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Notat om omskæring af drenge - Sundhedsstyrelsen

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OMSKÆRINGAF DRENGE<strong>Notat</strong>2013


Omskæring <strong>af</strong> <strong>drenge</strong>. <strong>Notat</strong>© <strong>Sundhedsstyrelsen</strong>, 2013. Publikationen kan frit refereres med tydelig kildeangivelse.<strong>Sundhedsstyrelsen</strong>Axel Heides Gade 12300 København SURL: http://www.sst.dkEmneord: Omskæring, <strong>drenge</strong><strong>om</strong>skæringSprog: DanskKategori: Faglig rådgivningVersion: 1.0Versionsdato: 26. juni 2013Format: pdfUdgivet <strong>af</strong> <strong>Sundhedsstyrelsen</strong>, juni 2013.Elektronisk ISBN: 978-87-7104-532-1<strong>Notat</strong> <strong>om</strong> <strong>om</strong>skæring <strong>af</strong> <strong>drenge</strong> 2 / 21


Indhold1 <strong>Sundhedsstyrelsen</strong>s sammenfatning 52 Omskæring 62.1 Kirurgiske metoder 72.2 Smertedækning ved <strong>om</strong>skæring 72.2.1 Sukkervand 72.2.2 Lokalbedøvende gel eller creme 82.2.3 Nerveblok 82.2.4 Fuld bedøvelse 82.3 Beskrivelse <strong>af</strong> den jødiske <strong>om</strong>skæring 82.4 Beskrivelse <strong>af</strong> den muslimske <strong>om</strong>skæring 92.5 Helbredsmæssige fordele 102.6 K<strong>om</strong>plikationer til <strong>om</strong>skæring 113 Omskæring i Danmark 133.1 Skøn over antal <strong>om</strong>skæringer i Danmark 133.2 Lovgivning og regler 133.3 Tilsynssager 153.4 Patientklager og patienterstatningssager 164 Omskæring i andre land 174.1 Sverige 174.2 Norge 174.3 Tyskland 174.4 England 184.5 Australien 184.6 USA 185 Konklusion 206 Bilagsfortegnelse 21<strong>Notat</strong> <strong>om</strong> <strong>om</strong>skæring <strong>af</strong> <strong>drenge</strong> 3 / 21


ForordMinisteriet for Sundhed og Forebyggelse har i en mail <strong>af</strong> den 1. november 2012anmodet <strong>Sundhedsstyrelsen</strong> <strong>om</strong> at undersøge <strong>om</strong>skæring <strong>af</strong> <strong>drenge</strong>børn i Danmark,herunder at skabe et overblik over <strong>om</strong>fanget <strong>af</strong> eventuelle sundhedsmæssige problemerforbundet med rituel <strong>om</strong>skæring.<strong>Sundhedsstyrelsen</strong> har <strong>af</strong>dækket <strong>om</strong>rådet ved hjælp fra styrelsens faste sagkyndigei kirurgi og anæstesi og har derudover indhentet bistand fra Dansk Pædiatrisk Selskabfor så vidt angår børneurologi. Styrelsen har endvidere holdt møder med forskelligeinteressenter på <strong>om</strong>rådet; Det Mosaiske Trossamfund, Muslimernes Fællesråd;foreningen Intact og forsker på Seruminstituttet Morten Frisch.Anne Mette DonsEnhedschef for Tilsyn & Patientsikkerhed<strong>Sundhedsstyrelsen</strong>, juni 2013.<strong>Notat</strong> <strong>om</strong> <strong>om</strong>skæring <strong>af</strong> <strong>drenge</strong> 4 / 21


1 <strong>Sundhedsstyrelsen</strong>s sammenfatningOmskæring <strong>af</strong> <strong>drenge</strong> er et kirurgisk indgreb, hvor forhuden <strong>af</strong> penis skæres bort.Omskæringen kan være medicinsk eller kulturelt/religiøst begrundet. Cirka en tredjedel<strong>af</strong> mænd verden over er <strong>om</strong>skåret. Efter <strong>Sundhedsstyrelsen</strong>s oplysninger er rituel<strong>om</strong>skæring ikke forbudt ved lov i nogen lande.I Danmark registrerer man ikke et barns religiøse tilhørsforhold, når det fødes. Derfindes heller ikke en selvstændig registrering <strong>af</strong>, hvor mange rituelle <strong>drenge</strong><strong>om</strong>skæringerder foretages i Danmark. Der foreligger derfor ikke data for, hvor mange<strong>drenge</strong>børn der får foretaget rituel <strong>om</strong>skæring i Danmark. Det er <strong>Sundhedsstyrelsen</strong>sskøn, at antallet <strong>af</strong> rituelle <strong>om</strong>skæringer <strong>om</strong> året i Danmark ligger mellem1000 – 2000 <strong>om</strong> året.Omskæring er et kirurgisk indgreb, der efter dansk lovgivning er forbeholdt lægerat foretage. Hvilken kirurgisk metode og bedøvelse der anvendes, er lægens valg isamråd med forældrene. Rituel/kulturel <strong>om</strong>skæring tilbydes ikke i det offentligesundhedsvæsen i Danmark, hvorfor indgrebet ofte foretages på private lægeklinikker.I <strong>Sundhedsstyrelsen</strong>s vejledning <strong>om</strong> <strong>om</strong>skæring præciseres, hvordan lægenudviser <strong>om</strong>hu og samvittighedsfuldhed ved <strong>om</strong>skæring <strong>af</strong> <strong>drenge</strong>børn. Det er styrelsensgenerelle indtryk, at vejledningen følges.<strong>Sundhedsstyrelsen</strong> modtager et par henvendelser årligt grundet mulige k<strong>om</strong>plikationertil <strong>om</strong>skæring, eller at disse ikke er udført korrekt. Patient<strong>om</strong>buddet har fra2003-2010 behandlet 20 klager over rituel <strong>om</strong>skæring. I 11 sager er der udtalt kritik;disse sager lå før <strong>Sundhedsstyrelsen</strong>s vejledning i 2005. I de restende 9 sager,efter 2005, har Patient<strong>om</strong>buddet ikke udtalt kritik <strong>af</strong> lægernes faglige virke. Patientforsikringenhar de sidste 17 år fået 14 anmeldelser vedrørende rituelle <strong>om</strong>skæringer<strong>af</strong> <strong>drenge</strong>, hvor<strong>af</strong> ingen har ført til udbetaling <strong>af</strong> erstatning.Der har fra flere sider været rejst bekymring for seksualiteten hos den voksne mands<strong>om</strong> følge <strong>af</strong> <strong>om</strong>skæring. Selv <strong>om</strong> nogle studier tyder på, at <strong>om</strong>skæring senere henkan føre til psykologiske og seksuelle problemer, mangler der fortsat studier overlangtidseffekten <strong>af</strong> <strong>om</strong>skæring på voksne mænd, herunder på deres seksualitet. Enregistrering i eksempelvis Landspatientregisteret (LPR) <strong>af</strong> alle <strong>om</strong>skæringer kanovervejes mhp. evt. senere opfølgning.Det er <strong>Sundhedsstyrelsen</strong>s vurdering, at der ikke er tilstrækkelig sundhedsfagligdokumentation til generelt at anbefale <strong>om</strong>skæring <strong>af</strong> <strong>drenge</strong>børn. Samtidig er derikke sådanne risici ved indgrebet, når det foretages korrekt og <strong>af</strong> k<strong>om</strong>petente læger,at styrelsen finder anledning til at anbefale et forbud <strong>af</strong> rituel <strong>om</strong>skæring <strong>af</strong> <strong>drenge</strong>børn.Det er videre <strong>Sundhedsstyrelsen</strong>s opfattelse, at det ud fra et sundhedsfaglig, patientsikkerhedsmæssigsynspunkt kan være en fordel, at <strong>drenge</strong>børn <strong>om</strong>skæres såtidligt s<strong>om</strong> muligt, da indgrebet er mindre og giver færre umiddelbare k<strong>om</strong>plikationer,når det foretages i de første uger <strong>af</strong> barnets levetid.K<strong>om</strong>plikationer til indgrebet er få. Ifølge <strong>Sundhedsstyrelsen</strong>s oplysninger, har derikke været alvorlige k<strong>om</strong>plikationer ved rituelle <strong>drenge</strong><strong>om</strong>skæringer foretaget <strong>af</strong>læger i Danmark. Da der er dokumenteret flere k<strong>om</strong>plikationer, jo ældre barnet er,kan man overveje at stille krav <strong>om</strong>, at <strong>drenge</strong>børn, der skal <strong>om</strong>skæres ud over deførste leveuger, får indgrebet foretaget på en lægeklinik eller på sygehus.<strong>Notat</strong> <strong>om</strong> <strong>om</strong>skæring <strong>af</strong> <strong>drenge</strong> 5 / 21


Endelig finder <strong>Sundhedsstyrelsen</strong>, at det fortsat skal være forbeholdt læger at udføreindgrebet under overholdelse <strong>af</strong> styrelsens vejledning <strong>om</strong> <strong>om</strong>skæring <strong>af</strong> <strong>drenge</strong>børn.2 OmskæringOmskæring <strong>af</strong> <strong>drenge</strong> er et kirurgisk indgreb, hvor forhuden <strong>af</strong> penis skæres bort.Omskæringen kan være medicinsk eller kulturelt/religiøst begrundet (f.eks. stammekultur,jøded<strong>om</strong>, islam eller anden kulturel tradition). Omkring en tredjedel <strong>af</strong>mænd verden over er <strong>om</strong>skåret. Antallet <strong>af</strong> rituelle <strong>om</strong>skæringer er <strong>af</strong>tagende i defleste vestlige lande.Omskæring er lægefagligt begrundet hos <strong>drenge</strong> ved forhudsforsnævring, hvor forhudenikke kan trækkes tilbage over glans penis (penishovedet). Normalt forventesen dreng at kunne trække forhuden tilbage, når han er fyldt seks år. Diagnosen 'forhudsforsnævring'stilles derfor først på dette tidspunkt, med mindre <strong>drenge</strong>n indenda har besvær med at lade vandet eller får betændelse under forhuden. Forhudsforsnævringkan give risiko for infektioner, fordi de hygiejniske forhold vanskeliggøres.Det især muslimer og jøder, s<strong>om</strong> lader deres <strong>drenge</strong> rituelt <strong>om</strong>skære. Mandligekonvertitter til den jødiske eller muslimske tro lader sig også <strong>om</strong>skære. Mandlig<strong>om</strong>skæring er påkrævet inden for jøded<strong>om</strong>men og stort set universel inden for islam,<strong>om</strong>end den her ikke er foreskrevet.Dansk Pædiatrisk Selskab ved professor i pædiatri, overlæge, dr. med. Søren Rittig(specialist i nyresygd<strong>om</strong>me hos børn) har ved et møde med <strong>Sundhedsstyrelsen</strong> understreget,at der på de danske hospitaler udelukkende foretages <strong>om</strong>skæring på lægefagligindikation, f.eks. for at mindske risiko for urinvejsinfektion hos <strong>drenge</strong>børn.Diagnosen urinvejsinfektion hos <strong>drenge</strong> under et års alderen er ofte svær atstille, og behandlingen kræver indgift <strong>af</strong> antibiotika direkte i blodbanen i mindst tre<strong>Notat</strong> <strong>om</strong> <strong>om</strong>skæring <strong>af</strong> <strong>drenge</strong> 6 / 21


døgn under indlæggelse på sygehus. Små <strong>drenge</strong>, der har h<strong>af</strong>t betændelse i urinvejene,skal derudover følges på <strong>af</strong> en børne<strong>af</strong>deling, fordi der er risiko for, at de udviklerarvæv i nyrerne med permanent nyreskade og nyrefunktionstab til følge.Dansk Pædiatrisk Selskab finder dog, at den eksisterende viden <strong>om</strong> <strong>om</strong>skæring ikkeberettiger til, at man s<strong>om</strong> i USA generelt anbefaler <strong>om</strong>skæring <strong>af</strong> raske <strong>drenge</strong>med baggrund i sundhedsmæssige fordele i Danmark.2.1 Kirurgiske metoderDer findes forskellige kirurgiske metoder til <strong>om</strong>skæring. Valget <strong>af</strong> <strong>om</strong>skæringsmetoden<strong>af</strong>hænger <strong>af</strong>, hvilken teknik lægen finder mest hensigtsmæssig at bruge i detkonkrete tilfælde. De mest almindelige kirurgiske instrumenter s<strong>om</strong> bruges til <strong>om</strong>skæringer G<strong>om</strong>co klemmen, Morgen klemmen og Plastik-ringen. Omskæring kanogså udføres ved ”<strong>om</strong>skærelse i fri hånd”. Hvert instrument og teknik har sine fordeleog ulemper, s<strong>om</strong> den enkelte kirurg skal vurdere.2.2 Smertedækning ved <strong>om</strong>skæringI dag bruges forskellige metoder til bedøvelse ved <strong>om</strong>skæring alt efter barnets alder,kirurgens ønske og indgrebets type.• Sukkervand• Lokal bedøvende creme• Nerveblokade• Fuld bedøvelse.Hvilken metode lægen vælger at bruge ved <strong>om</strong>skæring er en <strong>af</strong>vejning <strong>af</strong>, hvilkenform der er mest hensigtsmæssig i det konkrete tilfælde.2.2.1 SukkervandStudier har vist, at sukkervand <strong>af</strong> en vis koncentration (over 25 %), givet i mundenunder indgrebet på den nyfødte, kan have en vis smertelindrende effekt. 1 Detteskyldes formentlig, at sukker interagerer med kemiske processer i hjernen, s<strong>om</strong>frembringer en følelse <strong>af</strong> velvære hos barnet. Denne følelse forstærkes ved suttefunktionen,f.eks. hvis sukkervandet gives på sutten. Metoden kan ikke bruges alene,men kan bruges s<strong>om</strong> supplement til de andre <strong>om</strong>talte metoder.1Skogsdal et al., Analgesia in newborns given oral glucose, Acta Paediatrica, 1997, 86: 217-220.<strong>Notat</strong> <strong>om</strong> <strong>om</strong>skæring <strong>af</strong> <strong>drenge</strong> 7 / 21


2.2.2 Lokalbedøvende gel eller cremeLokalbedøvende creme er ofte brugt til nyfødte. Cremen eller gelen smøres påspædbarnets forhud 60 - 90 min før indgrebet for at opnå smertelindring. Metodengiver ikke smertefrihed, men smertelindring. Metoden er ikke egnet til større børneller voksne.Cremen kan give lokal irritation <strong>af</strong> huden i form <strong>af</strong> rødme, men der ses sjældent alvorligebivirkninger, når den bruges s<strong>om</strong> lokalbedøvende til <strong>om</strong>skæring hos nyfødte.2.2.3 NerveblokOmskæringer kan foretages i lokal bedøvelse, f.eks. nerveblok, s<strong>om</strong> anlægges medto injektioner <strong>af</strong> et bedøvende lægemiddel. Nerveblokade er en anæstesiform, hvorman fremkalder midlertidig blokering <strong>af</strong> nervesignalerne gennem en stor nervebaneved at sprøjte et lokalanæstesimiddel ind i nervens umiddelbare nærhed. Ofte læggesførst en lokalbedøvelse.Denne metode kan bruges til alle aldre. Lokalbedøvelse med injektion er genereltmere effektiv til at mindske smerten end brugen <strong>af</strong> hudbedøvende creme. 2 Dog kanselve injektionerne medføre smerte/ubehag. Barnet kan få en blodansamling vedindstiksstedet.2.2.4 Fuld bedøvelseVed fuld bedøvelse sover barnet under indgrebet og er fuldt smertedækket. Fuldbedøvelse anbefales ikke til børn under 6 måneder, med mindre det er absolut nødvendigt.Fuld bedøvelse <strong>af</strong> spædbørn er en opgave for en erfaren speciallæge i anæstesiologi(narkoselæge) med særlig k<strong>om</strong>petence i bedøvelse <strong>af</strong> små børn.2.3 Beskrivelse <strong>af</strong> den jødiske <strong>om</strong>skæringDet Mosaiske Trossamfund i Danmark har i august 2012 udgivet ”WhitePaper – rituel<strong>om</strong>skæring <strong>af</strong> <strong>drenge</strong>”. Her<strong>af</strong> fremgår det, at en specialuddannet person, s<strong>om</strong>regel rabbineren, på barnets 8. levedag foretager <strong>om</strong>skæringen. Omskæringen foregåri hjemmet. En læge er til stede ved <strong>om</strong>skæringen. Lægen kontrollerer barnet ogjournalfører før og efter indgrebet. Ifølge ”WhitePaper – rituel <strong>om</strong>skæring <strong>af</strong> <strong>drenge</strong>”skal barnet før <strong>om</strong>skæringen være almindeligt velbefindende, veje <strong>om</strong>kring 3kg eller derover og må ikke have gulsot. I tvivlstilfælde udsættes <strong>om</strong>skæringen.En <strong>om</strong>skæring er en festlig begivenhed inden for jøded<strong>om</strong>men, og derfor er barnetsforældre og øvrige familie også tilstede. Der påsmøres hudbedøvende creme ca. entime inden <strong>om</strong>skæringen. Under selve handlingen får barnet lidt vin på en sut, ogdermed koncentrerer barnet sig <strong>om</strong> at sutte. Selve <strong>om</strong>skæringen foregår ved, at2Butler-O´hara et al., Analgesia for Neonatal circumcision: A Rand<strong>om</strong>ized Controlled Trial of EMLAcreme versus Dorsal penile nerve Block., Pediatrics 1998.<strong>Notat</strong> <strong>om</strong> <strong>om</strong>skæring <strong>af</strong> <strong>drenge</strong> 8 / 21


arnet ligger på en pude på et bord. Rabbineren står på den ene side, og lægen stårpå den modsatte side og holder barnets ben. Rabbineren løsner forhuden og trækkerden op over penishovedet og sætter en klemme i den optrukne forhud. Herved sikres,at penishovedet ikke beskadiges. Der foretages et snit oven for klemmen, ogforhuden falder <strong>af</strong>. Herefter sørges der for, at også den indre forhud er trukket heltned ved roden. Rabbineren stopper blødningen med pres og bandager. Hele seancener overstået på to til tre minutter.Efter ceremonien kontroller lægen og rabbineren, at barnet har det godt, og at bandagener tør og ligger korrekt. Journalen underskrives og opbevares <strong>af</strong> lægen. Familieninstrueres i, hvorledes bleerne de næste fem til seks bleskift vil se ud. Familienhar direkte kontakt med rabbineren, og skulle familien være i tvivl <strong>om</strong> noget,besøger rabbineren altid familien umiddelbart. Rabbineren besøger familien senestdagen efter og tager s<strong>om</strong> regel bandagen <strong>af</strong>, imens barnet bades. Enkelte gangelægges ny bandage for at holde forhuden nede, men oftest kan bandagen fjernes.Familien får nye instruktioner, s<strong>om</strong> først og fremmest går på, at lade <strong>drenge</strong>n liggelidt uden ble ved bleskift.Det Mosaiske Trossamfund i Danmark ved overrabbiner Bent Lexner har på etmøde med <strong>Sundhedsstyrelsen</strong> forklaret, at <strong>om</strong>skæring <strong>af</strong> det jødiske samfund betragtess<strong>om</strong> én <strong>af</strong> hovedhjørnestenene i at være jøde. Omskæring er et identitetstegnfor jøder og har betydning for barnets tilknytning til den jødiske kultur, detsfamilie og religionen. Det gælder for jøded<strong>om</strong>men i modsætning til kristend<strong>om</strong>men,at jøded<strong>om</strong>men har flere love og forskrifter, s<strong>om</strong> man betragter s<strong>om</strong> gudd<strong>om</strong>melige,og s<strong>om</strong> man ikke kan ændre på, herunder <strong>om</strong>skæringstraditionen, s<strong>om</strong>har fundet sted i mere end 3000 år.Bent Lexner understregede, at et forbud mod <strong>om</strong>skæring <strong>af</strong> <strong>drenge</strong>børn ville stridemod religionsfriheden i Den Danske Grundlov. Selv<strong>om</strong> debatten <strong>om</strong> <strong>om</strong>skæringhar været oppe med jævne mellemrum, har dette ikke resulteret i en intern diskussioneller en nedgang i ønsket <strong>om</strong> <strong>om</strong>skæring inden for Det Mosaiske Trossamfundi Danmark.Der udføres årligt ca. 15 jødiske <strong>om</strong>skæringer i Danmark. Ifølge Bent Lexner erder ikke observeret k<strong>om</strong>plikationer ved de jødiske <strong>om</strong>skæringer i Danmark.2.4 Beskrivelse <strong>af</strong> den muslimske <strong>om</strong>skæringMuslimernes Fællesråd ved formand Asmat Mojaddedi, oplyste på et møde med<strong>Sundhedsstyrelsen</strong>, at Muslimernes Fællesråd er den største samarbejdsorganisationfor muslimer i Danmark. Muslimernes Fællesråd har ikke officielt udmeldtsynspunkter i forbindelse med <strong>om</strong>skæring <strong>af</strong> muslimske <strong>drenge</strong>børn i Danmark.Omskæringen foretages ofte på en privat lægeklinik, men nogen læger foretagerogså <strong>om</strong>skæringen hjemme hos barnet. Rådet er bekendt med, at en muslimsk foreningi Danmark (s<strong>om</strong> ikke er en del <strong>af</strong> Muslimernes Fællesråd) inviterer en lægefra udlandet hertil, s<strong>om</strong> foretager <strong>om</strong>skæring <strong>af</strong> flere <strong>drenge</strong> samtidig i foreningen.Rådet er ikke bekendt med, at der i det muslimske samfund i Danmark foregår <strong>om</strong>skæringer,s<strong>om</strong> udføres <strong>af</strong> personer, der ikke er læger, eller bliver udført uden bedøvelse.Muslimernes Fællesråd er ikke bekendt med antallet <strong>af</strong> muslimske <strong>om</strong>skæringeri Danmark.<strong>Notat</strong> <strong>om</strong> <strong>om</strong>skæring <strong>af</strong> <strong>drenge</strong> 9 / 21


Ifølge Asmat Mojaddedi, s<strong>om</strong> selv udfører rituelle <strong>om</strong>skæringer i sin lægepraksis iDanmark, foretages <strong>om</strong>skæringen primært i spædbarnsalderen, men forek<strong>om</strong>merogså i andre aldersgrupper især inden for det tyrkiske samfund. Barnet skal værevelbefindende forud for indgrebet. Der gives bedøvende hudcreme rundt <strong>om</strong> penisrodenen time før, der lægges en nerveblokade. Under selve injektionen får spædbarnetlidt sukkervand. Indgrebet foregår under sterile forhold.Asmat Mojaddedi bruger primært ”ring metoden” til spædbørn. Her trækkes forhudentilbage, og der sættes en plastikring på glans penis. Forhuden trækkes tilbagepå ringen, og en steril snor strammes rundt <strong>om</strong> forhuden på ringen. Herefter klippesforhuden <strong>af</strong> med en kirurgisk saks. Den stramme snor <strong>om</strong> ringen forhindrer blødning.Ringen falder <strong>af</strong> tre til syv dage efter indgrebet.Til større børn bruger han ”suturmetoden”. Her fjernes forhuden ved hjælp <strong>af</strong> elektrokirurgi,og de to lag syes sammen med tråd.Barnet kontrolleres på 2. dagen. Der er givet både mundtlig og skriftlig information<strong>om</strong> mulige k<strong>om</strong>plikationer forud for indgrebet, og begge forældre har givet skriftligtsamtykke. Ifølge den praktiserende læge får forældrene et telefonnummer, s<strong>om</strong>han kan kontaktes på døgnet rundt ved tilstødende k<strong>om</strong>plikationer. Lægen opleverdog sjældent k<strong>om</strong>plikationer til indgrebet.2.5 Helbredsmæssige fordeleOmskæring kan være nødvendigt <strong>af</strong> helbredsmæssige årsager s<strong>om</strong> f.eks. forhudsforsnævring,hvor forhuden ikke kan trækkes tilbage over penishovedet, hvilket indebærerstørre risiko for infektion.Det er <strong>om</strong>diskuteret, <strong>om</strong> <strong>om</strong>skæring herudover kan have nogle sundhedsmæssigefordele. Det skal ses i lyset <strong>af</strong>, hvor mange raske <strong>drenge</strong>børn, der skal <strong>om</strong>skæresfor at opnå et positivt helbredsresultat. Nogle <strong>af</strong> de undersøgelser, s<strong>om</strong> underbyggerde positive resultater <strong>af</strong> <strong>om</strong>skæring <strong>af</strong> <strong>drenge</strong>børn, er foretaget i Afrika, hvor desundhedsmæssige forhold er væsentlige anderledes end i vesten.De dokumenterede helbredsmæssige fordele:Nedsat risiko for urinvejsinfektioner: Drenge, s<strong>om</strong> er <strong>om</strong>skåret i spædbarnsalderen,har færre tilfælde <strong>af</strong> urinvejsinfektioner end <strong>drenge</strong>, s<strong>om</strong> ikke er <strong>om</strong>skåret. Hyppigheden<strong>af</strong> urinvejsinfektioner hos små <strong>drenge</strong> er dog lav.Nedsat risiko for peniskræft: Studier tyder på at peniskræft er mindre udbredt hos<strong>om</strong>skårede mænd. Peniskræft er en generelt en sjælden sygd<strong>om</strong>.Nedsat risiko for kønssygd<strong>om</strong>me: Omskårne mænd kan have en lavere risiko forvisse kønssygd<strong>om</strong>me, sås<strong>om</strong> HIV. WHO (World Health Organization) har udmeldt,at der er evidens for, at mandlig <strong>om</strong>skæring reducerer risikoen for HIV hosheteroseksuelle mænd med ca. 60 %. Derfor anbefaler WHO, at mandlig <strong>om</strong>skæringbør overvejes s<strong>om</strong> en effektiv intervention mod HIV, s<strong>om</strong> beskyttelse/forebyggelsei lande og regioner med heteroseksuelle epidemier, s<strong>om</strong> f.eks. vis-<strong>Notat</strong> <strong>om</strong> <strong>om</strong>skæring <strong>af</strong> <strong>drenge</strong> 10 / 21


se <strong>om</strong>råder i Afrika. WHO understreger, at mandlig <strong>om</strong>skæring kun delvis beskyttermod HIV og derfor kun er ét element i den samlede forebyggelse.For så vidt angår urinvejsinfektioner, er hyppigheden i Danmark så lav, at der ikkeer grundlag for generelt at <strong>om</strong>skære <strong>drenge</strong>børn <strong>af</strong> den årsag. Peniskræft er en megetsjælden sygd<strong>om</strong>, og derfor vil der skulle <strong>om</strong>skæres uforholdsmæssigt mange<strong>drenge</strong>børn, før et tilfælde <strong>af</strong> peniskræft kunne forebygges. Kønssygd<strong>om</strong>sproblematikkener adresseret <strong>af</strong> WHO, men de forhold, hvorunder de anbefaler <strong>om</strong>skæring,er meget forskellige fra vestlige forhold s<strong>om</strong> i Danmark. Anbefalingen vedrørerogså voksne mænd. <strong>Sundhedsstyrelsen</strong> kan oplyse, at ingen <strong>af</strong> de store medicinskeorganisationer i vesten anbefaler rutinemæssig <strong>om</strong>skæring <strong>af</strong> raske <strong>drenge</strong>børn.2.6 K<strong>om</strong>plikationer til <strong>om</strong>skæringI vestlige lande antages k<strong>om</strong>plikationsraten at ligge på 1-2 % <strong>af</strong> alle <strong>om</strong>skæringer.En artikel fra tidsskriftet Pediatrics, fra 2012, opgiver k<strong>om</strong>plikationsraten i Europatil ca. 2 %. 3Omskæring <strong>af</strong> <strong>drenge</strong> kan medføre k<strong>om</strong>plikationer i form <strong>af</strong> bl.a. blødning, infektionog urinrørsforsnævring. Blødning og infektion er de hyppigste k<strong>om</strong>plikationertil <strong>om</strong>skæring og ofte de letteste at behandle. Dødsfald er, <strong>om</strong> end meget sjældent,beskrevet i litteraturen s<strong>om</strong> følge <strong>af</strong> blødning og infektion, men der er ikke registreretdødsfald efter <strong>om</strong>skæring i Danmark.Videnskabelige undersøgelser tyder på, at der er færre k<strong>om</strong>plikationer, hvis det raske<strong>drenge</strong>barn <strong>om</strong>skæres i den nyfødte periode og under optimale forhold (erfarenlæge og sterile forhold). 4 Dette kan forklares ved, at barnet i den nyfødte periodehar moderens antistoffer til at bekæmpe en eventuel infektion, at det er mindre forhold,s<strong>om</strong> opereres på, og at indgrebet ikke kræver syning. Ydermere er helingsprocessenhos nyfødte god. K<strong>om</strong>plikationsraten til en hvilken s<strong>om</strong> helst operationvil altid <strong>af</strong>hænge <strong>af</strong> barnets alder ved indgrebet, den kirurgiske teknik, indikationen,udførerens k<strong>om</strong>petencer, under hvilke forhold indgrebet bliver udført, og barnetsøvrige helbredsforhold.Der foreligger kun begrænset viden <strong>om</strong> senk<strong>om</strong>plikationer i voksenlivet til <strong>om</strong>skæring,herunder seksualfunktionen. Der er behov for yderligere forskning på <strong>om</strong>rådet.5<strong>Sundhedsstyrelsen</strong> kan oplyse, at der ikke findes en selvstændig registrering <strong>af</strong>,hvor mange rituelle <strong>drenge</strong> <strong>om</strong>skæringer, der foretages i Danmark, liges<strong>om</strong> der ikkefindes en registrering <strong>af</strong> henvendelser til de offentlige sygehuse i forbindelse3Pediatrics, Task Force on Circumcision, 2012, Sep;130(3):e756-854Weiss et al., C<strong>om</strong>plications of circumcision in male neonates, infants and children: a systematic review,BMC Urology 2010, Feb 16;10:2.5Morten Frisch et al., Cultural Bias in the AAP´s 2012 Technical report and Policy Statement onMale Circumcision, Pediatrics, 2013, 796-800<strong>Notat</strong> <strong>om</strong> <strong>om</strong>skæring <strong>af</strong> <strong>drenge</strong> 11 / 21


med k<strong>om</strong>plikationer efter rituel <strong>om</strong>skæring. Dette skyldes, at der ved sygehusindlæggelseri forbindelse med k<strong>om</strong>plikationer efter rituel <strong>om</strong>skæring, hverken registreresårsag til k<strong>om</strong>plikationen, eller hvor operationen er foretaget i Landspatientregisteret.<strong>Sundhedsstyrelsen</strong> modtager gennemsnitlig 2-4 henvendelser <strong>om</strong> året <strong>om</strong> k<strong>om</strong>plikationeri forbindelse med <strong>om</strong>skæring <strong>af</strong> <strong>drenge</strong>børn. Årsagerne til henvendelsernefra sundhedspersonerne er primært, at der har været mistanke <strong>om</strong>, at børnene ikkehar været tilstrækkeligt smertedækket i forbindelse med indgrebet. Derudover harder været sager, hvor der var mistanke <strong>om</strong> infektion, eller at indgrebet var foretaget<strong>af</strong> en person, der ikke var autoriseret læge. I ingen <strong>af</strong> sagerne har børnenes helbredværet i fare. <strong>Sundhedsstyrelsen</strong> er ikke bekendt med, at der i Danmark er sket dødsfalds<strong>om</strong> følge <strong>af</strong> <strong>om</strong>skæring.Overlæge Morten Frisch ved epidemiologisk forskning, Statens Serum Institut, ogadjungeret professor i seksuel sundhedsepidemiologi, Aalborg Universitet, har vedet møde i <strong>Sundhedsstyrelsen</strong> givet udtryk for, at der hos <strong>drenge</strong>, der er <strong>om</strong>skåret,kan der senere i livet opstå problemer <strong>af</strong> fysisk, psykologisk og seksuel karakter.Hans forskning viser, at mænd, der er blevet <strong>om</strong>skåret, har tre gange så høj risikofor at opleve hyppigt besvær med at opnå orgasme, og at kvinder med partnere,s<strong>om</strong> er <strong>om</strong>skåret, oplever dobbelt så stor risiko for, at deres seksuelle behov ikkebliver opfyldt. Overlæge Morten Frisch er ikke er modstander <strong>af</strong> rituelle <strong>om</strong>skæringer,men mener, at <strong>om</strong>skæring først bør foretages, når <strong>drenge</strong>n forstår indgrebetskonsekvenser og selv kan give samtykke hertil.”Intact Denmark – foreningen mod børne<strong>om</strong>skæring” har på et møde i <strong>Sundhedsstyrelsen</strong>ved formand Lena Nyhus og næstformand Leo Milgr<strong>om</strong> oplyst, at foreningener <strong>af</strong> den opfattelse, at rituel <strong>om</strong>skæring <strong>af</strong> <strong>drenge</strong>børn anat<strong>om</strong>isk kan sidestillesmed <strong>om</strong>skæring <strong>af</strong> piger. Derfor bør rituel <strong>om</strong>skæring <strong>af</strong> <strong>drenge</strong> juridisksidestilles hermed og forbydes ved lov, indtil myndighedsalderen er indtrådt, så<strong>drenge</strong>ne selv kan give samtykke til indgrebet. Foreningen er også <strong>af</strong> den opfattelse,at rituel <strong>om</strong>skæring er kønslemlæstelse med det resultat, at en væsentlig del <strong>af</strong><strong>drenge</strong>ne senere ikke kan opnå en normal seksualfunktion.Dansk Pædiatrisk Selskab ved professor i pædiatri, overlæge, dr. med. Søren Rittig,har givet udtryk for, at man bør være opmærks<strong>om</strong> på forek<strong>om</strong>sten <strong>af</strong> k<strong>om</strong>plikationertil kirurgiske indgreb på børn, der foretages på ikke-lægefaglig indikation. Selskabetbakker derfor op <strong>om</strong> <strong>Sundhedsstyrelsen</strong>s vejledning <strong>om</strong> <strong>om</strong>skæring <strong>af</strong> <strong>drenge</strong>fra 2005, s<strong>om</strong> klart formulerer, at <strong>om</strong>skæring er et operativt indgreb, der kun måforetages <strong>af</strong> læger. Selv <strong>om</strong> der ikke foreligger landsdækkende opgørelser overk<strong>om</strong>plikationer til <strong>drenge</strong><strong>om</strong>skæringer foretaget på ikke-lægefaglig indikation, erdet selskabets indtryk, at de danske børne<strong>af</strong>delinger aktuelt kun oplever meget fåtilfælde <strong>af</strong> k<strong>om</strong>plikationer til <strong>om</strong>skæring, s<strong>om</strong> er sårinfektion og blødning. Selskabetfinder ikke anledning til at advare mod <strong>om</strong>skæring <strong>af</strong> <strong>drenge</strong>børn.<strong>Notat</strong> <strong>om</strong> <strong>om</strong>skæring <strong>af</strong> <strong>drenge</strong> 12 / 21


3 Omskæring i DanmarkFor en del år siden blev rituel <strong>drenge</strong><strong>om</strong>skæring foretaget på de offentlige sygehuse,der dog ophørte med at udføre indgrebet i 90erne, da der ikke var tale <strong>om</strong> sygd<strong>om</strong>sbehandling.Det fik den konsekvens, at de rituelle <strong>om</strong>skæringer i Danmark idag foregår uden for de offentlige sygehuse, enten hos privatpraktiserende speciallægereller i hjemmet hos barnet.Der findes ikke en registrering <strong>af</strong>, hvor mange rituelle <strong>om</strong>skæringer der foretages iDanmark, liges<strong>om</strong> der ikke findes oplysninger <strong>om</strong> antallet <strong>af</strong> k<strong>om</strong>plikationer.3.1 Skøn over antal <strong>om</strong>skæringer i DanmarkI Danmark registrerer man ikke et barns religiøse tilhørsforhold, når det fødes.<strong>Sundhedsstyrelsen</strong> kan oplyse, at der i 2012 i følge Danmarks Statistik blev født ca.3.500 <strong>drenge</strong>børn i Danmark <strong>af</strong> mødre med ikke-vestlig oprindelse. <strong>Sundhedsstyrelsen</strong>antager, at en stor del <strong>af</strong> disse mødre tilhører den muslimske trosretning.I følge Muslimernes Fællesråd vil næsten alle muslimer i Danmark lade deres nyfødte<strong>drenge</strong>børn <strong>om</strong>skære. Herudover har <strong>Sundhedsstyrelsen</strong> fået oplyst <strong>af</strong> DetMosaiske Trossamfund, at der <strong>om</strong>skæres <strong>om</strong>kring 15 jødiske <strong>drenge</strong>børn <strong>om</strong> året.Det er på baggrund her<strong>af</strong> <strong>Sundhedsstyrelsen</strong>s vurdering, at antallet <strong>af</strong> mulige rituelle<strong>om</strong>skæringer <strong>om</strong> året i Danmark ligger mellem 1000 - 2000. Det skal dog understreges,at der alene er tale <strong>om</strong> et skøn baseret på ovennævnte tal.3.2 Lovgivning og reglerI modsætning til <strong>om</strong>skæring <strong>af</strong> kvinder, jf. str<strong>af</strong>felovens § 245a 6 , er der i Danmarkikke forbud mod at <strong>om</strong>skære <strong>drenge</strong>børn. Der er så vidt <strong>Sundhedsstyrelsen</strong> har fåetoplyst ikke noget land, hvor rituel <strong>om</strong>skæring <strong>af</strong> <strong>drenge</strong> er forbudt.Det er foreskrevet i Sundhedslovens § 14, at for en patient, der ikke selv kan varetagesine interesser, indtræder den eller de personer, s<strong>om</strong> efter lovgivningen er bemyndigethertil, i patientens rettigheder, i det <strong>om</strong>fang det er nødvendigt for at varetagepatientens interesser i den pågældende situation. Det betyder, at det er forældrenetil barnet, der i henhold til sundhedslovens §§ 15 og 16 skal informeres <strong>om</strong>indgrebet og samtykke på barnets vegne. Hvis der er tale <strong>om</strong> en barn, der kan forståbehandlingssituationen, skal barnet informeres og inddrages i drøftelserne <strong>af</strong> behandlingen,herunder skal barnets tilkendegivelser, i det <strong>om</strong>fang de er aktuelle ogrelevante, tillægges betydning, jf. sundhedslovens § 20.6Lovbekendtgørelse nr. 1007 <strong>af</strong>24. oktober 2012 <strong>af</strong> str<strong>af</strong>feloven § 245 a, hvor<strong>af</strong> fremgår, at den,s<strong>om</strong> ved et legemsangreb med eller uden samtykke bortskærer eller på anden måde fjerner kvindeligeydre kønsorganer helt eller delvis, str<strong>af</strong>fes med fængsel indtil 6 år.<strong>Notat</strong> <strong>om</strong> <strong>om</strong>skæring <strong>af</strong> <strong>drenge</strong> 13 / 21


Det fremgår <strong>af</strong> autorisationslovens 7 § 74, at operative indgreb er forbeholdt lægerat udføre. Et operativt indgreb er blandt andet defineret ved gennembrud <strong>af</strong> hud ogvæv. Det er således forbeholdt læger at udføre <strong>om</strong>skæring. En læge skal ved sinvirks<strong>om</strong>hed udvise <strong>om</strong>hu og samvittighedsfuldhed, jf. autorisationslovens § 17.En læge kan anvende medhjælp til at udføre <strong>om</strong>skæringen. Det er nærmere præcisereti <strong>Sundhedsstyrelsen</strong> bekendtgørelse og vejledning <strong>om</strong> autoriserede sundhedspersonersbenyttelse <strong>af</strong> medhjælp (delegation <strong>af</strong> forbeholdt virks<strong>om</strong>hed), 8 hvordanen autoriseret sundhedsperson, i forbindelse med delegation <strong>af</strong> opgaver inden forsit forbeholdte virks<strong>om</strong>heds<strong>om</strong>råde, lever op til kravet <strong>om</strong> at udvise <strong>om</strong>hu og samvittighedsfuldhed.<strong>Sundhedsstyrelsen</strong> har i vejledning <strong>om</strong> <strong>om</strong>skæring <strong>af</strong> <strong>drenge</strong> 9 konkret præciseret,hvordan man udviser <strong>om</strong>hu og samvittighedsfuldhed, når man foretager <strong>om</strong>skæring.Af vejledningen fremgår det bl.a.:• At der skal være en læge tilstede under indgrebet, når der anvendes medhjælptil indgrebet.• At der ved <strong>om</strong>skæring <strong>af</strong> <strong>drenge</strong> under 15 år skal foreligge et informeret samtykkefra forældremyndighedens indehaver, inden indgrebet udføres. Drenge,der er fyldt 15 år, kan selv give informeret samtykke til <strong>om</strong>skæring.• At almindelig god faglig standard vedrørende kirurgisk hygiejne skal overholdes,herunder at operations<strong>om</strong>rådet vaskes sterilt, <strong>af</strong>dækkes og at der anvendessterile instrumenter.• At alle børn, også spædbørn, skal sikres den nødvendige, tilstrækkelige og tidssvarendesmertelindring under indgrebet og perioden efter indgrebet.• At lægen skal følge den faglige udvikling på <strong>om</strong>rådet og besidde de nødvendigefaglige forudsætninger for både indgrebet og smertelindringen.• At forældrene eller forældremyndighedsindehaveren skal informeres, herunder<strong>om</strong> pleje i perioden efter indgrebet, hygiejniske forholdsregler og smertelindring.• At der skal føres journal efter reglerne for journalføring.7Lovbekendtgørelse nr. 877 <strong>af</strong> 4. august 2011 <strong>om</strong> autorisation <strong>af</strong> sundhedspersoner og <strong>om</strong> sundhedsfagligvirks<strong>om</strong>hed (autorisationsloven)8Bekendtgørelse nr. 1219 <strong>af</strong> 11. december 2009 og vejledning nr. 115 <strong>af</strong> 11. december 20099Vejledning nr. 9267 <strong>af</strong> 23. maj 2005 <strong>om</strong> <strong>om</strong>skæring <strong>af</strong> <strong>drenge</strong><strong>Notat</strong> <strong>om</strong> <strong>om</strong>skæring <strong>af</strong> <strong>drenge</strong> 14 / 21


