PEDIATRICS Vol. 105 No. 3 March 2000, pp. 681-684

CircumcisionThe Debates Goes On

To the Editor.

The AAP circumcision policy in the March issue of Pediatrics still leaves me with the following questions concerning foreskin and penile hygiene.

1. What active interventions are recommended to ensure eventual retraction of the foreskin, if indeed such retraction is necessary for intercourse and reproduction? I understand that the production of smegma dissects free the foreskin's adhered epithelial layers over time. Does this process require the help of a caretaker's increasingly vigorous attempts to roll back the foreskin or does the genital play of the infant or masturbation of the older child assist the process? Does the 7-year-old with a long, adhered foreskin and no symptoms require surgical release of these adhesions? I've heard it rumored that "popping" the glans free of the adhered foreskin is a father-son "ritual" in some cultures. It used to be a pediatrician-patient ritual in ours. Finally, even after circumcision, the cut foreskin often readheres to the corona of the glans. One can see pearls of smegma accumulated under the adhesions. Should this rim of adhesions be manually lysed followed by application of antibiotic ointment or perhaps premarin cream, as pediatricians who lyse female labia minora adhesions have done for years (another questionable practice). Does this cause or prevent senechial adhesions between foreskin and glans?
2. What is meant by penile hygiene? Does this imply rolling back the easily retractable foreskin for a soap and water wash to remove smegma and bacteria, then replacing it to physiologic position? Should the washwater be dried from the glans? Is it possible, teleologically, that smegma by pH or bacteriostatic function has a protective function and normal sterile urine cleanses the redundant foreskin? We recommend against vaginal douching and know the pH of cerumen seems to prevent otitis externa. The AAP statement does not support smegma as carcinogenic, so perhaps it has a physiologic function and need not be washed away for other than aesthetic reasons.

I have been in practice for 25 years and perform plastibel circumcisions on parental request.

Gary Preiser, MD, FAAP
Delaware Valley Hospital
Walton, NY 13856

To the Editor.

I am very surprised and concerned that the "Circumcision Policy Statement"¹ of the AAP's Task Force on Circumcision endorses EMLA cream for analgesia while acknowledging that "the analgesic effect is limited during the phases associated with extensive tissue trauma such as during lysis of adhesions and tightening of the clamp." They comment that sucrose "cannot be recommended as the sole method of analgesia" although we believe it is probably at least as effective as EMLA cream.²

Dorsal penile nerve block is recognized as the standard for analgesia. I am dismayed that the Task Force would endorse EMLA cream, as well, as a sole method of analgesia because it is not effective during the most painful parts of the operative procedure.

Marguerite Herschel, MD
University of Chicago Hospitals
Department of Pediatrics
Chicago, IL 60637

REFERENCES

1. American Academy of Pediatrics, Task Force on Circumcision Circumcision policy statement. Pediatrics. 1999; 103:686-693 [Abstract/Free Full Text]
2. Herschel M, Khoshnood B, Ellman C, Maydew N, Mittendorf R Neonatal circumcision: randomized trial of a sucrose pacifier for pain control. Arch Pediatr Adolesc Med. 1998; 152:279-284 [Abstract/Free Full Text]

To the Editor.

As a pediatrician, I am dedicated to providing the best possible care for all of my patients, and I do so without regard to race, financial status, or gender. Thus, I am concerned about the apparent disparity in the opinions of the AAP regarding the circumcision of males and females.

In July 1998, the AAP Committee on Bioethics issued a statement condemning the mutilation of female genitalia.¹ Although female genital mutilation (FGM) exists in many horrendous variations, that statement clearly included within its definition of FGM "excision of the skin surrounding the clitoris" [paragraph 6]. In that report the Committee also clearly stated that pediatricians should "decline performing all medically unnecessary procedures to alter female genitalia" [paragraph 4]. Furthermore, under the heading "Cultural and Ethical Issues" the Committee stated that the parents' cultural, societal, and religious beliefs do not give them the right to consent to a medically unnecessary procedure for their child.

Therefore, I was dismayed to read that in March 1999 the AAP Task Force on Circumcision failed to afford the same protection to our male patients.² This report stated that male circumcision "is not essential to the child's well-being"in other words, it is not medically necessary. However, the Task Force stated that "it is legitimate for parents to take into account cultural, religious, and ethnic traditions ... when making this decision." This is something with which I strongly disagree. Just as no surgeon would perform a medically unnecessary appendectomy just because the parents desire one for their child, so should we, as the protectors of children, refuse to perform unnecessary mutilating procedures on our patients simply because of their parents' desires. Remember, we are not "religious" or "cultural" or "ethnic" practitioners. We are physicians who should practice medicine, not rituals.

Therefore, I hope that my fellow pediatricians will join me in declining to perform medically unnecessary procedures to alter either male or female genitalia, and I ask the AAP to reconvene the Committee on Bioethics to review the policy statement of the Task Force on Circumcision.

