. The Australia High Court ruled in favor of a broader interpretation of the words "mutilate" (as in "female genital mutilation" or FGM) and "clitoris" in 2019. In the UK in 2019, a mother of a three-year-old became the first person convicted of "FGM". In the U.S., 2020 federal legislation strengthened opposition to FGC of minors. Twenty-one U.S. states have developed legislation since 2017 that was enacted to oppose such FGC. The 14th Amendment to the U.S. Constitution affords equal protection under the law without regard to sex or gender, prompting increased inclusion of neonatal male circumcision and normalizing surgery for children with intersex traits in the FGC legislation debate. More widely, the principle of equal application of the law raises questions about the legality of adult female genital cosmeticsurgery where adult "FGM" is banned. Tensions between state law and religious law introduce complexities to allowing religious and cultural communities to practice their preferred way of life when this conflicts with human and civil rights afforded to individuals within secular liberal democracies. For consistency, the anti-FGC framework in the U.S. may need to shift towards calls to protect all children, regardless of sex characteristics (i.e., including male and intersex children) from medically unnecessary, non-consensual genital cutting.

Evaluation of maternal preferences for neonatal male circumcision in Enugu Nigeria.

Background:Although circumcision in male neonates is one of the most common procedures performed in neonatal surgery, mothers’ preferences concerning the aspects of circumcision are not well-known. Since mother is the likely parent to present child for circumcision, her preferences should be given adequate consideration.Objectives:The objective of this study is to evaluate maternal preferences for neonatal male circumcision in Enugu.Methodology:A cross-sectional study where questionnaire was distributed by the researchers to consenting pregnant women attending antenatal clinics in two teaching hospitals in Enugu. Data analysis was performed using the SPSS. The results presented as means, percentages and tables. Test for significance was done using the Chi-square test.Results:Four hundred and sixty-one pregnant women participated in the study. Ninety-five percent (438/461) wanted circumcision and 83.5% (385/461) wanted it on or before the 8th day of life. The reasons were cultural/religious in 69% (302/447). Fifty-four percent (250/461) had no preferences as to methods, but for those who had, Plastibell was most preferred method in 28% (129/461) while 76% (235/309) preferred circumcision to be done in hospital. In 49.2% (227/461) preferred personnel were nurses but 79.6% (367/461) wanted doctors to attend to post-circumcision complications. In 79.2% (365/461), mothers will not insist on the use of anaesthesia for circumcision. Mothers with circumcised husbands were significantly more willing to circumcise a male child (P = 0.0018). Higher educational status of mother was significantly related to willingness to insist on the use of anaesthesia (P = 0.046) and use of analgesics after circumcision (P = 0.001).Conclusions:Most mothers prefer neonatal male circumcision by nurses, while preferring doctors for post-circumcision complications. These choices are not affected by parents' educational status. Mothers with circumcised husbands accepted circumcision more than those with uncircumcised husbands. Higher maternal education encourages anaesthesia during circumcision and post-circumcision analgesia.

Joining the tribe: adult circumcision among immigrant men in Israel and its traumatic aftermath

Neonatal male circumcision is closely tied to Jewish identity and is socially normative in Israel. Soon after the mass arrival of secular, uncircumcised Jewish immigrants from the former Soviet Union in the early 1990s, the state sponsored mass circumcision campaigns for adolescents and adult men enabling them to join the Jewish collective, socially and religiously. Some two decades later, these men break the silence exposing their traumatic experiences in the wake of this body-altering surgery. This paper builds on the narratives of these men, belonging to Generation 1.5 of Russian Israelis, emerging in online forums, media features, live events and personal interviews. Driven by social pressure and the need to belong, most young men (and their parents) consented to the operation without proper counselling and unaware of its ramifications. Men share their intimate memories of the rapid surgical procedure, painful recuperation, and their belated regrets, both aesthetic and sexual. The willingness to expose their lingering trauma signals evolving concepts of masculinity and vulnerability among these former Soviet men. Their voices join the local and international movement opposing medically-unnecessary genital surgeries of any kind – on men, women and intersex people.