Hvis en person, der hverken er læge, eller virker s<strong>om</strong> medhjælp for en læge, udfører<strong>om</strong>skæring, kan den pågældende person str<strong>af</strong>fes med fængsel i op til et år, ogunder formidlende <strong>om</strong>stændigheder med bøde. 10 Når <strong>Sundhedsstyrelsen</strong> får mistanke<strong>om</strong>, at en opskæring ikke er foretaget <strong>af</strong> en læge, anmoder styrelsen politiet<strong>om</strong> at efterforske sagen med henblik på tiltalerejsning. Det er imidlertid <strong>Sundhedsstyrelsen</strong>serfaring, at sagerne ofte må opgives, da det ikke er muligt for politiet atfinde ud <strong>af</strong>, hvem der rent faktisk har udført indgrebet.3.3 Tilsynssager<strong>Sundhedsstyrelsen</strong> fører tilsyn med den sundhedsfaglige virks<strong>om</strong>hed, der udføres<strong>af</strong> personer inden for sundhedsvæsenet. 11 <strong>Sundhedsstyrelsen</strong>s tilsyn med autoriseredesundhedspersoner, herunder læger, er s<strong>om</strong> udgangspunkt reaktivt. <strong>Sundhedsstyrelsen</strong>forudsætter, at alle autoriserede sundhedspersoner lever op til kravet <strong>om</strong>at udvise <strong>om</strong>hu og samvittighedsfuldhed under udøvelsen <strong>af</strong> deres virks<strong>om</strong>hed,herunder at de følger styrelsens vejledninger. <strong>Sundhedsstyrelsen</strong> iværksætter almindeligvisførst tilsynssager, når styrelsen bliver gjort opmærks<strong>om</strong> på konkretepatientforløb.<strong>Sundhedsstyrelsen</strong> kan dog oplyse, at fra den 1. oktober 2011 skal alle private sygehuse,klinikker og praksis, hvor der fortages lægelig patientbehandling, registrereshos styrelsen. 12 <strong>Sundhedsstyrelsen</strong> skal føre regelmæssigt tilsyn med behandlingsstederne.Her er der således indført et proaktivt tilsyn. Tilsynene skal øge patientsikkerhedenog foregår ved, at <strong>Sundhedsstyrelsen</strong>s regionale enheder, hverttredje år <strong>af</strong>lægger et varslet tilsynsbesøg på behandlingsstedet. Hvis <strong>Sundhedsstyrelsen</strong>finder væsentlige problemer med patientsikkerheden på et behandlingssted,vil behandlingsstedet blive bedt <strong>om</strong> at rette fejl og mangler, og <strong>Sundhedsstyrelsen</strong>kan vælge at <strong>af</strong>lægge behandlingsstedet genbesøg, indtil patientsikkerheden erbragt i orden.Det betyder, at de læger, der enten selv foretager <strong>om</strong>skæring eller vælger at benytteen medhjælp til at <strong>om</strong>skære på et behandlingssted, skal lade sig registrere i <strong>Sundhedsstyrelsen</strong>og vil få <strong>af</strong>lagt et tilsynsbesøg. Hvis en læge med eller uden en medhjælpvælger at foretage <strong>om</strong>skæring i private hjem, vil en sådan læge ikke skullelade sig registrere i <strong>Sundhedsstyrelsen</strong> eller få <strong>af</strong>lagt et tilsynsbesøg.<strong>Sundhedsstyrelsen</strong> fører således alene tilsyn med <strong>om</strong>skæring, når styrelsen bliveropmærks<strong>om</strong> på problemer med indgrebet eller hvis det foregår på en klinik der erregistreret i <strong>Sundhedsstyrelsen</strong>. <strong>Sundhedsstyrelsen</strong>s får kendskab til disse sager, nårlæger på de offentlige sygehuse kontakter styrelsen og gør opmærks<strong>om</strong> på, at dehar fået et barn ind på sygehuset, hvor der har været k<strong>om</strong>plikationer til en <strong>om</strong>skæring.Det skal dertil bemærkes, at sundhedspersoner ikke har pligt til at rette hen-10Autorisationslovens § 8911Autorisationlovens § 26 og Sundhedsloven (lbkg. nr. 913 <strong>af</strong> 20. juli 2010) § 21512Sundhedslovens § 215a og bekendtgørelse nr. 977 <strong>af</strong> 30. september 2011 <strong>om</strong> registrering <strong>af</strong> og tilsynmed visse sygehuse, klinikker og praksis.<strong>Notat</strong> <strong>om</strong> <strong>om</strong>skæring <strong>af</strong> <strong>drenge</strong> 15 / 21


vendelse til <strong>Sundhedsstyrelsen</strong>, hvis de får kendskab til, at et barn har fået k<strong>om</strong>plikationerefter en behandling, herunder efter en rituel <strong>om</strong>skæring.Hvis styrelsen bliver bekendt med, at barnet, efter de henvendende lægers opfattelse,er blevet <strong>om</strong>skåret <strong>af</strong> en person, der ikke er læge eller har været medhjælp foren læge, bliver sagen, s<strong>om</strong> nævnt ovenfor, sendt til politiet mhp. efterforskning ogtiltale.I de sager, hvor det har været læger, der har udført <strong>om</strong>skæringer, har <strong>Sundhedsstyrelsen</strong>vurderet, at der i nogle <strong>af</strong> sagerne ikke har været udvist tilstrækkelig <strong>om</strong>hu iforbindelse med operationerne, at lægens information i forbindelse med operationerneikke var fyldestgørende, samt at journalføringen har været mangelfuld.<strong>Sundhedsstyrelsen</strong> har også tidligere h<strong>af</strong>t enkelte læger i skærpet tilsyn på baggrund<strong>af</strong> rituel <strong>om</strong>skæring <strong>af</strong> <strong>drenge</strong>børn.3.4 Patientklager og patienterstatningssagerPatient<strong>om</strong>buddet har de seneste 7 år truffet <strong>af</strong>gørelse i 20 sager vedrørende rituel<strong>om</strong>skæring. Afgørelserne <strong>om</strong>handler både danske læger og læger med anden etniskbaggrund end dansk, s<strong>om</strong> i perioden 2003-2010 har foretaget rituelle <strong>om</strong>skæringerpå <strong>drenge</strong>børn i Danmark.I 11 sager har Patient<strong>om</strong>buddet udtrykt kritik <strong>af</strong> lægernes faglige virke. Behandlingerhar fundet sted i perioden 2003-2006:• En læge har i syv tilfælde fået kritik for behandling og journalføring. Dennelæge har været under <strong>Sundhedsstyrelsen</strong>s skærpet tilsyn bl.a. pga. <strong>af</strong> disse sager.• En læge har i to tilfælde fået kritik for sin behandling og journalføring.• De sidste to sager <strong>om</strong>handler to forskellige læger, s<strong>om</strong> har fået kritik for deresbehandling.I de restende 9 sager har Patient<strong>om</strong>buddet ikke udtalt kritik <strong>af</strong> lægernes faglige virke.Disse sager <strong>om</strong>handler perioden 2005-2010, hvor <strong>Sundhedsstyrelsen</strong>s vejledning<strong>om</strong> <strong>om</strong>skæring var trådt i kr<strong>af</strong>t.Patientforsikringen har de sidste 17 år fået 14 anmeldelser vedrørende rituelle <strong>om</strong>skæringer<strong>af</strong> <strong>drenge</strong> under 16 år. Af de 14 sager er:• Fem <strong>af</strong> sagerne <strong>af</strong>vist, fordi patienten ikke var påført en skade.• Syv <strong>af</strong> sagerne <strong>af</strong>vist, fordi erstatningen ville være under lovens minimumgrænsepå 10.000 kr. I denne gruppe kan der eventuelt være sager, s<strong>om</strong> villeblive anerkendt, hvis erstatningsbeløbet havde været større.• To <strong>af</strong> sagerne er <strong>af</strong>vist, fordi patienten ikke er påført en skade i forbindelsemed den offentlige efterbehandling.<strong>Notat</strong> <strong>om</strong> <strong>om</strong>skæring <strong>af</strong> <strong>drenge</strong> 16 / 21


4 Omskæring i andre landEfter <strong>Sundhedsstyrelsen</strong>s oplysninger er rituel <strong>om</strong>skæring ikke forbudt ved lov inogen lande.4.1 SverigeReguleringen i Sverige er stort set identisk med den danske regulering. I oktober2001 trådte en lov i kr<strong>af</strong>t (2001:499) <strong>om</strong> <strong>om</strong>skæring <strong>af</strong> <strong>drenge</strong>, hvortil Socialstyrelsenhar udarbejdet forskrifter og vejledninger <strong>om</strong> <strong>om</strong>skæring <strong>af</strong> <strong>drenge</strong>. Loven blevindført <strong>af</strong> hensyn til, at <strong>om</strong>skæringer kunne foregå på betryggende vis under hensynstagentil barnet. Det er forbeholdt læger at udføre <strong>om</strong>skæringen, dog kan derogså gives andre en særlig tilladelse til at udføre indgrebet (primært rabbinerne indenfor det jødiske samfund). For <strong>drenge</strong>børn ældre end to måneder er det dog foreskrevet,at indgrebet skal foretages <strong>af</strong> læger.Indgrebene foretages ikke på de offentlige sygehuse eller klinikker, da der ikke erpligt til at udføre indgrebet, med mindre det udføres på medicinsk indikation.4.2 NorgeI Norge findes der ikke en særlov <strong>om</strong> <strong>om</strong>skæring <strong>af</strong> <strong>drenge</strong>. Der er ikke noget forbudmod, at rituel <strong>om</strong>skæring kan udføres inden for religiøse samfund <strong>af</strong> andre endlæger.I 2011 sendte man et lovforslag i høring <strong>om</strong> rituel <strong>om</strong>skæring <strong>af</strong> <strong>drenge</strong>. Formåletvar især at sikre, at det var k<strong>om</strong>petente personer, der udførte indgrebet, at der fandteset tilgængeligt tilbud, samt at der blev foretaget ordentlig smertedækning og opfølgningi forbindelse med indgrebet. Det indgik også i lovforslaget, at der fra detoffentliges sundhedsvæsens side skulle tilbydes rituel <strong>om</strong>skæring på offentlige sygehuse,så indgrebet kunne foretages på forsvarlig vis – hovedsagelig i forbindelsemed fødslen. Der er dog endnu ikke k<strong>om</strong>met en regulering på <strong>om</strong>rådet.4.3 TysklandI 2012 fastslog en d<strong>om</strong>stol i Køln i Tyskland, at rituel <strong>om</strong>skæring var ulovlig ogkunne sidestilles med legemsbeskadigelse. Det tyske parlament vedtog i december2012 en lovændring, hvorefter rituel <strong>om</strong>skæring er lovligt i Tyskland. Det fremgår<strong>af</strong> den respektive bestemmelse, at forældre kan samtykke til, at deres barn bliver<strong>om</strong>skåret på anden indikation end lægefaglig, at indgrebet skal udføres i overensstemmelsemed anerkendte kirurgiske metoder, og at indgrebet også kan udføres <strong>af</strong>andre end læger, hvis de er særligt trænet og kvalificeret i at udføre indgrebet.<strong>Notat</strong> <strong>om</strong> <strong>om</strong>skæring <strong>af</strong> <strong>drenge</strong> 17 / 21


4.4 EnglandI 2006 udgav den britiske lægeforening, British Medical Association, en vejledningtil læger <strong>om</strong> <strong>om</strong>skæring. Vejledningen understreger, at <strong>om</strong>skæring <strong>af</strong> <strong>drenge</strong> ansesfor lovligt, hvis den udføres k<strong>om</strong>petent, og det skønnes, at det er i barnets interesse.Desuden skal der foreligge et informeret samtykke til indgrebet fra værge ellerforældre. Omskæring i England er, ifølge <strong>Sundhedsstyrelsen</strong>s oplysninger, ikkeforbeholdt læger.4.5 AustralienIndtil 1970’erne blev stort set alle <strong>drenge</strong>børn <strong>om</strong>skåret i Australien. Herefter hardet været faldende, og i dag <strong>om</strong>skæres ca. 14 % <strong>af</strong> alle australske <strong>drenge</strong> inden fordet første leveår. Der er dog stor variation mellem staterne.I Australien har <strong>om</strong>skæring primært været foretaget kulturelt/traditionsbetinget ogikke på religiøs baggrund. Der er på nuværende tidspunkt ingen specifikke regler,s<strong>om</strong> regulerer indgrebets udførelse. Omskæring i Australien er, ifølge <strong>Sundhedsstyrelsen</strong>soplysninger, ikke forbeholdt læger.The Royal Australasian College of Physicians (RACP) udmeldte i oktober 2010,efter gennemgang <strong>af</strong> evidens på <strong>om</strong>rådet, at de sundhedsmæssige fordele ved <strong>om</strong>skæringikke opvejer k<strong>om</strong>plikationsraten. Derfor anbefaler RACP ikke rutinemæssige<strong>om</strong>skæringer <strong>af</strong> <strong>drenge</strong>børn i Australien og New Zealand.4.6 USADrenge<strong>om</strong>skæring er lovligt i alle stater i USA. I de fleste stater er der et lovmæssigtkrav <strong>om</strong>, at der skal foreligge et skriftligt samtykke fra mindst en <strong>af</strong> forældreneforud for indgrebet. Der er dog stor variation i antallet <strong>af</strong> <strong>om</strong>skæringer mellem staterne.Liges<strong>om</strong> i Australien blev stort set alle <strong>drenge</strong>børn i USA indtil 1970´erne <strong>om</strong>skåret.Antallet er dog faldende. I følge Center for Disease Control and Prevention,s<strong>om</strong> er en del <strong>af</strong> den amerikanske sundhedsmyndighed, blev ca. 55 % <strong>af</strong> alle nyfødte<strong>drenge</strong>børn i USA <strong>om</strong>skåret, i 2009. Omskæring i USA er primært kulturelt ogtraditionsbetinget og sker ikke <strong>af</strong> religiøse grunde. Indgrebet er en <strong>af</strong> de mest almindeligekirurgiske procedurer i USA og er ifølge <strong>Sundhedsstyrelsen</strong>s oplysningerikke forbeholdt læger. Omskæringen sker s<strong>om</strong> regel inden spædbarnet forladerhospitalet.I 2012 udmeldte American Academy of Pediatrics (AAP), at de sundhedsmæssigefordele opvejer ulemperne ved indgrebet. Vurderingen begrundes med, at <strong>om</strong>skæringkan forebygge kræft i penis og seksuelt overførte sygd<strong>om</strong>me, herunder HIV ogHPV-virus, der igen kan forårsage livmorhalskræft og andre cancertyper. En yderligerefordel er, at risikoen for urinvejsinfektioner minimeres. AAP har ikke fundetbelæg for at sige, at <strong>om</strong>skæring påvirker mænds seksuelle funktion, føls<strong>om</strong>heden ipenis eller den seksuelle tilfredsstillelse. AAP tilføjer dog, at der i deres retningslinjerikke ligger en anbefaling <strong>om</strong> at lade alle <strong>drenge</strong>børn <strong>om</strong>skære, da de<strong>Notat</strong> <strong>om</strong> <strong>om</strong>skæring <strong>af</strong> <strong>drenge</strong> 18 / 21


sundhedsmæssige fordele ikke er tungtvejende nok, men hvis forældrene ønskerbarnet <strong>om</strong>skåret, kan det sundhedsmæssigt godt forsvares. 13En række internationale børnelæger og forskere har rettet en kritik <strong>af</strong> AAPs udmelding.Overlæge Morten Frisch er hovedforfatter på kritikken, der er publiceret itidsskriftet Pediatrics og underskrevet <strong>af</strong> 38 overlæger og professorer i 17 europæiskelande og Canada. De mener ikke, at der er dokumentation for eventuelle sundhedsfordeleved <strong>drenge</strong><strong>om</strong>skæring i vesten. Deres konklusion er derfor, at der ikkeforeligger tungtvejende sundhedsfaglige argumenter for <strong>drenge</strong><strong>om</strong>skæring i vesten,og at det derfor ikke er i overensstemmelse med god lægeskik at udføre medicinskubegrundet <strong>drenge</strong><strong>om</strong>skæring. Forfatterne mener <strong>om</strong>skæring bør vente til, at <strong>drenge</strong>neselv kan give samtykke til indgrebet. Endvidere konkluderer de, at selv<strong>om</strong>nogle studier tyder på, at <strong>om</strong>skæring senere hen kan føre til psykologiske og seksuelleproblemer, mangler der fortsat studier over langtidseffekten <strong>af</strong> <strong>om</strong>skæring. 1413Pediatrics, Task Force on Circumcision, 2012, Sep;130(3):e756-8514Morten Frisch et al., Cultural Bias in the AAP´s 2012 Technical report and Policy Statement onMale Circumcision, Pediatrics, 2013, 796-800<strong>Notat</strong> <strong>om</strong> <strong>om</strong>skæring <strong>af</strong> <strong>drenge</strong> 19 / 21


5 KonklusionDet er <strong>Sundhedsstyrelsen</strong>s vurdering, at der ikke er tilstrækkelig sundhedsfagligdokumentation til generelt at anbefale <strong>om</strong>skæring <strong>af</strong> <strong>drenge</strong>børn. Samtidig er derikke sådanne risici ved indgrebet, når det foretages korrekt og <strong>af</strong> k<strong>om</strong>petente læger,at styrelsen finder anledning til at anbefale et forbud <strong>af</strong> rituel <strong>om</strong>skæring <strong>af</strong> <strong>drenge</strong>børn.Der er videre <strong>Sundhedsstyrelsen</strong>s opfattelse, at der kan være fordele ved at <strong>om</strong>skære<strong>drenge</strong>børn i de første levemåneder set fra en ud fra en sundhedsfaglig patientsikkerhedsmæssigvinkel, da indgrebet er mindre og formentlig giver færre k<strong>om</strong>plikationer.K<strong>om</strong>plikationerne ved indgrebet er få og alvorlige k<strong>om</strong>plikationer er meget sjældne.Ifølge <strong>Sundhedsstyrelsen</strong>s oplysninger, har der ikke været alvorlige k<strong>om</strong>plikationerved rituelle <strong>drenge</strong><strong>om</strong>skæringer foretaget <strong>af</strong> læger i Danmark. Da litteraturentyder på flere k<strong>om</strong>plikationer, jo ældre barnet er, kan man overveje at stille krav<strong>om</strong>, at <strong>drenge</strong>børn, der skal <strong>om</strong>skæres ud over de første leveuger, får indgrebet foretagetpå en lægeklinik eller på sygehus.Der har fra flere sider været rejst bekymring for seksualiteten hos den voksne mands<strong>om</strong> følge <strong>af</strong> <strong>om</strong>skæring. Selv <strong>om</strong> nogle studier tyder på, at <strong>om</strong>skæring senere henkan føre til psykologiske og seksuelle problemer, mangler der fortsat studier overlangtidseffekten <strong>af</strong> <strong>om</strong>skæring. En registrering i eksempelvis landspatientregisteret(LPR) <strong>af</strong> alle <strong>om</strong>skæringer mhp. senere opfølgning kan overvejes.Endelig finder <strong>Sundhedsstyrelsen</strong>, at der fortsat skal være forbeholdt læger at udføreindgrebet under overholdelse <strong>af</strong> de sundhedslige regler, s<strong>om</strong> er foreskrevet i styrelsensvejledning <strong>om</strong> <strong>om</strong>skæring <strong>af</strong> <strong>drenge</strong>børn.<strong>Notat</strong> <strong>om</strong> <strong>om</strong>skæring <strong>af</strong> <strong>drenge</strong> 20 / 21


6 Bilagsfortegnelse:Bilag 1:<strong>Sundhedsstyrelsen</strong> – Vejledning <strong>om</strong> <strong>om</strong>skæring <strong>af</strong> <strong>drenge</strong>Bilag 2:Whitepaper – <strong>om</strong> ritual <strong>om</strong>skærelse <strong>af</strong> <strong>drenge</strong>.Bilag 3:Pediatrics. Male Circumcision. Task force on circumcision.Bilag 4:Pediatrics. Cultural Bias in the AAP’s 2012 Technical Report andPolicy Statement. On Male Circumcision.Bilag 5:C<strong>om</strong>plications of circumcision in male neonates, infants andchildren: a systematic review.Bilag 6:Socialstyrelsen – Rättsutredning <strong>om</strong> rättsläget kring <strong>om</strong>skärelseav pojkar.<strong>Notat</strong> <strong>om</strong> <strong>om</strong>skæring <strong>af</strong> <strong>drenge</strong> 21 / 21


HygiejneDen læge, s<strong>om</strong> har ansvaret for indgrebet, skal sikre sig, at almindelig godfaglig standard vedr. kirurgisk hygiejne overholdes, herunder at operations<strong>om</strong>rådetvaskes sterilt, <strong>af</strong>dækkes og at der anvendes sterile instrumenter.Side 2SmertelindringAlle børn, også spædbørn, skal sikres den nødvendige, tilstrækkelige og tidssvarendesmertelindring, s<strong>om</strong> indgrebet og den postoperative periode kræver.Der skal ved valg <strong>af</strong> smertelindring tages hensyn til barnets alder, modenhedsgradog øvrige medicinske forhold. Den smertelindring, der vælges,skal desuden være så god s<strong>om</strong> mulig med så lille risiko for bivirkninger ogk<strong>om</strong>plikationer s<strong>om</strong> muligt.23. maj 2005OperationsteknikOmskæring <strong>af</strong> <strong>drenge</strong> kan udføres på flere måder. Lægen skal følge den fagligeudvikling på <strong>om</strong>rådet og sikre sig, at han har de nødvendige forudsætningerfor både indgrebet og smertelindringen.Efter operationenDen ansvarlige læge skal sikre sig, at forældrene eller forældremyndighedsindehaverengives information <strong>om</strong> den postoperative pleje herunder hygiejniskeforholdsregler samt smertelindring.Enhed for kvalitet,overvågning og tilsyn<strong>Sundhedsstyrelsen</strong>JournalføringVed <strong>om</strong>skæring skal der føres journal efter vanlige retningslinjer for journalføring.3Michael von MagnusLena Graversen3 Bekendtgørelse nr. 846 <strong>af</strong> 10. oktober 2003 <strong>om</strong> lægers pligt til at føre ordnede optegnelserog Vejledning nr. 118 <strong>af</strong> 13. oktober 2003 <strong>om</strong> lægers journalføring.


WHITEPAPER– OM RITUEL OMSKÆRELSE AF DRENGES<strong>om</strong>meren 2012 har været præget <strong>af</strong> en meget heftig debat <strong>om</strong>, hvorvidtrituel <strong>om</strong>skærelse <strong>af</strong> <strong>drenge</strong> skal forbydes. Dette White Paper fra DetMosaiske Troessamfund – Det Jødiske Samfund i Danmark, har til formål atgive et overblik over de forskellige problemstillinger, der har været berørt idebatten. Der redegøres således for, hvordan en jødisk rituel <strong>om</strong>skærelserent faktisk gennemføres, og den religiøse baggrund beskrives, herunder at<strong>om</strong>skærelsen er en hovedhjørnesten i jødisk selvidentifikation og religion.Endvidere redegøres for de lægelige undersøgelser og de juridiskeproblemstillinger der har været fremført, og under henvisning til andre ogvæsentligt større lægelige undersøgelser gendrives påstandene,liges<strong>om</strong> de juridiske argumenter ligeledes gendrives.August 2012


White Paper <strong>om</strong> religiøs <strong>om</strong>skærelse <strong>af</strong> <strong>drenge</strong> s.1 August 2012


OM RITUEL JØDISK OMSKÆRELSE AF DRENGEIndledningS<strong>om</strong>meren 2012 har været præget <strong>af</strong> en meget heftig debat <strong>om</strong>, hvorvidt rituel <strong>om</strong>skærelse <strong>af</strong> <strong>drenge</strong> skalforbydes.Danmark ville i givet fald være det første land i verden, s<strong>om</strong> indfører et forbud mod <strong>om</strong>skærelse <strong>af</strong> <strong>drenge</strong>.Dette vel og mærke i en verden, hvor hver tredje mand er <strong>om</strong>skåret, og hvor Danmark via FN støtter WHO’s<strong>om</strong>skærelsesinitiativ i Afrika.Set fra Det Mosaiske Troessamfund – Det Jødiske Samfund i Danmark har debatten været præget <strong>af</strong> en langrække forskelligartede synspunkter, hvis forskellighed ofte har gjort debatten vanskelig at få et overblikover. Ikke mindst sammenblanding <strong>af</strong> jødiske og muslimske traditioner kan give anledning til forvirring.Dette ”White Paper” har til formål at give et overblik over de forskellige problemstillinger, der har væretberørt i debatten. Der redegøres således for, hvordan en jødisk rituel <strong>om</strong>skærelse rent faktisk gennemføres,således at fremførte misforståelser kan korrigeres. En <strong>om</strong>skærelse gennemføres på det 8 dage gamle<strong>drenge</strong>barn, hvilket efter lægelige undersøgelser medfører mindst antal k<strong>om</strong>plikationer ogsmerteoplevelse. Omskærelsen sker altid under tilsyn <strong>af</strong> en læge, i nærværelse <strong>af</strong> familien (naturligvis bådekvinder og mænd), og lægen journaliserer det passerede.Den religiøse baggrund beskrives, herunder at <strong>om</strong>skærelsen er en hovedhjørnesten i jødiskselvidentifikation og religion.De lægelige undersøgelser og de juridiske problemstillinger har været fremført, og under henvisning tilandre og væsentligt større lægelige undersøgelser gendrives påstandene, liges<strong>om</strong> de juridiske argumenterligeledes gendrives.Det er for ambitiøst at forvente, at modstanderne <strong>af</strong> rituel jødisk <strong>om</strong>skærelse vil blive <strong>om</strong>vendt <strong>af</strong> denneredegørelse, men håbet er dog, at en fremtidig debat kan få et mere ”informeret” <strong>af</strong>sæt.København, august 2012Finn SchwarzFormandWhite Paper <strong>om</strong> religiøs <strong>om</strong>skærelse <strong>af</strong> <strong>drenge</strong> s.2 August 2012


White Paper <strong>om</strong> religiøs <strong>om</strong>skærelse <strong>af</strong> <strong>drenge</strong> s.3 August 2012


White Paper <strong>om</strong> religiøs <strong>om</strong>skærelse <strong>af</strong> <strong>drenge</strong> s.5 August 2012


1. Overordnede konklusionerI dette ”White Paper” gennemgås en række problemstillinger, s<strong>om</strong> har været anført i debatten <strong>om</strong>rituel <strong>om</strong>skærelse <strong>af</strong> <strong>drenge</strong> over s<strong>om</strong>meren 2012.Et forbud mod religiøs <strong>om</strong>skærelse <strong>af</strong> <strong>drenge</strong> i Danmark vil være det første forbud <strong>af</strong> sin art påverdensplan.I <strong>af</strong>snit 2, der <strong>om</strong>handler den praktiske gennemførelse <strong>af</strong> rituel jødisk <strong>om</strong>skærelse i Danmark, anføresfølgende:1. Rituel jødisk <strong>om</strong>skærelse foretages under tilsyn <strong>af</strong> en læge ved en <strong>om</strong>skærer ioverensstemmelse med <strong>Sundhedsstyrelsen</strong>s regler.2. Omskærelsen foregår s<strong>om</strong> regel i hjemmet. Nogle gange med mange gæster, nogle gangekun med deltagelse <strong>af</strong> forældrene og/eller den allernærmeste familie. Såvel kvinder s<strong>om</strong>mænd deltager (naturligvis) i ceremonien.3. Forud for <strong>om</strong>skærelsen undersøges <strong>drenge</strong>n <strong>af</strong> lægen, der ligeledes journalfører før og efterindgrebet. Journalen gemmes i 10 år.4. Omskærelsen sker ved en almindeligt anerkendt metode, der sikrer, at det alene erforhuden, der fjernes.5. Selve <strong>om</strong>skærelsen tager mellem 2-3 minutter og opleves s<strong>om</strong> havende meget lille virkningpå det 8 dage gamle barn.6. Omskæreren besøger almindeligvis – under alle <strong>om</strong>stændigheder - familien dagen efter ogtager bandagen <strong>af</strong> s<strong>om</strong> regel ved bad. Enkelte gange lægges ny bandage for at holdeforhuden nede, da der jo ikke foretages syning, men oftest kan bandagen nu fjernes.7. Der er ikke igennem mange år konstateret k<strong>om</strong>plikationer relateret til jødisk rituel<strong>om</strong>skærelse i Danmark.Afsnit 3 beskriver den religiøse baggrund for den jødiske <strong>om</strong>skærelse.Her anføres:1. Den jødiske rituelle <strong>om</strong>skærelse er én <strong>af</strong> de 613 forskrifter, der findes i De 5Mosebøger, og s<strong>om</strong> jøder er forpligtet <strong>af</strong>.2. I 1. Mosebog kapitel 17 findes udgangspunktet for denne tradition: ”Dette er min pagt meddig og dine efterk<strong>om</strong>mere, s<strong>om</strong> I skal holde: Alle <strong>af</strong> mandkøn hos jer skal <strong>om</strong>skæres. v11 I skallade jeres forhud <strong>om</strong>skære, og det skal være tegn på pagten mellem mig og jer. v12 Ottedage gammel skal hver dreng hos jer <strong>om</strong>skæres, slægt efter slægt."3. Omskærelsen betragtes <strong>af</strong> jødiske samfund ude i verden samt <strong>af</strong> det jødiske samfund iDanmark s<strong>om</strong> én <strong>af</strong> hovedhjørnestenene i at være jøde, og uanset at <strong>om</strong>skærelsesdebattenWhite Paper <strong>om</strong> religiøs <strong>om</strong>skærelse <strong>af</strong> <strong>drenge</strong> s.6 August 2012


har været oppe med jævne mellemrum, har dette ikke resulteret i en intern diskussion elleren nedgang i ønsket <strong>om</strong> gennemførelse <strong>af</strong> <strong>om</strong>skærelser. Størstedelen <strong>om</strong>skæres rituelt mensnogle vælger at lade <strong>om</strong>skærelse ske ved en læge.4. Der har i debatten været peget på, at en lille gruppe amerikanske jøder anvender enmetode, der ikke er en <strong>om</strong>skærelse men derimod en ”prikning” i forhuden.5. Denne lille gruppes praksis er marginal i forhold til de jødiske samfund i verden, s<strong>om</strong> ikkeanerkender denne fremgangsmåde s<strong>om</strong> en rituel <strong>om</strong>skærelse. Denne praksis vil ikke kunne<strong>af</strong>løse den rituelle <strong>om</strong>skærelses karakter <strong>af</strong> at være en hjørnesten i det at være jøde.6. Omskærelse er tillige et identitetstegn for jøder. Det er et tegn på, at familien ønsker at væreen del <strong>af</strong> den jødiske historie såvel i fortid s<strong>om</strong> i fremtid.7. Omskærelsen er en hovedhjørnesten for 90 % <strong>af</strong> det jødiske folk (mænd) i verden og detsamme tal gælder også for jøderne i Danmark. Uden en mulighed for <strong>om</strong>skærelse i Danmarkvil det jødiske samfund inden for en overskuelig fremtid risikere at gå i opløsning.I <strong>af</strong>snit 4 beskrives den medicinske kontekst.Her anføres det at undersøgelsen, foretaget <strong>af</strong> Morten Frisch m.fl., publiceret i 2011, kan betragtess<strong>om</strong> ”en enlig svale” og er med rette kritiseret for følgende:Der er tale <strong>om</strong> en spørgeskemaundersøgelse <strong>om</strong> en række forskellige sundhedsemner (ca. 5000adspurgte), hvor under halvdelen <strong>af</strong> dem, der fik et spørgeskema besvarede – en så lav svarprocent ers<strong>om</strong> udgangspunkt problematisk, herunder er der ingen viden <strong>om</strong>, hvorvidt de inkluderede mænd errepræsentative for den gruppe, s<strong>om</strong> man ønsker at generalisere resultaterne til.1. Af 2345 mænd, der besvarede spørgeskemaundersøgelsen, var 125 <strong>om</strong>skåret, og <strong>af</strong> 2234kvinder, der besvarede spørgeskemaundersøgelsen var 83 samlevende med <strong>om</strong>skåredemænd.2. Af de 125 <strong>om</strong>skårede mænd rapporterede 7 (!) mænd, at de var muslimer (5) eller jøder (2).15 mænd rapporterede, at de var <strong>om</strong>skåret før 6 måneders alderen. Blandt de <strong>om</strong>skåredehavde 14 udenlandsk baggrund. Den langt overvejende del <strong>af</strong> dem, der besvaredespørgeskemaet og tilkendegav at være blevet <strong>om</strong>skåret, må således formodes – daspørgeskemaet ikke giver mulighed for at besvare dette - at være <strong>om</strong>skåret <strong>af</strong> medicinskeårsager, her<strong>af</strong> hyppigst forhudsforsnævring og i sjældne tilfælde peniscancer, hvilket i sigselv kan have indflydelse på personens mentale opfattelse og funktionelle praktisering <strong>af</strong> sitseksualliv. I et så lille materiale er det vigtigt, at det klart fremgår <strong>af</strong> datamaterialet, <strong>om</strong><strong>om</strong>skærelsen er udført <strong>af</strong> religiøse årsager, hvor hele forhuden fjernes, eller på basis <strong>af</strong>medicinsk indikation – og i givet fald for hvilke grupper, hvor forhuden kun fjernes delvist,idet disse oplysninger kan have en statistisk betydning for undersøgelsens analyse og udfald.3. Undersøgelsen <strong>om</strong>handler derfor i det væsentlige mænd, der er <strong>om</strong>skåret efter en lægeligundersøgelse og vurdering og ikke på raske personer og slet ikke på 8 dage gamle <strong>drenge</strong>,s<strong>om</strong> rituel, jødisk <strong>om</strong>skærelse foreskriver. Det er derfor meget betænkeligt, atWhite Paper <strong>om</strong> religiøs <strong>om</strong>skærelse <strong>af</strong> <strong>drenge</strong> s.7 August 2012


undersøgelsen søges anvendt til at argumentere for et forbud mod rituel <strong>om</strong>skærelse og atmedierne tager undersøgelsen til indtægt for et forbud. Morten Frisch sammenligner æblerog pærer og konkluderer således på forhold, s<strong>om</strong> undersøgelsen ikke giver basis for at udtalesig <strong>om</strong>.4. I en artikel, “Does sexual function survey in Denmark offer any support for male circumcisionhaving an adverse effect?” 1 kritiseres Morten Frisch’ undersøgelse (det statistiske grundlag)samt de konklusioner, Morten Frisch drager.5. I artiklen, ”C<strong>om</strong>plications of circumcision in male neonates, infants and children: a systematicreview” 2 , gennemgås en række undersøgelser foretaget i lande, der anvender <strong>om</strong>skærelser.Særligt skal nævnes en k<strong>om</strong>plikationsrisiko på 0,2 % i en undersøgelse foretaget i USA på130.475 <strong>om</strong>skårede mænd og en undersøgelse foretaget i Israel på 19.478 <strong>om</strong>skårede mændmed en k<strong>om</strong>plikationsrisiko på 0,1%.6. Teorien <strong>om</strong>, at <strong>om</strong>skærelse skulle medføre en mindre føls<strong>om</strong>hed, s<strong>om</strong> dels skulle medføreorgasmeproblemer hos manden og smerter ved samleje hos kvinden, har ingen støtte ianden forskning hverken relateret til hetero- eller h<strong>om</strong>oseksuelle oplevelser hos <strong>om</strong>skåredemænd og deres partnere, herunder meget store kliniske trials fra Afrika, s<strong>om</strong> inkluderermange tusinde mænd, der blev <strong>om</strong>skåret s<strong>om</strong> voksne.7. Klare undersøgelsesresultater viser, at såfremt <strong>om</strong>skærelsen gennemføres s<strong>om</strong> en ritueljødisk <strong>om</strong>skærelse på det spæde barn er k<strong>om</strong>plikationsrisikoen og oplevelse <strong>af</strong> ubehag m.v.mindst.Morten Frisch (og de øvrige forfattere) slutter deres artikel <strong>af</strong> med at angive, at dette <strong>om</strong>råde skalundersøges nærmere – et forbehold for egne resultater, der på ingen måde har præget Morten Frisch’uforbeholdne udtalelser over s<strong>om</strong>meren 2012.I relation til Patientforsikringen foreligger følgende:I en 16-årig periode (1996-2012) er der anmeldt 14 patientskader efter rituel <strong>om</strong>skæring foretaget <strong>af</strong>en læge, hvor<strong>af</strong> 2 er anerkendt <strong>af</strong> Patientforsikringen. Ingen <strong>af</strong> disse tilfælde har sammenhæng medrituel, jødisk <strong>om</strong>skærelse, hvorfor anførelsen <strong>af</strong> disse tal i debatten er misvisende.I relation til HIV-infektion har en række undersøgeler resulteret i, at et ekspertpanel under WHOanbefaler, at mandlig <strong>om</strong>skærelse blev inkluderet i metoderne til forebyggelse <strong>af</strong> heteroseksueltoverført HIV i lande med høj forek<strong>om</strong>st <strong>af</strong> HIV infektion.Følgende er i øvrigt lægeligt dokumenteret i relation til <strong>om</strong>skærelsens positive betydning:Betydelig reduktion i livmoderhalskræft hos den <strong>om</strong>skåredes partner.Reduktion med to tredjedele i antallet <strong>af</strong> peniscancer hos den <strong>om</strong>skårede.1 Bryan J. Morris m.fl. http://ije.oxfordjournals.org/content/41/1/310.full2 Helen A. Weiss m.fl., http://www.bi<strong>om</strong>edcentral.c<strong>om</strong>/1471-2490/10/2White Paper <strong>om</strong> religiøs <strong>om</strong>skærelse <strong>af</strong> <strong>drenge</strong> s.8 August 2012


To tredjedel færre infektioner på penishoved og 5-10 gange færre urinvejsinfektioner.Der ses langt færre seksuelt overførte sygd<strong>om</strong>me.Antal tilfælde <strong>af</strong> prostatacancer er mindre hos <strong>om</strong>skårede.På verdensplan anslås det, at 1/3 <strong>af</strong> verdens befolkning <strong>af</strong> mænd er <strong>om</strong>skåret, svarende til ca. 1.2 mia.mænd. Det må umiddelbart siges at have formodningen imod sig, at den foreliggende – med rette –kritiserede spørgeskemaundersøgelse endeligt fastslår, at <strong>om</strong>skærelse giver anledning til gener hosden <strong>om</strong>skårede mand og/eller dennes partner.Endelig i <strong>af</strong>snit 5 redegøres for den juridiske kontekst.Det konstateres, at jødisk rituel <strong>om</strong>skærelse gennemføres i overensstemmelse med det foreliggenderetsgrundlag, herunder med mulighed for at autoriserede sundhedspersoner benytter medhjælp.I forbindelse med debatten <strong>om</strong> <strong>om</strong>skærelse er det bl.a. anført, at FN's Børnekonvention fra 1989indebærer et forbud mod <strong>om</strong>skærelse <strong>af</strong> <strong>drenge</strong>.Dette er ikke korrekt.Børnekonventionens artikel 24, stk. 3, fastslår, at deltagerstaterne skal tage alle effektive og passendeforanstaltninger for at <strong>af</strong>sk<strong>af</strong>fe traditionsbundne ritualer, s<strong>om</strong> er skadelige for børns sundhed.Børnekonventionen er tiltrådt <strong>af</strong> en række stater, s<strong>om</strong> anerkender <strong>om</strong>skærelse <strong>af</strong> <strong>drenge</strong>, og der er enklar opfattelse i det internationale samfund og i det juridiske miljø i Danmark, at børnekonventionentilsigter at beskytte female genital mutilation (kvindelig <strong>om</strong>skærelse) og ikke angår <strong>om</strong>skærelse <strong>af</strong><strong>drenge</strong>. 3Dette stemmer da også overens med, at ikke et eneste land i verden har et forbud mod <strong>om</strong>skærelse <strong>af</strong><strong>drenge</strong>.Om barnets selvbestemmelsesret er anført, at det er alment accepteret at forældre, mens barnet ikkeer beslutningsmodent, kan træffe beslutninger på barnets vegne, og at forældre faktisk træffer enrække valg på det ufødte og fødte barns vegne.Det drejer sig bl.a. <strong>om</strong>:Abort – herunder abort i forbindelse med fosterdiagnostik.Kosmetiske operationer i relation til børn født med mere eller mindre alvorlige deformiteter.Disse kosmetiske operationer spænder fra deciderede deformiteter i ansigtet og på kroppen overhareskår og tandoperationer til mindre alvorlige tilfælde sås<strong>om</strong> tilretning <strong>af</strong> ’stritøre’.Rettelse <strong>af</strong> "skæve" næser mv.Piercing og huller i ørerne.3 Se Jurisdiktionsudvalgets udtalelse i forbindelse med indførelse <strong>af</strong> forbud mod kvindelig <strong>om</strong>skærelse samt KirstenKetscher i Nye retlige design, s. 14ff. 2003.White Paper <strong>om</strong> religiøs <strong>om</strong>skærelse <strong>af</strong> <strong>drenge</strong> s.9 August 2012


samt f.eks.:Moderens alkoholindtagelse under graviditet, s<strong>om</strong> beviseligt medfører en betydelig risiko forfosterskader.Forældres rygning i barnets hjem, s<strong>om</strong> beviseligt medfører en betydelig risiko for skader s<strong>om</strong>følge <strong>af</strong> passiv rygning.Deltagelse i – eller netop ikke deltagelse i – generelle vaccinationsprogrammer for børn.Det er evident, at der generelt set ikke er et ønske <strong>om</strong> at lovgive <strong>om</strong> disse forhold. Selv<strong>om</strong> det erutvivls<strong>om</strong>t, at f.eks. en overdreven alkoholindtagelse under en graviditet har direkte betydning foru<strong>af</strong>vendelige fosterskader, er der intet ønske <strong>om</strong> at kriminalisere den gravides indtagelse <strong>af</strong> alkoholover en vis mængde, samt kriminalisere købmandens eller supermarkedets salg <strong>af</strong> alkoholiske drikke tilgravide.Omskærelsen er <strong>af</strong> stor betydning for barnets tilknytning til den jødiske kultur, sin familie og religionenog har derfor sin berettigelse på samme vilkår s<strong>om</strong> almindelige kosmetiske indgreb, der også erbaseret i barnets tilknytning til kultur og det <strong>om</strong>kringliggende samfund – og i øvrigt på linje medaccepten <strong>af</strong>, at et barns forældre træffer en række direkte og indirekte valg på barnets vegne, s<strong>om</strong> hardirekte indflydelse på barnets opvækst og liv.Et forbud, begrundet i barnets selvbestemmelsesret, vil således være et markant brud på denne linje –navnlig når der ikke foreligger medicinske tvingende grunde (s<strong>om</strong> tilfældet var ved kvindelige<strong>om</strong>skærelser).Endelig fastslås det, at Grundlovens § 67 sikrer retten til at dyrke sin religion, og bestemmelsen skal sammenholdes medDen Europæiske Menneskerettigheds artikel 9.Det er fast antaget, at et indgreb i religionsfriheden kræver (1) lovhjemmel, (2) et legitimt formål ognødvendighed i et demokratisk samfund.Allerede s<strong>om</strong> følge <strong>af</strong>, at <strong>om</strong>skærelse <strong>af</strong> <strong>drenge</strong> ikke er forbudt i ét eneste land, der har tiltrådt denEuropæiske Menneskerettighedskonvention, er der meget der taler for, at et <strong>om</strong>skærelsesforbud ikkeer et legitimt formål og en nødvendighed i et demokratisk samfund.Den foreliggende medicinske forskning, se bemærkningerne ovenfor, er på ingen måde entydig, hvilketselv anføres <strong>af</strong> den forskning, der er kritisk overfor <strong>om</strong>skærelse <strong>af</strong> <strong>drenge</strong> (i modsætning til hvad dervar tilfældet for <strong>om</strong>skærelse <strong>af</strong> piger).Ved vurderingen <strong>af</strong> <strong>om</strong> der foreligger et legitimt formål og en nødvendighed i et demokratisk samfundmå man tillige tage i betragtning, hvilke andre (mere eller mindre) lignende forhold, der reguleres <strong>af</strong>lovgivningen, henholdsvis ikke reguleres <strong>af</strong> lovgivningen – den såkaldte "proportionalitetsvurdering".White Paper <strong>om</strong> religiøs <strong>om</strong>skærelse <strong>af</strong> <strong>drenge</strong> s.10 August 2012


