Original Article: Newborn Circumcision Techniques

Issue Date: June 1, 2020

See additional reader comments at: https://www.aafp.org/afp/2020/0601/p680.html

To the Editor: The article by Dr. Omole and colleagues describes common techniques for performing newborn circumcision. Although the technical discussion is sound, other sections of the article do not reflect the current literature.

The authors cite health benefits from circumcision, such as reduced risk of urinary tract infections (UTIs), penile cancer, phimosis, and HIV infection. However, these risks need context. UTIs are virtually always treatable and are relatively uncommon in boys regardless of circumcision status. The cited report suggests that the number of circumcisions needed to prevent one (likely treatable) UTI is approximately 100. Penile cancer is one of the rarest malignancies for which site-specific data are available in the United States.¹ Pathologic phimosis usually can be treated nonsurgically with a steroid cream.² The data on HIV infection come from studies of voluntary adult circumcision in sub-Saharan Africa where there is an epidemic of heterosexually transmitted HIV; the relevance of these data to newborn circumcision in the United States has not been established.¹

The risk of loss of the penile prepuce from circumcision is 100%.³ If this genital structure has any value, then its removal is a harm, whatever the (further) risk of surgical complications. The patient's inability to decide if his genitals should be permanently surgically altered is also a consideration. Circumcision removes anatomically normal, nondiseased, functional tissue—from a psychosexually significant part of the body—with no urgent medical need and without the consent of the patient.¹

Physicians should be aware of the rapidly changing ethical and legal landscapes for circumcision. A recent federal court case clarified that even a sterilized “ritual nick” to the vulva of a child or infant for religious reasons constitutes physical assault, which has implications for male circumcision.⁴ A group of more than 90 physicians, medical ethicists, legal scholars, and other experts argued that “cutting any person's genitals without their informed consent is a serious violation of their right to bodily integrity [and is] morally impermissible unless the person is nonautonomous (incapable of consent) and the cutting is medically necessary.”⁵

In Reply: Thank you for your comments on our article. We applaud your work on genital mutilation, sexual assault, and medical ethics as they relate to what has been accepted in society. Unfortunately, we did not address the medical ethics of newborn circumcision in this article because of word count restrictions; therefore, we listed the adverse effects that have been commonly cited for the procedure. The medical ethics of newborn circumcision is a formidable topic in itself and would require an additional article on how religion and culture impact science. We welcome collaboration on this topic at a future HeLa Conference at Morehouse School of Medicine to discuss ethical dilemmas in medicine.