Neonatal male circumcision is associated with altered adult socio-affective processing

BackgroundNeonatal male circumcision is a painful skin-breaking procedure that may affect infant physiological and behavioral stress responses as well as mother-infant interaction. Due to the plasticity of the developing nociceptive system, neonatal pain might carry long-term consequences on adult behavior. In this study, we examined whether infant male circumcision is associated with long-term psychological effects on adult socio-affective processing. MethodsWe recruited 408 men circumcised within the first month of life and 211 non-circumcised men and measured socio-affective behaviors and stress via a battery of validated psychometric scales. ResultsEarly-circumcised men reported lower attachment security and lower emotional stability while no differences in empathy or trust were found. Early circumcision was also associated with stronger sexual drive and less restricted socio-sexuality along with higher perceived stress and sensation seeking. LimitationsThis is a cross-sectional study relying on self-reported measures from a US population. ConclusionsOur findings resonate with the existing literature suggesting links between altered emotional processing in circumcised men and neonatal stress. Consistent with longitudinal studies on infant attachment, early circumcision might have an impact on adult socio-affective traits or behavior.

State-Level Public Insurance Coverage and Neonatal Circumcision Rates.

Seventeen states do not provide Medicaid coverage for neonatal male circumcision, despite American Academy of Pediatrics recommendations supporting access for families that choose it. Our study objectives were to (1) compare state-specific trends in neonatal circumcision to previously established estimates and (2) assess the impact of changes in Medicaid coverage of the procedure. The State Inpatient Databases were used to determine rates of neonatal male circumcision in 4 states (CO, FL, MI, and NY) at 4 time points (2001, 2006, 2011, 2016). Neonatal circumcision was defunded by Medicaid in Florida (2003) and Colorado (2011). A multivariable logistic regression model was created to assess associations between patient and state characteristics and odds of neonatal circumcision. Overall, 54.5% of neonates underwent circumcision. States where Medicaid defunded neonatal circumcision revealed a decrease in circumcision rates in subsequent years (47.4% to 37.5% in FL; 61.9% to 52.0% in CO). Neonates with private insurance had higher odds of circumcision compared with those with public insurance (adjusted odds ratio [aOR] 2.23; 95% confidence interval [CI] 2.21-2.25). When Medicaid coverage was available, Black neonates had higher odds of circumcision compared with white neonates (aOR 1.44; 95% CI 1.42-1.46). When Medicaid coverage was not available, Black neonates had lower odds compared with white neonates (aOR 0.40; 95% CI 0.39-0.41). State-specific data reveal trends in neonatal circumcision similar to previous national estimates. Colorado and Florida revealed 20.9% and 16.0% reductions in neonatal circumcision rates, respectively, after defunding. Black neonates appeared to be disproportionately affected by changes in Medicaid coverage.

Assessment of Neonatal Circumcision Availability at Chicago-Area Hospitals

This survey study assesses possible barriers to neonatal male circumcision by evaluating circumcision-related requirements and procedures among 44 birthing hospitals in the Chicago area in Illinois.

USA and UK: differences on neonatal circumcision

The popularity of neonatal circumcision has declined significantly in the last half century in the UK, but it persists in the USA where most boys are still circumcised soon after birth. In this article the author considers why the practice is now so different in the two countries and explores the pros and cons of neonatal male circumcision.

Physicians\u2019 and nurses\u2019 thoughts and concerns about introducing neonatal male circumcision in Thailand: a qualitative study

BackgroundNeonatal male circumcision (NMC) is an alternative approach to adult male circumcision for HIV prevention. Recent studies found that NMC was rarely performed in Thailand and that most Thai health professionals did not recognize that NMC could reduce the risk of HIV infection and would not want NMC services in their hospitals. This study explored the thoughts and concerns of Thai government health staff regarding the introduction of NMC in government health facilities as a public health measure.MethodsIn-depth interviews with physicians, nurses and physician administrators from four different levels of government hospitals in four provinces representing 4 regions of Thailand were conducted after provision of education regarding the benefits and risks of NMC. Interviews were audio recorded and analyzed using Atlas.ti software to develop themes.ResultsSix themes emerged from the data of 42 respondents: understanding of the benefits of NMC; risks of NMC; need for a pilot project; need for staff training and hospital readiness; need for parental/family education; and need for public awareness educational campaign. Major concerns included possible medical complications of NMC, infringement of child rights, and lack of understanding from staff and parents. The respondents emphasized the need for a clear policy, proper training of staff, financial and equipment support, and piloting NMC rollout before this measure could be fully implemented.ConclusionsThai health professionals who took part in this study expressed several concerns if NMC had to be performed in their health care facilities. There is significant preparation that needs to be done before NMC can be introduced in the country.