Der er en betydelig risiko for, at et forbud mod <strong>om</strong>skærelse <strong>af</strong> <strong>drenge</strong>børn vil stride mod religionsfrihedsretteni den danske grundlov, set i sammenhæng med den Europæiske Menneskerettighedskonvention,da et forbud ikke kan begrundes med et legitimt formål og en nødvendighed i etdemokratisk samfund og vil være ikke-proportionalt i forhold til, hvilke beslutninger forældre ellers fritkan træffe på sit barns vegne.___________________________________________________________________2. Beskrivelse <strong>af</strong> en <strong>om</strong>skærelse, foretaget i det jødiske samfund i Danmark2.1 Beskrivelse <strong>af</strong> hvordan det faktisk gennemføresOmskæreren - nedenfor betegnet med det hebraiske udtryk Mohel - kontaktes <strong>af</strong> forældrene.Hvis barnet ikke er født <strong>af</strong> en jødisk mor, henvises til lægeklinikker. Mohel undersøger barnetfor:Almindeligt velbefindendeBarnegulsot kontrolleres ved check i øjne eller <strong>om</strong>kring lysken.Hypospadi og lignende.I tvivlstilfælde kontaktes en læge.Generelt gælder, at barnet skal veje <strong>om</strong>kring 3 kg. og må ikke have en gulsot, der kunne tyde påen bilirubin over 120. I tvivlstilfælde udsættes <strong>om</strong>skærelsen.Hvis <strong>om</strong>skærerens (Mohels) undersøgelse viser, at forholdene i relation til en <strong>om</strong>skærelse er iorden, <strong>af</strong>tales <strong>om</strong> muligt <strong>om</strong>skærelse 8 dage efter fødslen.Selve <strong>om</strong>skærelsen foregår s<strong>om</strong> regel i hjemmet. Nogle gange med mange gæster, nogle gangekun med deltagelse <strong>af</strong> forældrene og/eller den allernærmeste familie. Såvel kvinder s<strong>om</strong> mænddeltager (naturligvis) i ceremonien.Forberedelsen forud for en <strong>om</strong>skærelse <strong>om</strong>fatter følgende:1. Sikring <strong>af</strong>, at instrumenterne er sterile.2. Forberedelse i hjemmet: Påsmøring <strong>af</strong> EMLA creme ca. 1 time inden <strong>om</strong>skærelsen.Barnet får ikke mad i timerne op til selve ceremonien.3. Mohel og den tilstedeværende ansvarlige læge ank<strong>om</strong>mer. Lægen kontrollerer barnetog journalfører før og efter indgrebet.White Paper <strong>om</strong> religiøs <strong>om</strong>skærelse <strong>af</strong> <strong>drenge</strong> s.11 August 2012


Om selve <strong>om</strong>skærelsesceremonien:Barnet ligger på en pude, og en person, man ønsker at ære, sidder med barnet på et solidtbord.Mohel står på den ene side og lægen modsat og holder barnets ben. Mohel trækker forhudenop over glansen og sætter en klemme i den optrukkede forhud. Herved sikres, at man ikke kanbeskadige penishovedet. Der foretages et snit ovenfor klemmen, og forhuden falder <strong>af</strong>.Herefter sørges der for, at også den indre forhud er trukket helt ned ved roden, og Mohelstopper blødningen med pres og bandager. Under selve handlingen får barnet lidt vin på en sut,og dermed koncentrerer barnet sig <strong>om</strong> at sutte. Hele seancen er overstået på 2-3 minutter.Ceremonien <strong>af</strong>sluttes med, at barnet får sit jødiske navn og velsignes <strong>af</strong> Mohel.Efter ceremonien indskrives barnet i ministerialprotokollen, og der indføres, hvem der harforetaget <strong>om</strong>skærelsen.Efter <strong>om</strong>skærelsesceremonien:Efter ceremonien mades barnet. Derefter kontrollerer lægen og Mohel, at barnet har det godt,og at bandagen er tør og ligger ordentligt.Journalen underskrives <strong>af</strong> lægen, og Mohel instruerer familien <strong>om</strong>, hvorledes bleerne de næste5 til 6 bleskift vil se ud. Familien har direkte kontakt med Mohel, og skulle familien være i tvivl<strong>om</strong> noget, besøger Mohel altid familien umiddelbart.Mohel besøger almindeligvis – og under alle <strong>om</strong>stændigheder - familien senest dagen efter ogtager s<strong>om</strong> regel bandagen <strong>af</strong> ved bad. Enkelte gange lægges ny bandage for at holde forhudennede, da der jo ikke foretages syning, men oftest kan bandagen nu fjernes. Familien får nyeinstruktioner, s<strong>om</strong> først og fremmest går på at lade <strong>drenge</strong>n ligge lidt uden ble ved bleskift.Det sker, at familier henvender sig nogle måneder efter indgrebet, idet familien fornemmer, atglansen ikke er helt fri. Årsagen er ofte, at barnet har meget ”hvalpefedt”, indtil det begynderat gå, og at dette bevirker, at lårene presser på penis. Mohel beroliger familien og har kun éngang været ude for, at en familie ikke ville vente til, at naturen ville klare problemet.2.2 Beskrivelse <strong>af</strong> hvem der er til stede – lægen, <strong>om</strong>skæreren, familienEn <strong>om</strong>skærelse er en festlig begivenhed, og derfor er barnets forældre og øvrige familietilstede, foruden den tilstedeværende ansvarlige læge og <strong>om</strong>skæreren.Det er ikke korrekt, når det i s<strong>om</strong>merens debat har været anført, at <strong>om</strong>skærelsen ikke sker ioverværelse <strong>af</strong> kvinder.White Paper <strong>om</strong> religiøs <strong>om</strong>skærelse <strong>af</strong> <strong>drenge</strong> s.12 August 2012


2.3 Beskrivelse <strong>af</strong> <strong>af</strong>rapporteringenS<strong>om</strong> anført ovenfor kontrollerer lægen barnet forud for <strong>om</strong>skærelsen og efter indgrebet ogjournalfører sine optegnelser.Lægens journal opbevares såvel hos lægen s<strong>om</strong> hos Mohel i 10 år.2.4 Utilsigtede hændelserUnder s<strong>om</strong>merens debat er det blevet anført, at der skulle være flere tilfælde <strong>af</strong> problematiske<strong>om</strong>skærelser, s<strong>om</strong> har resulteret i behandling på danske sygehuse.Dette er ikke korrekt. Der har igennem de sidste mange år været ét tilfælde, s<strong>om</strong> resulterede ien henvendelse til Rigshospitalet. Efterfølgende konstateredes det, at den <strong>om</strong>skårede drengvar smittet <strong>af</strong> en virus, s<strong>om</strong> et <strong>af</strong> <strong>drenge</strong>ns familiemedlemmer havde h<strong>af</strong>t, og s<strong>om</strong> havderesulteret i en særlig rødme. Barnet havde kort efter (og i dag) ingen gener <strong>af</strong> <strong>om</strong>skærelsen.3. Den religiøse baggrund3.1 BaggrundenDen jødiske rituelle <strong>om</strong>skærelse er én <strong>af</strong> de 613 forskrifter, der findes i De 5 Mosebøger, s<strong>om</strong>jøder er forpligtet <strong>af</strong>.Da der er tale <strong>om</strong> en religiøs forpligtelse, kan den kun udføres <strong>af</strong> en jøde.I 1. Mosebog, kapitel 17, finder vi udgangspunktet for denne tradition: ” Dette er min pagt meddig og dine efterk<strong>om</strong>mere, s<strong>om</strong> I skal holde: Alle <strong>af</strong> mandkøn hos jer skal <strong>om</strong>skæres. v11 I skallade jeres forhud <strong>om</strong>skære, og det skal være tegn på pagten mellem mig og jer. v12 Otte dagegammel skal hver dreng hos jer <strong>om</strong>skæres, slægt efter slægt."Den jødiske betegnelse for <strong>om</strong>skærelse er Brit Milah, der er hebraisk og betyder<strong>om</strong>skærelsespagten – betegnelsen forklarer bedre end noget andet den pagt s<strong>om</strong> Gud indgårmed Abraham, beskrevet i 1. Mosebog, kap. 17.Denne pagt blev indgået for 3.700 år siden og har været en forankret del <strong>af</strong> jøded<strong>om</strong>men siden.To gange i Bibelen er det nævnt, at der var perioder, hvor det jødiske folk ikke foretog<strong>om</strong>skærelse/Brit Milah.Omvendt kan man i historisk lys konstatere, hvorledes jøder har kæmpet mod magthavere, derforbød jøder at foretage <strong>om</strong>skærelse/Brit Milah. Både grækerne og r<strong>om</strong>erne bandlyste<strong>om</strong>skærelse/Brith Milah, idet både grækerne og r<strong>om</strong>erne helt korrekt forstod, at <strong>om</strong>skærelsener en hjørnesten i den jødiske tro, og at forbud mod Brit Milah ville være første trin til eneliminering <strong>af</strong> det jødiske folk. Selv under disse herskere gennemførte jødiske forældre BritMilah.White Paper <strong>om</strong> religiøs <strong>om</strong>skærelse <strong>af</strong> <strong>drenge</strong> s.13 August 2012


I historisk perspektiv kan også nævnes perioden under Den spanske Inkvisition, hvor detuanset, at det at være <strong>om</strong>skåret nærmest var at underskrive sin egen dødsd<strong>om</strong>, alligevel blevfastholdt, at jøder gennemførte Brit Milah.3.2 PraksisI det jødiske samfund i Danmark er der, i lighed med alle andre jødiske samfund verden over,næsten en undtagelsesfri praksis, hvorefter <strong>drenge</strong>børn bliver <strong>om</strong>skåret. Der har igennem heleden periode, hvor der har været jøder i Danmark (over 400 år), uanset at <strong>om</strong>skærelsesdebattenhar været oppe med jævne mellemrum, hverken været en intern diskussion eller en nedgang iønsket <strong>om</strong> gennemførelse <strong>af</strong> <strong>om</strong>skærelser. Størstedelen <strong>om</strong>skæres rituelt mens nogle vælger atlade <strong>om</strong>skærelse ske ved en læge.Det jødiske samfund i Danmark adskiller sig således ikke holdningsmæssigt fra jødiske samfundandre steder i verden, hvor den rituelle <strong>om</strong>skærelse <strong>af</strong> <strong>drenge</strong> anses for at være en hjørnesten idet at være jøde.3.3 Nye "bevægelser"Der har i debatten været peget på, at en lille gruppe amerikanske jøder anvender en metode,der ikke er en <strong>om</strong>skærelse, men derimod en ”prikning” i forhuden.Denne lille gruppes praksis er marginal i forhold til de jødiske samfund i verden, s<strong>om</strong> ikkeanerkender denne fremgangsmåde s<strong>om</strong> en rituel <strong>om</strong>skærelse.Denne praksis vil således ikke kunne <strong>af</strong>løse den rituelle <strong>om</strong>skærelses karakter <strong>af</strong> at være enhjørnesten i det at være jøde.3.4 Kristend<strong>om</strong>mens pragmatisme kontra jøded<strong>om</strong>menDet gælder for jøded<strong>om</strong>men i modsætning til kristend<strong>om</strong>men, at jøded<strong>om</strong>men har bundet sigtil love og forskrifter, s<strong>om</strong> man betragter s<strong>om</strong> nærmest gudd<strong>om</strong>melige, og s<strong>om</strong> man ikke bareændrer.Fortolkninger har altid fundet sted, men jøder har og holder fortsat fast i <strong>om</strong>skærelsestraditionen,s<strong>om</strong> har været gennemgående i de mere end 3000 år.Man er født s<strong>om</strong> jøde, hvis man er født <strong>af</strong> en jødisk mor. Der findes ikke i princippet jødiskedogmer, hvilket blandt andet betyder, at man ikke kan ”fratage” en jøde sin identitet s<strong>om</strong> jøde.Der er jøder, der slet ikke overholder jødiske regler i nogen s<strong>om</strong> helst form, og andre der harplukket ud <strong>af</strong> disse regler og overholder de regler, s<strong>om</strong> de vil. Det gælder også for <strong>om</strong>skærelse.Man kunne måske sige det på denne måde: ”Det er <strong>af</strong>gørende for de fleste jøder at være<strong>om</strong>skåret, men det er ikke <strong>af</strong>gørende at være <strong>om</strong>skåret for at være jøde”.White Paper <strong>om</strong> religiøs <strong>om</strong>skærelse <strong>af</strong> <strong>drenge</strong> s.14 August 2012


3.5 Betydningen for den jødiske familie og det jødiske samfund i DanmarkBrit Milah/<strong>om</strong>skærelse er naturligvis et spørgsmål <strong>om</strong> religionens påbud, men det er megetmere end dette.Brith Milah/<strong>om</strong>skærelse er et identitetstegn for jøder. Det er et tegn på, at familien ønsker atvære en del <strong>af</strong> den jødiske historie såvel i fortid s<strong>om</strong> i fremtid.For nogle familier kan der være andre grunde til ønsket <strong>om</strong>, at deres søn skal <strong>om</strong>skæres. Der ermange, der mener, at der er medicinske årsager, andre fysiologiske og endnu andre seksuelle.Under alle <strong>om</strong>stændigheder er Brit Milah/<strong>om</strong>skærelsen en hovedhjørnesten for 90% <strong>af</strong> detjødiske folk i verden og det samme tal gælder også for jøderne i Danmark. Uden en mulighedfor <strong>om</strong>skærelse i Danmark vil det jødiske samfund inden for en overskuelig fremtid risikere atgå i opløsning.4. Den medicinske kontekst4.1 Forskellen mellem mandlig og kvindelig <strong>om</strong>skærelse – forholdet til seksualitetFor god ordens skyld skal det præciseres, at der ingen sammenhæng er mellem en jødisk rituel<strong>om</strong>skærelse <strong>af</strong> et 8 dage gammelt <strong>drenge</strong>barn og <strong>om</strong>skærelse <strong>af</strong> kvinder, der har situdgangspunkt i <strong>af</strong>rikansk tradition.Kvindelig <strong>om</strong>skærelse dækker s<strong>om</strong> begreb forskellige indgreb, s<strong>om</strong> overordnet har det tilfælles, at kvinden gøres mindre ”tilgængelig” for seksualakten, og dermed forventes det tillige,at kvindens ønske <strong>om</strong> seksuel adfærd begrænses.I forbindelse med indførelse <strong>af</strong> det danske forbud mod kvindelig <strong>om</strong>skærelse anførtes følgende<strong>om</strong> kvindelig <strong>om</strong>skærelse i lovforslaget:Efter oplysninger fra <strong>Sundhedsstyrelsen</strong> er der i princippet tre former for kvindelig <strong>om</strong>skæring:»Sunna<strong>om</strong>skæring/klitoridect<strong>om</strong>i«: Sunna<strong>om</strong>skæring bruges ofte s<strong>om</strong> betegnelse for fjernelse <strong>af</strong>slimhindefolden over klitoris, men bl.a. på grund <strong>af</strong> de anat<strong>om</strong>iske forhold <strong>om</strong>kring klitoris, er der enmeget betydelig risiko for at bortskære mere end blot slimhindefolden, og <strong>Sundhedsstyrelsen</strong> haroplyst, at det næppe forek<strong>om</strong>mer i praksis, at dette indgreb foretages, uden at der også fjernes en del<strong>af</strong> klitoris. Klitoridect<strong>om</strong>i er betegnelsen for hel eller delvis fjernelse <strong>af</strong> klitoris.»Excision«: Herved forstås hel eller delvis fjernelse <strong>af</strong> klitoris samtidig med hel eller delvis fjernelse <strong>af</strong>de små skamlæber.»Infibulation«: Ved dette indgreb fjernes klitoris, de små skamlæber og en del <strong>af</strong> de store skamlæber,og de rå sårflader enten sys sammen eller holdes sammen på anden måde, således at der kunefterlades et meget lille hul til vandladning og menstruationsblod.Afgrænsningen mellem de forskellige former for <strong>om</strong>skæring er i praksis ikke skarp, og derforek<strong>om</strong>mer mellemformer. I lande, hvor kvindelig <strong>om</strong>skæring er udbredt, foretages indgrebet ofte <strong>af</strong>White Paper <strong>om</strong> religiøs <strong>om</strong>skærelse <strong>af</strong> <strong>drenge</strong> s.15 August 2012


uuddannede fødselshjælpere eller ældre kvinder i familien og uden bedøvelse, og det kan derforvariere meget, hvad der faktisk bliver skåret bort.Omskæring, specielt infibulation, kan have nogle umiddelbare helbredsmæssige følger og en rækkesenfølger, s<strong>om</strong> dels beror på indgrebets karakter, dels på den måde, indgrebet typisk bliver foretagetpå.Blandt de umiddelbare følger kan nævnes smertechok og psykisk chok på grund <strong>af</strong> indgrebetskarakter, blødning, smerter ved vandladning, infektioner, blodforgiftning og stivkrampe. Senfølgerneer bl.a. smerter ved menstruation, ophobning <strong>af</strong> menstruationsblod i skede og livmoder vedinfibulation, underlivssmerter, kronisk underlivsbetændelse, der kan medføre sterilitet, invaliderendevandladningsproblemer, gentagne urinvejsinfektioner, k<strong>om</strong>plikationer i forbindelse med graviditet ogfødsel på grund <strong>af</strong> uelastisk arvæv, smerter ved samleje og andre seksuelle problemer.Kvindelig <strong>om</strong>skæring er således et særdeles alvorligt indgreb, s<strong>om</strong> der efter regeringens opfattelse pådet kr<strong>af</strong>tigste må tages <strong>af</strong>stand fra.S<strong>om</strong> det fremgår <strong>af</strong> denne redegørelse fra <strong>Sundhedsstyrelsen</strong>, er <strong>om</strong>skærelse <strong>af</strong> et <strong>drenge</strong>barnvæsensforskellig fra kvindelig <strong>om</strong>skærelse og har hverken til formål at berøve seksualitet, ellerat begrænse nydelsen her<strong>af</strong>, og dette er da heller ikke konsekvensen <strong>af</strong> en mandlig<strong>om</strong>skærelse.4.2 Morten Frisch undersøgelseMorten Frisch har <strong>om</strong> nogen markeret sig i debatten <strong>om</strong> rituel <strong>om</strong>skærelse i s<strong>om</strong>meren 2012.Morten Frisch angiver selv, at hans grundholdning skyldes en spørgeskemaundersøgelse, s<strong>om</strong>er publiceret i 2011 4 , og s<strong>om</strong> skulle angive forhøjede k<strong>om</strong>plikationsprocenter ved <strong>om</strong>skærelserhos både den mandlige og kvindelige partner.Til forståelse <strong>af</strong> undersøgelsen skal følgende præciseres:1. Der er tale <strong>om</strong> en spørgeskemaundersøgelse <strong>om</strong> en række forskellige sundhedsemner(5000 adspurgte), hvor under halvdelen <strong>af</strong> dem, der fik et spørgeskema besvarede –dette er s<strong>om</strong> udgangspunkt problematisk, herunder er der ingen viden <strong>om</strong>, hvorvidtbesvareren er statistisk relevant.2. Af 2345 mænd, der besvarede spørgeskemaundersøgelsen, var 125 <strong>om</strong>skåret, og <strong>af</strong>2234 kvinder, der besvarede spørgeskemaundersøgelsen, var 83 samlevende med<strong>om</strong>skårede mænd.3. Af de 125 <strong>om</strong>skårede mænd rapporterede 7 (!), at de var muslimer (5) eller jøder (2).15 mænd rapporterede, at de var <strong>om</strong>skåret før 6 måneders alderen. Blandt de<strong>om</strong>skårede havde 14 udenlandsk baggrund. Den langt overvejende del <strong>af</strong> dem, derbesvarede spørgeskemaet og tilkendegav at være blevet <strong>om</strong>skåret, er således <strong>om</strong>skåret4Male circumcision and sexual function in men and w<strong>om</strong>en: a survey-based, cross-sectional study in Denmark, sammen med MortenLindholm og Morten Grønbæk, http://ije.oxfordjournals.org/content/early/2011/06/13/ije.dyr104.fullWhite Paper <strong>om</strong> religiøs <strong>om</strong>skærelse <strong>af</strong> <strong>drenge</strong> s.16 August 2012


<strong>af</strong> medicinske årsager, hvor<strong>af</strong> alvorlige tilstande s<strong>om</strong> peniscancer kan være årsagen,hvilket i sig selv kan have indflydelse på personens seksualliv. Hvis flertallet <strong>af</strong> de<strong>om</strong>skårede i forvejen havde et penisfunktionsproblem (grunden til, at de blev<strong>om</strong>skåret), er det sandsynligvis dette, s<strong>om</strong> resulterede i den øgede risiko for seksuelleproblemer – og ikke det faktum, at de er blevet <strong>om</strong>skåret. Man kan derfor ikke benyttedisse resultater til at beskrive langtidskonsekvenserne <strong>af</strong> <strong>om</strong>skærelse <strong>af</strong> raske<strong>drenge</strong>børn.4. Undersøgelsen <strong>om</strong>handler derfor i det væsentlige mænd, der er <strong>om</strong>skåret efter enlægelig undersøgelse og vurdering og ikke på raske personer og slet ikke på 8 dagegamle <strong>drenge</strong>, s<strong>om</strong> rituel, jødisk <strong>om</strong>skærelse foreskriver. Det er derfor megetbetænkeligt, at undersøgelsen søges anvendt til et forbud mod rituel <strong>om</strong>skærelse og, atmedierne tager undersøgelsen til indtægt for et forbud. Morten Frisch sammenligneræbler og pærer.5. Uanset et ringe statistisk materiale, konkluderer undersøgelsen, at <strong>om</strong>skærelse givernedsat orgasme hos både mænd og kvinder og for kvindernes vedk<strong>om</strong>mende desudensmerter og nedsat seksuel tilfredsstillelse.Morten Frisch (og de øvrige forfattere) slutter deres artikel <strong>af</strong> med at angive, at dette<strong>om</strong>råde skal undersøges nærmere – et forbehold for egne resultater, der på ingen mådehar præget Morten Frisch’ udtalelser hen over s<strong>om</strong>meren 2012. Dette harmonerer med, atMorten Frisch allerede forud for undersøgelsen har argumenteret mod rituel <strong>om</strong>skærelse<strong>af</strong> <strong>drenge</strong>.Morten Frisch’ undersøgelse samt teorierne <strong>om</strong> et stort antal k<strong>om</strong>plikationer harmonererikke med en lang række andre og betydeligt bredere (statistiske) undersøgelser:1. I en artikel, “Does sexual function survey in Denmark offer any support for malecircumcision having an adverse effect?” 5 kritiseres Morten Frisch’ undersøgelse (detstatistiske grundlag) samt de konklusioner, Morten Frisch drager.2. I artiklen, ”C<strong>om</strong>plications of circumcision in male neonates, infants and children: asystematic review” 6 , gennemgås en række undersøgelser foretaget i lande, deranvender <strong>om</strong>skærelser. Særligt skal nævnes en k<strong>om</strong>plikationsrisiko på 0,2% i enundersøgelse foretaget i USA på 130.475 <strong>om</strong>skårede mænd og en undersøgelseforetaget i Israel på 19.478 <strong>om</strong>skårede mænd med en k<strong>om</strong>plikationsrisiko på 0,1%.Sammenfattende kan det overordnet siges, at Morten Frisch’ undersøgelse udgør ”en enligsvale” og på ingen måde er det ”endelige bevis” på, at det er lægeligt kontraindiceret atforetage rituel jødisk <strong>om</strong>skærelse.Uanset dette, er der fremk<strong>om</strong>met 2 synspunkter, s<strong>om</strong> skal k<strong>om</strong>menteres nærmere.5 Bryan J. Morris m.fl. http://ije.oxfordjournals.org/content/41/1/310.full6 Helen A. Weiss m.fl., http://www.bi<strong>om</strong>edcentral.c<strong>om</strong>/1471-2490/10/2White Paper <strong>om</strong> religiøs <strong>om</strong>skærelse <strong>af</strong> <strong>drenge</strong> s.17 August 2012


For det første er det anført s<strong>om</strong> en teori, at <strong>om</strong>skærelse skulle medføre en mindre føls<strong>om</strong>hed,s<strong>om</strong> dels skulle medføre orgasmeproblemer hos manden og smerter ved samleje hos kvinden.Denne teori har ingen støtte i anden forskning hverken relateret til hetero- eller h<strong>om</strong>oseksuelleoplevelser hos <strong>om</strong>skårede mænd og deres partnere.For det andet er det anført, at man kan <strong>af</strong>vente, at barnet selv kan træffe et valg (f.eks. det 18.år). Der foreligger klare undersøgelsesresultater, der viser, at såfremt <strong>om</strong>skærelsen gennemføress<strong>om</strong> en rituel jødisk <strong>om</strong>skærelse på det spæde barn, er k<strong>om</strong>plikationsrisikoen og oplevelse<strong>af</strong> ubehag m.v. mindst. 74.3 Patientforsikringens talPatientforsikringen (forsikringsordningen for lægelig behandling) har redegjort for anmeldelseri relation til <strong>om</strong>skærelser i lægelig praksis. Ministeriet for sundhed og forebyggelse har i et svarden 2. juli 2012 til Folketingets Sundheds- og Forebyggelsesudvalg anført, at der i perioden1996 – 2012 har været 65 anmeldelser til Patientforsikringen <strong>af</strong> k<strong>om</strong>plikationer i relation til<strong>om</strong>skærelse.De korrekte tal fra Patientforsikringen er:51 anmeldelser efter ikke-rituelle <strong>om</strong>skærelser, dvs. <strong>om</strong>skærelser, der har fundet sted på enhospitals<strong>af</strong>deling eller hos en praktiserende speciallæge – og s<strong>om</strong> ofte vil være lægeligtindikeret (f.eks. forhudsforsnævring). Kun 1 <strong>af</strong> disse anmeldelser er anerkendt.14 anmeldelser efter rituelle <strong>om</strong>skærelser, udført <strong>af</strong> læger, dvs. ingen anmeldelser <strong>af</strong> rituelle,jødiske <strong>om</strong>skærelser, der udføres <strong>af</strong> en <strong>om</strong>skærer. Kun 2 <strong>af</strong> disse anmeldelser er anerkendtmed udbetaling <strong>af</strong> en erstatning på 10.000 kr.I en 16 årig periode er der således anmeldt 14 patientskader efter rituel <strong>om</strong>skæring, foretaget<strong>af</strong> en læge, hvor<strong>af</strong> 2 er anerkendt <strong>af</strong> Patientforsikringen. Ingen <strong>af</strong> disse tilfælde har sammenhængmed rituel, jødisk <strong>om</strong>skærelse, hvorfor anførelsen <strong>af</strong> disse tal i debatten er misvisende.4.4 WHO’s rek<strong>om</strong>mandationer vedrørende <strong>om</strong>skærelseFlere studier har påvist lavere HIV forek<strong>om</strong>st i lande, hvor en stor del <strong>af</strong> den mandligebefolkning er <strong>om</strong>skåret. Epidemiologiske undersøgelser kan imidlertid ikke bruges til atundersøge for eventuel årsagssammenhæng, dvs. <strong>om</strong> den lavere forek<strong>om</strong>st <strong>af</strong> HIV er betinget<strong>af</strong> stor udbredelse <strong>af</strong> mandlige <strong>om</strong>skærelser.Tre store rand<strong>om</strong>iserede (lodtræknings) undersøgelser, gennemført i hhv. Syd<strong>af</strong>rika, Kenya ogUganda, 8 9 10 har enslydende fundet nedsat hyppighed <strong>af</strong> ny HIV smitte blandt mænd, s<strong>om</strong> ved7 Helen A. Weiss m.fl., http://www.bi<strong>om</strong>edcentral.c<strong>om</strong>/1471-2490/10/2 og A ‘snip’ in time: what is the best age tocircumcise?, Bryan J. Morris m.fl. http://www.bi<strong>om</strong>edcentral.c<strong>om</strong>/1471-2431/12/208 Auvert B, Taljaard D, Lagarde E, Sobngwi-Tambekou J, Sitta R, Puren A: Rand<strong>om</strong>ized, controlled intervention trial of male circumcision forreduction of HIV infection risk: the ANRS 1265 Trial. PLoS Med 2005;2:e298.9 Bailey RC, Moses S, Parker CB, Agot K, Maclean I, Krieger JN, Williams CF, Campbell RT, Ndinya-Achola JO: Male circumcision for HIV prevention inyoung men in Kisumu, Kenya: a rand<strong>om</strong>ised controlled trial. Lancet 2007;369:643-656.White Paper <strong>om</strong> religiøs <strong>om</strong>skærelse <strong>af</strong> <strong>drenge</strong> s.18 August 2012


lodtrækning fik foretaget <strong>om</strong>skærelse umiddelbart i forhold til de mænd, s<strong>om</strong> var planlagt til atblive <strong>om</strong>skåret senere.Alle tre studier blev <strong>af</strong>brudt før tid, da man på grund <strong>af</strong> beskyttelsen mod pådragelse <strong>af</strong> HIVinfektionblandt dem, s<strong>om</strong> fik foretaget umiddelbar <strong>om</strong>skærelse, ikke fandt det etisk forsvarligtat fortsætte undersøgelserne. Risikoen for HIV-smitte blev nedsat med ca. 60 %. Samlet deltog>10.000 mænd i undersøgelserne. 11Resultaterne fra disse undersøgelser fik i 2007 et ekspertpanel under WHO til at anbefale, atmandlig <strong>om</strong>skærelse blev inkluderet i metoderne til forebyggelse <strong>af</strong> heteroseksuelt overførtHIV i lande med høj forek<strong>om</strong>st <strong>af</strong> HIV infektion. 12Beregninger tyder på, at man ved fuld implementering <strong>af</strong> <strong>om</strong>skærelse i det sydlige Afrika villekunne forhindre 1-4 millioner tilfælde <strong>af</strong> HIV-infektion over en 10-års periode. 13At WHO anbefaler <strong>om</strong>skærelse taler vel tillige imod, at <strong>om</strong>skærelse skulle medførebeskadigelser for den <strong>om</strong>skårede.4.5 Omskærelsers betydning for livmoderhalskræft, peniscancer, infektioner, urinvejsinfektioner,prostatacancer og seksuelt overførte sygd<strong>om</strong>meFølgende er lægeligt dokumenteret:Omskærelse medfører en betydelig reduktion i livmoderhalskræft hos den <strong>om</strong>skåredespartnerOmskærelse fører til reduktion med to tredjedele i antallet <strong>af</strong> peniscancer hos den<strong>om</strong>skåredeDer ses to tredjedel færre infektioner på penishoved og 5-10 gange færreurinvejsinfektioner, s<strong>om</strong> kan føre til permanente nyreskaderDer ses langt færre seksuelt overførte sygd<strong>om</strong>me, heriblandt herpes, syfilis og studiertyder på nedsat smitte med klamydia, s<strong>om</strong> er en <strong>af</strong> hovedårsagerne til nedsatfrugtbarhed hos kvinder.Endelig synes antallet <strong>af</strong> prostatacancer at være mindre hos <strong>om</strong>skårede mænd, set iforhold til ikke-<strong>om</strong>skårede mænd.10 Gray RH, Kigozi G, Serwadda D, Makumbi F, Watya S, Nalugoda F, Kiwanuka N, Moulton LH, Chaudhary MA, Chen MZ, Sewankambo NK,Wabwire-Mangen F, Bacon MC, Williams CF, Opendi P, Reynolds SJ, Laeyendecker O, Quinn TC, Wawer MJ: Male circumcision for HIV prevention inmen in Rakai, Uganda: a rand<strong>om</strong>ised trial. Lancet 2007;369:657-666.11 Mills E, Cooper C, Anema A, Guyatt G: Male circumcision for the prevention of heterosexually acquired HIV infection: a meta-analysis ofrand<strong>om</strong>ized trials involving 11,050 men. HIV Med 2008;9:332-335.12 WHO and UNAIDS announce rec<strong>om</strong>mendations fr<strong>om</strong> expert consultation on male circumcision for HIV prevention.http://www.who.int/mediacentre/news/releaes/2007/pr10/en/index.html: 2007.13 Williams BG, Lloyd-Smith JO, Gouws E, Hankins C, Getz WM, Hargrove J, de Z, I, Dye C, Auvert B: The potential impact of male circumcision on HIVin Sub-Saharan Africa. PLoS Med 2006;3:e262.White Paper <strong>om</strong> religiøs <strong>om</strong>skærelse <strong>af</strong> <strong>drenge</strong> s.19 August 2012


5. Den juridiske kontekst5.1 Det danske regelgrundlagEn række regler regulerer <strong>om</strong>skærelser <strong>af</strong> <strong>drenge</strong> i Danmark. 14I det følgende redegøres for (1) hvem der må foretage <strong>om</strong>skærelsen og (2) betydningen <strong>af</strong> etinformeret samtykke.(1) Hvem må foretage <strong>om</strong>skærelsen?Autorisationslovens § 18 bestemmer, at <strong>Sundhedsstyrelsen</strong> skal fastsætte nærmere regler <strong>om</strong>autoriserede sundhedspersoners benyttelse <strong>af</strong> medhjælp.<strong>Sundhedsstyrelsen</strong> har efter § 18 offentliggjort Delegationsbekendtgørelsen.Af Delegationsbekendtgørelsens § 1 fremgår, at autoriserede sundhedspersoner, herunderlæger, kan uddelegere alle former for sundhedsfaglig virks<strong>om</strong>hed til ikke-autoriseredepersoner, dog med undtagelse <strong>af</strong> virks<strong>om</strong>hed, der er nævnt i § 2.Delegationsbekendtgørelsens § 2 opremser en række sundhedsfaglige virks<strong>om</strong>heder, s<strong>om</strong> ikkekan delegeres ud. Af særlig interesse kan nævnes, at kosmetiske behandlinger ikke kan udføres<strong>af</strong> andre end en autoriseret sundhedsperson.Omskærelse defineres i Sundhedsloven dog ikke s<strong>om</strong> kosmetisk behandling, jf. listen nævnt iforarbejderne til Autorisationslovens kapitel 25 (LFF 2005-12-14 nr. 111).Af forarbejderne til Autorisationslovens § 74 fremgår endvidere, at <strong>om</strong>skærelse kan uddelegerestil lægers medhjælpere.Der anføres følgende: ”Hvis et indgreb uden terapeutisk formål er mere <strong>om</strong>fattende end denovennævnte gennembrydning <strong>af</strong> huden, regnes dette for et operativt indgreb i § 74's forstand,og er således forbeholdt læger (og tandlæger) og disses medhjælp at udføre. Eksempler pådette er <strong>om</strong>skæring <strong>af</strong> <strong>drenge</strong> og kosmetisk behandling.”Det følger også <strong>af</strong> Omskærelsesvejledningen, at en læges medhjælp kan udføre indgrebet.Ifølge Delegationsbekendtgørelsens § 3, stk. 1 skal lægen sikre sig, at medhjælperen erkvalificeret til og har modtaget instruktion i at udføre opgaven.14 Lovbekendtgørelse 2011-08-04 nr. 877 <strong>om</strong> autorisation <strong>af</strong> sundhedspersoner og <strong>om</strong> sundhedsfaglig virks<strong>om</strong>hed (herefter ”Autorisationsloven”).Lovbekendtgørelse 2010-07-13 nr. 913 (herefter ”Sundhedsloven”). Bekendtgørelse 2009-11-12 nr. 1219 <strong>om</strong> autoriserede sundhedspersonersbenyttelse <strong>af</strong> medhjælp (delegation <strong>af</strong> forbeholdt sundhedsfaglig virks<strong>om</strong>hed) (herefter ”Delegationsbekendtgørelsen”). Bekendtgørelse 1998-09-14, nr. 665 <strong>om</strong> information og samtykke og <strong>om</strong> videregivelse <strong>af</strong> helbredsoplysninger mv. (herefter ”Samtykkebekendtgørelsen”). Vejledning <strong>af</strong> 23-05-2005 nr. 9267 <strong>om</strong> <strong>om</strong>skæring <strong>af</strong> <strong>drenge</strong> (herefter ”Omskærelsesvejledningen”). Vejledning <strong>af</strong> 16-09-1998 nr. 161 <strong>om</strong> information og samtykke og<strong>om</strong> videregivelse <strong>af</strong> helbredsoplysninger mv. (Herefter ”Samtykkevejledningen”)White Paper <strong>om</strong> religiøs <strong>om</strong>skærelse <strong>af</strong> <strong>drenge</strong> s.20 August 2012


Endvidere skal lægen i fornødent <strong>om</strong>fang føre tilsyn med medhjælperens udførelse <strong>af</strong>virks<strong>om</strong>heden.S<strong>om</strong> anført ovenfor, er der altid en læge til stede til en jødisk <strong>om</strong>skærelse.Lægen sikrer sig, at personen, der <strong>om</strong>skærer <strong>drenge</strong>n, er kvalificeret til og har modtagetinstruktion i at udføre <strong>om</strong>skærelsen, hvilke kriterier Overrabbiner Bent Lexner opfylder.Det er således fuldstændig i overensstemmelse med dansk ret, at det er Overrabbiner BentLexner, der udfører selve <strong>om</strong>skærelsen, da <strong>om</strong>skærelsen er et indgreb, der kan udføres <strong>af</strong> enmedhjælper.(2) Informeret samtykkeS<strong>om</strong> udgangspunkt må der kun udføres indgreb, s<strong>om</strong> personen har givet sit informeredesamtykke til, jf. Sundhedslovens § 15.Såfremt personen er under 15 år, skal forældrene give informeret samtykke til indgrebet, jf.Sundhedslovens § 17 modsætningsvist. Dette understøttes <strong>af</strong> Samtykkevejledningens pkt. 2.1.I øvrigt skal de formelle betingelser i Samtykkebekendtgørelsen være opfyldt, hvilket blandtandet indebærer, at samtykket skal gives frivilligt på baggrund <strong>af</strong> fyldestgørende information.Jødiske forældre giver frivilligt samtykke til <strong>om</strong>skærelsen <strong>af</strong> deres søn efter forinden indgrebetat være informeret <strong>om</strong> indgrebets karakter, risici og konsekvenser.Den jødiske <strong>om</strong>skærelse opfylder således de almindelige danske lovkrav til informeretsamtykke, da det er forældrene, der kan give samtykket.5.2 Forholdet til børnekonventionenI forbindelse med debatten <strong>om</strong> <strong>om</strong>skærelse er det bl.a. anført, at FN's Børnekonvention fra1989 indebærer et forbud mod <strong>om</strong>skærelse <strong>af</strong> <strong>drenge</strong>.Dette er ikke korrekt.Børnekonventionens artikel 24, stk. 3, fastslår, at deltagerstaterne skal tage alle effektive ogpassende foranstaltninger for at <strong>af</strong>sk<strong>af</strong>fe traditionsbundne ritualer, s<strong>om</strong> er skadelige for børnssundhed.Børnekonventionen er tiltrådt <strong>af</strong> en række stater, s<strong>om</strong> anerkender <strong>om</strong>skærelse <strong>af</strong> <strong>drenge</strong>, ogder er en klar opfattelse i det internationale samfund og i det juridiske miljø i Danmark, atbørnekonventionen tilsigter at beskytte female genital mutilation (kvindelig <strong>om</strong>skærelse) ogikke angår <strong>om</strong>skærelse <strong>af</strong> <strong>drenge</strong>. 1515 Se Jurisdiktionsudvalgets udtalelse i forbindelse med indførelse <strong>af</strong> forbud mod kvindelig <strong>om</strong>skærelse samt Kirsten Ketscher i Nye retlige design, s.14ff. 2003.White Paper <strong>om</strong> religiøs <strong>om</strong>skærelse <strong>af</strong> <strong>drenge</strong> s.21 August 2012


Dette stemmer da også overens med, at ikke et eneste land i verden har et forbud mod<strong>om</strong>skærelse <strong>af</strong> <strong>drenge</strong>.5.3 Barnets selvbestemmelsesret – forældres beslutninger på barnets vegneOmskærelse <strong>af</strong> et <strong>drenge</strong>barn på otte dage besluttes udelukkende <strong>af</strong> forældrene, s<strong>om</strong> oftestalene <strong>af</strong> kulturelle og religiøse årsager. Det er klart, at barnet ikke selv har indflydelse påbeslutningen og <strong>om</strong>skærelse er dermed et ufrivilligt indgreb på barnets krop. Omskæringen eret varigt, fysisk indgreb, s<strong>om</strong> barnet ikke senere kan gøre <strong>om</strong>.S<strong>om</strong> det er påvist, er accepten <strong>af</strong> <strong>om</strong>skæring <strong>af</strong> <strong>drenge</strong>børn i overensstemmelse med dansk oginternational ret. Dette <strong>af</strong>snit skal således drøfte, hvorvidt hensynet til barnets selvbestemmelsesretbør tillægges en særlig vægt.Udgangspunktet er, at mennesket er født frit med ret til selvbestemmelse over eget liv og egenkrop. Det er derfor s<strong>om</strong> udgangspunkt det voksne menneske selv, der bestemmer over egenlivsførelse og egen krop i det <strong>om</strong>fang, det ikke skader andres ret til eget liv og krop.Det er dog alment accepteret, at forældre, mens barnet ikke er beslutningsmodent, kan træffebeslutninger på barnets vegne.Forældre træffer således i dag en række (faktiske) beslutninger på det ufødte og fødte barnsvegne. Det drejer sig bl.a. <strong>om</strong>:Abort – herunder abort i forbindelse med fosterdiagnostik.Kosmetiske operationer i relation til børn, født med mere eller mindre alvorligedeformiteter. Disse kosmetiske operationer spænder fra deciderede deformiteter iansigtet og på kroppen over hareskår og tandoperationer til mindre alvorlige tilfælde,sås<strong>om</strong> tilretning <strong>af</strong> ’stritøre’.Rettelse <strong>af</strong> "skæve" næser mv.Piercing og huller i ørerne.Det skal præciseres, at "deformiteter" ikke behøver at være begrundede i sundhedsstandarder.Personer med deformiteter kan have duelige og almindelige kropsfunktioner. Indgrebene erbaseret på at give personen en mulighed for en almindeligt, social livsførelse. Indgrebene erderfor kulturelt og socialt bestemt.Særligt <strong>om</strong> stritøreoperationer udtaler sundhedsminister Astrid Kragh, at det kan have alvorligepsykiske og sociale konsekvenser, såfremt man har stritører. 1616 Astrid Kraghs besvarelse <strong>af</strong> den 30. maj 2012 <strong>af</strong> Sophie Løhdes spørgsmål (S 3256)White Paper <strong>om</strong> religiøs <strong>om</strong>skærelse <strong>af</strong> <strong>drenge</strong> s.22 August 2012


Stritøreoperationer udføres både på børn og voksne, og der er ikke begrænsninger for, hvornåren sådan operation kan udføres og ej heller, <strong>om</strong> barnet selv indvilliger i det. 17Indgrebet foretages <strong>af</strong> kosmetiske årsager, da et manglende indgreb kan medføre psykiske ogsociale konsekvenser. Det må dog konstateres, at stritører i sig selv ikke er medvirkende til deneventuelle psykiske lidelse. Den psykiske lidelse må formodes at være grundet i de sociale ogkulturelle <strong>om</strong>stændigheder, da personen udvikler psykiske lidelser på baggrund <strong>af</strong> denbehandling, personen modtager, når denne har stritører. Det kan således konstateres, atindgreb på mindreårige kan begrundes i sociale og kulturelle <strong>om</strong>stændigheder.Forældrene træffer tillige i dag en række (indirekte) beslutninger på barnets vegne. Det drejersig bl.a. <strong>om</strong>:Moderens alkoholindtagelse under graviditet, s<strong>om</strong> beviseligt medfører en betydeligrisiko for fosterskader.Forældres rygning i barnets hjem, s<strong>om</strong> beviseligt medfører en betydelig risiko for skaders<strong>om</strong> følge <strong>af</strong> passiv rygning.Deltagelse i – eller netop ikke deltagelse i – generelle vaccinationsprogrammer for børn.Herudover træffer forældre naturligvis en række beslutninger på sine børns vegne, s<strong>om</strong>utvivls<strong>om</strong>t får <strong>af</strong>gørende betydning for barnets senere opvækst og liv.Det er evident, at der generelt set ikke er et ønske <strong>om</strong> at lovgive <strong>om</strong> disse forhold. Selv<strong>om</strong> deter utvivls<strong>om</strong>t, at f.eks. en overdreven alkoholindtagelse under en graviditet har direktebetydning for u<strong>af</strong>vendelige fosterskader, er der intet ønske <strong>om</strong> at kriminalisere den gravidesindtagelse <strong>af</strong> alkohol over en vis mængde, samt kriminalisere købmandens eller supermarkedetssalg <strong>af</strong> alkoholiske drikke til gravide.S<strong>om</strong> anført ovenfor, er den jødiske <strong>om</strong>skærelse en hovedhjørnesten i barnets tilknytning tilden jødiske kultur, sin familie og religionen.Man kan spørge (s<strong>om</strong> det er blevet gjort i den offentlige debat), hvorvidt tilknytningen til denjødiske kultur, familien og religionen sidder mellem benene?Liges<strong>om</strong> et <strong>om</strong>skåret jødisk barn senere kan fravælge kulturen, religionen og familien, vil etikke-<strong>om</strong>skåret jødisk barn i lige så høj grad vælge eller fravælge kulturen, religionen ogfamilien. Selv<strong>om</strong> det således ikke er en nødvendig betingelse for den jødiske tilknytning (ellerdet modsatte), at barnet er <strong>om</strong>skåret, har det alligevel en <strong>af</strong>gørende betydning for denkulturelle identitet og selvforståelse. Dette skal forstås på samme måde, s<strong>om</strong> når et barn får17 Se blandt andet: Privathospitalet Mølholm A/S – Patientinformation <strong>om</strong> operation for udestående ører/stritører og http://www.ouh.dk/wm186925(Odense Universitetshospitals beskrivelse <strong>af</strong> stritøreroperationer).White Paper <strong>om</strong> religiøs <strong>om</strong>skærelse <strong>af</strong> <strong>drenge</strong> s.23 August 2012


stritøreoperationer. Det er ikke nødvendigt for barnet at få stritøreoperationer for at føletilknytning til det <strong>om</strong>kringliggende samfund, men det anses for at være <strong>af</strong> betydning forbarnets muligheder dertil.Forskellen i <strong>om</strong>skærelse og for eksempel stritøreoperationer ligger i det <strong>om</strong>kringliggendesamfunds holdning til det nødvendige i indgrebet. Stritøreoperationer foretages på baggrund <strong>af</strong>sociale og kosmetiske årsager, s<strong>om</strong> er mere accepteret end begrundelserne for <strong>om</strong>skærelse,der ligger i det særegne kulturelle og religiøse. Dette ændrer dog ikke ved, at stritøreoperationeri sidste ende er baseret på kulturelle årsager – men blot andre kulturelle årsagerend <strong>om</strong>skærelsen.Omskæringen er <strong>af</strong> stor betydning for barnets tilknytning til den jødiske kultur, sin familie ogreligionen og har derfor sin berettigelse på samme vilkår, s<strong>om</strong> almindelige kosmetiske indgreb,der også er baseret i barnets tilknytning til kultur og det <strong>om</strong>kringliggende samfund – og i øvrigtpå linje med accepten <strong>af</strong>, at et barns forældre træffer en række direkte og indirekte valg påbarnets vegne, s<strong>om</strong> har direkte indflydelse på barnets opvækst og liv.Et forbud, begrundet i barnets selvbestemmelsesret, vil således være et markant brud pådenne linje – navnlig når der ikke foreligger medicinske tvingende grunde (s<strong>om</strong> tilfældet varved kvindelige <strong>om</strong>skærelser).5.4 Religionsfrihed – og proportionalitetGrundlovens § 67 sikrer retten til at dyrke sin religion og Den Europæiske Menneskerettighedsartikel 9, der er sålydende:Art. 9Stk.1. Enhver har ret til at tænke frit og til samvittigheds- og religionsfrihed; denne ret <strong>om</strong>fatterfrihed til at skifte religion eller tro samt frihed til enten alene eller sammen med andre,offentligt eller privat at udøve sin religion eller tro gennem gudstjeneste, undervisning, andagtog overholdelse <strong>af</strong> religiøse skikke.Stk.2. Frihed til at udøve sin religion eller tro skal kun kunne underkastes sådannebegrænsninger, s<strong>om</strong> er foreskrevet ved lov og er nødvendige i et demokratisk samfund <strong>af</strong>hensyn til den offentlige tryghed, for at beskytte den offentlige orden, sundheden ellersædeligheden eller for at beskytte andres rettigheder og friheder.Det er fast antaget, at et indgreb i religionsfriheden kræver (1) lovhjemmel, (2) et legitimtformål og nødvendighed i et demokratisk samfund.Allerede s<strong>om</strong> følge <strong>af</strong>, at <strong>om</strong>skærelse <strong>af</strong> <strong>drenge</strong> ikke er forbudt i et eneste land, der har tiltrådtDen Europæiske Menneskerettighedskonvention, er der meget der taler for, at et <strong>om</strong>skærelsesforbudikke er et legitimt formål og en nødvendighed i et demokratisk samfund.White Paper <strong>om</strong> religiøs <strong>om</strong>skærelse <strong>af</strong> <strong>drenge</strong> s.24 August 2012


Den foreliggende medicinske forskning, se bemærkningerne ovenfor, er på ingen måde entydig,hvilket selv anføres <strong>af</strong> den forskning, der er kritisk overfor <strong>om</strong>skærelse <strong>af</strong> <strong>drenge</strong> (i modsætningtil, hvad der var tilfældet for <strong>om</strong>skærelse <strong>af</strong> piger).Ved vurderingen <strong>af</strong> <strong>om</strong> der foreligger et legitimt formål og en nødvendighed i et demokratisksamfund, må man tillige tage i betragtning, hvilke andre (mere eller mindre) lige artede forhold,der reguleres <strong>af</strong> lovgivningen, henholdsvis ikke reguleres <strong>af</strong> lovgivningen – den såkaldte"proportionalitetsvurdering".S<strong>om</strong> anført foroven under pkt. 5.3, accepteres det i det danske samfund, at forældre harbetydelig valgfrihed og dermed beslutningsfrihed i relation til deres børn. Et forbud mod<strong>om</strong>skærelse <strong>af</strong> <strong>drenge</strong>, også i relation til denne beslutningsfrihed, siges at være ikkeproportional.Der er således sammenfattende en betydelig risiko for, at et forbud mod <strong>om</strong>skærelse <strong>af</strong><strong>drenge</strong>børn vil stride mod religionsfrihedsretten i den danske grundlov, set i sammenhængmed Den Europæiske Menneskerettighedskonvention, da et forbud ikke kan begrundes med etlegitimt formål og en nødvendighed i et demokratisk samfund og vil være ikke-proportionalt iforhold til, hvilke beslutninger forældre ellers frit kan træffe på sit barns vegne.Det Mosaiske Troessamfund, Det Jødiske Samfund i DanmarkKøbenhavn, august 2012White Paper <strong>om</strong> religiøs <strong>om</strong>skærelse <strong>af</strong> <strong>drenge</strong> s.25 August 2012


Male CircumcisionTASK FORCE ON CIRCUMCISIONPediatrics 2012;130;e756; originally published online August 27, 2012;DOI: 10.1542/peds.2012-1990The online version of this article, along with updated information and services, islocated on the World Wide Web at:http://pediatrics.aappublications.org/content/130/3/e756.full.htmlPEDIATRICS is the official journal of the American Academy of Pediatrics. A monthlypublication, it has been published continuously since 1948. PEDIATRICS is owned,published, and trademarked by the American Academy of Pediatrics, 141 Northwest PointBoulevard, Elk Grove Village, Illinois, 60007. Copyright © 2012 by the American Academyof Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.Downloaded fr<strong>om</strong> pediatrics.aappublications.org by guest on June 19, 2013


TECHNICAL REPORTMale CircumcisionabstractMale circumcision consists of the surgical removal of s<strong>om</strong>e, or all, of theforeskin (or prepuce) fr<strong>om</strong> the penis. It is one of the most c<strong>om</strong>mon proceduresin the world. In the United States, the procedure is c<strong>om</strong>monly performedduring the newborn period. In 2007, the American Academy ofPediatrics (AAP) convened a multidisciplinary workgroup of AAP membersand other stakeholders to evaluate the evidence regarding male circumcisionand update the AAP’s 1999 rec<strong>om</strong>mendations in this area. The TaskForce included AAP representatives fr<strong>om</strong> specialty areas as well as membersof the AAP Board of Directors and liaisons representing the AmericanAcademy of Family Physicians, the American College of Obstetricians andGynecologists, and the Centers for Disease Control and Prevention. TheTask Force members identified selected topics relevant to male circumcisionand conducted a critical review of peer-reviewed literature by usingthe American Heart Association’s template for evidence evaluation.Evaluation of current evidence indicates that the health benefits of newbornmale circumcision outweigh the risks; furthermore, the benefits ofnewborn male circumcision justify access to this procedure for familieswho choose it. Specific benefits fr<strong>om</strong> male circumcision were identified forthe prevention of urinary tract infections, acquisition of HIV, transmissionof s<strong>om</strong>e sexually transmitted infections, and penile cancer. Male circumcisiondoes not appear to adversely <strong>af</strong>fect penile sexual function/sensitivity or sexual satisfaction. It is imperative that those providing circumcisionare adequately trained and that both sterile techniques andeffective pain management are used. Significant acute c<strong>om</strong>plicationsare rare. In general, untrained providers who perform circumcisions havemore c<strong>om</strong>plications than well-trained providers who perform the procedure,regardless of whether the former are physicians, nurses, or traditionalreligious providers.Parents are entitled to factually correct, nonbiased information about circumcisionand should receive this information fr<strong>om</strong> clinicians before conceptionor early in pregnancy, which is when parents typically makecircumcision decisions. Parents should determine what is in the best interestof their child. Physicians who counsel families about this decisionshould provide assistance by explaining the potential benefits and risksand ensuring that parents understand that circumcision is an electiveprocedure. The Task Force strongly rec<strong>om</strong>mends the creation, revision,and enhancement of educational materials to assist parents of maleinfants with the care of circumcised and uncircumcised penises. The TaskForce also strongly rec<strong>om</strong>mends the development of educational materialsfor providers to enhance practitioners’ c<strong>om</strong>petency in discussingcircumcision’s benefits and risks with parents.The Task Force made the following rec<strong>om</strong>mendations:TASK FORCE ON CIRCUMCISIONKEY WORDcircumcisionABBREVIATIONSAAFP—American Academy of Family PhysiciansAAP—American Academy of PediatricsACOG—American College of Obstetricians and GynecologistsBV—bacterial vaginosisCB—caudal blockCDC—Centers for Disease Control and PreventionCDM—Charge Data MasterCI—confidence intervalDPNB—dorsal penile nerve blockHPV—human papill<strong>om</strong>avirusHSV—herpes simplex virusIELT—Intravaginal Ejaculatory Latency TimesMSM—men who have sex with menNHDS—National Hospital Discharge SurveyNIS—National Inpatient SampleOR—odds ratioRCT—rand<strong>om</strong>ized controlled trialSTI—sexually transmitted infectionUTI—urinary tract infectionThis document is copyrighted and is property of the AmericanAcademy of Pediatrics and its Board of Directors. All authorshave filed conflict of interest statements with the AmericanAcademy of Pediatrics. Any conflicts have been resolved througha process approved by the Board of Directors. The AmericanAcademy of Pediatrics has neither solicited nor accepted anyc<strong>om</strong>mercial involvement in the development of the content ofthis publication.The guidance in this report does not indicate an exclusivecourse of treatment or serve as a standard of medical care.Variations, taking into account individual circumstances, may beappropriate.All technical reports fr<strong>om</strong> the American Academy of Pediatricsaut<strong>om</strong>atically expire 5 years <strong>af</strong>ter publication unless re<strong>af</strong>firmed,revised, or retired at or before that time.www.pediatrics.org/cgi/doi/10.1542/peds.2012-1990doi:10.1542/peds.2012-1990PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).Copyright © 2012 by the American Academy of Pediatricse756FROM THE AMERICAN ACADEMY OF PEDIATRICSDownloaded fr<strong>om</strong> pediatrics.aappublications.org by guest on June 19, 2013


FROM THE AMERICAN ACADEMY OF PEDIATRICS Evaluation of current evidence indicatesthat the health benefits ofnewborn male circumcision outweighthe risks, and the benefitsof newborn male circumcision justifyaccess to this procedure forthose families who choose it. Parents are entitled to factuallycorrect, nonbiased information aboutcircumcision that should be providedbefore conception and early in pregnancy,when parents are most likelyto be weighing the option of circumcisionof a male child. Physicians counseling familiesabout elective male circumcisionshould assist parents by explaining,in a nonbiased manner, the potentialbenefits and risks and by ensuringthat they understand theelective nature of the procedure. Parents should weigh the healthbenefits and risks in light of theirown religious, cultural, and personalpreferences, as the medicalbenefits alone may not outweighthese other considerations for individualfamilies. Parents of newborn boys should beinstructed in the care of the penis,regardless of whether the newbornhas been circumcised or not. Elective circumcision should beperformed only if the infant’s conditionis stable and healthy. Male circumcision should be performedby trained and c<strong>om</strong>petentpractitioners, by using sterile techniquesand effective pain management. Analgesia is s<strong>af</strong>e and effective inreducing the procedural pain associatedwith newborn circumcision;thus, adequate analgesia shouldbe provided whenever newborncircumcision is performed.8Nonpharmacologic techniques(eg, positioning, sucrose pacifiers)alone are insufficient toprevent procedural and postproceduralpain and are notrec<strong>om</strong>mended as the sole methodof analgesia. They should beused only as analgesic adjunctsto improve infant c<strong>om</strong>fort duringcircumcision.8 If used, topical creams may causea higher incidence of skin irritationin low birth weight infants,c<strong>om</strong>pared with infants of normalweight; penile nerve block techniquesshould therefore be chosenfor this group of newborns. Key professional organizations(AAP, the American Academy ofFamily Physicians, the AmericanCollege of Obstetricians and Gynecologists,the American Society ofAnesthesiologists, the AmericanCollege of Nurse Midwives, andother midlevel clinicians such asnurse practitioners) should workcollaboratively to:8 Develop standards of traineeproficiency in the performanceof anesthetic and proceduretechniques, including suturing;8 Teach the procedure and analgesictechniques during postgraduatetraining programs;8 Develop educational materialsfor clinicians to enhance theirownc<strong>om</strong>petencyindiscussingthe benefits and risks of circumcisionwith parents;8 Offer educational materials toassist parents of male infantswith the care of both circumcisedand uncircumcised penises. The preventive and public health benefitsassociated with newborn malecircumcision warrant third-partyreimbursement of the procedure.The American College of Obstetriciansand Gynecologists has endorsed thistechnical report. Pediatrics 2012;130:e756–e785INTRODUCTION AND BACKGROUNDStatement of the IssueThe American Academy of Pediatrics’(AAP) statement on circumcision ofthe newborn penis was last issued inMay 1999. 1 The Circumcision PolicyStatement recognized the health benefitsof circumcision but did not deemthe procedure to be a medical necessityfor the well-being of the child. Sincethat time, substantial contributionshave been made to the peer-reviewedliterature concerning circumcision ofmales and its possible benefits. For thisreason, in 2007, the AAP formed a TaskForce charged with reviewing currentevidence on male circumcision andupdating the policy on this procedureto provide guidance to AAP membershipregarding the circumcision ofnewborn males.The American College of Obstetriciansand Gynecologists has endorsed thistechnical report.BackgroundMale circumcision consists of thesurgical removal of s<strong>om</strong>e, or all, of theforeskin (or prepuce) fr<strong>om</strong> the penis. Itis one of the most c<strong>om</strong>mon proceduresin the world. In the United States, theprocedure is most frequently performedduring the newborn period.Elective circumcision performed soon<strong>af</strong>ter the newborn period is generallya result of deferral because of lowbirth weight or illness in the newborn.Circumcision <strong>af</strong>ter the newborn periodis most c<strong>om</strong>monly performed becauseof the infant’s low birth weight or illnessprecluded newborn circumcision.Other infants are circumcisedlater in life because of the occurrenceof tight phimosis and/or urinary tractinfection (UTI).The 3 most c<strong>om</strong>mon operative methodsof circumcision for the newbornmale include: the G<strong>om</strong>co clamp, thePlastibell device, and the Mogen clamp(or variations derived fr<strong>om</strong> the samePEDIATRICS Volume 130, Number 3, September 2012Downloaded fr<strong>om</strong> pediatrics.aappublications.org by guest on June 19, 2013e757


principle on which each of thesedevices is based). The elements thatare c<strong>om</strong>mon to the use of each of thesedevices to acc<strong>om</strong>plish circumcisioninclude the following: estimation of theamount of external skin to be removed;dilation of the preputial orifice so thatthe glans can be visualized to ensurethat the glans itself is normal; bluntlyfreeing the inner preputial epitheliumfr<strong>om</strong> the epithelium of the glans;placing the device (at times a dorsalslit is necessary to do so); leavingthe device in situ long enough to producehemostasis; and removal of theforeskin.The extent of this practice in the UnitedStates has been estimated by variousfederally sponsored national surveys,each of which has its strengths andlimitations; thus, multiple measures ofcircumcision prevalence and incidenceare presented. There are large populationmeasures of male circumcisionin the United States, measuring eitherthe occurrence (ie, incidence) of malecircumcision among newborns or theexistence of the circumcised stateamong representative samples ofmales in the United States at a particularperiod in time (ie, prevalence).The findings of these studies arequalitatively similar and consistentlyestimate the rate of male circumcisionto range fr<strong>om</strong> 42% to 80% amongvarious populations. 2–6A recent Centers for Disease Controland Prevention (CDC) study assessedtrends in the incidence of in-hospitalnewborn male circumcision fr<strong>om</strong> 1999to 2010 using 3 independent sources ofdischarge data on in-patient hospitalizations:the National Center for HealthStatistics’ National Hospital DischargeSurvey (NHDS), the Agency for HealthcareResearch and Quality’s National InpatientSample (NIS), and the SDIHealth’s Charge Data Master (CDM). 2,3These sources were used to estimate theincidence of newborn male circumcisionin the first month of life. Overall fr<strong>om</strong>1999 to 2010, the CDC’s weightedanalysis found that the approximatepercentage of newborn US maleswho were circumcised was approximately59.1% according to the NHDS,57.8% according to the NIS, and 55.8%according to the CDM. The incidence ofnewborn male circumcision decreasedover time in all 3 data sources: fr<strong>om</strong>62.5% in 1999 to 56.9% in 2008according to the NHDS; fr<strong>om</strong> 63.5% in1999 to 56.3% in 2008 according tothe NIS; and fr<strong>om</strong> 58.4% in 2001 to54.7% in 2010 according to the CDM(Fig 1). A key limitation is that theseincidence rates were derived fr<strong>om</strong>hospital-based surveys and do not includeout-of-hospital circumcisions;thus, these data sources underestimatethe actual rate of newbornmale circumcision in the first monthof life.NISThe NIS is a database of 5 to 8 millionhospital inpatient stays drawn fr<strong>om</strong>states that participate in the HealthcareCost and Utilization Project(HCUP). In 2008, these states c<strong>om</strong>prised95% of the US population. TheNIS is used to track and analyze nationaltrends in health care utilization,delivery, and outc<strong>om</strong>es via a 20%stratified sample of 1000 c<strong>om</strong>munityhospitals. Weights are provided tocalculate national estimates. 4The NIS indicates that circumcisionwas performed in 57% of male newbornhospitalizations between 1998and 2005. NIS data fr<strong>om</strong> 1988 to 2008indicate that the rate of circumcisionperformed during newborn male deliveryhospitalizations increased significantlyfr<strong>om</strong> 48% in 1988–1991, to61% in 1997–2000, 5 then declined fr<strong>om</strong>61% to 56% in 2000–2008 6 (Fig 1).Circumcision rates were highest in theMidwestern states (74%), followed bythe Northeastern (67%) and Southernstates (61%). The lowest circumcisionrates were found in the Westernstates (30%) (Table 1). 3NHANESThe NHANES provides a snapshot of thehealth and nutritional status of the USpopulation aged 14 to 59 years at thetime of the survey, by using a probabilitysample of persons aged 0 toover 60 years. Prevalence of male circumcisionis derived fr<strong>om</strong> participantself-report and is thus subject t<strong>om</strong>isclassification. Fr<strong>om</strong> 1999 to 2004,NHANES found that, of the 6174 mensurveyed, 79% of men reported beingcircumcised, including 88% ofnon-Hispanic white men, 73% of non-Hispanic black men, 42% of Mexican-American men, and 50% of men ofother races/ethnicities 6 (Fig 2).However, prevalence rates are limitedby the accuracy of the examiner and/orthe self-report. 7,8 These findings underscorethe necessity of using astandardized clinical examination forestablishing circumcision status forthe purpose of research on circumcision.It also highlights the potentialdifficulty of advising on care of thecircumcised and uncircumcised peniswhen an individual and/or clinicianmay not know which condition ispresent.Ethical IssuesThe practice of medicine has longrespected an adult’s right to selfdeterminationin health care decisionmaking.This principle has beenoperationalized through the doctrineof informed consent. The process ofinformed consent obligates the clinicianto explain any procedure ortreatment and to enumerate the risks,benefits, and alternatives so the patientcan make an informed choice. Asa general rule, minors in the UnitedStates are not considered c<strong>om</strong>petentto provide legally binding consent regardingtheir health care, and parentse758FROM THE AMERICAN ACADEMY OF PEDIATRICSDownloaded fr<strong>om</strong> pediatrics.aappublications.org by guest on June 19, 2013


FROM THE AMERICAN ACADEMY OF PEDIATRICSFIGURE 1Incidence of in-hospital newborn male circumcision, according to data source; United States, 1999–2010. 2,3or guardians are empowered to makehealth care decisions on their behalf. 9In most situations, parents are grantedwide latitude in terms of thedecisions they make on behalf of theirchildren, and the law has respectedthose decisions except where they areclearly contrary to the best interestsof the child or place the child’s health,well-being, or life at significant risk ofserious harm. 10Parents and physicians each have anethical duty to the child to attempt tosecure the child’s best interest andwell-being. 11 Reasonable people maydisagree,however,astowhatisinthebest interest of any individual patient orhow the potential medical benefits andpotential medical harms of circumcisionshould be weighed against eachother. This situation is further c<strong>om</strong>plicatedby the fact that there are social,cultural, religious, and familial benefitsand harms to be considered as well. 12 Itis reasonable to take these nonmedicalbenefits and harms for an individualinto consideration when making a decisionabout circumcision. 13TABLE 1 Multivariate Cox Proportional Hazards Regression of Selected Factors Associated WithCircumcision Among Male Newborn Delivery Hospitalizations, United States, 1998–2005 2CharacteristicWeighted % of MaleInfant CircumcisionsAdjusted PrevalenceRate Ratios (95% CI)Hospital regionMidwest 74 3.53 (3.23–3.87)Northeast 67 2.90 (2.64–3.18)South 61 2.80 (2.56–3.07)West 30 1.00PayerPrivate 67 1.76 (1.70–1.82)Public 45 1.00Hospital locationUrban 66 1.29 (1.24–1.34)Rural 56 1.00Newborn health statusTerm, healthy 61 1.22 (1.20–1.23)Not term, healthy 54 1.00In cases such as the decision to performa circumcision in the newbornperiod (where there is reasonabledisagreement about the balance betweenmedical benefits and harms,where there are nonmedical benefitsand harms that can result fr<strong>om</strong> a decisionon whether to perform theprocedure, and where the procedureis not essential to the child’s immediatewell-being), the parents shoulddetermine what is in the best interestof the child. In the pluralistic societyof the United States, where parentsare <strong>af</strong>forded wide authority for determiningwhat constitutes appropriatechild-rearing and child welfare, itis legitimate for the parents to takeinto account their own cultural, religious,and ethnic traditions, in additionto medical factors, when makingthis choice. 11Physicians who counsel families aboutthis decision should assist parents byobjectively explaining the potentialbenefits and risks of circumcising theirinfant. 10 Becauses<strong>om</strong>efamiliesmayoptto circumcise as part of religious ortraditional practice, discussion shouldalso enc<strong>om</strong>pass risks and benefits ofPEDIATRICS Volume 130, Number 3, September 2012Downloaded fr<strong>om</strong> pediatrics.aappublications.org by guest on June 19, 2013e759


FIGURE 2Prevalence of male circumcision, according to self-report; United States, 1999–2004. 5having a medical professional performthis procedure in a clinical settingversus having it performed bya traditional/religious provider ina nonmedical environment.Parents may wish to consider whetherthe benefits of the procedure can beattained in equal measure if the procedureis delayed until the child is ofsufficient age to provide his own informedconsent. These interests includethe medical benefits; the culturaland religious implications of beingcircumcised; and the fact that theprocedure has the least surgical riskand the greatest accumulated healthbenefits if performed during the newbornperiod. Newborn males who arenot circumcised at birth are much lesslikely to elect circumcision in adolescenceor early adulthood. Parents whoare considering deferring circumcisionshould be explicitly informed that circumcisionperformed later in life hasincreased risks and costs. Furthermore,deferral of the procedure alsorequires longer healing time than ifperformed during the newborn periodand requires sexual abstinence duringhealing. Those who are already sexuallyactivebythetimetheyhavetheprocedurelose s<strong>om</strong>e opportunities forthe protective benefit against sexuallytransmitted infection (STI) acquisition,including HIV; moreover, there is therisk of acquiring an STI if the individualis sexually active during thehealing process. (See the section entitledSexually Transmitted Diseases,Including HIV.)Finally, there is a moral obligation totake reasonable steps to reduce therisk of harm associated with theperformance of any surgical intervention.These include ensuring thatthe providers who perform circumcisionhave adequate training anddemonstrate c<strong>om</strong>petence in performingthe procedure; the provision ofadequate procedural analgesia andpostprocedural pain control; and thatthe risks of infection are minimizedthrough appropriate infection controlmeasures, such as a sterile environmentand sterilized instruments. 14 TheTask Force advises against the practiceof mouth-to-penis contact duringcircumcision, which is part of s<strong>om</strong>ereligious practices, because it posesserious infectious risk to the child.TASK FORCE ON MALECIRCUMCISIONC<strong>om</strong>mittee Membership andResearch QuestionsIn December 2007, the AAP formeda multidisciplinary workgroup of AAPmembers and other stakeholders toevaluate the evidence on male circumcisionand update the AAP’s rec<strong>om</strong>mendationsin this area. The Task Forceincluded AAP representatives fr<strong>om</strong> specialtyareas, including anesthesiology/pain management, bioethics, child healthcare financing, epidemiology, fetusand newborn medicine, infectiousdiseases (including pediatric AIDS),and urology. The Task Force also includedmembers of the AAP Board ofDirectors and liaisons representingthe American Academy of FamilyPhysicians (AAFP), the American Collegeof Obstetricians and Gynecologists(ACOG), and the CDC. The Task Force’sevidence review was supplemented byan independent, AAP-contracted, physicianand doctoral-level epidemiologistwho was also part of the entire evidencereview process.Literature Search OverviewThe Task Force members identifiedthe following topics and questions asrelevant to male circumcision and tobe addressed through a critical reviewof the peer-reviewed literature: What is the current epidemiologyof male circumcision in the UnitedStates? What are the most c<strong>om</strong>mon proceduresand techniques for newbornmale circumcision? What best supports the parentaldecision-making process regardingcircumcision? What is the association betweenmale circumcision and both morbidityand sexual function/satisfaction? What is the impact of anesthesiaand analgesia? What are the c<strong>om</strong>mon c<strong>om</strong>plicationsand the c<strong>om</strong>plication rates associatedwith male circumcision? What workforce issues <strong>af</strong>fect newbornmale circumcision?e760FROM THE AMERICAN ACADEMY OF PEDIATRICSDownloaded fr<strong>om</strong> pediatrics.aappublications.org by guest on June 19, 2013


FROM THE AMERICAN ACADEMY OF PEDIATRICS What are the trends in financingand payment for elective circumcision?The group agreed on parameters forreviewing the literature on associationsbetween male circumcision andother outc<strong>om</strong>es. The literature reviewc<strong>om</strong>prised analytic studies (includingmeta-analyses) in the topic areas inEnglish-language, peer-reviewed, scientificliterature. The Task Force evaluatedstudies that addressed theidentified clinical questions, includingall meta-analyses; all rand<strong>om</strong>ized controlledtrials; and all case-control,prospective and retrospective cohort,and cross-sectional studies based onthe American Heart Association’s templatefor evidence evaluation (see thefollowing section). Case reports, caseseries, ecological studies, reviews, andopinions were excluded fr<strong>om</strong> the review.Although case reports and caseseries are important for generatinghypotheses, the Task Force limited itselfto reviewing analytic studies. The TaskForce c<strong>om</strong>piled and vetted MedicalSubject Headings, which are defined bythe National Library of Medicine.Searches were conducted in Medline,Cochrane Database, and Embase forthe period 1995 through 2010. Theliterature search produced 1388 abstractsthat were reviewed by both theepidemiologist and the Task Forcechair, and those citations meeting theestablished criteria were included;ultimately, 1014 articles were includedin the review (Table 2). A second searchwas conducted in April 2010, whichyielded 42 additional citations, of which17 were included. All 1031 acceptedarticles were reviewed by the contractedphysician epidemiologist and atleast 1 Task Force member; any differenceswere resolved by consensus.In 2011, individual Task Force membersalso identified other key articles thatappeared in the peer-reviewed literature;these articles were consulted inthe preparation of the current reportand cited accordingly. These additionalarticles did not <strong>af</strong>fect the findings ofthe Task Force. Areas in which therewere no analytic studies available forthe time period of interest are noted assuch within this document.Evidence Quality and Use inForming Rec<strong>om</strong>mendationsArticles were reviewed by using theAmerican Heart Association’s templatefor evidence evaluation. 15 The articleswere also assigned a level of evidence(Table 3) based on the methodologyused. Among those with evidence levels1 through 4, the reviewers assessedthe quality of the evidence as “excellent,”“good,” “fair,” or “poor” dependingon how well the methodology wasapplied. Articles with an evidence levelof 5 or higher were not included in thisreview. A critical assessment was madeof each article/source in terms of theresearch design and methods, by usingthe American Heart Association’s template(Table 4).RESULTSAs a result of these findings, the TaskForce made the following rec<strong>om</strong>mendations,which are describedfurther in the following text: Evaluation of current evidence indicatesthat the health benefits ofnewborn male circumcision outweighthe risks, and the benefitsof newborn male circumcision justifyaccess to this procedure forthose families who choose it. Parents are entitled to factuallycorrect, nonbiased information aboutcircumcision that should be providedbefore conception and early in pregnancy,when parents are most likelyto be weighing the option of circumcisionof a male child. Physicians counseling families aboutelective male circumcision shouldassist parents by explaining, in anonbiased manner, the potentialbenefits and risks, and by ensuringthat they understand the electivenature of the procedure. Parents should weigh the healthbenefits and risks in light of theirown religious, cultural, and personalpreferences, as the medicalbenefits alone may not outweighthese other considerations for individualfamilies. Parents of newborn boys shouldbe instructed in the care of thepenis at the time of dischargefr<strong>om</strong> the newborn hospital stay, regardlessof whether the newbornhas been circumcised or not. Elective circumcision should beperformed only if the infant’s conditionis stable and healthy. Male circumcision should be performedby trained and c<strong>om</strong>petentpractitioners, by using sterile techniquesand effective pain management. Analgesia is s<strong>af</strong>e and effective inreducing the procedural pain associatedwith newborn circumcision;thus, adequate analgesia shouldbe provided whenever newborncircumcision is performed.88Nonpharmacologic techniques(eg, positioning, sucrose pacifiers)alone are insufficient toprevent procedural and postproceduralpain and are not rec<strong>om</strong>mendedas the sole methodof analgesia. They should beused only as analgesic adjunctsto improve infant c<strong>om</strong>fort duringcircumcision.If used, topical creams maycause a higher incidence ofskin irritation in low birth weightinfants, c<strong>om</strong>pared with infantsof normal weight; penile nerveblock techniques should thereforebe chosen for this groupof newborns.PEDIATRICS Volume 130, Number 3, September 2012Downloaded fr<strong>om</strong> pediatrics.aappublications.org by guest on June 19, 2013e761


TABLE 2 Results fr<strong>om</strong> Medline, CochraneDatabase, and Embase Search for1995–2010Clinical Topic Area a No. of Articles IncludedHIV/STI 231Procedure and219c<strong>om</strong>plicationsUTI 53Pain management 159Penile dermatoses 107Penile hygiene 76Phimosis 64Parental decisionmaking60Carcin<strong>om</strong>a (penile) 58Carcin<strong>om</strong>a (cervical) 3Sexual satisfaction 1a Does not include nonclinical areas such as ethics andfinancing. Key professional organizations (AAP,AAFP, ACOG, the American Society ofAnesthesiologists, the AmericanCollege of Nurse Midwives, andother midlevel clinicians such asnurse practitioners) should workcollaboratively to:8 Develop standards of traineeproficiency in the performanceof anesthetic and proceduretechniques, including suturing;8 Teach the procedure and analgesictechniques during postgraduatetraining programs;TABLE 3 Evidence LevelsLevelDefinition1 RCTs or meta-analyses of multiple clinicaltrials with substantial treatment effects2 RCTs with smaller or less significanttreatment effects3 Prospective, controlled, nonrand<strong>om</strong>ized,cohort studies4 Historic, nonrand<strong>om</strong>ized, cohort or casecontrolstudies5 Case series: patients c<strong>om</strong>piled in serialfashion, lacking a control group (excludedfr<strong>om</strong> review)6 Animal studies or mechanical model studies(excluded fr<strong>om</strong> review)7 Extrapolations fr<strong>om</strong> existing data collectedfor other purposes, theoretical analyses(excluded fr<strong>om</strong> review)8 Rational conjecture (c<strong>om</strong>mon sense);c<strong>om</strong>mon practices accepted beforeevidence-based guidelines (excludedfr<strong>om</strong> review)Develop educational materials8for clinicians to enhance practitioners’c<strong>om</strong>petency in discussingthe benefits and risksof circumcision with parents;8 Offer educational materials toassist parents of male infantswith the care of both circumcisedand uncircumcised penises. The preventive and public healthbenefits associated with newbornmale circumcision warrantthird-party reimbursement of theprocedure.Parental Decision-Making Task Force Rec<strong>om</strong>mendations:8 Parents are entitled to factuallycorrect, nonbiased informationabout circumcision that shouldbe provided before conceptionand early in pregnancy, whenparents are most likely to beweighing the option of circumcisionof a male child.8 Physicians counseling familiesabout elective male circumcisionshould assist parents byexplaining, in a nonbiased manner,the potential benefits andrisks, and by ensuring that theyunderstand the elective natureof the procedure.8 Parents should weigh thehealth benefits and risks inlight of their own religious, cultural,and personal preferences,as the medical benefitsalone may not outweigh theseother considerations for individualfamilies.The decision of whether to circumcisea male newborn is frequently madeearly in the pregnancy and even beforeconception. 16–18 In a cross-sectionalstudy of parents of 55 male infantspresenting to a family practice clinicfor a well-child visit, 80% of parentsreported that the circumcision decisionwas made before a discussionoccurred with the clinician about thisissue. Only 4% of parents reportedlydiscussed circumcision with their clinicianbefore the pregnancy. 16 Thisfinding is substantiated by the 2009AAP survey of 1620 members witha response rate of 57%, in which mostrespondents reported that parentsof newborn male patients generallydo not seek their pediatrician’srec<strong>om</strong>mendation regarding circumcision;only 5% reported that “all” or“most” parents “are uncertain aboutcircumcision and seek their rec<strong>om</strong>mendation”about the procedure. 19There is fair evidence that parentaldecisions about circumcision areshaped more by family and socioculturalinfluences than by discussionwith medical clinicians or by parentaleducation. 16,20In 4 cross-sectional studies with fairevidence, US parents most oftenreported that they chose to have theirnewborn son circumcised for health/medical benefits, including hygieneand cleanliness of the penis (reportedby 39.6%, 46%, 53%, and 67%, respectively).16,17,21,22 Social concerns(such as having a father or brotherwho was circumcised) were also animportant reason given for newbornmale circumcision (22.8%, 23.5%, 28%,and 37%). Religious requirements forcircumcision, such as those of theJewish and Islamic faiths, were rankedless highly in importance (11%, 12.1%,13%, and 19%). Although one of thesestudies was small and included only 55patients drawn fr<strong>om</strong> a h<strong>om</strong>ogeneouspopulation, 16 the findings coincide withthe 3 larger and more diverse studies.For parents to receive nonbiased informationabout male circumcision intime to inform their decisions, cliniciansneed to provide this informationat least before conception and/orearly in the pregnancy, probably as ae762FROM THE AMERICAN ACADEMY OF PEDIATRICSDownloaded fr<strong>om</strong> pediatrics.aappublications.org by guest on June 19, 2013


FROM THE AMERICAN ACADEMY OF PEDIATRICSTABLE 4 Assessment of Research Design and MethodsC<strong>om</strong>ponent ofStudy andRatingExcellent Good Fair Poor UnsatisfactoryDesign andMethodsHighly appropriatesample or model,rand<strong>om</strong>ized, propercontrols ANDoutstanding accuracy,precision, and datacollection in its classHighly appropriatesample or model,rand<strong>om</strong>ized, propercontrols ORoutstanding accuracy,precision, and datacollection in its classAdequate design butpossibly biased ORadequate under thecircumstancesSmall or clearly biasedpopulation or modelOR weakly defensiblein its class, limiteddata or measuresAnecdotal, no controls, offtarget end points OR notdefensible in its class,insufficient data ormeasurescurriculum item in childbirth classes.Information to assist in parental decision-makingshould be made availableas early as possible. For thisreason, obstetrician-gynecologists andfamily physicians who manage prenatalcare probably have a more pivotal rolein this decision than do pediatricians.Bright Futures: Guidelines for HealthSupervision of Infants, Children, andAdolescents, Third Edition, supportsprenatal pediatric visits, at which timepediatricians can provide counselingabout male circumcision (http://brightfutures.aap.org). Medical benefitsand risks need to be presented accuratelyand in a nonbiased fashion sofamilies can make a decision in light oftheir own cultural, religious, and personalpreferences.There is fair evidence that there arefinancial barriers to the circumcisiondecision in the United States; whenthe procedure is not covered by insurance,parents are less likely tochoose to have their child circumcised.21 This finding does not seem tobe true in Canada, where the prevalenceof circumcision did not change<strong>af</strong>ter circumcision for ritual, religious,cultural, or cosmetic reasonswas delisted fr<strong>om</strong> insurance benefitsin 1994. 17,23Care of the Circumcised VersusUncircumcised Penis Task Force Rec<strong>om</strong>mendations:8 Parents of newborn boysshould be instructed in thecare of the penis at the timeof discharge fr<strong>om</strong> the newbornhospital stay, regardless ofwhether the newborn has beencircumcised or not.This review found no systematicstudies in infants and children on thecare of the uncircumcised versuscircumcised penis.Parents of newborn boys should beinstructed in the care of the penisat the time of discharge fr<strong>om</strong> thenewborn hospital stay, regardless ofwhether they choose circumcision ornot. The circumcised penis should bewashed gently without any aggressivepulling back of the skin. 24 The noncircumcisedpenis should be washedwith soap and water. Most adhesionspresent at birth spontaneously resolvebyage2to4months,andtheforeskin should not be forcibly retracted.When these adhesions disappearphysiologically (which occursat an individual pace), the foreskincan be easily retracted, and thewhole penis washed with soap andwater. 25Circumcision reduces the bacteriathat accumulate under the prepucewhich can cause UTIs and, in the adultmale, can be a reservoir for bacteriathat cause STIs. In an internallycontrolled study with fair evidence,researchers cultured the periurethraland glandular sulcus of 50children aged 1 to 12 weeks beforeand 4 weeks <strong>af</strong>ter circumcisionand found the pathogenic bacterialargely disappeared <strong>af</strong>ter circumcision(33 children had pathogenicbacteria before circumcision and4 had pathogenic bacteria <strong>af</strong>tercircumcision). 26In adults and children, there is fairevidence that periurethral flora containsfewer pathogens <strong>af</strong>ter circumcisionthan before circumcision. 26,27Because these studies looked at cultures1 time (4 weeks <strong>af</strong>ter the circumcision),the long-term significanceof the findings is unclear.Penile wetness (defined as the observationof a diffuse h<strong>om</strong>ogeneousfilm of moisture on the surface of theglans and coronal sulcus) is considereda marker for poor penile hygieneand is more prevalent in uncircumcisedthan in circumcised men. 28Penile wetness has been associatedwith HIV infection in 1 cross-sectionalstudy, although the temporal relationshipis unclear and the evidencelevel is fair. 29 A related study with fairevidence assessed the frequency ofwashing the whole penis (includingretracting the foreskin for uncircumcisedmen) and found that notalways washing the whole penis wasapproximately 10 times more c<strong>om</strong>monin uncircumcised than in circumcisedmen. 30 The relationshipbetween penile wetness and thoroughwashing of the penis is unclearand, because the studies were conductedin STI clinics, the findingsmay not be generalizable to thepopulation at large.PEDIATRICS Volume 130, Number 3, September 2012Downloaded fr<strong>om</strong> pediatrics.aappublications.org by guest on June 19, 2013e763