The Goose and the Gander: The Genital Wars

Should there be gender equity in genital cutting? In Germany (and much of Europe), the native inhabitants tend to argue there is moral equivalence between customary male circumcision and customary female circumcision and both should be proscribed. In Sierra Leone (and several other countries in Africa), the native inhabitants tend to argue there is moral equivalence between customary male circumcision and customary female circumcision and both should be permitted. In the United States, the native inhabitants tend to argue against moral equivalence, permitting customary circumci- sions for boys while proscribing them for girls. Who has the better of the argument? And what are the implications of the argument for Jews and other circumcising ethnic groups living in Europe, Africa, and North America? It is rumored that when God issued the command, Abraham looked up at the heavens and said 'Youwantustodowhat?'According to legend Sarah was not party to the conversation and was notincluded inthe deal. Suchstoriesdon't surprise me.I hesitated toowhen myson was born,at least until the absentee ballots came flooding infrom generations of ancestors; for the dead had a vote, including Abraham. And when my daughter was born the thought 'why aren' tJ ewish women circumcised?' never occurred to my wife. Not once did she look up at the heavens and say 'What kind of justice is this? Shouldn't there be gender equity in genital cutting?' That however is the question fully considered by Shaye Cohen in WhyAren't Jewish Women Circumcised? 1 His book is an exegesis of medieval rabbinic understandings of the genital cutting required of Jewish males in Genesis 17. It is also an eye-opening account of Jewish attempts to respond to early anti-Semitic Christian accusations that neonatal male circumcision is not only gender biased, patriarchal, and exclusionary (of the female half of the Jewish population) but also morally inferior to the ecumenical and gender inclusive practice of Christian baptism. The author, who is a Professor of Hebrew Literature and Philosophy at Harvard University, then brings us up to date by observing that contemporary opponents of Jewish male circumcision 'assume (moral) parity between male circumcision, which is toler- ated, and female circumcision, which is proscribed,' with the aim of expanding existing legal prohibitions of female genital mutilation (FGM) to include the male circumcision of minors. 2 What's good for the goose is good for the gander. Or so argue today's opponents of childhood male circumcision.

Are Physicians Blameworthy for Iatrogenic Harm Resulting from Unnecessary Genital Surgeries?

We argue that physicians should, in certain cases, be held accountable by patients and their families for harm caused by "successful" genital surgeries performed for social and aesthetic reasons. We explore the question of physicians' blameworthiness for three types of genital surgeries common in the United States. First, we consider surgeries performed on newborns and toddlers with atypical sex development, or intersex. Second, we discuss routine neonatal male circumcision. Finally, we consider cosmetic vaginal surgery. It is important for physicians not just to know when and why to perform genital surgery, but also to understand how their patients might react to wrongful performance of these procedures. Equally, physicians should know how to respond to their own blameworthiness in socially productive and morally restorative ways.

Mandatory Neonatal Male Circumcision in Sub-Saharan Africa and the Common Good: An Exploration of Ethical Justification

Mandatory Neonatal Male Circumcision in Sub-Saharan Africa and the Common Good: An Exploration of Ethical Justification

A "Wear and Tear" Hypothesis to Explain Sudden Infant Death Syndrome.