Male Circumcision and Diseases,Morbidities, and Sexual Function/SatisfactionSTIs, Including HIV Task Force Rec<strong>om</strong>mendation:8 Evaluation of the current evidenceindicates that the healthbenefits of newborn male circumcisionoutweigh the risks, andthe benefits of newborn malecircumcision justify access tothis procedure for those familieswho choose it.The most notable research contributionsto the literature since 1995are studies of male circumcision andthe acquisition of HIV and the transmissionof other STIs. Review of theliterature revealed a consistently reportedprotective effect of 40% to 60%for male circumcision in reducing therisk of HIV acquisition among heterosexualmales in areas with high HIVprevalence due to heterosexual transmission(ie, Africa).There is also good evidence fr<strong>om</strong>rand<strong>om</strong>ized controlled trials thatmale circumcision is associated witha lower prevalence of human papill<strong>om</strong>avirus(HPV) infection 31,32 and herpessimplex virus type 2 (HSV-2)transmission, 31,33 as well as a decreasedlikelihood of bacterial vaginosis(BV) in female partners. 80 Theevidence for male circumcision beingprotective against syphilis is lessstrong, 65–68 however, and male circumcisionwas not found to be associatedwith decreased risk ofgonorrhea 84,85,91–93 or chlamydia. 84–89It is biologically plausible that thecircumcised state may confer protectionagainst STIs (including HIV).Possible mechanisms for the protectiveeffect of circumcision includethe fact that the foreskin’s thin innersurface is susceptible to microtearsand abrasions (especially during sexualactivity), which provides a port ofentry for pathogens. The foreskin alsocontains a high density of HIV targetcells (ie, Langerhans cells, CD4 T cells,macrophages), which facilitates HIVinfection of host cells. The preputialspace provides an environment that isthought to “trap” pathogens and bodilysecretions and favor their survival andreplication. 26,27,34 The circumcised malehas no foreskin and may likely providea less welc<strong>om</strong>ing environment for suchsubstances. In addition, STI-containingsecretions have increased contact timein the prospective uncircumcised malehost, which may increase the likelihoodof transmission and infection. The exposedsurfaces of the uncircumcisedpenis do not offer the same physicalbarrier to resist infection that thehighly keratinized surface of a circumcisedpenis does. Finally, the higherrates of sexually transmitted genitalulcerative disease (eg, HSV-2) observedin uncircumcised men may alsoincrease susceptibility to HIV infection,as the presence of genitalulcers, irrespective of circumcisionstatus, increases the likelihood of HIVacquisition. 35–37HIVThe CDC estimates that 1.2 millionpeople in the United States are livingwith HIV, the virus that causes AIDS,which is incurable. Approximately 50 000Americans are newly infected withHIV each year; more than 619 000people in the United States have diedof AIDS since the epidemic began. 38In the United States, HIV/AIDS pred<strong>om</strong>inantly<strong>af</strong>fects men who have sex withmen (MSM), who account for almosttwo-thirds (61%) of all new infections.Heterosexual exposure accounts for27% of new HIV infections, and injectiondrug use accounts for 9% ofnew HIV cases. In other parts of theworld (eg, Africa), heterosexual transmissionis far more c<strong>om</strong>mon. 39Fourteen studies provide fair evidencethat circumcision is protective againstheterosexually acquired HIV infectionin men. 40–53 One study with fair evidencefound that male circumcisionbefore puberty (specifically before 12years of age) is more protective thancircumcision occurring at a laterage. 50 Three large rand<strong>om</strong>ized controlledtrials provide good evidence ofsuch protection. 54–56 A cross-sectionalstudy with fair evidence is neutralregarding the relationship betweencircumcision and HIV infection. 57 Twoother studies with a cross-sectionaldesign provide fair evidence that circumcisionincreases the risk of HIVinfection, although one of these studieshighlights the HIV risks associatedwith circumcision performed outsidethe hospital setting and without sterileequipment and medically trainedpersonnel. 58,59A recently published study fr<strong>om</strong> theCDC provides good evidence that, inthe United States, male circumcisionbefore the age of sexual debut wouldreduce HIV acquisition among heterosexualmales. 60 Although individualsexual practices are difficult to predictin the newborn period, the majorityof US males are heterosexualand could benefit fr<strong>om</strong> male circumcision.Mathematical modeling by theCDC shows that, taking an averageefficacy of 60% fr<strong>om</strong> the African trials,and assuming the protective effect ofcircumcision applies only to heterosexuallyacquired HIV, there would bea 15.7% reduction in lifetime HIV riskfor all males. This is taking into accountthe proportion of HIV that isacquired through heterosexual sexand reducing that by 60%. The percentreduction in HIV cases was determinedby assessing the proportion ofnew cases of HIV infection that couldbe prevented by analyzing whichinfections would be presumed to occurin uncircumcised males and whatthe reduction would be if those whowould not already be circumcisede764FROM THE AMERICAN ACADEMY OF PEDIATRICSDownloaded fr<strong>om</strong> pediatrics.aappublications.org by guest on June 19, 2013


FROM THE AMERICAN ACADEMY OF PEDIATRICSwould be circumcised. The proportionsof transmissions prevented arelower than in Africa because a higherproportion of US HIV transmissionoccurs between MSM. In addition, aportion of the population would becircumcised without any policy change,and the prevented cases would onlyoccur in the additional circumcisedmales. This ranges fr<strong>om</strong> an estimated8% reduction in non-Hispanic whitemalestoanestimated21%reductionamong non-Hispanic black males. TheCDC study suggests that newborn circumcisionperformed in the UnitedStates to prevent HIV infection is costeffectivewithout consideration of otherhealth benefits. The CDC rec<strong>om</strong>mendationsstate that all parents of newbornmales should be given the choiceof circumcision.Specific HIV Risk PopulationsMSMThe association of circumcision andthe decreased likelihood of HIVacquisition applies to heterosexualmales. Circumcision seems to be lesslikely to protect MSM, however, andhas not been associated with decreasedacquisition of HIV amongMSM. 61 There is fair evidence fr<strong>om</strong> 1study that there is a protective effectof circumcision fr<strong>om</strong> HIV infection inMSM; however, this study used selfreportto establish circumcision status.62 One study with fair evidence isneutral regarding the relationshipbetween circumcision and HIV infectionin MSM. 61 It is probable thatthe differences found in the level ofprotection (or lack of protection) bystudies of MSM are confounded bythe fact that MSM c<strong>om</strong>monly performboth receptive and insertive sex. It isnot known to what extent circumcisionmay be protective against HIVtransmission for MSM who practiceinsertive sex versus for those whoengage in receptive sex.Heterosexual W<strong>om</strong>enW<strong>om</strong>en account for 23% of new HIVinfections in the United States; HIV infectionin w<strong>om</strong>en is primarily attributedeither to heterosexual contact or injectiondrug use. 38 Two prospectivecohort studies with fair evidence lookedat the relationship between aw<strong>om</strong>an’s risk of HIV infection andwhether her primary male partner iscircumcised. The first study describesa protective effect but had considerableloss-to-follow-up and possiblemisclassification of the partners’ circumcisionstatus. 63 The other studyshowed nonsignificant protection in thehigh-risk group (ie, w<strong>om</strong>en who weremore likely to have ever engaged in sexwork; to have reported 2 or morepartners in the last 3 months; and/orto have had a higher median lifetimenumber of sex partners) but neitherprotection nor increased risk in thestudy population as a whole. 64 Ametaanalysiswith good evidence of dat<strong>af</strong>r<strong>om</strong> 1 rand<strong>om</strong>ized controlled trial(RCT) and 6 longitudinal analyses foundlittle evidence that male circumcisiondirectly reduces their female partner’srisk of acquiring HIV (summary relativerisk: 0.8 [95% confidence interval (CI):0.53–1.36]); however, male circumcision’sprotective effect did not reacha level of statistical significance. 65 OneUgandan RCT study with good evidencefound that, at 24 months, the risk of HIVinfection among w<strong>om</strong>en whose malepartners were circumcised was 21.7%c<strong>om</strong>pared with 13.4% for female partnersof uncircumcised men. 66Ulcerative STIsGenital ulcers are notable both becauseof the morbidity and mortality associatedwith the causative organism andbecause the presence of the ulcer itselffacilitates the transmission of HIV.SyphilisFr<strong>om</strong> 2009 to 2010, there were 13 604cases of early latent syphilis reportedto the CDC and 18 079 cases of lateand late latent syphilis. The rate of primaryand secondary syphilis in 2010was 4.5 cases per 100 000 individuals,2.2% lower than the 2009 rate. “Thetotal number of cases of syphilis(primary and secondary, early latent,late, late latent, and congenital) reportedto CDC increased 2.2% (fr<strong>om</strong>44,830 to 45,834 cases) during 2009–2010.” 67 A large percentage of syphiliscases occur in MSM; in 2010, 67% ofthe reported primary and secondarysyphilis cases were among MSM. 67The balance of evidence suggests thatmale circumcision is protective againstsyphilis. 68–70 One meta-analysis withgood evidence describes a protectiveeffect (relative risk: 0.67 [95% CI:0.54–0.83]), but there is considerableheterogeneity among the studies included.68 An additional cohort studywith fair evidence found that circumcisedmen were significantly lesslikely to have active syphilis at thepoint of study recruitment; when themen were followed up prospectivelyfor 2 years, a protective effect wasalso observed but was nonsignificant.69 Good evidence fr<strong>om</strong> a largeRCT reported no reduction or trendtoward reduction for male circumcisionand the incidence of syphilis 71 ;however, the extent to which protectionmight be <strong>af</strong>forded, and amongwhich specific populations, is difficultto determine.Genital HerpesGenital herpes is an STI c<strong>om</strong>monlymanifested by recurrent genital ulcerscaused by HSV-1 or HSV-2. HSV may notbe clinically evident despite infection.Approximately 16.2% of US individualsaged 14 to 49 years have HSV-2. 31,72Case reporting data for genital HSVare not available, but 2005–2008NHANES data indicate that the percentageof NHANES participants aged20 to 49 years who reported havingPEDIATRICS Volume 130, Number 3, September 2012Downloaded fr<strong>om</strong> pediatrics.aappublications.org by guest on June 19, 2013e765


een diagnosed with genital herpes ats<strong>om</strong>e point was 18.9%. 72One meta-analysis with good evidencefound s<strong>om</strong>e protective effect of circumcisionagainst HSV-2 of borderlinestatistical significance. 68 Good evidenceof the protective effect of male circumcisionis available fr<strong>om</strong> two of thelarge rand<strong>om</strong>ized controlled trials inAfrica. In the South African study, theincidence of HSV-2 was 34% lower incircumcised men. 73 In the Ugandastudy, the risk of HSV-2 infection (adjustedfor other factors) was 28%lower in circumcised men. 71 There isfair evidence fr<strong>om</strong> 1 study that malecircumcision protects female partnersagainst HSV-2 infection. 33 Two studieswith fair evidence found that there isno effect of circumcision on the risk ofHSV-2 acquisition. 6,74ChancroidChancroid is a bacterial disease spreadthrough sexual contact. It is rare in theUnited States, with a total of 24 casesreported in 2010 (a rate of 0.08 case per100 000 individuals). 75The literature search produced noindividual studies since 1995 exploringthe relationship between male circumcisionand chancroid. One metaanalysiswith good evidence foundthat 6 of 7 older studies (85%) describedcircumcision as having a protectiveeffect against chancroid. Thismeta-analysis did not provide a summaryvalue for the relationship due todifferences in the definition and ascertainmentof outc<strong>om</strong>es and variabilityamong the c<strong>om</strong>parison groups. 68One methodologically poor meta-analysisfound no effect of male circumcision onchancroid. 76Lymphogranul<strong>om</strong>a Venereum andGranul<strong>om</strong>a Inguinale (Donovanosis)The CDC reports that the frequency oflymphogranul<strong>om</strong>a venereum infectionis thought to be rare in industrializedcountries, although its identification isnot always obvious; the number ofcases of this infection in the UnitedStates is unknown. 77 Granul<strong>om</strong>a inguinaleis a genital ulcerative diseasethat is rare in the United States butendemic in s<strong>om</strong>e tropical and developingareas. The lesions might developsecondary bacterial infection orcan coexist with other sexually transmittedpathogens.The literature search produced nostudies since 1995 exploring the relationshipbetween male circumcisionand lymphogranul<strong>om</strong>a venereumor granul<strong>om</strong>a inguinale. One metaanalysisprovided fair evidence thatgenital ulcerative disease was morec<strong>om</strong>mon in uncircumcised men but notto a statistically significant degree. 78One cross-sectional study with fairevidence found that male circumcisionwas protective against genitalulcers, but the findings were based onrespondents self-reporting a historyof genital ulcerative disease and maynot be accurate. 79Nonulcerative STIsNonulcerative STIs generally cause inflammationand scarring along the reproductivetract. Untreated infectioncan cause cancer, can interfere withreproduction, and can negatively impactnewborn health. Additionally, these infectionscan facilitate the transmissionof HIV.BVBV is a condition “in w<strong>om</strong>en where thenormal balance of bacteria in the vaginais disrupted and replaced by anovergrowth of certain bacteria.” 80 BVis c<strong>om</strong>mon among pregnant w<strong>om</strong>en;an estimated 1 080 000 pregnant w<strong>om</strong>enhave BV annually.There is good evidence fr<strong>om</strong> 1 largerand<strong>om</strong>ized controlled trial that malecircumcision is protective against BVin female partners. 81 Asmallprospectivecohort study with good evidence alsofound that male circumcision, amongother factors, was protective against BVin female partners. 82 A cross-sectionalstudy with fair evidence found no effectbut may have lacked the power to detectan effect. 83ChlamydiaChlamydia is the most c<strong>om</strong>monlyreported notifiable disease in theUnited States and the most c<strong>om</strong>monSTI reported to the CDC, with 1 307 893chlamydial infections (426.0 cases per100 000 individuals) reported to theCDC in 2010. 84The balance of evidence does not revealany relationship between circumcisionand chlamydia infection. 85–87 The1 prospective cohort study with fairevidence showed a protective effect,but the study had a c<strong>om</strong>posite endpoint with several STIs c<strong>om</strong>bined andused self-report of STI as the outc<strong>om</strong>e(increasing the possibility ofmisclassification). 88 Two studies withfair evidence explored the effect ofmale circumcision on chlamydia infectionin female partners. The first,a prospective cohort study, found anonsignificant increased risk in thefemale partners of circumcised men. 89The second, a cross-sectional study,found a significantly decreased riskof chlamydia infection among w<strong>om</strong>enwith circumcised male sexual partners,but a possible selection bias mayhave <strong>af</strong>fected results because only51.8% of subjects had specimens foranalysis. 90GonorrheaGonorrhea is the second most c<strong>om</strong>monlyreported STI in the United States,with 309 341 cases reported to the CDC(a rate of 100.8 cases per 100 000individuals) in 2010. 91The evidence does not demonstrateany relationship between circumcisionand gonorrheal infection. 85,86,92–94 Thee766FROM THE AMERICAN ACADEMY OF PEDIATRICSDownloaded fr<strong>om</strong> pediatrics.aappublications.org by guest on June 19, 2013


FROM THE AMERICAN ACADEMY OF PEDIATRICSstudies that show a protective effectare either barely significant or havepoorly defined or self-reported outc<strong>om</strong>es,thus offering only a fair levelof evidence. 79,88HPVHPV is among the most c<strong>om</strong>monly occurringSTIs in the United States andcan lead to the development of cancers,including cervical cancer. Thepopulation-based data fr<strong>om</strong> NHANES2003–2006 indicate that the overallprevalence of high- and low-oncogenicriskHPVtypeswas42.5%amongUSw<strong>om</strong>en aged 14 to 59 years. Theprevalence of infection was lower forthe 2 viral types with the highest riskof causing cancer, however, at 4.7% forHPV type 16 and 1.9% for HPV type 18. 95There is good evidence that male circumcisionis protective against alltypes of HPV infection (nononcogenicand oncogenic). Two prevalence studieswith good evidence found a 30% to 40%reduction in risk of infection amongcircumcised men. 96,97 These studies failto provide information on the risk ofacquiring HPV and may reflect persistenceof HPV rather than acquisition ofinfection. Four studies provide fair evidencethat male circumcision protectsagainst HPV. 98–101 The selection of anat<strong>om</strong>icsites sampled may influencethe results. 98Good evidence of the protective effectof male circumcision against HPV isavailable fr<strong>om</strong> two of the large rand<strong>om</strong>izedcontrolled trials in Africa. Inthe South African study, the prevalenceof high-risk HPV was 32% lowerin circumcised men. 102 In the Ugandastudy, the risk of oncogenic HPV infection(adjusted for other factors)was 35% lower in circumcised men. 71There is also good evidence that malecircumcision reduces the risk of maleto-femaletransmission of high-riskHPV fr<strong>om</strong> HIV-uninfected men. In theUganda rand<strong>om</strong>ized controlled trial, theprevalence of high-risk HPV infectionwas 28% lower in female partners ofcircumcised HIV-uninfected men, whilethe incidence was 23% lower. 32 Goodevidence fr<strong>om</strong> another Uganda rand<strong>om</strong>izedcontrolled trial of male circumcisionin HIV-infected men indicatesthat a circumcision did not reduce therisk of male-to-female transmission ofhigh-risk HPV fr<strong>om</strong> HIV-infected men. 103Male Circumcision and UTIsAccording to the CDC, “A urinary tractinfection (UTI) is an infection involvingany part of the urinary system, includingurethra, bladder, ureters, andkidney.” 104 UTIs are the most c<strong>om</strong>montype of health care–associated infectionreported to the National HealthcareS<strong>af</strong>ety Network among USindividuals. The majority of UTIs inmales occur during the first year oflife. In children, UTIs usually necessitatea physician visit and may involvethe possibility of an invasive procedureand hospitalization.Most available data were publishedbefore 1995 and consistently show anassociation between the lack of circumcisionand increased risk of UTI.Studies published since 1995 havesimilar findings. There is good evidencefr<strong>om</strong> 2 well-conducted metaanalyses105,106 and a cohort study 107that UTI incidence among boys underage 2 years is reduced in those whowere circumcised c<strong>om</strong>pared with uncircumcisedboys. The data fr<strong>om</strong> rand<strong>om</strong>izedcontrolled trials are limited.However, there are large cohort andcase-controlled studies with similarfindings. Given that the risk of UTIamong this population is approximately1%, the number needed tocircumcise to prevent UTI is approximately100. The benefits of male circumcisionare, therefore, likely to begreater in boys at higher risk of UTI,such as male infants with underlyinganat<strong>om</strong>ic defects such as reflux orrecurrent UTIs.There is fair evidence fr<strong>om</strong> 5 observationalstudies that UTI incidenceamong boys under age 2 years is reducedin circumcised infant boys,c<strong>om</strong>pared with uncircumcised boysunder the age of 2. 108–112 The degree ofreduction is between threefold and10-fold in all studies.There is fair evidence fr<strong>om</strong> a prospectivestudy that there is a decreased prevalenceof uropathogens in the periurethralarea 3 weeks <strong>af</strong>ter circumcision,c<strong>om</strong>pared with similar cultures taken atthe time of circumcision. 113 By usingthese rates and the increased riskssuggested fr<strong>om</strong> the literature, it is estimatedthat 7 to 14 of 1000 uncircumcisedmale infants will developa UTI during the first year of life, c<strong>om</strong>paredwith 1 to 2 infants among 1000circumcised male infants.There is a biologically plausible explanationfor the relationship betweenan intact foreskin and an increasedassociation of UTI during infancy. Increasedperiurethral bacterial colonizationmay be a risk factor for UTI. 114During the first 6 months of life, thereare more uropathogenic organismsaround the urethral meatus of uncircumcisedmale infants than aroundthose of circumcised male infants(this colonization decreases in bothgroups <strong>af</strong>ter the first 6 months). 115 Inaddition, an experimental preparationfound that uropathogenic bacteriaadhered to, and readily colonized, themucosal surface of the foreskin butdid not adhere to the keratinized skinsurface of the foreskin. 116CancerPenile CancerPenile cancer is rare, and rates seemto be declining. In the United States,Surveillance, Epidemiology, and EndPEDIATRICS Volume 130, Number 3, September 2012Downloaded fr<strong>om</strong> pediatrics.aappublications.org by guest on June 19, 2013e767


Results data indicate that the incidenceof primary, malignant penilecancer was 0.58 case per 100 000individuals for 1993 to 2002, a declinefr<strong>om</strong> 0.84 case per 100 000 individualsfr<strong>om</strong> 1973 to 1982. 117 An analysis ofthe Danish Cancer Registry found thatthe incidence of epidermoid cancerof the penis (excluding scrotal, epididymal,and nonepidermoid) declinedfr<strong>om</strong> a rate of 1.15 cases per 100 000individuals fr<strong>om</strong> 1943 to 1947 to 0.82case per 100 000 individuals in 1988 to1990. 118Thus, declines have been noted innations with both low and high circumcisionrates (Denmark and theUnited States, respectively). Declinesare not explained by changing patternsin circumcision utilization; it is thoughtthat socioecon<strong>om</strong>ic and econ<strong>om</strong>ic developmentfactors (including effects onhygiene habits) may have an importantrole.The literature review yielded 2 casecontrolstudies; although the studieswere well designed, the evidencelevel for case-control studies is onlydeemed to be fair. 119,120 These studiesshow an association between circumcisionand a decreased likelihoodof invasive penile cancer. For all menwith penile cancer (carcin<strong>om</strong>a in situand squamous cell carcin<strong>om</strong>a), theabsence of circumcision confers anincreased risk with an odds ratio (OR)of 1.5, although this finding was notsignificant (P = .07), with a CI of 1.1–2.2. 119 An OR indicates the odds of anevent happening in 1 group divided bythe odds of an event happening inanother group. An OR of 1 thus meansthat there is an equal chance for theevent to occur in each group. Whenseparated into squamous cell carcin<strong>om</strong>aand carcin<strong>om</strong>a in situ, the absenceof circumcision was a risk factorfor invasive squamous cell carcin<strong>om</strong>a(OR: 2.3 [CI: 1.3–4.1]) but not for carcin<strong>om</strong>ain situ (OR: 1.1 [CI not provided]).Phimosis is a condition in which theforeskin cannot be fully retracted fr<strong>om</strong>the penis. A history of phimosis aloneconfers a significantly elevated risk ofinvasive cancer (OR: 11.4). In fact, inmen with an intact prepuce and nophimosis, there is a decreased risk ofinvasive penile cancer (OR: 0.5). Whenexcluding phimosis, the risk disappears,which suggests that thebenefit of circumcision is conferred byreducing the risk of phimosis and thatthe phimosis is responsible for theincreased risk. Other forms of penileinjury or irritation likewise can posea significant risk factor for cancer.There is accumulating evidence thatcircumcised men have a lower prevalenceof oncogenic (high-risk) andnononcogenic (low-risk) HPV whenc<strong>om</strong>pared with uncircumcised men,and this may be another means bywhich circumcision has a protectiveeffect against invasive penile cancer (asdiscussed in the earlier STI section).It is difficult to establish how many malecircumcisions it would take to preventa case of penile cancer, and at whatcost econ<strong>om</strong>ically and physically. Onestudy with good evidence estimates thatbased on having to do 909 circumcisionsto prevent 1 penile cancer event,2 c<strong>om</strong>plications would be expected forevery penile cancer event avoided. 121However, another study with fairevidence estimates that more than322 000 newborn circumcisions are requiredto prevent 1 penile cancer eventper year. 122 This would translate into644 c<strong>om</strong>plications per cancer event, byusing the most favorable rate of c<strong>om</strong>plications,including rare but significantc<strong>om</strong>plications. 123 The clinical valueof the modest risk reduction fr<strong>om</strong> circumcisionfor a rare cancer is difficultto measure against the potential forc<strong>om</strong>plications fr<strong>om</strong> the procedure. Inaddition, these findings are likely todecrease with increasing rates of HPVvaccination in the United States.Cervical CancerUp to 12 000 new cases of cervicalcancer are diagnosed in the UnitedStates annually. Cervical cancer isa leading cause of death for w<strong>om</strong>en indeveloping countries; more than 80%of all cervical cancer deaths occur indeveloping countries. 124 PersistentHPV infection with high-risk (ie, oncogenic)types (HPV types 16, 18, 31, 33,35, 39, 45, 51, 52, 56, 58, 59, 68, 73,and 82) is the main prerequisiteto developing cervical squamous carcin<strong>om</strong>a.The association of cervical cancer,penile HPV infection, and circumcisionwas studied in an article of fair qualitythat found a protective effect of malecircumcision against cervical cancerin the female partner(s) of men whohave multiple female partners. 100There was a lower incidence of HPVdetection in circumcised men c<strong>om</strong>paredwith uncircumcised men (5.5%and 19.6%, respectively). The OR formen who self-reported having beencircumcised and who had penileHPV was 0.37 (95% CI: 0.16–0.85). Inw<strong>om</strong>en whose partner had morethan 6 lifetime sexual partners, malecircumcision lowered her odds ofcervical cancer significantly (OR: 0.42).The overall rate of cervical cancerfor w<strong>om</strong>en who currently had circumcisedmale partners was notsignificantly decreased. Thus, thecontribution of male circumcision toprevention of cervical cancer is likelyto be small.Penile Dermatoses and PhimosisPenile dermatoses enc<strong>om</strong>pass a widerange of genital skin diseases, s<strong>om</strong>e ofwhich are rarer than others. These diseasescan include psoriasis, inflammation(ie, balanitis, balanoposthitis),infections (ie, superficial skin and softtissue infections such as cellulitis), lichensclerosis, lichen planus, lichensimplex, seborrheic dermatitis, atopice768FROM THE AMERICAN ACADEMY OF PEDIATRICSDownloaded fr<strong>om</strong> pediatrics.aappublications.org by guest on June 19, 2013


FROM THE AMERICAN ACADEMY OF PEDIATRICSeczema, and irritant dermatitis, amongothers.Fr<strong>om</strong> 1995 to 2011, all publicationsaddressing this concern were caseseries and were therefore excludedfr<strong>om</strong> the literature forming the currentanalysis. Before 1995, a New Zealandprospective cohort study with goodevidence explored rates of penileproblems for 635 boys fr<strong>om</strong> birth to 8years of age. 125 Four types of penileproblems were defined: first was thenumber of episodes of inflammation ofthe penis experienced by the child.Penile inflammation included balanitis,meatitis, inflammation of the prepuce,and conditions in which the penis wasdescribed as sore or inflamed withoutany further diagnostic elaboration. Thesecond type was the number of episodesof phimosis experienced by thechild. These episodes included everytime medical attention was sought forphimosis and associated sympt<strong>om</strong>s.Episodes in which the child wasbrought to medical attention for “tight”or “non-retractable” foreskin but wasnot treated were not classified asphimosis, due to the likelihood thatmost of these attendances resultedfr<strong>om</strong> parental anxiety or uncertaintyabout the development of the foreskinrather than any pathologic condition inthe child. The third type was inadequatecircumcision requiring repairor recircumcision. Fourth waspostoperative infection <strong>af</strong>ter circumcisionfr<strong>om</strong> birth to 8 years of age bycircumcision status. Findings were inconclusivefor the first year of life; theadjusted rate of problems experiencedwas 5.2 penile problems per 100 circumcisedboys over the study period,c<strong>om</strong>pared with 1.2 penile problems inuncircumcised boys at risk. Fr<strong>om</strong> ages1through8years,therateswere6.5penile problems per 100 circumcisedboys over the study period, c<strong>om</strong>paredwith 17.2 penile problems per 100 uncircumcisedboys.Sexual Function and Penile SexualSensitivityThe literature review does not supportthe belief that male circumcision adversely<strong>af</strong>fects penile sexual functionor sensitivity, or sexual satisfaction,regardless of how these factors aredefined.Sexual Satisfaction and SensitivityLiterature since 1995 includes 2 goodqualityrand<strong>om</strong>ized controlled trialsthat evaluated the effect of adult circumcisionon sexual satisfaction andsensitivity in Uganda and Kenya, respectively.126,127 Among 5000 Ugandanparticipants, circumcised men reportedsignificantly less pain on intercoursethan uncircumcised men. 126At 2 years’ postcircumcision, sexualsatisfaction had increased significantlyfr<strong>om</strong> baseline measures in thecontrol group (fr<strong>om</strong> 98% at baselineto 99.9%); satisfaction levels remainedstable among the circumcised men(98.5% at baseline, 98.4% 2 years <strong>af</strong>terthe procedure). This study included n<strong>om</strong>easures of time to ejaculation orsensory changes on the penis. In theKenyan study (which had a nearlyidentical design and similar results),64% of circumcised men reportedmuch greater penile sensitivity postcircumcision.127 At the 2-year followup,55% of circumcised men reportedhaving an easier time reaching orgasmthan they had precircumcision, althoughthe findings did not reach statisticalsignificance. The studies’ limitation isthat the outc<strong>om</strong>es of interest weresubjective, self-reported measuresrather than objective measures.Other studies in the area of function,sensation, and satisfaction have beenless rigorous in design, and they fail toprovide evidence that the circumcisedpenis has decreased sensitivity c<strong>om</strong>paredwith the uncircumcised penis.There is both good and fair evidencethat no statistically significant differencesexist between circumcised anduncircumcised men in terms of sexualsensation and satisfaction. 128–131 Sensationend points in these studies includedsubjective touch and painsensation, response to the InternationalIndex of Erectile Function, the Brief MaleSexual Function Inventory, pudendalnerve evoked potentials, and IntravaginalEjaculatory Latency Times (IELTs).There is fair evidence that men circumcisedas adults demonstrate ahigher threshold for light touchsensitivity with a static monofilamentc<strong>om</strong>pared with uncircumcised men;these findings failed to attain statisticalsignificance for most locations on thepenis, however, and it is unclear thatsensitivity to static monofilament (asopposed to dynamic stimulus) has anyrelevance to sexual satisfaction. 132There is fair evidence fr<strong>om</strong> a crosssectionalstudy of Korean men of decreasedmasturbatory pleasure <strong>af</strong>teradult circumcision. 133Sexual FunctionThere is both good and fair evidencethat sexual function is not adversely<strong>af</strong>fected in circumcised men c<strong>om</strong>paredwith uncircumcised men. 131,134–136 Thereis fair evidence that no significant differenceexists between circumcisedand uncircumcised men in terms ofsexual function, as assessed by usingthe IELT. 129Limitations to consider with respect tothis issue include the timing of IELTstudies <strong>af</strong>ter circumcision, becausestudies of sexual function at 12 weekspostcircumcision by using IELT measuresmay not accurately reflect sexualfunction at a later period. Also, the selfreportof circumcision status mayimpact study validity. This could bein an unpredictable direction, althoughit is most likely that the effect wouldbe to cause an underestimation ofthe association. Other biases includePEDIATRICS Volume 130, Number 3, September 2012Downloaded fr<strong>om</strong> pediatrics.aappublications.org by guest on June 19, 2013e769


participants’ ages and any coexistingmedical conditions.Analgesia and Anesthesia Task Force Rec<strong>om</strong>mendation:8 Trained and c<strong>om</strong>petent practitioners,by using steriletechniques and effective painmanagement, should performmale circumcision. Analgesia iss<strong>af</strong>e and effective in reducingthe procedural pain associatedwith newborn circumcision;thus, adequate analgesia shouldbe provided whenever newborncircumcision is performed.8 Nonpharmacologic techniques(eg, positioning, sucrose pacifiers)alone are insufficient toprevent procedural and postproceduralpain and are notrec<strong>om</strong>mended as the solemethod of analgesia. They shouldbe used only as analgesicadjuncts to improve infant c<strong>om</strong>fortduring circumcision.8 If used, topical creams maycause a higher incidence of skinirritation in low birth weightinfants, c<strong>om</strong>pared with infantsof normal weight, so penilenerve block techniques shouldbe chosen for this group ofnewborns.The analgesics used for newborn circumcisioninclude nonpharmacologicand pharmacologic (topical and nerveblocks) techniques. The Task Force’sreview included nonnutritive sucking,a pacifier dipped in sucrose, acetaminophen,topical 4% lidocaine (ie,LMX4 cream), a eutectic mixture oflidocaine-prilocaine local anesthetic(EMLA), subcutaneous ringblock, and the dorsal penile nerveblock (DPNB). These methods, whichreduce the pain and stress of newborncircumcision, are representativeof the principles discussed in the AAPPolicy Statement on Prevention andManagement of Pain in the Neonate,which was updated in 2006. 137,138There are no evidence-based rec<strong>om</strong>mendationsthat state there is persistentpain that must be treated <strong>af</strong>ter thelocal preprocedure anesthetic wears off.Analgesia is s<strong>af</strong>e and effective in reducingthe procedural pain associatedwith newborn circumcision, as indicatedby changes in heart rate, oxygensaturation, facial action, crying,and other measures. 139–145 Therefore,adequate analgesia should be providedwhen newborn circumcision isperformed. Topical 4% lidocaine,DPNB, and a subcutaneous ring blockare all effective options, although thelatter may provide the most effectiveanalgesia. In addition there is goodevidence that infants circumcisedwithout analgesia exhibit a strongerbehavioral pain response to subsequentroutine immunization at 4 to 6months of age, c<strong>om</strong>pared with bothinfants circumcised with analgesiaand with uncircumcised infants. 145The literature search did not produceany reports of local anesthetic toxicity,such as seizures or cardiovascularinstability, among the newborns receivingeither local anesthetic injectionsor topical applications (ie, topical4% lidocaine).Nonpharmacologic TechniquesThere is good evidence that oral sucroseand oral analgesics are notdifferent fr<strong>om</strong> placebo or environmentalmodification in their ability tocontrol pain. 141,142,144 There is goodevidence that a more physiologic positioningof the infant in a paddedenvironment may decrease distressduring the procedure. 146 There is fairevidence that sucrose on a pacifier hasbeen demonstrated to be more effectivethan water alone for decreasingcrying during circumcision. 147–149 Nonpharmacologictechniques alone areinsufficient to prevent procedural pain,however. Positioning and a sucrosepacifier should be used as analgesicadjuncts to improve infant c<strong>om</strong>fortduring circumcision but are not rec<strong>om</strong>mendedas the sole method of analgesia.Topical Local Anesthesia TechniquesThere is good evidence that topicalanesthesia with lidocaine-prilocaine(which contains 2.5% lidocaine and2.5% prilocaine) or 4% lidocaine issuperior to no anesthesia in preventingpain during male circumcision. 150There is good evidence fr<strong>om</strong> a prospectivecohort study that lidocaineprilocainecream attenuates the painresponse to circumcision (as measuredby using heart rate, oxygensaturation, facial actions, and time andcharacteristics of crying) when applied60 to 90 minutes before theprocedure. 150,151 There is fair evidencefr<strong>om</strong> an RCT that lidocaine-prilocainecream attenuates the pain responseto circumcision, although it was lesseffective in doing so than DPNB or ringblock. 152 There is good evidence thattopical 4% lidocaine is as effective aslidocaine-prilocaine at preventingpain. 140,153 Topical 4% lidocaine hasthe advantage of having a faster onsetof action (2 g applied 30 minutes beforecircumcision, c<strong>om</strong>pared with 1 to 2hours before circumcision for lidocaineprilocaine).Both topical preparationsrequire coverage with plastic wrap tokeep the cream in place. Topical 4% lidocaineis the preferred topical localanesthetic (over lidocaine-prilocaine)because there is no risk of methemoglobinemia.The most c<strong>om</strong>mon c<strong>om</strong>plications reportedwith analgesic techniques werean 8% to 14% incidence of erythema,swelling, and blistering associatedwith topical analgesia. 142,150,153,154 Thereis fair evidence that adverse effectsof topical anesthetic creams aree770FROM THE AMERICAN ACADEMY OF PEDIATRICSDownloaded fr<strong>om</strong> pediatrics.aappublications.org by guest on June 19, 2013


FROM THE AMERICAN ACADEMY OF PEDIATRICSinfrequent and include only eitherminor skin reactions (ie, erythema,swelling) or, more rarely, blistering(especially in low birth weight infants).154 For this reason, penilenerve block techniques should bechosen for low birth weight infants.There is good and fair evidence thatboth reactions are less c<strong>om</strong>monwith 4% lidocaine than with lidocaineprilocainecream. 142,150,153–155There is a theoretical risk of methemoglobinemiawith lidocaine-prilocaine. 152However, when methemoglobin has beenmeasured <strong>af</strong>ter lidocaine-prilocaineapplication, the level, although elevated,was not clinically significant. 150Nevertheless, there have been isolatedcase reports of clinically significantmethemoglobinemia involving prolongedapplication time or use in prematureinfants. 156,157,158DPNBMost c<strong>om</strong>monly, DPNB consists ofinjections of 0.4 mL of 1% lidocainewithout epinephrine on both sides ofthe base of the penis. Systemic lidocainelevels obtained with use of thistechnique reached peak concentrationsat 60 minutes <strong>af</strong>ter injectionand were well below toxic ranges. 159There is good evidence that DPNB iseffective in reducing the behavioraland physiologic indicators of paincaused by circumcision, regardless ofthe device used. 144 There is good evidencethat DPNB is superior tolidocaine-prilocaine in relieving painduring and <strong>af</strong>ter circumcision innewborns. 142,160–162 One good-qualityprospective cohort study of 491 newborncircumcisions measured c<strong>om</strong>plicationsof DPNB analgesia; itreported an 11% incidence of bruisingand a 0.2% incidence of hemat<strong>om</strong>a,none of which required any change inmanagement. 163 Another good-quality,blinded, rand<strong>om</strong>ized controlled trialfound a 43% incidence of smallhemat<strong>om</strong>as in preterm and term newbornscircumcised by using DPNB. 142Subcutaneous Ring BlockTwo studies with fair evidence foundthat the subcutaneous circumferentialring block (0.8 mL of 1% lidocainewithout epinephrine injected at thebase or midsh<strong>af</strong>t of the penis) is effectivein mitigating pain and its consequencesduring circumcision ofnewborns. 164One study presented fair evidence thatthe ring block was superior to usingno anesthesia but found a 5% failurerate with the technique (1 in 20 ringblock infants had heart rate and behavioralpain scores that were abovethe control mean during at least 50%of the measured intervals, while 19 of20 had heart rate and pain scoresless than the control mean). Therewere no hemat<strong>om</strong>as in the infantsreceiving ring blocks. A second ringblock study had fair evidence that themethod was superior to either DPNBor lidocaine-prilocaine cream for painrelief in newborn circumcision, as thering block seemed to prevent cryingand increases in heart rate during allphases of the circumcision, with lesscrying and lower heart rates duringforeskin separation and incision thanseen with DPNB or lidocaine-prilocaine.152 No c<strong>om</strong>plications have beenreported in the use of this simple andhighly effective technique.Analgesia and Anesthesia fora Circumcision After the NewbornPeriodIn the United States, <strong>af</strong>ter the newbornperiod, general anesthesia is usedduring male circumcision because thesurgical procedure takes longer andinvolves hemostasis and the suturingof skin edges. Use of adjuvant localanesthetic techniques in addition togeneral anesthesia provides longerlastingpostoperative analgesia, minimizesthe need for intraoperative orpostoperative opioid administration,reduces adverse postoperative eventssuch as nausea and v<strong>om</strong>iting, anddecreases recovery time. Long-lastinganalgesia is achieved with either penilenerve block, by using any of themethods mentioned earlier, or caudalepidural analgesia in infants andchildren up to 3 years of age.General anesthesia carries a low riskof mortality (1 death per 400 000instances of general anesthesia). Therisk of adverse events (especially respiratoryevents) during general anesthesiaremains higher in infantsunder 1 year of age. 165 These risks areminimized when the procedure isperformed in infants in their optimalstate of health (no active reactiveairway disease or upper respiratoryinfection) and in a facility familiarwith the anesthesia care of infants. 166Additional concerns associated withsurgical circumcision in older infantsinclude time lost by parents andpatients fr<strong>om</strong> work and/or school.Caudal BlockCaudal block (CB) with bupivacaine isan anesthetic technique used forpostoperative analgesia for circumcisionin infants and older children up to3 years of age, as an alternative to ringblock and DPNB techniques. There isgood and fair evidence that there isa longer time to first postoperativeurination <strong>af</strong>ter CB without adverseclinical consequences. 167,168 There isgood evidence for a high incidence ofmild postoperative motor block anddelay in walking <strong>af</strong>ter the CB procedure(21% to 44%) in older children.167,169,170 Caudal analgesia maybe less available in facilities that donot treat many pediatric patients.DPNBThe reported failure rate of DPNB is1% to 10%. 171–175 When DPNB is usedPEDIATRICS Volume 130, Number 3, September 2012Downloaded fr<strong>om</strong> pediatrics.aappublications.org by guest on June 19, 2013e771


without general anesthesia in boys 3to 5 years of age, the technique hasa failure rate of 15%; for boys aged 6and older, the failure rate is 1.5%. 175There is good and fair evidence thatincidence of hemat<strong>om</strong>a with DPNBranges fr<strong>om</strong> 0.001% to 24%; severalstudies report rates of approximately6%. 174–177 One study with fair evidencereports a 0.001% rate of “improperneedle position with bleeding” anda similar number of “medicationerrors.” 176 Studies with good and fairevidence report a 12% to 83% rate ofedema in the area of injection of thelocal anesthetic <strong>af</strong>ter DPNB. 174,175,177Subcutaneous Ring BlockThere is good evidence for thereported 8% failure rate using the ringblock. 168 In children, edema and distortionof tissue layers <strong>af</strong>ter the ringblock make surgery more difficult,c<strong>om</strong>pared with using a CB to preventpostoperative pain. 178C<strong>om</strong>parison of MethodsDPNB, subcutaneous ring block, andCB techniques may be used in conjunctionwith general anesthesiadepending on the age of the childand are also used to provide postcircumcisionanalgesia. There is goodevidence that there is no difference inthe quality of postoperative analgesiaor parent satisfaction between DPNBand CB using bupivacaine. 169 A c<strong>om</strong>parisonof CB with or without a subcutaneousring block with bupivacaineshowed good evidence that CB witha subcutaneous ring block had significantlylonger duration of postoperativeanalgesia. 168 A techniquedescribing ultrasound guidance forcorrect needle placement for DPNB inchildren under general anesthesiadescribes lower pain scores in thefirst postoperative hour and a longerinterval until rescue analgesia wasrequired. 179,180C<strong>om</strong>plications and Adverse Events Task Force Rec<strong>om</strong>mendation:8 Elective circumcision should beperformed only if the infant’scondition is stable and healthy.8 Male circumcision should beperformed by trained and c<strong>om</strong>petentpractitioners, by usingsterile techniques and effectivepain management.The true incidence of c<strong>om</strong>plications<strong>af</strong>ter newborn circumcision is unknown,in part due to differing definitionsof “c<strong>om</strong>plication” and differingstandards for determining the timingof when a c<strong>om</strong>plication has occurred(ie, early or late). Adding to the confusionis the c<strong>om</strong>ingling of “early”c<strong>om</strong>plications, such as bleeding orinfection, with “late” c<strong>om</strong>plications suchas adhesions and meatal stenosis. Also,c<strong>om</strong>plication rates <strong>af</strong>ter an in-hospitalprocedure with trained personnel maybe far different fr<strong>om</strong> those of the developingworld and/or by untrainedritual providers. For the purposesof this document, c<strong>om</strong>plications aregrouped in terms of the timing of theprocedure. (Citations for the followingstatements below are provided in thesection <strong>af</strong>ter this summary.)Significant acute c<strong>om</strong>plications arerare, occurring in approximately 1 in500 newborn male circumcisions.Acute c<strong>om</strong>plications are usually minorand most c<strong>om</strong>monly involve bleeding,infection, or an imperfect amount oftissue removed. Late c<strong>om</strong>plications dooccur, most c<strong>om</strong>monly adhesions, skinbridges, and meatal stenosis. Thereare 2 schools of thought regardingthe cause of penile adhesions, whichare c<strong>om</strong>mon <strong>af</strong>ter circumcision. Oneis that fine adhesions represent inc<strong>om</strong>pletelysis of physiologic adhesionsat the time of circumcision; theother is that the fine adhesions occurbecause of raw serosa surfaces.It is unknown how often these latec<strong>om</strong>plications require surgical repair;this area requires further study.In general, the specific technique useddoes not <strong>af</strong>ford a significant differencein risk of c<strong>om</strong>plications. However, boysundergoing circumcisions in medicalfacilities in industrialized settingsperformed by trained practitionershave fewer c<strong>om</strong>plications than boys innonindustrialized nations who havecircumcisions performed by poorlytrained (or untrained) practitioners innonmedical surroundings. If circumcisionis performed, it is imperativethat those providing the service haveadequate training in the method usedand resources for and practice ofadequate analgesia and infectioncontrol.Contraindications to newborn circumcisioninclude significantly prematureinfants, those with blood dyscrasias,individuals who have a family history ofbleeding disorders, and those who havecongenital abnormalities such as hypospadias,congenital chordee, or deficientsh<strong>af</strong>t skin such as penoscrotalfusion or congenital buried penis. Inaddition, before performing newbornmale circumcision, the clinician shouldconfirm that vitamin K has been administered,in accordance with standardpractice of newborn care. 181Newborn Elective CircumcisionTwo large US hospital-based studieswith good evidence estimate the risk ofsignificant acute circumcision c<strong>om</strong>plicationsin the United States to bebetween 0.19% and 0.22%. 121,123Bleeding was the most c<strong>om</strong>monc<strong>om</strong>plication (0.08% to 0.18%), followedby infection (0.06%) and penileinjury (0.04%). For c<strong>om</strong>parison, anaudit of 33 921 tonsillect<strong>om</strong>ies foundan incidence of hemorrhage of 1.9%among children aged 0 to 4 years. 182An Israeli prospective cohort studywith fair evidence examined 19 478male infants born in 2001 who weree772FROM THE AMERICAN ACADEMY OF PEDIATRICSDownloaded fr<strong>om</strong> pediatrics.aappublications.org by guest on June 19, 2013