Sudden infant death syndrome (SIDS) is the leading cause of death among USA infants under 1 year of age accounting for ~2,700 deaths per year. Although formally SIDS dates back at least 2,000 years and was even mentioned in the Hebrew Bible (Kings 3:19), its etiology remains unexplained prompting the CDC to initiate a sudden unexpected infant death case registry in 2010. Due to their total dependence, the ability of the infant to allostatically regulate stressors and stress responses shaped by genetic and environmental factors is severely constrained. We propose that SIDS is the result of cumulative painful, stressful, or traumatic exposures that begin in utero and tax neonatal regulatory systems incompatible with allostasis. We also identify several putative biochemical mechanisms involved in SIDS. We argue that the important characteristics of SIDS, namely male predominance (60:40), the significantly different SIDS rate among USA Hispanics (80% lower) compared to whites, 50% of cases occurring between 7.6 and 17.6 weeks after birth with only 10% after 24.7 weeks, and seasonal variation with most cases occurring during winter, are all associated with common environmental stressors, such as neonatal circumcision and seasonal illnesses. We predict that neonatal circumcision is associated with hypersensitivity to pain and decreased heart rate variability, which increase the risk for SIDS. We also predict that neonatal male circumcision will account for the SIDS gender bias and that groups that practice high male circumcision rates, such as USA whites, will have higher SIDS rates compared to groups with lower circumcision rates. SIDS rates will also be higher in USA states where Medicaid covers circumcision and lower among people that do not practice neonatal circumcision and/or cannot afford to pay for circumcision. We last predict that winter-born premature infants who are circumcised will be at higher risk of SIDS compared to infants who experienced fewer nociceptive exposures. All these predictions are testable experimentally using animal models or cohort studies in humans. Our hypothesis provides new insights into novel risk factors for SIDS that can reduce its risk by modifying current infant care practices to reduce nociceptive exposures.

In developed countries male circumcision prevalence is inversely related to HIV prevalence.

A study by Chemtob and co-workers found significantly lower prevalence of HIV amongst heterosexual men and women in Israel compared with the Netherlands and France. Risk factors for heterosexual HIV infection in these countries were similar, apart from one, namely, a strikingly higher prevalence of male circumcision (MC) in Israel compared with the Netherlands and France. It is now well established that MC protects heterosexual men against becoming infected with HIV during sexual intercourse with an infected woman. In epidemic settings, such as countries in sub-Saharan Africa, in which heterosexual contact is the primary driver for HIV infection, MC is being implemented to reduce HIV prevalence. The results of the new study by Chemtob and co-workers support the evidence and recent polices in the United States advocating MC to reduce the spread of HIV. While prevalence in developed countries is generally low, it is rising. In the long term, neonatal MC is the most desirable option, since not only is it simpler, safer, cheaper and more convenient than MC later, it provides immediate protection from infections, penile inflammation, genital cancers and physical problems. It is also cost-effective. European countries have not supported MC for its public health benefits. The new findings add to calls for European and other countries with low MC prevalence to consider developing evidence-based policies favoring MC in order to reduce HIV and other infections and diseases and at the same time reduce suffering, mortality and the cost of treating these.

Thai health care provider knowledge of neonatal male circumcision in reducing transmission of HIV and other STIs.

BackgroundMale circumcision (MC) reduces the risk of female-to-male transmission of HIV and other sexually transmitted infections (STIs). MC has not been practiced as a disease prevention measure in Thailand probably because of low recognition of its benefits among stakeholders. Neonatal male circumcision (NMC) is simpler, safer and cheaper than adult MC. This study aimed to assess Thai health care provider knowledge of benefits implementing NMC in Thailand.MethodsMulti-stage sampling identified 16 government hospitals to represent various hospital sizes and regions of the country. Researchers administered a fixed choice questionnaire, developed by the research team based on a previous study, to physician administrators, practicing physicians, and nurses whose jobs involved NMC clinical procedures or oversight. The participants reviewed printed educational materials on the benefits of NMC during questionnaire completion. Data were analyzed using descriptive statistics, chi square tests, odds ratios, and logistic regression.ResultsOne hundred thirty-three individuals participated in this quantitative study. Only 38 % of the participants agreed that NMC reduced the risk of sexual transmission of HIV while 65 % indicated that they knew that NMC prevented STIs. Most participants recognized the benefits of NMC on hygiene (96 %) as well as cancer prevention (74 %). Major concerns raised were potential trauma to the child, child rights and safety of NMC. After reviewing written information about the benefits of NMC, 59 % of the participants agreed that NMC should be offered in their hospital. Physicians and nurses who had previous experience with circumcising patients of all ages were more reluctant to have NMC performed in their hospital.ConclusionsA clear policy advocating NMC, thorough preparation of health facilities, and staff training are needed before NMC could be used in Thailand as prevention strategy for HIV and other STIs.