FROM THE AMERICAN ACADEMY OF PEDIATRICScircumcised primarily by trained, ritualproviders in nonmedical settings,and reported similarly low c<strong>om</strong>plicationrates. The overall c<strong>om</strong>plicationrate was 0.34%, including bleeding in0.08% and infection in 0.01%. 183 Approximatelyone-third of the identifiedc<strong>om</strong>plications were immediate (ie,bleeding, infection, penile injury),whereas two-thirds occurred later (ie,excess foreskin, penile torsion, shortageof skin, phimosis, inclusion cyst).There is fair evidence of a more frequentc<strong>om</strong>plication rate of 3.1% ina study based on abstraction of 1951hospital medical (rather than billing)records on newborn circumcision inAtlanta. 184 In this study, c<strong>om</strong>plicationswere found to be much more c<strong>om</strong>mon,with bleeding occurring in 2.1%,although most reports of bleedingwere mild in nature. Likewise, a reviewwith fair evidence of 1000 newborncircumcisions by using theG<strong>om</strong>co clamp in a hospital setting inSaudi Arabia found an overall c<strong>om</strong>plicationrate of 1.9%. 185 Bleeding occurredin 0.6%, infection in 0.4%, andredundant prepuce in 0.3%.Late c<strong>om</strong>plications of newborn circumcisioninclude excessive residualskin (inc<strong>om</strong>plete circumcision), excessiveskin removal, adhesions (naturaland vascularized skin bridges),meatal stenosis, phimosis, and epithelialinclusion cysts. These c<strong>om</strong>plicationsare considered “late,” asopposed to “acute” (or immediate)c<strong>om</strong>plications such as bleeding orinfection, which may still presentduring infancy but not during the immediatepostprocedural time frame.In 1 outpatient-based study of 214boys with poor evidence, the c<strong>om</strong>plicationsseen included adhesions (observedin 55 boys [25.6%]), redundantresidual prepuce (44 boys [20.1%]),balanitis (34 boys [15.5%]), skinbridge (9 boys [4.1%]), and meatalstenosis (1 boy [0.5%]). 76Outside the United States, a crosssectionalstudy fr<strong>om</strong> Nigeria of 370consecutive male infants (322 ofwh<strong>om</strong> had been circumcised) attendingan infant welfare clinic forimmunization with fair evidencereported an overall c<strong>om</strong>plication rateof 20.2%. 186 C<strong>om</strong>plications includedredundant prepuce (12.9%), excessiveskin removal (5.9%), skin bridge(4.1%), and buried penis (0.4%). Themajority of the procedures (81%)were performed in the hospital; 19%were performed at h<strong>om</strong>e. Nursesperformed 56% of procedures (n =180), physicians performed 35% (n =113), and traditional circumcisersperformed 9% (n = 29). The Israelistudy noted earlier with fair evidencereported a late c<strong>om</strong>plicationof redundant prepuce in 0.2% of the19 478 male infants studied. 183There is good evidence that circumcisionof a premature infant isassociated with an increased risk oflater-occurring c<strong>om</strong>plications (ie, poorcosmesis, increased risk of trappedpenis, adhesions). There is also goodevidence that circumcision of a newbornwho has a pr<strong>om</strong>inent suprapubicfat pad or penoscrotal webbing hasa higher risk for the same long-termc<strong>om</strong>plications. 187 One prospectivestudy with fair evidence examined thenatural course of penile adhesions<strong>af</strong>ter circumcision and found thatadhesions disappeared at s<strong>om</strong>e point6 months postcircumcision withoutintervention, except for thick adhesions(called “bridging adhesions”).The authors rec<strong>om</strong>mended lysis forskin bridges. 188Post-newborn CircumcisionThere have been few reports of acutec<strong>om</strong>plications <strong>af</strong>ter non-newborn circumcisionin the United States. Furthermore,there are no adequatestudies of late c<strong>om</strong>plications inboys undergoing circumcision in thepost-newborn period; this area requiresmore study.Although adverse outc<strong>om</strong>es are rareamong non-newborn circumcisions,the incidence tends to be orders ofmagnitude greater for boys circumcisedbetween 1 and 10 years of age,c<strong>om</strong>pared with those circumcised asnewborns. 189 As noted, general anesthesia,which is used for proceduresperformed <strong>af</strong>ter the newborn period,confers additional risk.The most c<strong>om</strong>mon surgical c<strong>om</strong>plicationis excessive bleeding (eg, bleedingthat did not stop with local pressure,perhaps requiring a suture), reportedin 0.6% of 1742 male infants. 184 Contactburns were reported with electrocauterywhen used with metal, and itshould not be used with the G<strong>om</strong>coclamp in newborn circumcisionsbecause it can cause devastatingburns. 184,190,191 A study with fair evidencereviewed the records of 476boys undergoing circumcision duringchildhood and found that c<strong>om</strong>plicationsoccurred in 8 records (1.7%), ofwhich 3 were related to anesthesia. 192The most c<strong>om</strong>mon surgical c<strong>om</strong>plicationwas excessive bleeding in 0.6%.In another report with fair evidence,which examined 267 patients whohad circumcision by using topicalglue rather than skin sutures, excessivebleeding occurred in 0.75% ofcases. 193European centers report an overallc<strong>om</strong>plication rate of 1.2% to 3.8% forcircumcisions performed in boysduring the newborn or non-newbornperiod. 194–196 In a study with fair evidenceof trained medical personnel inthe United Kingd<strong>om</strong>, the rate ofbleeding was 0.8% and of infectionwas 0.3%. In this study of a historicalcohort of over 75 boys aged 0 to 14years, 0.5% required surgical repair.195In a Turkish prospective cohort studyof 700 boys with fair evidence, bleedingPEDIATRICS Volume 130, Number 3, September 2012Downloaded fr<strong>om</strong> pediatrics.aappublications.org by guest on June 19, 2013e773


was reported in 2.2% of cases andinfection in 1.3% of boys circumcisedin a hospital, versus a bleeding rate of3.6% and an infection rate of 2.7% inboys undergoing a nonhospital-basedmass religious procedure, despitethe latter procedure being performedby trained personnel. 196There are no adequate analytic studiesof late c<strong>om</strong>plications in boys undergoingcircumcision in the post-newborn period.An Iranian cross-sectional studywith good evidence reported a latec<strong>om</strong>plication rate of 7.4%, includingredundant skin in 3.6%, excessive skinremoval in 1.3%, and meatal stenosisin 0.9%. 197Major C<strong>om</strong>plicationsThe majority of severe or even catastrophicinjuries are so infrequent asto be reported as case reports (andwere therefore excluded fr<strong>om</strong> thisliterature review). These rare c<strong>om</strong>plicationsinclude glans or penile amputation,198–206 transmission of herpessimplex <strong>af</strong>ter mouth-to-penis contactby a mohel (Jewish ritual circumcisers)<strong>af</strong>ter circumcision, 207–209 methicillinresistantStaphylococcus aureus infection,210 urethral cutaneous fistula, 211glans ischemia, 212 and death. 213Medical Versus Traditional ProvidersIn general, untrained providers createmore c<strong>om</strong>plications when performingmale circumcision than dowell-trained providers, regardless ofwhether they are physicians, nurses, ortraditional religious providers. Physiciansin a hospital setting generallyhave fewer c<strong>om</strong>plications than traditionalproviders in the c<strong>om</strong>munitysetting.A prospective study in Kenya with goodevidence found an overall c<strong>om</strong>plicationrate of 35% in 443 children and youngmen aged 5 to 21 years who hadtraditional circumcision performed ina village or household setting, c<strong>om</strong>paredwith an overall c<strong>om</strong>plicationrate of 17% in those whose circumcisionwas performed by trained providersin a medical setting such asa hospital, health center, or physician’soffice. 214 The most c<strong>om</strong>mon c<strong>om</strong>plicationswere bleeding and infection;excessive pain, lacerations, torsion,and erectile dysfunction were alsoobserved. A study in Turkey with fairevidence studied a historical cohortand found a significantly higher rate ofc<strong>om</strong>plications when male circumcisionwas performed by traditional circumcisers,c<strong>om</strong>pared with those performedby physicians; c<strong>om</strong>plicationrates were 85% for traditional providersversus 2.6% for physicians. 215A study in Israel with fair evidencefound there was no difference in therate of c<strong>om</strong>plications in newborncircumcision between hospital-basedphysicians and well-trained, h<strong>om</strong>ebasedritual circumcisers (mohels). 183C<strong>om</strong>plications With Different Methodsof Male CircumcisionThere have been few studies c<strong>om</strong>paringthe 3 most c<strong>om</strong>monly usedtechniques for male circumcision inthe United States (the G<strong>om</strong>co clamp,the Plastibell device, and the Mogenclamp). Steps c<strong>om</strong>mon to all 3 includeestimation of the amount of externalskin to be removed; dilation of thepreputial orifice so the glans can bevisualized to ensure that the glans itselfis normal; bluntly freeing the innerpreputial epithelium fr<strong>om</strong> the epitheliumof the glans; placing the device;leaving the device in place long enoughto produce hemostasis; and surgicallyremoving the foreskin.G<strong>om</strong>co ClampThe G<strong>om</strong>co clamp was specificallydesigned for performing circumcisions.In this procedure, “the foreskinis cut lengthwise through thestretched tissue (dorsal slit) to allowspace to insert the circumcision device.The bell of the G<strong>om</strong>co clamp isplaced over the glans, and the foreskinis pulled over the bell. The baseof the G<strong>om</strong>co clamp is placed over thebell, and the G<strong>om</strong>co clamp’s arm isfitted. After the surgeon confirmscorrect fitting and placement (and theamount of foreskin to be excised), thenut on the G<strong>om</strong>co clamp is tightenedand left in place for 3 to 5 minutes toallow hemostasis to occur, then theforeskin is removed using a scalpel.The G<strong>om</strong>co’s base and bell are thenremoved.” 216One study of the G<strong>om</strong>co clamp with fairevidence reviewed 1000 newborn circumcisionsin a hospital setting inSaudi Arabia and found an overallc<strong>om</strong>plication rate of 1.9%. 185 Bleedingoccurred in 0.6% of cases, infection in0.4%, and redundant prepuce in 0.3%.Another study of 521 newborn malecircumcisions performed at a Houstonoutpatient clinic with fair evidencereported a 2.9% incidence of phimosis(trapped penis) <strong>af</strong>ter newborn circumcisionusing the G<strong>om</strong>co clamp. 217Plastibell DevicePlastibell circumcision involves a surgicalprocedure in which a plastic ringis inserted under the foreskin, anda tie is placed over the ring to providehemostasis. The ring remains on thepenis for several days until the tissuenecroses and the ring falls off spontaneously.Bleeding ranged fr<strong>om</strong> 0.8% to3% of cases; infection occurred in 2.1%of cases. 218 Urinary retention 219,220 andproblems with the Plastibell ring havebeen reported in 3.6% of cases. 221Studies of the Plastibell device with fairand good evidence found, overall, thatc<strong>om</strong>plications range fr<strong>om</strong> 2.4% to5%. 218,221–223Mogen ClampThe Mogen clamp is a device consistingof 2 flat blades that have a limitede774FROM THE AMERICAN ACADEMY OF PEDIATRICSDownloaded fr<strong>om</strong> pediatrics.aappublications.org by guest on June 19, 2013


FROM THE AMERICAN ACADEMY OF PEDIATRICS(slit-like) space between them anda mechanism that draws the bladestogether and locks them in place. Theslit is limited to 3 mm to allow theforeskin, but not the glans, to crossthe opening. The preputial adhesionsare gently taken down by a probe andthe glans pushed downward, therebyprotecting it fr<strong>om</strong> the blades. Theprepuce distal to the glans is drawninto the slit between the blades andpositioned. The blades are locked together,crushing the skin and creatinghemostasis. The skin is excised fr<strong>om</strong>above the clamp. The clamp is removedand the skin pushed proximallyinto proper position.There were no specific studies ofc<strong>om</strong>plications of the Mogen becausec<strong>om</strong>plications are rare; thus, one canonly rely on available case reports ofamputation. 201,202,222–228C<strong>om</strong>parisonA study with fair evidence evaluatedthe use of the G<strong>om</strong>co versus thePlastibell device in 350 newborninfants. 229 The incidence of infectionwas higher with the G<strong>om</strong>co clamp(2%) versus a lower c<strong>om</strong>plication rate(1.3%) with the Plastibell device.Adhesions were also more c<strong>om</strong>monwith the G<strong>om</strong>co clamp, at a rate of20% vs 6.6% for the Plastibell device.Stratification of RisksBased on the data reviewed, it isdifficult, if not impossible, to adequatelyassess the total impact ofc<strong>om</strong>plications, because the data arescant and inconsistent regarding theseverity of c<strong>om</strong>plications. For example,studies that report bleeding asa c<strong>om</strong>plication do not uniformly reporthow frequently the bleeding wascontrolled with local measures versusrequiring a transfusion or surgicalintervention. Similarly, infectionis rarely further divided into localtissue infection versus bacteremia orsepsis. Financial costs of care, emotionaltolls, or the need for futurecorrective surgery (with the attendantanesthetic risks, family stress,and expense) are unknown.S<strong>om</strong>e reports have attempted toc<strong>om</strong>pare potential benefits of circumcisionwith reported c<strong>om</strong>plicationrates. One study with good evidenceattempted to estimate c<strong>om</strong>plicationrates c<strong>om</strong>pared with benefits fr<strong>om</strong>male circumcision. Based on an estimatethat 100 circumcisions mustbe performed to prevent 1 UTI, and909 circumcisions must be performedto prevent 1 case of penile cancer,the study yields an estimate of 1c<strong>om</strong>plication for every 5 UTIs preventedand 2 c<strong>om</strong>plications for every1caseofpenilecancerprevented. 121Assuming an overall minor adverseevent rate for newborn circumcisionof 0.2%, and a severe adverse eventrate of 0.005%, another study withfair evidence estimated that over322 000 newborn male circumcisionsare required to prevent 1 case of penilecancer per year. 122 Similar modelingfor HIV, herpes, and HPV in theUnited States is not available.A recently published CDC study foundthat male circumcision before theage of sexual debut was cost-effectivefor the prevention of HIV. 60 The studydid not take into account the positivebenefits of newborn circumcision forother conditions such as costs ofcaring for UTIs. 106,107,110,112,230–233 Italso did not include recent evidencethat circumcision (either as an infantor later in life) is associated withreduced risk for other STIs, penileand cervical cancers, phimosis, andpenile dermatoses. 36,88,234,235 Theauthors did not include adverseeffects that make newborn circumcisionless cost-effective, such asbleeding, infection, and revision. Consideringall these factors, however,the authors concluded that malecircumcision was a cost-effectivestrategy for HIV prevention in theUnited States. 60Workforce Development and MaleCircumcision Task Force Rec<strong>om</strong>mendations:8 Physicians counseling familiesabout elective male circumcisionshould assist parents byexplaining, in a nonbiasedmanner, the potential benefitsand risks, and by ensuring thatthey understand the electivenature of the procedure.8 Parents are entitled to factuallycorrect, nonbiased informationabout circumcision that shouldbe provided before conceptionand early in pregnancy,when parents are mostlikely to be weighing the optionof circumcision of a malechild.8 Parents of newborn boysshould be instructed in thecare of the penis at the timeof discharge fr<strong>om</strong> the newbornhospital stay, regardless ofwhether the newborn is circumcisedor not.8 Male circumcision should beperformed by trained andc<strong>om</strong>petent practitioners, byusing sterile techniques andeffective pain management. Analgesiais s<strong>af</strong>e and effectivein reducing the proceduralpain associated with newborncircumcision; thus, adequateanalgesia should be providedwhenever newborn circumcisionis performed.8 Key professional organizations(AAP, AAFP, ACOG, the AmericanSociety of Anesthesiologists,the American College ofNurse Midwives, and othermidlevel clinicians such asPEDIATRICS Volume 130, Number 3, September 2012Downloaded fr<strong>om</strong> pediatrics.aappublications.org by guest on June 19, 2013e775


nurse practitioners) should workcollaboratively to: Develop standards of trainee proficiencyin performance of anestheticand procedure techniques,including suturing; Teach the procedure and analgesictechniques during postgraduatetraining programs; Develop educational materials forclinicians to enhance practitioners’c<strong>om</strong>petency in discussing the benefitsand risks of circumcision withparents; Offer educational materials to assistparents of male infants withthe care of both circumcised anduncircumcised penises.Workforce Development and ParentalDecision-makingThere is fair evidence that s<strong>om</strong>eclinicians do not convey current ormedically accurate information aboutcircumcision to parents, either verballyor in written materials. 18 Providinginformation about the risks andbenefits of circumcision does notseem to lead to lower circumcisionrates. 236Parents are entitled to factually correct,nonbiased information aboutcircumcision and should receive thisinformation fr<strong>om</strong> clinicians beforeconception and/or early in pregnancy,which is when they are making choicesabout circumcision. As noted, in 2009,the AAP surveyed members on theirattitudes and practices around circumcision.19 According to the responses,67% of pediatricians reporteddiscussing the pros and cons of circumcisionwith parents. Almost twothirds(62%) reported that theymade no rec<strong>om</strong>mendation regardingcircumcision to the majority of theirpatients; 18% responded rec<strong>om</strong>mendingto all or most of theirpatients’ parents that circumcision beperformed; 7% reported rec<strong>om</strong>mendingto all or nearly all of the parentsof newborn males that circumcisionnot be performed.As described earlier, there is fair evidencethat parental decision-makingabout circumcision tends to occurwell before the child’s birth. Thus, informationto assist in parentaldecision-making should be madeavailable as early as possible, even aspart of guidance to parents beforeconception occurs. For this reason,obstetrician-gynecologists and familyphysicians who manage w<strong>om</strong>en’shealth and prenatal care probablyhave a more pivotal role in this decisionthan do pediatricians. Publichealth authorities have an importantrole in educating the public on therole of newborn male circumcision indisease prevention.Workforce Development and Provisionof CircumcisionIn the United States, obstetricians,family physicians, and pediatriciansare the principal clinicians who performnewborn circumcisions in medicalsettings; there is no single systemof training or credentialing for circumcisionin use nationwide. 237 Thereis good and fair evidence of considerablevariation in provider type byregion and by hospital, 238–240 withmidwives performing circumcision ins<strong>om</strong>e locations. 18,241Training curricula for teaching newborncircumcision in departments ofpediatrics 237,242 and family medicine 243have been described but do not provideinformation on how widely usedthey are or the trainings’ results and/or effectiveness. One pediatric program’straining consisted of the residentperforming 3 to 5 circumcisionswith assistance fr<strong>om</strong> a faculty instructor,3 to 5 circumcisions underdirect observation but without handsonfaculty involvement, and 2 testcircumcisions for grading and departmentalcredentialing. 242 The other2 programs did not describe actualresident experience performing a circumcision.Most residency training programs inthe respective specialties teach techniques,including the G<strong>om</strong>co clamp,Mogen clamp, and Plastibell device. 238As of 2006, 97% of programs that includedtraining in performance ofcircumcision taught the use of eitherlocal or topical anesthetics for circumcisionanalgesia, an increasefr<strong>om</strong> 45% to 74% in 1998. 238–240 Althoughcase studies were excludedfr<strong>om</strong> this review, it was noted that 2record reviews with fair evidenceaddressed the need for circumcisionrevision based on the medical disciplineof the physician who performed theoriginal procedure. 241,244None of the articles reviewed addressedcurrent or future workforceneeds, which seems to depend onthe number of surgeries being performed,the future demand, andreimbursement for the procedure.Sustaining a workforce that is capableof counseling families and performingthe newborn male circumcision procedures<strong>af</strong>ely is increasingly important,as the number of clinicians whoare able to perform this procedure islikely to decline with curtailment ofMedicaid coverage for it in variousstates.The Task Force strongly rec<strong>om</strong>mendsthe creation, revision, and enhancementof educational materials to assistparents of male infants with the careof both circumcised and uncircumcisedpenises. The Task Force alsostrongly rec<strong>om</strong>mends the developmentof educational materials forclinicians to enhance practitioners’c<strong>om</strong>petency in discussing the benefitsand risks of circumcision withparents. A structured decision-makingtool that clinicians can use to helpe776FROM THE AMERICAN ACADEMY OF PEDIATRICSDownloaded fr<strong>om</strong> pediatrics.aappublications.org by guest on June 19, 2013


FROM THE AMERICAN ACADEMY OF PEDIATRICSparents c<strong>om</strong>plete would assist in thedecision of whether to circumcise ornot. To this end, the Task Force rec<strong>om</strong>mendsthat key professionalorganizations (AAP, ACOG, AAFP, AmericanSociety of Anesthesiologists,American College of Nurse Midwives,and other entities supporting midlevelclinicians) work together to developa consensus plan about which groupsare best suited to perform circumcisionsin newborn males; teach theprocedure and analgesic techniquesduring postgraduate training programs;and develop standards oftrainee proficiency. In addition, healthdepartments should be involved in thedissemination of educational materialsand coordinating educational effortswith professional organizations.Financing Newborn MaleCircumcision Task Force rec<strong>om</strong>mendation:1. The preventive and publichealth benefits associated withnewborn male circumcisionwarrant third-party reimbursementof the procedure.The CDC estimates that, fr<strong>om</strong> 2005 to2006, the average cost of providingnewborn male circumcision (includingphysician- and facility-related costs)ranged fr<strong>om</strong> $216 to $601 across thenation. 60 Hospitals in states whereMedicaid covers routine newbornmale circumcision have circumcisionrates that are 24% higher than hospitalsin states without such coverage.23 As of 2009, 15 states did notcover newborn male circumcision intheir Medicaid programs; 2 additionalstates had variable coverage dependenton the enrollment plan. 245There seems to be a relationship betweencircumcision incidence andthird-party payment.Circumcised newborns are more likelyto be privately insured than publiclyinsured infants. 246 The weighted ratesof circumcision over the 13-year periodfr<strong>om</strong> 1991 to 2005 were 40.8% forMedicaid clients versus 43.3% for theuninsured and 64.4% for insurednewborns. 5 The associations with insurancestatus were independent ofrace/ethnicity and socioecon<strong>om</strong>icstatus in this study. 246As noted, a recent cost-effectivenessanalysis by the CDC concluded thatnewborn circumcision is a societalcost-saving HIV prevention intervention.60 African-American and Hispanicmales in the United States aredisproportionately <strong>af</strong>fected by HIVand other STIs, and thus would derivethe greatest benefit fr<strong>om</strong> circumcision;the HIV prevention evidencefor non-Hispanic white males was notas strong as for African-American andHispanic males. However, the African-American and Hispanic populationsare the most likely to have Medicaidcoverage. 247 In 2010, 50% of Hispanicchildren (up to age 18 years) and 54%of African-American children werecovered by Medicaid, c<strong>om</strong>pared with23% of white children. 248 Thus, recentefforts by state Medicaid programs tocurb payment for newborn male circumcision<strong>af</strong>fect those populations thatcould benefit the most fr<strong>om</strong> the procedure.60 The CDC authors rec<strong>om</strong>mendedthat: “Financial barriers thatprevent parents fr<strong>om</strong> having the choiceto circumcise their male newbornsshould be reduced or eliminated.”AREAS FOR FUTURE RESEARCHIn the course of its work, the TaskForce identified important gaps in ourknowledge of male circumcision andurges the research c<strong>om</strong>munity to seriouslyconsider these gaps as futureresearch agendas are developed. Althoughit is clear that there is goodevidence on the risks and benefits ofmale circumcision, it will be useful forthis benefit to be more precisely definedin a US setting and to monitoradverse events. Specifically, the TaskForce rec<strong>om</strong>mends additional studiesto better understand: The performance of elective malecircumcisions in the United States,including those that are hospitalbasedand nonhospital-based, ininfancy and subsequently in life. Parental decision-making to developuseful tools for c<strong>om</strong>munication betweenproviders and parents on theissueofmalecircumcision. The impact of male circumcision ontransmission of HIV and other STIs inthe United States because key studiesto date have been performed inAfrican populations with HIV burdensthat are epidemiologically differentfr<strong>om</strong> HIV in the United States. The risk of acquisition of HIV andother STIs in 0- to 18-year-olds, tohelp inform the acceptance of theprocedure during infancy versusdeferring the decision to performcircumcision (and thus the procedure’sbenefits) until the child canprovide his own assent/consent.Because newborn male circumcisionis less expensive and morewidely available, a delay often meansthat circumcision does not occur. Itwill be useful to more precisely definethe prevention benefits conferredby male circumcision toinform parental decision-makingand to evaluate cost-effectivenessand benefits of circumcision, especiallyin terms of numbers needed totreat to prevent specific outc<strong>om</strong>es. The population-based incidence ofc<strong>om</strong>plications of newborn malecircumcision (including stratificationsaccording to timing of procedure,type of procedure, providertype, setting, and timing of c<strong>om</strong>plications[especially severe and nonacutec<strong>om</strong>plications]). The impact of the AAP Male Circumcisionpolicy on newborn malePEDIATRICS Volume 130, Number 3, September 2012Downloaded fr<strong>om</strong> pediatrics.aappublications.org by guest on June 19, 2013e777


circumcision practices in theUnited States and elsewhere. The extent and level of training of theworkforce to sustain the availabilityof s<strong>af</strong>e circumcision practices fornewborn males and their families.CONCLUSIONSThis technical report provides rec<strong>om</strong>mendationsregarding the practiceof male circumcision, particularly inthe newborn period. It emphasizes theprimacy of parental decision-makingand the imperative for those whoperform male circumcisions to beadequately trained and use both effectivesterile techniques and painmanagement. The report evaluatedcurrent evidence regarding the effectof male circumcision on the preventionof STIs (including HIV), UTIs, cancer, andother morbidities. Evidence about c<strong>om</strong>plicationsresulting fr<strong>om</strong> male circumcisionand the use of analgesiaand anesthesia were also discussed.The Task Force concluded that thehealth benefits of newborn male circumcisionoutweigh the risks andjustify access to this procedure forfamilies who choose it.The Task Force also made the followingrec<strong>om</strong>mendations: Evaluation of current evidence indicatesthat the health benefits ofnewborn male circumcision outweighthe risks, and the benefitsof newborn male circumcision justifyaccess to this procedure forthose families who choose it. Parents are entitled to factually correct,nonbiased information aboutcircumcision that should be providedbefore conception and earlyin pregnancy, when parents aremost likely to be weighing the optionof circumcision of a male child. Physicians counseling families aboutelective male circumcision shouldassist parents by explaining, ina nonbiased manner, the potentialbenefits and risks, and by ensuringthat they understand the electivenature of the procedure. Parents should weigh the healthbenefits and risks in light of theirown religious, cultural, and personalpreferences, as the medicalbenefits alone may not outweighthese other considerations for individualfamilies. Parents of newborn boys should beinstructed in the care of the penisat the time of discharge fr<strong>om</strong> thenewborn hospital stay, whether thenewborn is circumcised or not. Elective circumcision should beperformed only if the infant’s conditionis stable and healthy. Trained and c<strong>om</strong>petent practitioners,by using sterile techniquesand effective pain management,should perform male circumcision. Analgesia is s<strong>af</strong>e and effective inreducing the procedural painassociated with newborn circumcision;thus, adequate analgesiashould be provided whenevernewborn circumcision is performed.8Nonpharmacologic techniques(such as positioning and sucrosepacifiers) alone are insufficientto prevent proceduraland postprocedural pain andare not rec<strong>om</strong>mended as thesole method of analgesia. Theyshould be used only as analgesicadjuncts to improve infantc<strong>om</strong>fort during circumcision.8 If used, topical creams maycause a higher incidence of skinirritation in low birth weight infants,c<strong>om</strong>pared with infants ofnormal weight, so penile nerveblock techniques should be chosenfor this group of newborns. Key professional organizations (AAP,AAFP, ACOG, the American Societyof Anesthesiologists, the AmericanCollege of Nurse Midwives, and othermidlevel clinicians such as nursepractitioners) should work collaborativelyto:8 Develop standards of traineeproficiency in performance ofanesthetic and procedure techniques,including suturing;8 Teach the procedure and analgesictechniques during postgraduatetraining programs;8 Develop educational materialsfor clinicians to enhance practitioners’c<strong>om</strong>petency in discussingthe benefits and risks ofcircumcision with parents;8 Offer educational materials to assistparents of male infants withthe care of both circumcised anduncircumcised penises. The preventive and public healthbenefits associated with newbornmale circumcision warrant thirdpartyreimbursement of the procedure.TASK FORCE ON CIRCUMCISIONSusan Blank, MD, MPH, ChairpersonMichael Brady, MD, Representing the C<strong>om</strong>mitteeon Pediatric AIDSEllen Buerk, MD, Representing the AAP Board ofDirectorsWaldemar Carlo, MD, Representing the AAPC<strong>om</strong>mittee on Fetus and NewbornDouglas Diekema, MD, MPH, Representing theAAP C<strong>om</strong>mittee on BioethicsAndrew Freedman, MD, Representing the AAPSection on UrologyLynne Maxwell, MD, Representing the AAP Sectionon Anesthesiology and Pain MedicineSteven Wegner, MD, JD, Representing the AAPC<strong>om</strong>mittee on Child Health FinancingLIAISONSCharles LeBaron, MD – Centers for DiseaseControl and PreventionLesley Atwood, MD – American Academy ofFamily PhysiciansSabrina Craigo, MD – American College ofObstetricians and GynecologistsCONSULTANTSSusan K. Flinn, MA – Medical WriterEsther C. Janowsky, MD, PhDSTAFFEdward P. Zimmerman, MSe778FROM THE AMERICAN ACADEMY OF PEDIATRICSDownloaded fr<strong>om</strong> pediatrics.aappublications.org by guest on June 19, 2013


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Tzeng YS, Tang SH, Meng E, Lin TF, Sun GH.Ischemic glans penis <strong>af</strong>ter circumcision.Asian J Androl. 2004;6(2):161–163213. Mogotlane SM, Ntlangulela JT, OgunbanjoBG. Mortality and morbidity among traditionallycircumcised Xhosa boys in theEastern Cape Province, South Africa.Curationis. 2004;27(2):57–62214. Bailey RC, Egesah O, Rosenberg S. Malecircumcision for HIV prevention: a prospectivestudy of c<strong>om</strong>plications in clinicaland traditional settings in Bung<strong>om</strong>a,Kenya. Bull World Health Organ. 2008;86(9):669–677215. Atikeler MK, Geçit I, Yüzgeç V, Yalçin O.C<strong>om</strong>plications of circumcision performedwithin and outside the hospital. Int UrolNephrol. 2005;37(1):97–99216. Wikipedia. G<strong>om</strong>co clamp. Available at: http://en.wikipedia.org/wiki/G<strong>om</strong>co_clamp#cite_note-8217. Blalock HJ, Vemulakonda V, Ritchey ML,Ribbeck M. Outpatient management ofphimosis following newborn circumcision.JUrol. 2003;169(6):2332–2334218. Manji KP. Circumcision of the young infantin a developing country using the Plastibell.Ann Trop Paediatr. 2000;20(2):101–104219. Mihssin N, Moorthy K, Houghton PW. Retentionof urine: an unusual c<strong>om</strong>plicationof the Plastibell device. BJU Int. 1999;84(6):745220. Bliss DP, Jr;Healey PJ, Waldhausen JH.Necrotizing fasciitis <strong>af</strong>ter Plastibell circumcision.J Pediatr. 1997;131(3):459–462221. Palit V, Menebhi DK, Taylor I, Young M,Elmasry Y, Shah T. A unique service in UKdelivering Plastibell circumcision: reviewof 9-year results. Pediatr Surg Int. 2007;23(1):45–48222. Duncan ND, Dundas SE, Brown B, Pinnock-Ramsaran C, Badal G. Newborn circumcisionusing the Plastibell device: an audit of practice.West Indian Med J. 2004;53(1):23–26223. Lazarus J, Alexander A, Rode H. Circumcisionc<strong>om</strong>plications associated with thePlastibell device. S Afr Med J. 2007;97(3):192–193224. Beniamin F, Castagnetti M, Rigamonti W.Surgical management of penile amputationin children. J Pediatr Surg. 2008;43:1939–1943225. de Lagausie P, Jehanno P. Six years followupof a penis replantation in a child. JPediatr Surg. 2008;43:E11–E12226. Perovic SV, Djinovic RP, Bumbasirevic MZ,Santucci RA, Djordjevic ML, Kourbatov D.Severe penile injuries: a problem of severityand reconstruction. BJU Int. 2009;104:676–687e784FROM THE AMERICAN ACADEMY OF PEDIATRICSDownloaded fr<strong>om</strong> pediatrics.aappublications.org by guest on June 19, 2013


FROM THE AMERICAN ACADEMY OF PEDIATRICS227. Shaeer O. Restoration of the penis followingamputation at circumcision: Shaeer’sA-Yplasty.J Sex Med. 2008;5:1013–1021228. Binous MY, Haddad B, Fekih W, BoudokhaneM, Hellali K, Fodha M. [Amputationof a penile glans distal third and successfulreattachment]. Tunis Med. 2008;86:608–609229. Machmouchi M, Alkhotani A. Is neonatalcircumcision judicious? Eur J PediatrSurg. 2007;17(4):266–269230. Wiswell TE, Smith FR, Bass JW. Decreasedincidence of urinary tract infections incircumcised male infants. Pediatrics.1985;75(5):901–903231. Wiswell TE, Roscelli JD. Corroborative evidencefor the decreased incidence of urinarytract infections in circumcised maleinfants. Pediatrics. 1986;78(1):96–99232. Wiswell TE. The prepuce, urinary tractinfections, and the consequences. Pediatrics.2000;105:860–862233. Lerman SE, Liao JC. Neonatal circumcision.Pediatr Clin North Am. 2001;48(6):1539–1557234. Schoen EJ, Colby CJ, To TT. Cost analysis ofneonatal circumcision in a large healthmaintenance organization. J Urol. 2006;175(3 pt 1):1111–1115235. Vergidis PI, Falagas ME, Hamer DH. Metaanalyticalstudies on the epidemiology,prevention, and treatment of human immunodeficiencyvirus infection. Infect DisClin North Am. 2009;23(2):295–308236. Waldeck SE. Social norm theory and malecircumcision: why parents circumcise. AmJ Bioeth. 2003;3(2):56–57237. Soper RJ, Brooks G, Fletcher K, Sampson M. Atraining model for circumcision of the newborn.Clin Pediatr (Phila). 2001;40(7):409–412238. Yawman D, Howard CR, Auinger P,Garfunkel LC, Allan M, Weitzman M. Painrelief for neonatal circumcision: a followupof residency training practices. AmbulPediatr. 2006;6(4):210–214239. Stang HJ, Snellman LW. Circumcisionpractice patterns in the United States.Pediatrics. 1998;101(6). Available at: www.pediatrics.org/cgi/content/full/101/6/e5240. Howard CR, Howard FM, Garfunkel LC, deBlieck EA, Weitzman M. Neonatal circumcisionand pain relief: current trainingpractices. Pediatrics. 1998;101(3 pt 1):423–428241. Brisson PA, Patel HI, Feins NR. Revision ofcircumcision in children: report of 56cases. JPediatrSurg. 2002;37(9):1343–1346242. Chandran L, Latorre P. Neonatal circumcisionsperformed by pediatric residents:implementation of a training program.Ambul Pediatr. 2002;2(6):470–474243. Brill JR, Wallace B. Neonatal circumcisionmodel and c<strong>om</strong>petency evaluation forfamily medicine residents. Fam Med. 2007;39(4):241–243244. Al-Ghazo MA, Banihani KE. Circumcisionrevision in male children. Int Braz J Urol.2006;32(4):454–458245. Clark SJ, Kilmarx PH, Kretsinger K. Coverageof newborn and adult male circumcisionvaries among public andprivate US payers despite health benefits.Health Aff (Millwood). 2011;30(12):2355–2361246. Warner L, Cox S, Kuklina E, et al. Updatedtrends in the incidence of circumcisionamong male newborn delivery hospitalizationsin the United States, 2000-2008.National HIV Prevention Conference; August26, 2010; Atlanta, GA247. Th<strong>om</strong>as M, James C. Race, Ethnicity &Health Care Issue Brief: The Role of HealthCoverage for C<strong>om</strong>munities of Color. MenloPark, CA: The Henry J. Kaiser FamilyFoundation; 2009248. SHADAC, State Health Access Data AssistanceCenter. American C<strong>om</strong>munity Survey(ACS). SHADAC data center, 2010. Availableat: http://www.shadac.org/datacenter.Accessed May 4, 2012PEDIATRICS Volume 130, Number 3, September 2012Downloaded fr<strong>om</strong> pediatrics.aappublications.org by guest on June 19, 2013e785


Male CircumcisionTASK FORCE ON CIRCUMCISIONPediatrics 2012;130;e756; originally published online August 27, 2012;DOI: 10.1542/peds.2012-1990Updated Information &ServicesReferencesCitationsPost-PublicationPeer Reviews (P 3 Rs)Subspecialty CollectionsPermissions & LicensingReprintsincluding high resolution figures, can be found at:http://pediatrics.aappublications.org/content/130/3/e756.full.htmlThis article cites 215 articles, 46 of which can be accessedfree at:http://pediatrics.aappublications.org/content/130/3/e756.full.html#ref-list-1This article has been cited by 9 HighWire-hosted articles:http://pediatrics.aappublications.org/content/130/3/e756.full.html#related-urls6 P 3 Rs have been posted to this articlehttp://pediatrics.aappublications.org/cgi/eletters/130/3/e756This article, along with others on similar topics, appears inthe following collection(s):Task Force on Circumcisionhttp://pediatrics.aappublications.org/cgi/collection/task_force_on_circumcisionInformation about reproducing this article in parts (figures,tables) or in its entirety can be found online at:http://pediatrics.aappublications.org/site/misc/Permissions.xhtmlInformation about ordering reprints can be found online:http://pediatrics.aappublications.org/site/misc/reprints.xhtmlPEDIATRICS is the official journal of the American Academy of Pediatrics. A monthlypublication, it has been published continuously since 1948. PEDIATRICS is owned, published,and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, ElkGrove Village, Illinois, 60007. Copyright © 2012 by the American Academy of Pediatrics. Allrights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.Downloaded fr<strong>om</strong> pediatrics.aappublications.org by guest on June 19, 2013


Cultural Bias in the AAP's 2012 Technical Report and Policy Statement on MaleCircumcisionMorten Frisch, Yves Aigrain, Vidmantas Barauskas, Ragnar Bjarnason, Su-AnnaBoddy, Piotr Czauderna, Robert P.E. de Gier, T<strong>om</strong> P.V.M. de Jong, Günter Fasching,Willem Fetter, Manfred Gahr, Christian Graugaard, Gorm Greisen, AnnaGunnarsdottir, Wolfram Hartmann, Petr Havranek, Rowena Hitchcock, SimonHuddart, St<strong>af</strong>fan Janson, Poul Jaszczak, Christoph Kupferschmid, TuijaLahdes-Vasama, Harry Lindahl, Noni MacDonald, Trond Markestad, Matis Märtson,Solveig Marianne Nordhov, Heikki Pälve, Aigars Petersons, Feargal Quinn, NielsQvist, Thrainn Rosmundsson, Harri Saxen, Olle Söder, Maximilian Stehr, VolkerC.H. von Loewenich, Johan Wallander and Rene WijnenPediatrics; originally published online March 18, 2013;DOI: 10.1542/peds.2012-2896PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthlypublication, it has been published continuously since 1948. PEDIATRICS is owned,published, and trademarked by the American Academy of Pediatrics, 141 Northwest PointBoulevard, Elk Grove Village, Illinois, 60007. Copyright © 2013 by the American Academyof Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.Downloaded fr<strong>om</strong> pediatrics.aappublications.org by guest on June 19, 2013


The online version of this article, along with updated information and services, islocated on the World Wide Web at:http://pediatrics.aappublications.org/content/early/2013/03/12/peds.2012-2896PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthlypublication, it has been published continuously since 1948. PEDIATRICS is owned,published, and trademarked by the American Academy of Pediatrics, 141 Northwest PointBoulevard, Elk Grove Village, Illinois, 60007. Copyright © 2013 by the American Academyof Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.Downloaded fr<strong>om</strong> pediatrics.aappublications.org by guest on June 19, 2013


Cultural Bias in the AAP’s 2012 Technical Reportand Policy Statement on Male CircumcisionabstractThe American Academy of Pediatrics recently released its new TechnicalReport and Policy Statement on male circumcision, concludingthat current evidence indicates that the health benefits of newbornmale circumcision outweigh the risks. The technical report is basedon the scrutiny of a large number of c<strong>om</strong>plex scientific articles.Therefore, while striving for objectivity, the conclusions drawn bythe 8 task force members reflect what these individual physiciansperceived as trustworthy evidence. Seen fr<strong>om</strong> the outside, culturalbias reflecting the normality of nontherapeutic male circumcision inthe United States seems obvious, and the report’s conclusions aredifferent fr<strong>om</strong> those reached by physicians in other parts of theWestern world, including Europe, Canada, and Australia. In thisc<strong>om</strong>mentary, a different view is presented by non–US-based physiciansand representatives of general medical associations and societiesfor pediatrics, pediatric surgery, and pediatric urology inNorthern Europe. To these authors, only 1 of the arguments putforward by the American Academy of Pediatrics has s<strong>om</strong>e theoreticalrelevance in relation to infant male circumcision; namely, thepossible protection against urinary tract infections in infant boys,whichcaneasilybetreatedwithantibiotics without tissue loss. Theother claimed health benefits, including protection against HIV/AIDS,genital herpes, genital warts, and penile cancer, are questionable,weak, and likely to have little public health relevance in a Westerncontext, and they do not represent c<strong>om</strong>pelling reasons for surgerybefore boys are old enough to decide for themselves. Pediatrics2013;131:796–800Circumcision rates are steadily decreasing in most Western countriesaround the world, including the United States. 1 Still, a majority ofnewborn male infants undergo the procedure in the United States. In itsnewly released Technical Report and Policy Statement on male circumcision,2,3 the American Academy of Pediatrics (AAP) has changedfr<strong>om</strong> a neutral to a more positive attitude toward circumcision,claiming that possible health benefits now outweigh the risks andpossible negative long-term consequences. The AAP does not rec<strong>om</strong>mendroutine circumcision of all infant boys as a public healthmeasure but asserts that the benefits of the procedure are sufficientto warrant third-party payment. In Europe, Canada, and Australia,where infant male circumcision is considerably less c<strong>om</strong>mon than inthe United States, the AAP report is unlikely to influence circumcisionpractices because the conclusions of the report and policy statementseem to be strongly culturally biased.AUTHORS: Morten Frisch, MD, PhD, a Yves Aigrain, MD,PhD, b Vidmantas Barauskas, MD, PhD, c Ragnar Bjarnason,MD, PhD, d Su-Anna Boddy, MD, e Piotr Czauderna, MD, PhD, fRobert P.E. de Gier, MD, g T<strong>om</strong> P.V.M. de Jong, MD, PhD, hGünter Fasching, MD, i Willem Fetter, MD, PhD, j ManfredGahr, MD, k Christian Graugaard, MD, PhD, l Gorm Greisen,MD, PhD, m Anna Gunnarsdottir, MD, PhD, n WolframHartmann, MD, o Petr Havranek, MD, PhD, p RowenaHitchcock, MD, q Simon Huddart, MD, r St<strong>af</strong>fan Janson, MD,PhD, s Poul Jaszczak, MD, PhD, t Christoph Kupferschmid,MD, u Tuija Lahdes-Vasama, MD, v Harry Lindahl, MD, PhD, wNoni MacDonald, MD, x Trond Markestad, MD, y MatisMärtson, MD, PhD, z Solveig Marianne Nordhov, MD, PhD, aaHeikki Pälve, MD, PhD, bb Aigars Petersons, MD, PhD, ccFeargal Quinn, MD, dd Niels Qvist, MD, PhD, ee ThrainnRosmundsson, MD, ff Harri Saxen, MD, PhD, gg Olle Söder, MD,PhD, hh Maximilian Stehr, MD, PhD, ii Volker C.H. vonLoewenich, MD, jj Johan Wallander, MD, PhD, kk and ReneWijnen, MD, PhD llaDepartment of Epidemiology Research, Statens Serum Institut,Copenhagen and Center for Sexology Research, Department ofClinical Medicine, Aalborg University, Aalborg, Denmark;bDepartment of Pediatric Surgery, Hôpital Necker EnfantsMalades, Université Paris Descartes, Paris, France; c LithuanianSociety of Paediatric Surgeons, Kaunas, Lithuania; d Departmentof Pediatrics, Landspitali University Hospital, Reykjavik, Iceland;eChildren’s Surgical Forum of the Royal College of Surgeons ofEngland, London, United Kingd<strong>om</strong>; f Polish Association of PediatricSurgeons, Gdansk, Poland; g Working Group for Pediatric Urology,Dutch Urological Association, Utrecht, Netherlands;hDepartments of Pediatric Urology, University Children’s HospitalsUMC Utrecht and AMC Amsterdam, Netherlands; i Austrian Societyof Pediatric and Adolescent Surgery, Klagenfurt, Austria;jPaediatric Association of the Netherlands, Utrecht, Netherlands;kGerman Academy of Paediatrics and Adolescent Medicine,Berlin, Germany; l Center for Sexology Research, Department ofClinical Medicine, Aalborg University, Aalborg, Denmark;mDepartment of Pediatrics, Rigshospitalet, Copenhagen,Denmark; n Departments of Pediatric Surgery, LandspitaliUniversity Hospital, Reykjavik, Iceland, and Karolinska UniversityHospital, Stockholm, Sweden; o German Association ofPediatricians, Cologne, Germany; p Department of PediatricSurgery, Th<strong>om</strong>ayer Hospital, Charles University, Prague, CzechRepublic; q British Association of Paediatric Urologists, London,United Kingd<strong>om</strong>;(Continued on last page)796 FRISCH et alDownloaded fr<strong>om</strong> pediatrics.aappublications.org by guest on June 19, 2013


COMMENTARYIn this c<strong>om</strong>mentary, a different view ispresented by non–US-based physiciansand representatives of generalmedical associations and societiesfor pediatrics, pediatric surgery,and pediatric urology in NorthernEurope.CRITERIA FOR PREVENTIVEMEDICINEIt is c<strong>om</strong>monly accepted that medicalprocedures always need to be justifiedbecause of their invasive nature andpossible damaging effects. Preventivemedical procedures need more andstricter justification than do therapeuticmedical procedures, as they areaimed at people who are generally freeof medical problems. Even strictercriteria apply for preventive medicalprocedures in children, who cannotweigh the evidence themselves andcannot legally consent to the procedure.4The most important criteria for thejustification of medical proceduresare necessity, cost-effectiveness, subsidiarity,proportionality, and consent.For preventive medical procedures,this means that the procedure musteffectively lead to the prevention ofa serious medical problem, that thereis no less intrusive means of reachingthe same goal, and that the risks ofthe procedure are proportional to theintended benefit. In addition, whenperformed in childhood, it needs to beclearly demonstrated that it is essentialtoperformtheprocedurebeforeanage at which the individual can makea decision about the procedure for himorherself.The AAP technical report points to 4health-related arguments in favor ofcircumcision: the reduced risks ofurinary tract infections (UTIs), penilecancer, s<strong>om</strong>e traditional sexually transmitteddiseases (STDs), and HIV infectionand AIDS.URINARY TRACT INFECTIONSAccording to the literature reviewed,∼1% of boys will develop a UTI withinthe first years of life. 2 There are norand<strong>om</strong>ized controlled trials (RCTs)linking UTIs to circumcision status.The evidence for clinically significantprotection is weak, and with easyaccess to health care, deaths or longtermnegative medical consequencesof UTIs are rare. UTI incidence doesnotseemtobelowerintheUnitedStates, with high circumcision ratesc<strong>om</strong>pared with Europe with low circumcisionrates, and the AAP reportsuggests it will take ∼100 circumcisionstoprevent1caseofUTI.Usingreasonable European estimates citedin the AAP report for the frequency ofsurgical and postoperative c<strong>om</strong>plications(∼2%), for every 100 circumcisions,1 case of UTI may beprevented at the cost of 2 cases ofhemorrhage, infection, or, in rareinstances, more severe outc<strong>om</strong>es oreven death.Circumcision fails to meet the criteriato serve as a preventive measure forUTI, even though this is the only 1 ofthe AAP report’s 4 most favored argumentsthat has any relevance beforethe boy gets old enough to decide forhimself.PENILE CANCERPenile cancer is 1 of the rarest formsof cancer in the Western world (∼1case in 100 000 men per year), almostalways occurring at a later age. Whendiagnosed early, the disease generallyhas a good survival rate. Accordingto the AAP report, 2 between909 and 322 000 circumcisions areneeded to prevent 1 case of penilecancer. Penile cancer is linked to infectionwith human papill<strong>om</strong>aviruses, 5which can be prevented withouttissue loss through cond<strong>om</strong> useand prophylactic vaccination. It isremarkable that incidence rates of penilecancer in the United States, where∼75% of the non-Jewish, non-Muslimmale population is circumcised, 1 aresimilar to rates in northern Europe,where #10% of the male populationis circumcised. 6As a preventive measure for penilecancer, circumcision also fails to meetthe criteria for preventive medicine: theevidence is not strong; the disease israre and has a good survival rate; thereare less intrusive ways of preventingthe disease; and there is no c<strong>om</strong>pellingreason to deny boys their legitimateright to make their own informed decisionwhen they are old enough todo so.TRADITIONAL STDsAccording to the AAP report, 2 there isevidence that circumcision providesprotection against 2 c<strong>om</strong>mon viralSTDs: genital herpes and genital warts.However, the evidence in favor of thisclaim is based primarily on findings inRCTs conducted among adult men insub-Saharan Africa. For other STDs,such as syphilis, gonorrhea, and chlamydia,circumcision offers no convincingprotection. The authors of theAAP report forget to stress that responsibleuse of cond<strong>om</strong>s, regardlessof circumcision status, will provideclose to 100% reduction in risk forany STD. In addition, STDs occur only<strong>af</strong>ter sexual debut, which implies thatthe decision of whether to circumcisecan be postponed to an age whenboys are old enough to decide forthemselves.HIV AND AIDSFr<strong>om</strong> a public health perspective,what seems to be the AAP technicalreport’s most important argument isthat circumcision may reduce the burdenof heterosexually transmitted HIVPEDIATRICS Volume 131, Number 4, April 2013 797Downloaded fr<strong>om</strong> pediatrics.aappublications.org by guest on June 19, 2013


infections in the United States. 2 ThreeRCTs in Kenya, Uganda, and SouthAfrica suggest that circumcision inadulthood may lead to a noticeablereduction in risk of heterosexual HIVacquisition in areas with extremelyhigh HIV prevalence. 7–9 Specifically, theAfrican RCTs seemed to show thatadult male circumcision halves heterosexualmen’s (but not w<strong>om</strong>en’s)risk of HIV infection in the firstfew years <strong>af</strong>ter the operation fr<strong>om</strong>2.49% to 1.18% in high-endemic areaswhere viral transmission occurs mainlythrough heterosexual intercourse. Thisevidence, however, is contradicted byother studies, which show no relationshipbetween HIV infection rates andcircumcision status. 10However, there is no evidence that circumcision,whether in infancy, childhood,or adulthood, is effective inpreventing heterosexual transmissionin countries where HIV prevalence ismuch lower and routes of transmissionare different, such as Europeand the United States. Sexually transmittedHIV infections in the West occurpred<strong>om</strong>inantly among men who havesexwithmen,andthereisnoevidencethat circumcision offers any protectionagainst HIV acquisition in thisgroup. 11,12The African findings are also not in linewith the fact that the United Statesc<strong>om</strong>bines a high prevalence of STDsand HIV infections with a high percentageof routine circumcisions. Thesituation in most European countriesis precisely the reverse: low circumcisionratesc<strong>om</strong>binedwithlowHIVandSTD rates. Therefore, other factorsseem to play a more important role inthe spread of HIV than circumcisionstatus. This finding also suggeststhat there are alternative, less intrusive,and more effective ways ofpreventing HIV than circumcision,such as consistent use of cond<strong>om</strong>s,s<strong>af</strong>e-sex programs, easy access toantiretroviral drugs, and clean needleprograms.As with traditional STDs, sexual transmissionof HIV occurs only in sexuallyactive individuals. Consequently, fr<strong>om</strong>an HIV prevention perspective, if atall effective in a Western context, circumcisioncan wait until boys are oldenough to engage in sexual relationships.Boys can decide for themselves,therefore, whether they wantto get circumcised to obtain, at best,partial protection against HIV or ratherremain genitally intact and adopts<strong>af</strong>e-sex practices that are far moreeffective.As with the other possible benefits,circumcision for HIV protection inWestern countries fails to meet thecriteria for preventive medicine: thereis no strong evidence for effectivenessand other, more effective, and less intrusivemeans are available. There isalso no c<strong>om</strong>pelling reason why theprocedure should be performed longbefore sexual debut; sexually transmittedHIV infection is not a relevantthreat to children.COMPLICATIONSAs mentioned in the AAP report, 2 theprecise risk and extent of c<strong>om</strong>plicationsof circumcision are unknown. It isclear, however, that infections, hemorrhages,meatal strictures, and otherproblems do occur. Incidental deathsand (partial) amputations of the penishave also been reported, but exactfigures are not available. Althoughs<strong>om</strong>e studies suggest that circumcisioncan lead to psychological, painrelated,and sexual problems later inlife, 13–15 population-based prospectivestudies of long-term psychological,sexual, and urological effects of circumcisionare lacking.It seems that the authors of the AAPreport consider the foreskin to bea part of the male body that has n<strong>om</strong>eaningful function in sexuality. However,the foreskin is a richly innervatedstructure that protects the glans andplays an important role in the mechanicalfunction of the penis duringsexual acts. 16–20 Recent studies, severalof which were not included in theAAP report (although they were publishedwithin the inclusion period of1995–2010), suggest that circumcisiondesensitizes the penis 21,22 and maylead to sexual problems in circumcisedmen and their partners. 23–29 In light ofthese uncertainties, physicians shouldheed the precautionary principle andnot rec<strong>om</strong>mend circumcision for preventivereasons.CONCLUSIONSThe AAP’s extensive report 2 was basedon the scrutiny of a large number ofc<strong>om</strong>plex scientific articles. Therefore,while striving for objectivity, the conclusionsdrawn by the 8 task forcemembers reflect what these individualphysicians perceived as trustworthyevidence. Cultural bias reflecting thenormality of nontherapeutic male circumcisionin the United States seemsobvious. The conclusions of the AAPTechnical Report and Policy Statementare far fr<strong>om</strong> those reached by physiciansin most other Western countries.As mentioned, only 1 of the <strong>af</strong>orementionedarguments has s<strong>om</strong>e theoreticalrelevance in relation to infant malecircumcision; namely, the questionableargument of UTI prevention in infantboys. The other claimed health benefitsare also questionable, weak, and likelyto have little public health relevance ina Western context, and they do notrepresent c<strong>om</strong>pelling reasons for surgerybefore boys are old enough todecide for themselves. Circumcisionfails to meet the c<strong>om</strong>monly acceptedcriteria for the justification of preventivemedical procedures in children.798 FRISCH et alDownloaded fr<strong>om</strong> pediatrics.aappublications.org by guest on June 19, 2013


COMMENTARYThe cardinal medical question shouldnot be whether circumcision can preventdisease, but how disease can bestbe prevented.The AAP report 2 lacks a serious discussionof the central ethical dilemmawith, on 1 side, parents’ right to act inthe best interest of the child on thebasis of cultural, religious, and healthrelatedbeliefs and wishes and, on theother side, infant boys’ basic right tophysical integrity in the absence ofc<strong>om</strong>pelling reasons for surgery. Physicalintegrity is 1 of the most fundamentaland inalienable rights a childhas. Physicians and their professionalorganizations have a professional dutyto protect this right, irrespective of thegender of the child.There is growing consensus amongphysicians, including those in theUnited States, that physicians shoulddiscourage parents fr<strong>om</strong> circumcisingtheir healthy infant boys because nontherapeuticcircumcision of underageboys in Western societies has noc<strong>om</strong>pelling health benefits, causespostoperative pain, can have seriouslong-term consequences, constitutesa violation of the United Nations’ Declarationof the Rights of the Child, andconflicts with the Hippocratic oath:primum non nocere: First, do no harm.REFERENCES1. World Health Organization, Departmentof Reproductive Health and Researchand Joint United Nations Programme onHIV/AIDS (UNAIDS). Male Circumcision.Global Trends and Determinants of Prevalence,S<strong>af</strong>ety and Acceptability. Geneva,Switzerland: World Health Organization;20072. American Academy of Pediatrics TaskForce on Circumcision. Male circumcision.Pediatrics. 2012;130(3). Available at:www.pediatrics.org/cgi/content/full/130/3/e7563. American Academy of Pediatrics TaskForce on Circumcision. Circumcision policystatement. Pediatrics. 2012;130(3):585–5864. BMA Ethics C<strong>om</strong>mittee. Consent, Rights andChoices in Health Care for Children andYoung People. London, United Kingd<strong>om</strong>:BMJ Books, Wiley; 20005. Backes DM, Kurman RJ, Pimenta JM, SmithJS. Systematic review of human papill<strong>om</strong>avirusprevalence in invasive penilecancer. Cancer Causes Control. 2009;20(4):449–4576. Parkin DM, Whelan SL, Ferlay JLT, Th<strong>om</strong>asDB. Cancer Incidence in Five Continents. VolVIII. Lyon: IARC Scientific Publications, No155. Lyon, France: International Agency forResearch on Cancer; 20027. Auvert B, Taljaard D, Lagarde E, Sobngwi-Tambekou J, Sitta R, Puren A. Rand<strong>om</strong>ized,controlled intervention trial of male circumcisionfor reduction of HIV infectionrisk: the ANRS 1265 Trial [published correctionappears in PloS Med. 2006;3:e298].PLoS Med. 2005;2(11):e2988. Gray RH, Kigozi G, Serwadda D, et al. Malecircumcision for HIV prevention in men inRakai, Uganda: a rand<strong>om</strong>ised trial. Lancet.2007;369(9562):657–6669. Bailey RC, Moses S, Parker CB, et al. Malecircumcision for HIV prevention in youngmen in Kisumu, Kenya: a rand<strong>om</strong>ised controlledtrial. Lancet. 2007;369(9562):643–65610. Boyle GJ, Hill G. Sub-Saharan Africanrand<strong>om</strong>ised clinical trials into male circumcisionand HIV transmission: methodological,ethical and legal concerns. J LawMed. 2011;19(2):316–33411. Sánchez J, Sal Y Rosas VG, Hughes JP,et al. Male circumcision and risk of HIVacquisition among MSM. AIDS. 2011;25(4):519–52312. Millett GA, Flores SA, Marks G, Reed JB,Herbst JH. Circumcision status and risk ofHIV and sexually transmitted infectionsamong men who have sex with men: a metaanalysis.JAMA. 2008;300(14):1674–168413. Boyle GJ, Bensley GA. Adverse sexual andpsychological effects of male infant circumcision.Psychol Rep. 2001;88(3 pt 2):1105–110614. Goldman R. The psychological impact ofcircumcision. BJU Int. 1999;83(suppl 1):93–10215. Taddio A, Katz J, Ilersich AL, Koren G. Effectof neonatal circumcision on pain responseduring subsequent routine vaccination.Lancet. 1997;349(9052):599–60316. Moldwin RM, Valderrama E. Immunochemicalanalysis of nerve distribution patternswithin prepucial tissue [abstract]. J Urol.1989;141(4 pt 2):499A17. Podnar S. Clinical elicitation of the penilocavernosusreflex in circumcised men. BJUInt. 2012;109(4):582–58518. Taylor JR, Lockwood AP, Taylor AJ. Theprepuce: specialized mucosa of the penisand its loss to circumcision. Br J Urol.1996;77(2):291–29519. Tuncali D, Bingul F, Talim B, Surucu S, SahinF, Aslan G. Histologic characteristics of thehuman prepuce pertaining to its clinicalbehavior as a dual gr<strong>af</strong>t. Ann Plast Surg.2005;54(2):191–19520. Wu ZM, Chen YF, Qiu PN, Ling SC. Correlationbetween the distribution of SP and CGRPimmunopositive neurons in dorsal rootganglia and the <strong>af</strong>ferent sensation of preputialfrenulum. Anat Rec (Hoboken). 2011;294(3):479–48621. Smith DK, Taylor A, Kilmarx PH, et al. Malecircumcision in the United States for theprevention of HIV infection and other adversehealth outc<strong>om</strong>es: report fr<strong>om</strong> a CDCconsultation. Public Health Rep. 2010;125(suppl 1):72–8222. Yang DM, Lin H, Zhang B, Guo W. Circumcision<strong>af</strong>fects glans penis vibrationperception threshold [in Chinese].Zhonghua Nan Ke Xue. 2008;14(4):328–33023. Cortés-González JR, Arratia-Maqueo JA,Gómez-Guerra LS. Does circumcision hasan effect on female’s perception of sexualsatisfaction [in Spanish]? Rev Invest Clin.2008;60(3):227–23024. Fink KS, Carson CC, DeVellis RF. Adult circumcisionoutc<strong>om</strong>es study: effect on erectilefunction, penile sensitivity, sexualactivity and satisfaction. JUrol. 2002;167(5):2113–211625. Frisch M, Lindholm M, Grønbæk M. Malecircumcision and sexual function in menand w<strong>om</strong>en: a survey-based, cross-sectionalstudy in Denmark. Int J Epidemiol.2011;40(5):1367–1381PEDIATRICS Volume 131, Number 4, April 2013 799Downloaded fr<strong>om</strong> pediatrics.aappublications.org by guest on June 19, 2013


26. Kim D, Pang MG. The effect of male circumcisionon sexuality. BJU Int. 2007;99(3):619–62227. Shen Z, Chen S, Zhu C, Wan Q, Chen Z. Erectilefunction evaluation <strong>af</strong>ter adult circumcision[in Chinese]. Zhonghua Nan Ke Xue. 2004;10(1):18–1928. Sorrells ML, Snyder JL, Reiss MD, et al.Fine-touch pressure thresholds in the adultpenis. BJU Int. 2007;99(4):864–86929. Tang WS, Khoo EM. Prevalence and correlatesof premature ejaculation in aprimary care setting: a preliminary crosssectionalstudy. J Sex Med. 2011;8(7):2071–2078(Continued fr<strong>om</strong> first page)r British Association of Paediatric Surgeons, London, United Kingd<strong>om</strong>; s C<strong>om</strong>mittee on Ethics and Children’s Rights, Swedish Paediatric Society, Stockholm, Sweden;t Ethics C<strong>om</strong>mittee of the Danish Medical Association, Copenhagen, Denmark; u Ethics C<strong>om</strong>mittee of the German Academy of Pediatrics and Adolescent Medicine,Berlin, Germany; v Finnish Association of Pediatric Surgeons, Tampere, Finland; w Department of Pediatric Surgery, Helsinki University Children’s Hospital, Helsinki,Finland; x Department of Pediatrics, IWK Health Centre, Dalhousie University, Halifax, Nova Scotia, Canada; y Ethics C<strong>om</strong>mittee of the Norwegian Medical Association,Oslo, Norway; z Estonian Society of Paediatric Surgeons, Tallinn, Estonia; aa Norwegian Paediatric Association, Tr<strong>om</strong>sø, Norway; bb Finnish Medical Association,Helsinki, Finland; cc Latvian Association of Pediatric Surgeons, Riga, Latvia; dd Department of Pediatric Surgery, Our Lady’s Children’s Hospital, Dublin, Ireland;ee Department of Surgery, Odense University Hospital, Odense, Denmark; ff Department of Pediatric Surgery, Landspitali University Hospital, Reykjavik, Iceland;gg Department of Pediatrics, Helsinki University Children’s Hospital, Helsinki, Finland; hh Swedish Pediatric Society, Stockholm, Sweden; ii Department of PediatricSurgery, Dr. v. Haunersches Kinderspital, Ludwig-Maximilians Universität, Munich, Germany; jj C<strong>om</strong>mission for Ethical Questions, German Academy of Pediatrics,Frankfurt, Germany; kk Swedish Society of Pediatric Surgery, Stockholm, Sweden; and ll Dutch Society of Pediatric Surgery, Rotterdam, NetherlandsKEY WORDSAIDS, HIV infection, male circumcision, penile carcin<strong>om</strong>a, sexually transmitted disease, urinary tract infectionABBREVIATIONSAAP—American Academy of PediatricsRCT—rand<strong>om</strong>ized controlled trialsSTD—sexually transmitted diseaseUTI—urinary tract infectionOpinions expressed in these c<strong>om</strong>mentaries are those of the author and not necessarily those of the American Academy of Pediatrics or its C<strong>om</strong>mittees.www.pediatrics.org/cgi/doi/10.1542/peds.2012-2896doi:10.1542/peds.2012-2896Accepted for publication Jan 3, 2013Address correspondence to Morten Frisch, MD, PhD, Statens Serum Institut, Department of Epidemiology Research, 5 Artillerivej, Copenhagen S, DK-2300 Denmark.E-mail: mfr@ssi.dkPEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).Copyright © 2013 by the American Academy of PediatricsFINANCIAL DISCLOSURE: Dr MacDonald declares World Health Organization advisor and consultant work on vaccines and vaccine s<strong>af</strong>ety; the other authors haveindicated they have no financial relationships relevant to this article to disclose.FUNDING: No external funding.COMPANION PAPER: A c<strong>om</strong>panion to this article can be found on page 801, and online at www.pediatrics.org/cgi/doi/10.1542/peds.2013-0081.800 FRISCH et alDownloaded fr<strong>om</strong> pediatrics.aappublications.org by guest on June 19, 2013


Cultural Bias in the AAP's 2012 Technical Report and Policy Statement on MaleCircumcisionMorten Frisch, Yves Aigrain, Vidmantas Barauskas, Ragnar Bjarnason, Su-AnnaBoddy, Piotr Czauderna, Robert P.E. de Gier, T<strong>om</strong> P.V.M. de Jong, Günter Fasching,Willem Fetter, Manfred Gahr, Christian Graugaard, Gorm Greisen, AnnaGunnarsdottir, Wolfram Hartmann, Petr Havranek, Rowena Hitchcock, SimonHuddart, St<strong>af</strong>fan Janson, Poul Jaszczak, Christoph Kupferschmid, TuijaLahdes-Vasama, Harry Lindahl, Noni MacDonald, Trond Markestad, Matis Märtson,Solveig Marianne Nordhov, Heikki Pälve, Aigars Petersons, Feargal Quinn, NielsQvist, Thrainn Rosmundsson, Harri Saxen, Olle Söder, Maximilian Stehr, VolkerC.H. von Loewenich, Johan Wallander and Rene WijnenPediatrics; originally published online March 18, 2013;DOI: 10.1542/peds.2012-2896Updated Information &ServicesPermissions & LicensingReprintsincluding high resolution figures, can be found at:http://pediatrics.aappublications.org/content/early/2013/03/12/peds.2012-2896Information about reproducing this article in parts (figures,tables) or in its entirety can be found online at:http://pediatrics.aappublications.org/site/misc/Permissions.xhtmlInformation about ordering reprints can be found online:http://pediatrics.aappublications.org/site/misc/reprints.xhtmlPEDIATRICS is the official journal of the American Academy of Pediatrics. A monthlypublication, it has been published continuously since 1948. PEDIATRICS is owned, published,and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, ElkGrove Village, Illinois, 60007. Copyright © 2013 by the American Academy of Pediatrics. Allrights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.Downloaded fr<strong>om</strong> pediatrics.aappublications.org by guest on June 19, 2013


Weiss et al. BMC Urology 2010, 10:2http://www.bi<strong>om</strong>edcentral.c<strong>om</strong>/1471-2490/10/2RESEARCH ARTICLEOpen AccessC<strong>om</strong>plications of circumcision in male neonates,infants and children: a systematic reviewHelen A Weiss 1* , Natasha Larke 1 , Daniel Halperin 2 , Inon Schenker 3AbstractBackground: Approximately one in three men are circumcised globally, but there are relatively few data on thes<strong>af</strong>ety of the procedure. The aim of this paper is to summarize the literature on frequency of adverse eventsfollowing pediatric circumcision, with a focus on developing countries.Methods: PubMed and other databasess were searched with keywords and MeSH terms including infant/newborn/pediatric/child, circumcision, c<strong>om</strong>plications and adverse events. Searches included all available years andwere conducted on November 6 th 2007 and updated on February 14th 2009. Additional searches of the Arabicliterature included searches of relevant databases and University libraries for research theses on male circumcision.Studies were included if they contained data to estimate frequency of adverse events following neonatal, infantand child circumcision. There was no language restriction. A total of 1349 published papers were identified, ofwhich 52 studies fr<strong>om</strong> 21 countries met the inclusion criteria. The Arabic literature searches identified 46 potentiallyrelevant papers, of which six were included.Results: Sixteen prospective studies evaluated c<strong>om</strong>plications following neonatal and infant circumcision. Moststudies reported no severe adverse events (SAE), but two studies reported SAE frequency of 2%. The medianfrequency of any c<strong>om</strong>plication was 1.5% (range 0-16%). Child circumcision by medical providers tended to beassociated with more c<strong>om</strong>plications (median frequency 6%; range 2-14%) than for neonates and infants. Traditionalcircumcision as a rite of passage is associated with substantially greater risks, more severe c<strong>om</strong>plications thanmedical circumcision or traditional circumcision among neonates.Conclusions: Studies report few severe c<strong>om</strong>plications following circumcision. However, mild or moderatec<strong>om</strong>plications are seen, especially when circumcision is undertaken at older ages, by inexperienced providers or innon-sterile conditions. Pediatric circumcision will continue to be practiced for cultural, medical and as a long-termHIV/STI prevention strategy. Risk-reduction strategies including improved training of providers, and provision ofappropriate sterile equipment, are urgently needed.BackgroundAn estimated one in three males worldwide are circumcised,with almost universal coverage in s<strong>om</strong>e settingsand very low prevalence in others [1]. As with any surgicalprocedure, circumcision can result in c<strong>om</strong>plications[2-4]. The most c<strong>om</strong>mon early (intra-operative) c<strong>om</strong>plicationstend to be minor and treatable: pain, bleeding,swelling or inadequate skin removal. However, seriousc<strong>om</strong>plications can occur during the procedure, includingdeath fr<strong>om</strong> excess bleeding and amputation of the glans* Correspondence: helen.weiss@lshtm.ac.uk1 MRC Tropical Epidemiology Group, Department of Epidemiology andPopulation Health, London School of Hygiene & Tropical Medicine, KeppelStreet, London WC1E 7HT, UKpenisiftheglansisnotshieldedduringtheprocedure[5-10]. Late (post-operative) c<strong>om</strong>plications include pain,wound infection, the formation of a skin-bridge betweenthe penile sh<strong>af</strong>t and the glans, infection, urinary retention,meatal ulcer, meatal stenosis, fistulas, loss of penilesensitivity, sexual dysfunction and edema of the glanspenis [11]. Circumcision is c<strong>om</strong>monly conducted inneonates, infants and children for religious, cultural andmedical reasons, yet there have been no systematicreviews of the published literature on c<strong>om</strong>plicationsassociated with the procedure at this age.Male circumcision is of public health interest as recentrand<strong>om</strong>ized controlled trials (RCT) have shown thatadult circumcision reduces the risk of acquiring HIV© 2010 Weiss et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative C<strong>om</strong>monsAttribution License (http://creativec<strong>om</strong>mons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction inany medium, provided the original work is properly cited.


Weiss et al. BMC Urology 2010, 10:2http://www.bi<strong>om</strong>edcentral.c<strong>om</strong>/1471-2490/10/2Page 2 of 13infection by about 60% [12-14]. Several countries withhigh prevalence of HIV are now planning to expandaccess to s<strong>af</strong>e circumcision [15], and the World HealthOrganisation (WHO) and the Joint United Nations Programmeon HIV/AIDS (UNAIDS) have rec<strong>om</strong>mendedconsidering neonatal circumcision in addition to adultcircumcision as a longer-term HIV prevention strategy[16]. Pilot projects for neonatal and infant circumcisionsare now being considered in several African countries,and to inform these programs, we undertook a systematicreview of practices of paediatric circumcision, includingprevalence, age at circumcision, types and trainingof providers, circumcision methods used, frequency ofc<strong>om</strong>plications and cost. Since expansion of male circumcisionfor HIV prevention is rec<strong>om</strong>mended inregions with high rates of heterosexual transmission (inpractice, much of southern and parts of eastern Africa),we carried out searches specifically for non-Westernregions of the world. In this paper, we report findings offrequencies of adverse events associated with neonatal,infant and child circumcision.MethodsSearch strategyPubMed, African Healthline, LILACS and the CochraneCentral Register of Controlled Trials databases weresearched with keywords and MeSH terms includinginfant/newborn/pediatric/child, circumcision, c<strong>om</strong>plicationsadverse events, Africa, Asia and Arabic. For example,we searched PubMed with the following searchterms: “Circumcision, Male” [Mesh] AND “Infant, Newborn”[Mesh] AND ("Africa” [Mesh] OR “Asia” [Mesh]);“c<strong>om</strong>plications “ [Subheading] OR “Intraoperative C<strong>om</strong>plications”[Mesh] OR “Postoperative C<strong>om</strong>plications”[Mesh]) AND “Circumcision, Male” [Mesh] AND("Africa” [Mesh] OR “Asia” [Mesh]); ("Child” [Mesh]AND “Circumcision, Male” [Mesh]) AND ("Africa”[Mesh] OR “Asia” [Mesh]); ("Infant, Newborn” [Mesh]OR “Child” [Mesh]) AND ("Circumcision, Male” [Mesh]OR ("Circumcision, Male/adverse effects” [Mesh] OR“Circumcision, Male/c<strong>om</strong>plications” [Mesh] OR “Circumcision,Male/contraindications” [Mesh] OR “Circumcision,Male/mortality” [Mesh])); “Circumcision”[Mesh] “Circumcision, Male “ [Mesh] AND “Arabic”.Searches were conducted on November 6 th 2007 andupdated on February 14th 2009. There was no languagerestriction. We also searched reference lists of relevantpapers, including a systematic review of c<strong>om</strong>plicationsof male circumcision in Anglophone Africa [17]. A totalof 1349 published papers were identified through thesesearches. The abstracts of these papers were read andfull copies of 223 papers with information on c<strong>om</strong>plicationswere obtained. Data were extracted by HW andNL into standardised forms in Access.Infant and child circumcision is almost universal inthe Arab world, and we conducted additional searchesof the Arabic literature, including searches of relevantdatabases, book reviews in 10 key academic centres onMiddle Eastern Studies and searches of the Hebrew Universityof Jerusalem libraries for Masters and PhDresearch thesis focused on male circumcision. Searcheswere conducted fr<strong>om</strong> June to August 2008. The Arabicliterature searches identified 46 potentially relevantpapers, of which six contained information on circumcisionc<strong>om</strong>plications.Analysis methods and definitionsHospital-based studies of circumcision-related c<strong>om</strong>plicationsare usually retrospective and record-based[9,18,19]. C<strong>om</strong>plications in these studies are c<strong>om</strong>monlyrecorded fr<strong>om</strong> discharge sheets, so tend to under-estimatethe true frequency of c<strong>om</strong>plications because eventsoccurring <strong>af</strong>ter discharge are not captured. Furthermore,not all post-operative c<strong>om</strong>plications will be seen againat the same hospital. We therefore present results separatelyfor prospective and retrospective studies. Age atcircumcision, and type of provider (medical or nonmedical)were also thought a-priori to be associatedwith frequency of c<strong>om</strong>plications, and we present resultsstratified by these factors. We define neonatal as age upto 28 days, infant as 28 days-11 months, and child as 12months-12 years. Many studies included boys circumcisedat a range of ages. We included studies in whichthe mean or median age at circumcision was age 12years or younger.Definitions of c<strong>om</strong>plications varied between studies.To report c<strong>om</strong>plications as consistently as possiblebetween studies, we excluded all cases of oozing orbleeding which was easily stopped by c<strong>om</strong>pression, asthese were not consistently reported in all studies. Casesof excess residual foreskin or inadequate circumcisionare also excluded - these are adverse outc<strong>om</strong>e of circumcisionand may involve further surgery, but are notmedical c<strong>om</strong>plications per se. Wealsoexcludeds<strong>om</strong>eother minor c<strong>om</strong>plications fr<strong>om</strong> studies as noted underindividual studies. We have also reported seriousadverse events separately - these include c<strong>om</strong>plicationsdefined as ‘severe’ or ‘serious’ by authors, or with longtermor life-threatening sequalae.ResultsFr<strong>om</strong> the 223 potentially relevant papers, we identified52 studies fr<strong>om</strong> 21 countries which included sufficientinformation to estimate frequency of adverse events followingneonatal, infant and child circumcision. Theremaining papers were largely case-reports and case-seriesof circumcision-related c<strong>om</strong>plications. We excludedone study among people with haemophilia [20], as any


Weiss et al. BMC Urology 2010, 10:2http://www.bi<strong>om</strong>edcentral.c<strong>om</strong>/1471-2490/10/2Page 3 of 13surgical procedure in hae<strong>om</strong>philiacs is associated with ahigh risk of post-operative bleeding and is not representativeof general populations.C<strong>om</strong>plications following neonatal or infant circumcisionWe identified 16 prospective studies of c<strong>om</strong>plicationsfollowing neonatal and infant circumcision, fr<strong>om</strong> 12countries [9-11,21-33] (Table 1). Of these, most usedthe Plastibell [11,22,23,25-28], with others using theG<strong>om</strong>co clamp [21,24,30,32], freehand circumcision[9,31], or a c<strong>om</strong>bination of methods [27,29,33].The median frequency of any adverse event was 1.5%(range 0-16%), and median frequency of any seriousadverse event was 0% (range 0-2%). Nine studies reportedno serious adverse events, but three studies reported that1-2% of boys had a serious c<strong>om</strong>plication [10,27,29]. One, aCanadian study of 100 neonates circumcised in 1961/1962using the G<strong>om</strong>co clamp or Plastibell reported one severeinfection requiring antibiotics and one severe meatal ulcer[29]. Less severe c<strong>om</strong>plications were reported in a further13 boys in this study. The other two studies with seriousc<strong>om</strong>plications were fr<strong>om</strong> Nigeria. In one, among 141 boyscircumcised in 3 hospitals in southeast Nigeria, c<strong>om</strong>plicationswere assessed at a 6 week post-operative visit or ifthey presented earlier with any c<strong>om</strong>plication [27]. Threeboys (2.1%) had a urethral laceration. The most c<strong>om</strong>monc<strong>om</strong>plications in this study were minor including bleeding(9%) and meatal stenosis (3.5%). C<strong>om</strong>plications were substantiallymore c<strong>om</strong>mon when circumcision had been performedfreehand (27% excluding inc<strong>om</strong>plete circumcision)rather than using the Plastibell (8%), and when performedby midwives (19%) rather than doctors (7%). Moreover,among the doctors, the reported frequency of c<strong>om</strong>plicationsat the public (University Teaching) hospital was1.6%, c<strong>om</strong>pared to 20% at private hospitals where the levelof training and supervision is lower. A much higher frequency(90%) was seen at the mission hospital, which actsas a referral centre for c<strong>om</strong>plicated circumcisions. Threecircumcisions had been performed by a traditional birthattendant, and all three had resultant c<strong>om</strong>plications (onebleeding, one inc<strong>om</strong>plete circumcision, and one urethralfistula). The other study was among 322 infants attendinga welfare clinic in Ibadan [10], in which there were 2 casesof amputation of the glans penis and one buried (trapped)penis. Overall in this study, c<strong>om</strong>plications were reportedin 9.3% of boys, with a further 11% having excess residualforeskin. The most c<strong>om</strong>mon c<strong>om</strong>plication was excessiveloss of foreskin (n = 16; 5%). Unusually, no cases of bleeding,wound infection, or haemat<strong>om</strong>a were reported in thisstudy. The method used was not reported for the majorityof infants, and c<strong>om</strong>plications were most frequent whenthe procedure was performed by nurses rather than doctorsor traditional circumcisers (data not given).Of the remaining 13 studies, five reported adverseevents in 0.3% or fewer boys [9,22,26,30,32], four inaround 2% [11,21,23,25], and the remaining four studiesreported adverse events in up to 16% of boys[24,28,31,33]. The studies with highest frequency ofc<strong>om</strong>plications are fr<strong>om</strong> Pakistan and the United Kingd<strong>om</strong>(UK). The study fr<strong>om</strong> Pakistan reports on 200infants circumcised under local anaesthesia at a MilitaryHospital using either the freehand or bone-cuttermethod (a forceps-guided method which does not shieldthe glans) [31]. Bleeding (defined as requiring more thanan application of a pressure bandage) was reported in9% of boys, and 7% had a local infection of the skin andmucosa. In the UK study, 1129 infants were circumcisedby nurses using the Plastibell under local anaesthesia[28], and overall 125 (11.1%) of infants required s<strong>om</strong>edegree of follow-up, with c<strong>om</strong>plications seen in 5.5%.The most c<strong>om</strong>mon c<strong>om</strong>plication involved the Plastibellring device itself (3.6%), which is left on <strong>af</strong>ter the procedureand normally takes 7-10 days to fall off. The problemsincluded delayed separation of the ring,inc<strong>om</strong>plete separation of the ring, or the ring bec<strong>om</strong>ingstuck on the penile sh<strong>af</strong>t. In all cases, the ring wasremoved without need of anaesthesia and the authorsreport this removal was quick, simple and atraumatic.Three studies reported substantial variation in c<strong>om</strong>plicationfrequencies by age or circumcision method. Forexample, a US study of circumcision by the G<strong>om</strong>coclamp stratified by age at circumcision and found noc<strong>om</strong>plications in 98 boys circumcised neonatally, butthat 12/32 (30%) of infants aged 3-8.5 months had postoperativebleeding requiring suture repair [24]. These 32boys were circumcised under general anaesthesia and noc<strong>om</strong>plications fr<strong>om</strong> the general anesthesia werereported. In another study, c<strong>om</strong>plications were seenmore frequently using the Plastibell (12/381; 3.1%) thanthe sleeve technique (4/205; 1.95% [33]).A further ten studies on neonatal/infant circumcisionwere retrospective hospital-record based studies (Table2). Five of these were fr<strong>om</strong> the USA, two fr<strong>om</strong> Pakistan,one each fr<strong>om</strong> Israel, Oman and Turkey. Reported frequencyof c<strong>om</strong>plications were slightly lower than for theprospective studies, with five studies finding very lowfrequencies (≤0.6%) [19,34-37] and four in the range 2-4% [38-41]. The study reporting the highest proportion(4% in neonates, 10% in infants) included late c<strong>om</strong>plications(most c<strong>om</strong>monly foreskin adhesions (7.8%)), with3 cases (1.3%) of meatitis and 3 requiring circumcisionrevision (1.3%) [42]. As with prospective studies in neonatesand infants, few serious adverse events werereported (


Weiss et al. BMC Urology 2010, 10:2http://www.bi<strong>om</strong>edcentral.c<strong>om</strong>/1471-2490/10/2Page 4 of 13Table 1 Prospective studies of frequency of c<strong>om</strong>plications in studies of neonatal and infant circumcisionAuthor Country No. ofpatientsAl Samarrai[11]Amir d [21]Banieghbal[32]Ben Chaim[9]SaudiArabiaSaudiArabiaSouthAfricaAge Type of provider Method Follow-up period Frequency ofadverseevents a2000 2-3 days Junior st<strong>af</strong>f withsupervision1000 Mean 9daysPlastibell6 weeks plusimmunisationclinic visits1.4% c 0%Surgeon G<strong>om</strong>co clamp 1 year 1.6% 0%583 Neonatal Surgeon G<strong>om</strong>co clamp 1 month 0.3% 0%Israel 19,478 Mean 8days83% Mohel17% PhysicianFreehand - 0.1% 0.1%Bhat [22] Oman 250 Neonatal Paediatrician Plastibell - 0% 0%(min 1 day)Duncan[23]Jamaica 205 Neonatal Surgeon Plastibell 1 week 1.5% 0%Horowitz[24]USA 130 98 neonatal32 infants(3-8.5months)Manji [25] Tanzania 368 7 days to 9monthsMousavi[33]Pediatric urologist G<strong>om</strong>co clamp 3 days Overall: 7.4%Neonatal: 0%Infants: 30%Pediatrician Plastibell - 2.8% e 0%Iran 586


Weiss et al. BMC Urology 2010, 10:2http://www.bi<strong>om</strong>edcentral.c<strong>om</strong>/1471-2490/10/2Page 5 of 13Table 2 Retrospective studies of frequency of c<strong>om</strong>plications in studies of neonatal and infant circumcisionAuthor Country Year of study NumberofpatientsAl-Marhoon[34]Age Type of provider Method used Frequency ofadverseevents aFrequency ofserious adverseevents bOman 1997-2000 171 Neonatal Surgeon Plastibell 1.2% c 0% (Two neededsutures)Christakis [35] USA 1987-1996 130475 Neonatal - - 0.2% 0.2%Eroglu [41] Turkey 2001-2002 214 Neonatal Surgeon G<strong>om</strong>co clamp 2.3% 0% (One neededsutures)Gee [38] USA 1963-1972 5521 Neonatal Supervised medicalstudent, resident, orphysicianIftikhar [36] Pakistan 1998-2001 316 0-12 yrs (72%within 1 weekof birth)Metcalf [42] USA 1974-1979 591 61% Neonatal39% PostneonatalPediatric surgeon52% G<strong>om</strong>coclamp 48%PlastibellPlastibell(


Weiss et al. BMC Urology 2010, 10:2http://www.bi<strong>om</strong>edcentral.c<strong>om</strong>/1471-2490/10/2Page 6 of 13Table 3 Prospective studies of frequency of c<strong>om</strong>plications in studies of child circumcision undertaken by medicalprovidersAuthor Country Years Setting N Age Provider Method Indication FollowupperiodAhmed [43,59]C<strong>om</strong>orosIslands1997-1998H<strong>om</strong>e 3824 2-8 years Surgical aids,nurses &midwifesAldemir [48] Turkey 2006 Hospital 200 2-9 years Urologist 65% Smartclamp35%DissectionBazmamoun[45]Iran 2006-2007Hospital 394 Mean 9monthsGriffiths [49] England 1985 Hospital 99 Mean4.3 yearsOzdemir [46] Turkey 1990s Mass circ.in hospitalSchmitz [51] Holland 1997 Healthcentre700 8 daystopuberty94 Median3 yearsSchmitz [50] Malaysia 2001 C<strong>om</strong>munity 64 Median10 yearsSharma [44] India 2003 Hospital 15 2-25yearsSorensen [52] Denmark 1981-1983Subramaniam[47]Hospital 43 Mean6.5 years(range 1-13)Singapore - Hospital 152 Mean 7yearsFrequency ofadverseevents aDorsal slit Routine 11 days 2.3% 0.5%Surgeon Sleeve Routine 6months- Dissection 85%medical11%religious4% other- ForcepsguidedGP residentsundersupervisionof a surgeonMedicalassistantssupervisedby doctorsRoutine 6 weeks 5% 1%3-5weeksRoutine 3months7-10% c 0%Frequencyof seriousadverseevents b6.4% d 2.8% e8% f 0%Freehand Religious 1 week 12% 0%TaraKlamp Routine 6 weeks 1.6% 0%Surgeons Dorsal slit Medical orreligiousSurgeon(early stagein training)Plastibell Medical Mean29months90 days 13.3% 0%Immediate 0%postoperative(reported) 9.3%gLatec<strong>om</strong>plications(reported) 0% hSurgeon CO 2 laser Not given - 4.6% 0.7%a Cases of minor bleeding stopped with simple pressure or ‘conservative management’ and excessive foreskin/inadequate circumcision are not includedb Includes c<strong>om</strong>plications defined as ‘serious’ or ‘severe’ by authors, or with long-term or life-threatening sequalae (partial amputation of glans, urethral laceration,need for re-surgery or plastic surgery)c 13 boys had meatal stenosis and 26 had infection. It is not clear whether there is overlap between these two groups.d Defined by the authors as any admission to hospital or further surgery.e Acute re-admissions to hospitalf Includes 15 cases of inadequate circumcision, since these were acc<strong>om</strong>panied by secondary phimosisg One case of haemorrhage that stopped spontanesouly, 2 cases of erythema and pus with no confirmed infection or antibiotic treatment and 24 cases ofdysuria due to irritation of the meatus due to the presences of a Plastibell excludedh Seven cases of slight irritation of the glans excludedc<strong>om</strong>plication, most c<strong>om</strong>monly infection (2.7%) andinadequate foreskin removal acc<strong>om</strong>panied by secondaryphimosis (2.1%).Adverse events in 11 retrospective studies tended tobe less frequent than for the prospective studies, probablydue to under-ascertainment of c<strong>om</strong>plications.Most studies reported no serious adverse events(Table 4), but one [53] reported that 2/79 (2.5%) boysrequired circumcision revisions following circumcisionby the Plastibell device. Frequencies of any adverseevent varied fr<strong>om</strong> 0.3% in a study fr<strong>om</strong> Nigeria (5minor c<strong>om</strong>plications reported out of 1563 circumcisionsin the hospital over a 15 year period [7]) to 12%(15/129) in South Africa (mostly bleeding, haemat<strong>om</strong>aand infection) and 17.5% (28/160) among boys circumcisedwith a new disposable device (the ShenghuanDisposable Minimally Invasive CircumcisionAnast<strong>om</strong>osis Device) in China (mainly mild oedema(10%) but also moderate oedema and 2 cases ofinfection).


Weiss et al. BMC Urology 2010, 10:2http://www.bi<strong>om</strong>edcentral.c<strong>om</strong>/1471-2490/10/2Page 7 of 13Table 4 Retrospective studies of frequency of c<strong>om</strong>plications in studies of child circumcision undertaken by medicalprovidersAuthor Country Years Setting N Age MethodusedAhmed[7]Atikeler[54]Cathcart[74]Lazarus[53]Leitch[69]Millar [75]Ozdemir[46]Nigeria 1981-1995 Hospital 1563 Mean 4yearsTurkey 1999-2002 Hospital 782 Mean 6yearsIndicationFrequency ofadverse events a- Routine 0.3% -- Medicalindication orreligious reasons2.6% 0%UK 1997-2004 Hospital 66519 0-15 years - 98% Medical 1.2% 0%SouthAfrica1999-2005 Hospital 95 ‘boys’ - Medical orreligiousAustralia 1960s Hospital 200 Mean 2yearsSouthAfrica1985-1987 Hospital 129 3 monthsto 10 yearsTurkey 1990s Hospital 600 8 days topuberty- 71% Medical29% Cultural5.1% 2.5%11% 0%Plastibell 19 revisions 12% -Forcepsguided?Peng [76] China 2005-2007 Hospital 160 5-12 years ShenghudisposabledeviceRoutine 1.7% 0%Mainly medicalC<strong>om</strong>plicationswhilst wearingdevice : 17.5% cC<strong>om</strong>plications <strong>af</strong>terremoval of device :0.6%Rizvi [64] Pakistan 1981-1991 Hospital 3096 ‘children’ - - 1.6% -Wiswell[18]Yegane[77]USA 1985-1992 Hospital 476 Mean 3yearsIran 2002 C<strong>om</strong>munity 1766 71% <strong>af</strong>ter 2years ofageFreehand orsleeveCultural (67%)Medical (33%)Frequency ofserious adverseevents b0.6%1.7% 0.2%- - 4.6% overall (latec<strong>om</strong>plications)2.8% Urologists/surgeons6.1% GPs/pediatricians9.1% Paramedicsa Cases of minor bleeding stopped with simple pressure or ‘conservative management’ and excessive foreskin/inadequate circumcision are not includedb Includes c<strong>om</strong>plications defined as ‘serious’ or ‘severe’ by authors, or with long-term or life-threatening sequalae (partial amputation of glans, urethral laceration,need for re-surgery or plastic surgery)c Seventy cases of swelling pain fr<strong>om</strong> nocturnal erection excluded0%C<strong>om</strong>plications following child circumcision by nonmedicallytrained personnelTable 5 summarizes the five studies of c<strong>om</strong>plicationsfollowing circumcision by non-medically trained providers.In these studies, frequencies of adverse events aregenerally higher, and c<strong>om</strong>plications more serious, evenincluding penile amputation [7]. A high frequency ofc<strong>om</strong>plications was seen in a retrospective study fr<strong>om</strong>Turkey of 407 boys circumcised at two traditional masscircumcision events [54]. The mean age of the boys attime of circumcision was 7 years (range 1-14 years) andthe procedure had taken place in non-sterile conditionsby unlicensed providers. Overall, c<strong>om</strong>plications wereseen in 73% of boys, with the most c<strong>om</strong>mon c<strong>om</strong>plicationsbeing wound infection (14%), subcutaneous cysts(14%), bleeding which needed suturing (12%), and haemat<strong>om</strong>a(6%). Five boys (1.3%) developed a urinaryinfection requiring hospitalisation and intravenousantibiotics. A further 12% of boys were deemed to haveinc<strong>om</strong>plete circumcision. In addition, 3 patients with(contra-indicated) hypospadias had been circumcisedindicating inadequate screening of the boys.The retrospective study fr<strong>om</strong> the Philippines interviewed114 males aged 13-51 (mean age 25.9 years), ofwh<strong>om</strong> 94% reported having been circumcised below theage of 14 years. Most (68%) had been circumcised bynon-medical personnel, and 60% of participants reportedpost-circumcision c<strong>om</strong>plications (inflammation andswelling) to their circumciser, and 4 (3.5%) reportedprofuse bleeding [55]. In contrast, in a household-basedstudy in southwest Nigeria, respondents reported veryfew c<strong>om</strong>plications (2.8%) following circumcision, mainlyby traditional providers [56]. Among 750 child circumcisions,there were 12 cases reported of excessive bleeding,6 infections, 2 cases of tetanus and one death. Theauthors report that, although they include the death,


Weiss et al. BMC Urology 2010, 10:2http://www.bi<strong>om</strong>edcentral.c<strong>om</strong>/1471-2490/10/2Page 8 of 13Table 5 Retrospective studies of frequency of c<strong>om</strong>plications in studies of child circumcision undertaken by nonmedicalprovidersAuthor Country Years Setting Number ofmalesAhmed [7] Nigeria 1981-1995 C<strong>om</strong>munity 1360(approx)Age atcircumcisionProviderFrequency ofadverse events aMean 4 years Traditional 3.4% -Atikeler [54] Turkey 1999-2002 C<strong>om</strong>munity 407 Mean 7 years Traditional 73% cLee [55] Phillipines 2002 C<strong>om</strong>munity 114 42% 5-9 years52% 10-14years5% 15-18 years32% medical68%traditionalMyers [56] Nigeria - C<strong>om</strong>munity 750 Infant/child 68%traditional25% nurse/midwife4% doctorYegane [77] Iran 2002 C<strong>om</strong>munity 1359 71% <strong>af</strong>ter 2years of ageTraditionalcircumcisers63% d 3.5%2.8% -2.7%% (latec<strong>om</strong>plications)Frequency of seriousadverse events ba Cases of minor bleeding stopped with simple pressure or ‘conservative management’ and excessive foreskin/inadequate circumcision are not includedb Includes c<strong>om</strong>plications defined as ‘serious’ or ‘severe’ by authors, or with long-term or life-threatening sequalae (partial amputation of glans, urethral laceration,need for re-surgery or plastic surgery)c This very high rate of c<strong>om</strong>plications consisted of bleeding (24%), infection (14%), inc<strong>om</strong>plete circumcision (12%), subcutaneous cysts (15%), haemat<strong>om</strong>a (6%),ischaemia (3%), penile adhesion (3%), and other conditions. Of the 97 cases of bleeding, 48 could not be stopped by haemostatic bandage and were sutured.Infections were treated with parenteral or oral antibiotics.d Of these,94% were reported swollen or inflamed penises. Four respondents (3.5%) of those circumcised) reported profuse bleeding0%there was insufficient information to be certain it wascaused by circumcision. A study fr<strong>om</strong> Iran reported alate-phase c<strong>om</strong>plication frequency of 2.7% following traditionalcircumcision and a further 5% had excessiveresidual foreskin. This was similar to circumcisions performedby urologists or surgeons (2.8%), but lower thanfor GPs/paediatricians (6.1%) or paramedical personnel(9.1%). The authors argue that this is because traditionalcircumcisers in Iran are experienced and paramedicalpersonnel do not receive effective training.DiscussionMale circumcision is a c<strong>om</strong>mon surgical procedure, butfew epidemiological studies have reported frequency ofadverse events, most c<strong>om</strong>monly bleeding and infection.Our review shows that serious adverse events are rare,but there is wide variation in reported frequencies ofadverse events following circumcision. This is likely tobe due to several factors directly associated with c<strong>om</strong>plicationssuch as age at circumcision, training and expertiseof the provider, the sterility of the conditions underwhich the procedure is undertaken and the indication(medical/cultural) for circumcision. In addition, there isvariation due to methodological issues such as durationof follow-up, epidemiological study design, and definitionof c<strong>om</strong>plications.In general, c<strong>om</strong>plications (reported by parents) occurleast frequently among neonates and infants than amongolder boys, with the majority of prospective studies in neonatesand infants finding no serious c<strong>om</strong>plications, andrelatively few other adverse events, which were minor andtreatable. The prospective studies in older boys also foundvirtually no serious adverse events, but a higher frequencyof c<strong>om</strong>plications (up to 14%) even when conducted bytrained providers in sterile settings [47]. The lower frequencyof c<strong>om</strong>plications among neonates and infants islikely to be attributable to the simpler nature of the procedurein this age group, and the healing capability in thenewborn. Further, a major advantage of neonatal circumcisionis that suturing is not usually necessary, whereas itis c<strong>om</strong>monly needed for circumcisions in the post-neonatalperiod. This advantage is illustrated by the US study inwhich no c<strong>om</strong>plications were seen among 98 boys circumcisedin the first month of life, but 30% of boys aged 3-8.5months had significant postoperative bleeding [24]. Thereare alternatives to suturing, either with the disposableclamps, or with alternatives such as cynoacrylate glue [44]and further research in this area is needed.Several studies stress the importance of careful trainingand experience of the provider, and the sterility of the setting.This was most clearly noted in a Nigerian study [27]in which 24% of boys had reported c<strong>om</strong>plications (includingretention of excess residual foreskin), but only 1.6% ofthose circumcised at the public (University Teaching) hospitalby medical doctors. Similarly, two case-control studiesfr<strong>om</strong> Israel have found that UTI are 3-4 times morelikely to occur following circumcised by a traditional,rather than medical provider [57,58]. However, as noted inour review, neonatal circumcision following traditional circumcisionin Israel has low c<strong>om</strong>plication rates overall [9].A further example is the study fr<strong>om</strong> the C<strong>om</strong>oros Islandswhich reported results of an exercise in which specific


Weiss et al. BMC Urology 2010, 10:2http://www.bi<strong>om</strong>edcentral.c<strong>om</strong>/1471-2490/10/2Page 9 of 13training had been given to surgical aids and nurses to performcircumcisions. The proportion of boys with c<strong>om</strong>plications(2.3%) was reported to be a great improvement onthat by traditional non-medically trained providers [43,59].The high frequency of adverse events following circumcisionby untrained providers in non-sterile settings is strikingin two studies of traditional circumcision which foundalarmingly high prevalence of around 80% [54,60]. Notably,in one of these, the self-reported frequency was muchlower, illustrating the under-ascertainment that can occurin retrospective studies. Mass circumcisions are particularlyrisky,evenwhenundertakeninthehospital.Forexample, the Turkish study of 700 children circumcisedduring a 5 day period recorded a c<strong>om</strong>plication frequencyof 8%, likely due to the difficulty in providing sufficientsterile equipment and conditions [46]. The reason for surgerycan also influence the risk of adverse events as seenin the studies of child circumcision where more c<strong>om</strong>plicationswere generally seen if circumcision was conductedfor medical rather than religious reasons.Our systematic review was restricted to circumcisionc<strong>om</strong>plications among boys aged 12 years or under.However, there are several published studies of circumcisionc<strong>om</strong>plications among adolescent and adult men(Table 6) and these indicate a generally higher frequencyof c<strong>om</strong>plications than seen in neonates, infants and children.In the three RCTs of circumcision in adult men,c<strong>om</strong>plications were observed in 2-7% of HIV-negativemen [14,61,62], and in 6-8% of HIV positive men[14,62]. The most detailed observational study was conductedamong the Babukusu ethnic group in westernKenya. Of 562 adolescents circumcision by a medicalprovider (or reported as such), 18% had a c<strong>om</strong>plication,as did 35% of boys circumcised traditionally [60]. A substudyin the same population directly observed 24 boysundergoing medical and traditional circumcision respectivelyand found that of those circumcised medically,only one boy had no adverse events, and 3 permanentadverse sequalae were reported, including one very seriouslife-threatening case by a ‘medical’ practitioner whowas later found to have no documented medical qualifications[60]. Among the 12 directly observed traditionalcircumcisions, c<strong>om</strong>plications were seen in 10 boys(83%), and 4 (33%) were judged to have permanentadverse sequelae. None had fully healed by 30 dayspost-operation. Detailed examination showed that traditionalcircumcision was also associated with slower healing,more swelling, laceration and keloid scarring [60].These results show that under non-sterile conditions,adolescent and adult circumcision can frequently beassociated with severe c<strong>om</strong>plications. Other case-seriesof circumcision c<strong>om</strong>plications among adolescents andyoung men also report severe morbidity and mortality[63-68]. Reported c<strong>om</strong>plications tend to be morec<strong>om</strong>mon in this age group than for neonates andinfants, even when circumcision is conducted under the‘gold standard’ conditions such as in the RCTs.A major challenge in our review was to standardisethe definition of c<strong>om</strong>plications. For example, Okeke etal [10] report c<strong>om</strong>plications in 20% of boys, of whichhalf were excessive residual foreskin - an adverse eventbut arguably not a medical risk. We excluded thesecases where possible. Similarly, the paper by Gee et al[38] cites a total of 110 c<strong>om</strong>plications out of 5521(2.0%) but states that only 14 c<strong>om</strong>plications (0.2%)were considered ‘really significant’ (one life-threateninghemorrhage, 4 systemic infections, 8 circumcisions ofinfants with hypospadias and one c<strong>om</strong>plete denudationof the penile sh<strong>af</strong>t). The other c<strong>om</strong>plications includedbleeding, infection, circumcision of hypospadiasis, anda Plastibell ring that was too tight. The problem ofdefining c<strong>om</strong>plications is also highlighted in the early(1961-1962) study fr<strong>om</strong> Canada in which moderate orsevere c<strong>om</strong>plications (bleeding, infection, meatal ulcer,meatal stenosis and phimosis) were seen in 15 infants(15%) but a further 68 infants had mild bleeding, meatalulcers or infection [29]. C<strong>om</strong>plication risks in thisstudy have previously been reported as 55% [4], whichincludes any bleeding, including oozing. A furtherexample is the Australian study [69] which reportedc<strong>om</strong>plications in 8% of boys, which included severalcases of mild bleeding which either ceased spontaneouslyor with simple management such as digitalpressure. We have attempted to report ‘severe’ or ‘serious’adverse events as a separate outc<strong>om</strong>e, but dataon this is often limited and it would be useful to producea standard classification of mild, moderate andsevere c<strong>om</strong>plications following circumcision so that infuture studies may be more easily c<strong>om</strong>parable. Otherlimitations related to the design of the epidemiologicalstudies. The length of follow-up varies between, andwithin, studies, and may <strong>af</strong>fect the estimated frequencyof c<strong>om</strong>plications. For this reason we tend not to termthe frequency as a ‘risk’. It is also possible that thelower frequencies of c<strong>om</strong>plications in prospective studiesare due to improved procedures by practitionersor improved hygiene by patients as a result of participatingin the study. Finally, a number of studies aresmall and the estimates of frequency of c<strong>om</strong>plicationswill be correspondingly imprecise.We excluded one study of circumcision amongpatients with inherited bleeding disorders [20] as wewere interested in c<strong>om</strong>plications in general populations.In this study, of 71 patients diagnosed fr<strong>om</strong> 1961-1996,52% had a record of post circumcision bleeding. Inmany settings, boys are not asked about a family historyof bleeding disorders and this can potentially lead tosevere circumcision-related c<strong>om</strong>plications.


Weiss et al. BMC Urology 2010, 10:2http://www.bi<strong>om</strong>edcentral.c<strong>om</strong>/1471-2490/10/2Page 10 of 13Table 6 Frequency of c<strong>om</strong>plications in studies of adolescent and adult circumcisionAuthor Country Years Setting N Age Provider Method Indication FollowupperiodAuvert[14]Auvert[14]Bailey[60]Bailey[60]Bailey[60]Bailey[60]Bowa[78]Kigozi[62]Kigozi[62]Krieger[61]Magoha[79]Peltzer[80]SouthAfricaSouthAfrica2002-20042002-2004GP offices 1495HIV negGP officesKenya 2004 H<strong>om</strong>e orc<strong>om</strong>munityKenya 2004 H<strong>om</strong>e orc<strong>om</strong>munityKenya 2004 Hospital,healthcentre, orprivate officeKenya 2004 Hospital,healthcentre, orprivate officeZambia 2004-2006Uganda 2003-2005Uganda 2003-2006Kenya 2002-2005Nigeria& KenyaSouthAfrica1981-1998UrologyoutpatientclinicTrialoperatingtheatreTrialoperatingtheatre73 HIVpositive445 66% agedbelow 15years18-24 years GPs Forcepsguided18-24 years GPs ForcepsguidedEnrolled intrialEnrolled intrial1month1monthTraditional - Cultural 30-89days12 Traditional - Cultural ~3months562 90% agedbelow 15yearsClinician e - Cultural 30-89days12 - Clinician j - Cultural ~3months900 5 monthsto 96 years2326HIV neg420 HIVpositiveTrained clinicalofficer15-49 years Trainedphysician15-49 years TrainedphysicianTrial clinic 1475 18-24 years Medical andclinical officersHospital 249 32%neonates6% children61%adolescent/adult78 Median 19years(range 16-25)SurgeonDoctors andnursesfollowing 1day trainingDorsal slitmethodSleevemethod/Sleevemethod/ForcepsguidedForcepsguidedFrequencyof adverseevents a3.6% -8.2% -35% 24% cFrequencyof seriousadverseevents b83% 33% d18% f 19% h92% e 25% iCultural 8 weeks 3.0% 0.06% at 8weeksEnrolled intrialEnrolled intrialEnrolled intrial72%Cultural/religious12%Parentalrequest16%MedicalCultural(Xhosainitiat6 weeks 7.4% 0.2% severe3.3%moderate6 weeks 6.0% 0% severe(3.1%moderate)90 days 1.8% 0% severe(0.7%moderate)- 11% 2.8% severe g- 3.8% 0%a Cases of minor bleeding stopped with simple pressure or ‘conservative management’ and excessive foreskin/inadequate circumcision are not includedb Includes c<strong>om</strong>plications defined as ‘serious’ or ‘severe’ by authors, or with long-term or life-threatening sequalae (partial amputation of glans, urethral laceration,need for re-surgery or plastic surgery)c Wound not healed at 60 days <strong>af</strong>ter surgeryd Permanent adverse sequalee Anyone considered by the participant to be a clinicianf Including an unknown number with residual foresking Includes severe haemorrhage (n = 3), scrotal laceration (n = 2), penile sh<strong>af</strong>t denudation (n = 1) and glandular injury (n = 1).ConclusionMale circumcision is c<strong>om</strong>monly practiced and will continueto occur for religious, cultural and medical reasons.In general, c<strong>om</strong>plications are minor and treatable,especially at young ages, but high frequency of c<strong>om</strong>plications,and severe c<strong>om</strong>plications, are seen when theprocedure is undertaken by inexperienced providers, innon-sterile settings or with inadequate equipment andsupplies. Further prospective studies with monitoring ofrisks following circumcision are needed to documentc<strong>om</strong>plications using standardised definitions, and toc<strong>om</strong>pare the risks associated with different methods, ageat circumcision, and to evaluate the impact of specificand ongoing training of providers. Such studies are


Weiss et al. BMC Urology 2010, 10:2http://www.bi<strong>om</strong>edcentral.c<strong>om</strong>/1471-2490/10/2Page 11 of 13underway in s<strong>om</strong>e settings where male circumcision servicesare being expanded for HIV prevention. A set ofguidelines on expansion of male circumcision have beenproduced by WHO/UNAIDS, and include operationalguidance for scaling up male circumcision for HIV prevention,a surgical manual for male circumcision underlocal anaesthesia, guidance for decision-makers onhuman rights, ethical and legal considerations protocolsfor monitoring and evaluation [70].There is a clear need to improve s<strong>af</strong>ety of male circumcisionat all ages through improved training or retrainingfor both traditional and medically trained providers,and to ensure that providers have adequate suppliesof necessary equipment and instruments for s<strong>af</strong>ecircumcision. Strategies for training and quality assuranceare needed and will be context specific. In Swaziland,“Operation AB” demonstrated a c<strong>om</strong>prehensivemodel of training teams of medical providers in s<strong>af</strong>e andswift adolescent and adult circumcisions, with improvedsterilization equipment and clients’ education, at c<strong>om</strong>munity-levelclinics [71] In Ghana, where neonatal circumcisionis almost universal, the formal Health Serviceprovides training to traditional providers in Accra, withtraining on basic hygiene and provision of necessaryequipment, such as sterile gloves and dressings [72]. InSouth Africa it has been suggested that c<strong>om</strong>munityhealth nurses create opportunities to educate traditionalcircumcisers of adolescents and adults on basic hygienerequirements to be met before, during and <strong>af</strong>ter circumcision[72], USAID/PATH/MSH have designed a trainingprogram in the Eastern Cape for training traditionalproviders about s<strong>af</strong>e circumcision practices [73]. Linksbetween the formal and informal health sectors shouldbe explored elsewhere to institute quality standard practicesfor both traditional and medical circumcisers, forexample wearing sterile gloves, using sterile instrumentsand appropriate <strong>af</strong>tercare, and creating a formal structurethrough which to monitor and regulate the conductof circumcision. Through these steps, it is likely that thes<strong>af</strong>ety of this c<strong>om</strong>mon procedure can be substantiallyimproved.AbbreviationsGP: General Practitioner; RCT: Rand<strong>om</strong>ised controlled trials; UK: UnitedKingd<strong>om</strong>; UNAIDS: The Joint United Nations Programme on HIV/AIDS; USA:United States of America; WHO: World Health Organisation.AcknowledgementsWe are grateful to the Bill & Melinda Gates Foundation for funding thisresearch and providing funding for NL. HW was funded by the UK MedicalResearch Council.Author details1 MRC Tropical Epidemiology Group, Department of Epidemiology andPopulation Health, London School of Hygiene & Tropical Medicine, KeppelStreet, London WC1E 7HT, UK.2 Dept of Global Health and Population,Harvard School of Public Health, 665 Huntington St, Boston, MA, USA.3 TheJerusalem AIDS Project, 4 Eliezer Hagadol Street, Jerusalem 91072, Israel.Authors’ contributionsThe review was designed and conducted by HW and NL. The first dr<strong>af</strong>t ofthe paper was written by HW. IS and DH critically reviewed the manuscriptand approved the final version. All authors read and approved the finalversion of the paper.C<strong>om</strong>peting interestsThe authors declare that they have no c<strong>om</strong>peting interests.Received: 13 July 2009Accepted: 16 February 2010 Published: 16 February 2010References1. WHO/UNAIDS: Male circumcision: global trends and determinants ofprevalence, s<strong>af</strong>ety and acceptability. World Health Organization 2008.2. Kaplan GW: C<strong>om</strong>plications of circumcision. Urol Clin North Am 1983,10:543-549.3. Lerman SE, Liao JC: Neonatal circumcision. Pediatr Clin North Am 2001,48:1539-1557.4. Williams N, Kapila L: C<strong>om</strong>plications of circumcision. Br J Surg 1993,80:1231-1236.5. Gluckman GR, Stoller ML, Jacobs MM, Kogan BA: Newborn penile glansamputation during circumcision and successful reattachment. J Urol1995, 153:778-779.6. Shenfeld OZ, Ad-El D: [Penile reconstruction <strong>af</strong>ter c<strong>om</strong>plete glansamputation during ritual circumcision]. Harefuah 2000, 139:352-354, 407..7. Ahmed A, Mbibi NH, Dawam D, Kalayi GD: C<strong>om</strong>plications of traditionalmale circumcision. Ann Trop Paediatr 1999, 19:113-117.8. Strimling BS: Partial amputation of glans penis during Mogen clampcircumcision. 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O’Brien TR, Calle EE, Poole WK: Incidence of neonatal circumcision inAtlanta, 1985-1986. South Med J 1995, 88:411-415.40. R<strong>af</strong>iq K: Plastibell-A Quick Technique to Decrease the Distress ofNeonatal Circumcision. Ann King Edward Med Coll 2000, 6:412-413.41. Eroglu E, Dayanikli P, Sarman G, Yorukalp O, Ozkan H, Dora F: Newborncircumcision using a G<strong>om</strong>co clamp. J Turk Assoc Pediatr Surg 2005,2005:31-34.42. Metcalf TJ, Osborn LM, Mariani EM: Circumcision. A study of currentpractices. Clin Pediatr (Phila) 1983, 22:575-579.43. Ahmed A: Childhood circumcision: a planned approach. Trop Doct 2007,37:239-241.44. Sharma PP: Sutureless circumcision: Wound closure <strong>af</strong>ter circumcisionwith cynoacrylate glue - a preliminary Indian study. Indian Journal ofSurgery 2004, 66:286-288.45. Bazmamoun H, Ghorbanpour M, Mousavi-Bahar SH: Lubrication ofcircumcision site for prevention of meatal stenosis in children youngerthan 2 years old. Urol J 2008, 5:233-236.46. Ozdemir E: Significantly increased c<strong>om</strong>plication risks with masscircumcisions. Br J Urol 1997, 80:136-139.47. Subramaniam R, Jacobsen AS: Sutureless circumcision: a prospectiverand<strong>om</strong>ised controlled study. Pediatr Surg Int 2004, 20:783-785.48. Aldemir M, Cakan M, Burgu B: Circumcision with a new disposable clamp:Is it really easier and more reliable?. Int Urol Nephrol 2007, 40:377-381.49. Griffiths DM, Atwell JD, Freeman NV: A prospective survey of theindications and morbidity of circumcision in children. Eur Urol 1985,11:184-187.50. Schmitz RF, Abu Bakar MH, Omar ZH, Kamalanathan S, Schulpen TW,Werken van der C: Results of group-circumcision of Muslim boys inMalaysia with a new type of disposable clamp. Trop Doct 2001,31:152-154.51. Schmitz RF, Schulpen TW, van Wieringen JC, Kijlstra M, Verleisdonk EJ,Werken van der C: [Good results fr<strong>om</strong> circumcisions of Muslim boysperformed outside the hospital]. 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Weiss et al. BMC Urology 2010, 10:2http://www.bi<strong>om</strong>edcentral.c<strong>om</strong>/1471-2490/10/2Page 13 of 1377. Yegane RA, Kheirollahi AR, Salehi NA, Bashashati M, Khoshdel JA, Ahmadi M:Late c<strong>om</strong>plications of circumcision in Iran. Pediatr Surg Int 2006,22:442-445.78. Bowa K, Lukobo M: Male circumcision and HIV infection in Zambia. Eastand Central African Journal of Surgery 2006, 11:66-71.79. Magoha GA: Circumcision in various Nigerian and Kenyan hospitals. EastAfr Med J 1999, 76:583-586.80. Peltzer K, Kanta X: Medical circumcision and manhood initiation rituals inthe Eastern Cape, South Africa: a post intervention evaluation. CultHealth Sex 2009, 11:83-97.Pre-publication historyThe pre-publication history for this paper can be accessed here:http://www.bi<strong>om</strong>edcentral.c<strong>om</strong>/1471-2490/10/2/prepubdoi:10.1186/1471-2490-10-2Cite this article as: Weiss et al.: C<strong>om</strong>plications of circumcision in maleneonates, infants and children: a systematic review. BMC Urology 201010:2.Submit your next manuscript to BioMed Centraland take full advantage of:• Convenient online submission• Thorough peer review• No space constraints or color figure charges• Immediate publication on acceptance• Inclusion in PubMed, CAS, Scopus and Google Scholar• Research which is freely available for redistributionSubmit your manuscript atwww.bi<strong>om</strong>edcentral.c<strong>om</strong>/submit


2013-06-21 Dnr x.x-xxxxx/xxxx 1(4)TillsynsavdelningenPer-Anders Sunessonper-anders.sunesson@socialstyrelsen.seAnne Mette DonsOverlæge, Chef for Tilsyn og Patientsikkerhed<strong>Sundhedsstyrelsen</strong>Axel Heidesgade 1DK-2300 København SRättsutredning <strong>om</strong> rättsläget kring <strong>om</strong>skärelse av pojkar- Lagen (2001:499) <strong>om</strong> <strong>om</strong>skärelse av pojkar (OmskL)- Socialstyrelsens föreskrifter och allmänna råd (SOSFS 2001:14)<strong>om</strong> <strong>om</strong>skärelse av pojkar.- Omskärelse av pojkar - Rapport av ett regeringsuppdrag till Socialstyrelsen(S2005/7490/SK)Omskärelselagen infördes för att garantera att <strong>om</strong>skärelser äger rum påett betryggande sätt i enlighet med vad hänsynen till barnets bästa kräveroch är i överensstämmelse med de krav s<strong>om</strong> ställs i bl.a. FN:s konvention<strong>om</strong> barnets rättigheter när det gäller åtgärder s<strong>om</strong> rör barn.Lagen (2001:499) <strong>om</strong> <strong>om</strong>skärelse av pojkar (OmskL) trädde i kr<strong>af</strong>t den1 oktober 2001.Socialstyrelsen har även utfärdat föreskrifter och allmänna råd (SOSFS2001:14) <strong>om</strong> <strong>om</strong>skärelse av pojkar.Med beaktande av svenska förhållanden, görs bedömningen in<strong>om</strong>svensk hälso- och sjukvård att det saknas medicinskt hållbara skäl föratt här, generellt, utföra ingreppet av medicinskt förebyggande skäl.Omskärelser kan anses s<strong>om</strong> medicinskt motiverade eller indikerade –och därmed s<strong>om</strong> hälso- och sjukvård – endast i sådana fall då de utförsvid exempelvis förhudsförträngning samt vid vissa infektioner och skador.I lagen avses sådana <strong>om</strong>skärelser s<strong>om</strong> företas på religiöst eller kulturelltbetingade grunder (dvs. sådana <strong>om</strong>skärelser s<strong>om</strong> ibland brukarbetecknas s<strong>om</strong> ”etniska” eller ”rituella”) och sådana <strong>om</strong>skärelser s<strong>om</strong>företas på grund av uppfattningen att ingreppet generellt sett främjarhygien och bör ses s<strong>om</strong> förebyggande hälsovård.I Sverige utförs <strong>om</strong>skärelse i regel av hälso- och sjukvårdspersonaläven i de fall då ingreppet görs utan medicinsk indikation. Omskärelserav pojkar utan medicinsk indikation utförs in<strong>om</strong> såväl offentligt s<strong>om</strong>SOCIALSTYRELSEN106 30 StockholmTelefon 075-247 30 00socialstyrelsen@socialstyrelsen.sewww.socialstyrelsen.seFax 075-247 32 52Org.nr 202100-0555Plusgiro 15616-6


SOCIALSTYRELSEN 2013-06-21 Dnr 2(4)privat bedriven hälso- och sjukvård. Vanligast är att ingreppet utförs iöppen vård. Ingreppet kan dock också utföras av personer s<strong>om</strong> inte harmedicinsk k<strong>om</strong>petens 1 .Omskärelser av den typ s<strong>om</strong> <strong>om</strong>fattas här, anses inte vara hälso- ochsjukvård i hälso- och sjukvårdslagens (1982:763) mening. Det är dockett kirurgiskt ingrepp s<strong>om</strong> enligt lagens motiv ska utföras i enlighetmed vetenskap och beprövad erfarenhet. Ingreppet ligger nära <strong>om</strong>fångetför hälso- och sjukvården. Därtill k<strong>om</strong>mer, att i lagen (1998:531)<strong>om</strong> yrkesverksamhet på hälso- och sjukvårdens <strong>om</strong>råde <strong>om</strong>fattas även<strong>om</strong>skärelser av icke medicinska skäl i begreppet hälso- och sjukvård (1kap. 2 §). Efters<strong>om</strong> <strong>om</strong>skärelse av det aktuella slaget inte är hälso- ochsjukvård har det tydliggjorts i 2 § OmskL, att när en legitimerad läkareutför en <strong>om</strong>skärelse enligt lagen, eller när legitimerad läkare eller legitimeradsjuksköterska <strong>om</strong>besörjer smärtlindring enligt lagen, gällerpatientsäkerhetslagen (2010:659), patientskadelagen (1996:799) ochpatientdatalagen (2008:355).Med hänsyn till barnets bästa har Socialstyrelsen låtit göra en gen<strong>om</strong>gångav de ärenden s<strong>om</strong> rör <strong>om</strong>skärelse av pojkar och s<strong>om</strong> Socialstyrelsenpå ett eller annat sätt har fått känned<strong>om</strong> <strong>om</strong> från år 2000 till 2007.Under åren 2000–2001 utreddes två ärenden 2 med allvarliga k<strong>om</strong>plikationer.Åren 2002 och fram till 2007 har Socialstyrelsen utrett 14 ärenden3 .I Sverige saknas idag en rätt att få ingreppet utfört in<strong>om</strong> den offentligahälso- och sjukvården. Det finns därmed heller ingen motsvarande skyldighetför sjukvårdshuvudmännen att låta utföra ingreppet.Socialstyrelsen konstaterar i rapporten dock att lagens utformninginte fyller sitt syfte när det gäller söner till föräldrar av muslimskt ursprungeller till andra föräldrar s<strong>om</strong> låter <strong>om</strong>skära sina söner. Ett stortantal pojkar <strong>om</strong>skärs utanför hälso- och sjukvården, främst därför attföräldrarna inte vet vart de ska vända sig. I dessa fall ökar riskerna föratt föräldrarna vänder sig till icke k<strong>om</strong>petenta personer. Möjligheten atti Sverige kunna utföra <strong>om</strong>skärelser även utanför hälso- och sjukvården1 In<strong>om</strong> islam kan, men behöver inte, läkaren vara muslim. In<strong>om</strong> de judiska församlingarna i Sverige finnssedan lång tid en etablerad organisation för <strong>om</strong>skärelse av pojkar. Den s<strong>om</strong> utför judiska <strong>om</strong>skärelser kallasmohel. Det ställs inga krav på att en person måste vara läkare för att utses till mohel, men det finns mohelers<strong>om</strong> också är läkare. En mohel måste vara jude och ha särskilda kunskaper <strong>om</strong> den judiska religionen. Hanmåste också ha gen<strong>om</strong>gått särskild utbildning. Den blivande mohelen lärs upp av en erfaren mohel. Detfinns dock inte någon standardiserad utbildning. Det förek<strong>om</strong>mer också att en mohel <strong>om</strong>skär muslimskapojkar.2 I det ena fallet avled pojken och i det andra blev pojken okontaktbar och fördes akut till sjukhus på grundav överdosering av bedövningsmedel. I båda fallen utfördes ingreppet av legitimerade läkare och Socialstyrelsenhade anledning att göra anmälan till Hälso- och sjuk-vårdens ansvarsnämnd respektive till åklagare.3 I ett av dem gjordes anmälan av utföraren själv till Socialstyrelsen enligt Lex Maria. Anmälan ledde dockinte till någon kritik från Socialstyrelsen, efters<strong>om</strong> den k<strong>om</strong>plikation s<strong>om</strong> uppstod (blödning) ansågs varaen normal risk vid ett sådant ingrepp.


SOCIALSTYRELSEN 2013-06-21 Dnr 3(4)har införts främst mot bakgrund av att det anses fungera väl in<strong>om</strong> denjudiska traditionen.Förutsättningarna för att en <strong>om</strong>skärelse skall få utföras är att den enligt 3 §OmskL sker på begäran av, eller efter medgivande av, pojkens vårdnadshavareoch efter det att vårdnadshavaren har informerats <strong>om</strong> vad ingreppetinnebär. Står pojken under vårdnad av två vårdnadshavare, gäller dettabåda. Det är den s<strong>om</strong> ska utföra ingreppet s<strong>om</strong> själv ansvarar för att informationenges eller att den ges av en medicinskt kunnig person. Dens<strong>om</strong> ska utföra ingreppet skall förvissa sig <strong>om</strong> att information har lämnatsoch att pojkens vårdnadshavare, eller pojken själv, förstår den. Ett ingreppfår inte utföras <strong>om</strong> sådan information inte har lämnats. Den s<strong>om</strong> skall utföraingreppet skall också försöka ta reda på pojkens inställning <strong>om</strong> pojkenär gammal och mogen nog att kunna ge uttryck för en sådan. En pojke fårinte <strong>om</strong>skäras <strong>om</strong> han tydligt visar att han motsätter sig att det sker. Pojkenhar vetorätt. Även <strong>om</strong> vårdnadshavarna vill att ingreppet görs får det inteutföras mot pojkens vilja.Enligt 4 § OmskL ska ingreppet utföras med smärtlindring s<strong>om</strong> <strong>om</strong>besörjsav legitimerad läkare eller legitimerad sjuksköterska, under betryggandehygieniska förhållanden och med hänsyn till vad s<strong>om</strong> är bäst för pojken.Samma krav gäller vid <strong>om</strong>skärelser s<strong>om</strong> utförs av personer med särskilttillstånd. Hänsynen till barnens bästa måste vara avgörande när det gällervilken smärtlindring s<strong>om</strong> ska ges.Det är enligt 5 § OmskL endast legitimerade läkare eller personer s<strong>om</strong> harsärskilt tillstånd s<strong>om</strong> är behöriga att utföra <strong>om</strong>skärelser av pojkar Bestämmelsenanger vilka s<strong>om</strong> är behöriga att utföra <strong>om</strong>skärelser och förbjudersamtidigt andra att utföra ingreppet. På pojkar s<strong>om</strong> är äldre än tvåmånader får dock ingen annan person än en legitimerad läkare utföra <strong>om</strong>skärelse.Bakgrunden till detta är att ingreppet, enligt föredragande statsråd,är minst k<strong>om</strong>plicerat när pojken är riktigt liten och att <strong>om</strong>skärelser iden judiska församlingen inte sker på pojkar s<strong>om</strong> är äldre än två månader.Då det saknas en reglering i lag att läkare skall ha viss k<strong>om</strong>petens för attutföra <strong>om</strong>skärelse av medicinska skäl har man heller inte ansett att sådanakrav borde införas i OmskL.Det har det framk<strong>om</strong>mit av ärenden s<strong>om</strong> Socialstyrelsen har fått känned<strong>om</strong><strong>om</strong> via sjukvården, av enkäter riktade till BVC och av intervjuer, att detförek<strong>om</strong>mer k<strong>om</strong>plikationer efter <strong>om</strong>skärelser s<strong>om</strong> har gjorts utanförhälso- och sjukvården. De här <strong>om</strong>skärelserna har ibland utförts under osteril<strong>af</strong>örhållanden och utan eller med otillfredsställande smärtlindring förbarnet. Den s<strong>om</strong> har utfört ingreppet har inte h<strong>af</strong>t k<strong>om</strong>petens att bedöma ivilka fall ingreppet är olämpligt att utföra. De här <strong>om</strong>skärarna ger intenågon möjlighet till återbesök vid behov. Socialstyrelsen bedömde 2007att det utförs 1 000–2 000 <strong>om</strong>skärelser av den här typen av varje år. De


SOCIALSTYRELSEN 2013-06-21 Dnr 4(4)k<strong>om</strong>plikationer s<strong>om</strong> oftast uppmärksammas på BVC är enligt enkätsvareninfektioner, blödningar, svårigheter att kissa och förträngningar. Andr<strong>af</strong>örek<strong>om</strong>mande k<strong>om</strong>plikationer är att stygn har varit svåra att avlägsna,svullnad, vävnadsdöd och blodstockning. Mer än en tredjedel av de BVCs<strong>om</strong> har svarat ser ofta eller ibland infektioner s<strong>om</strong> k<strong>om</strong>plikation. Detframk<strong>om</strong>mer inte av svaren <strong>om</strong> de här infektionerna har samband medingrepp s<strong>om</strong> har utförts utanför hälso- och sjukvården.I ärenden s<strong>om</strong> har k<strong>om</strong>mit till Socialstyrelsens känned<strong>om</strong> har det i principvarit av samma karaktär s<strong>om</strong> vid ovan nämnda händelser. Det har alltsåbl.a. varit fråga <strong>om</strong> infektioner av olika grad, smärtpåverkan och gapandesår. Inget av dessa fall synes dock ha behövt reopereras.I 10 av 13 ärenden s<strong>om</strong> Socialstyrelsen har utrett har utförandet skett avicke behöriga personer. Ingreppen har utförts i pojkarnas hem av tillresandeperson(er), enligt uppgift med annan nordisk läkarlegitimation, elleri läkarens hem i ett annat nordiskt land. De har alltså saknat svensk läkarlegitimationeller särskilt tillstånd att utföra <strong>om</strong>skärelser. I några fall harpersoner s<strong>om</strong> inte är legitimerade läkare <strong>om</strong>skurit barn s<strong>om</strong> var äldre äntvå månader.I flera fall har Socialstyrelsen heller inte kunnat identifiera den person s<strong>om</strong>har utfört <strong>om</strong>skärelsen. Vid kontakt med föräldrarna har de inte vetat merän ett förnamn på utföraren. Socialstyrelsen har alltså inte kunnat fortsättautredningen i dessa fall.Det finns landsting 4 s<strong>om</strong> sett till att ha ett vårdavtal med en privatkliniks<strong>om</strong> är specialiserad på <strong>om</strong>skärelse av pojkar verkar fungera väl och varasäker för patienterna. Avgörande är att kliniken har ett kvalitetsarbete meduppföljning av sina operationer. Detta har redovisat en mycket låg k<strong>om</strong>plikationsfrekvens.Detta är ett exempel på att sätta barnets bästa i förstahand och kan förhindra att pojkar far illa in<strong>om</strong> <strong>om</strong>skärelseverksamheten.4 Stockholms läns landsting

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