Thomas Bartman, MD, PhD
Department of Pediatrics
University of California, San Francisco
San Francisco, CA 94143-0110

REFERENCES

1. American Academy of Pediatrics, Committee on Bioethics Female genital mutilation. Pediatrics. 1998; 102:153-156 [Abstract/Free Full Text]
2. American Academy of Pediatrics, Task Force on Circumcision Circumcision policy statement. Pediatrics. 1999; 103:686-693

To the Editor.

The AAP Task Force on Circumcision correctly emphasizes that parents of male children should be given accurate and unbiased information regarding circumcision.¹ As with any irreversible surgical procedure, however, neonatal circumcision removes options whereas postponement allows for the decision to be informed by future developments. Hence, together with the benefits and risks of neonatal circumcision, an expected value of postponement should be carefully assessed and considered.

Regarding the relationship of circumcision to sexually transmitted diseases (STDs), for example, the acknowledged need for more information argues for postponing the procedure. In addition to the possible associated negative effects of the foreskin which the Task Force relates, the cited studies also point to possible beneficial effects, with evidence indicating in particular that chlamydial infection occurs more often in men with circumcision.² But it is not the prevalence or transmission of STDs today that is primarily at issue. Rather, of relevance to the neonate is the possible role of the foreskin in the transmission or prevention of STDs decades hence, and this is both unknown and unknowable at birth.

Postponement also has other advantages. Although the Task Force refers to the risk attendant to general anesthesia if it is used, it should be noted that the pain of circumcision may be more simply and more effectively managed after the neonatal period.

To make an informed choice, parents of male infants should be given accurate and unbiased information regarding postneonatal, as well as neonatal, circumcision. In choosing whether to forego future options during the neonatal period, the expected benefits and risks of performing circumcision at this age should be assessed together with an expected value of the flexibility that would be lost and of the future information that might otherwise inform the decision. That information includes, not least but also not only, the patient's own advice.³

Carl Andersson, PhD
Munich 81671 Germany

REFERENCES

1. American Academy of Pediatrics, Task Force on Circumcision Circumcision policy statement. Pediatrics. 1999; 103:686-693
2. Laumann EO, Masi CM, Zuckerman EW Circumcision in the United States. JAMA. 1997; 277:1052-1057 [Abstract]
3. Leplège A, Hunt S The problem of quality of life in medicine. JAMA. 1997; 278:47-50 [Abstract]

To the Editor.

The American Academy of Pediatrics' (AAP) Task Force on Circumcision statement is seriously flawed. The body of the statement indicates neonatal circumcision to have both potential benefits and risks, neither one being more compelling than the other. It logically would follow that the conclusion should simply state these benefits and risks, as did the 1989 Task Force, allowing the parents to choose with physician advice. Instead, the Task Force concluded "these data are not sufficient to recommend routine neonatal circumcision," implying that the AAP is now opposed to neonatal circumcision. Indeed, this is how it was perceived in the media.^1,2 The AAP should have had sufficient media savvy to foresee this and choose more appropriate, neutral language.

The statement claims that the report is "evidence-based," yet the Task Force clearly courted anticircumcision forces, which may have unduly influenced the analysis. The AAP invited anticircumcision activist Robert Van Howe to appear before it in June 1997. Van Howe subsequently claimed that he served as a consultant to the Task Force.³ I have contacted the individuals who have been most directly involved in research concerning the link between the foreskin and penile cancer, urinary tract infections, and sexually transmissible diseases (including HIV). Neither these individuals nor others who have studied potential medical advantages of circumcision were asked to appear before the Task Force. It seems only fair to have both sides queried. Why was one side invited but not the other?

The Task Force review of the literature was quite superficial, ignoring relevant studies and citing obsolete data. Furthermore, it often placed greater emphasis on those studies that showed only minimal benefits to circumcision. Regarding penile cancer, the Task Force improperly compares various countries using nonstandardized data from incompatible studies.⁴ Moreover, the Task Force ignored the WHO data published in Cancer Incidence in Five Continents.⁵ Had it utilized the WHO data and properly compared populations of opposite circumcision status, it would have found that Israel (almost all circumcised) has an annual incidence of 0.1 per 100 000 (age standardized world rate), which is 1/10 that of Denmark (mostly uncircumcised) in the years 1983 to 1987. The same source indicates even greater differences between third- world circumcised nations such as Nigeria and uncircumcised nations such as Uganda and Puerto Rico. The international epidemiologic WHO data clearly indicates that circumcision confers substantial protection against penile cancerfar more than the small threefold difference cited from a single center that improperly mixed invasive cancer with carcinoma in situ.⁶

The new pamphlet, "Circumcision: Information for Parents," is also flawed. If the Task Force intended the pamphlet to be "evidence-based," why does it contain such items as "the belief that circumcision makes the tip of the penis less sensitive, causing a decrease in sexual pleasure later in life." Such "beliefs," devoid of scientific support, have no place in an AAP pamphlet.

In conclusion, the Task Force constructed a flawed study, allowed itself to be exposed to undue anticircumcision pressure, used inadequate data, and produced a statement all too easily misconstrued. Furthermore, the AAP pamphlet for new parents contained "beliefs" of no scientific merit.

Stefan A. Bailis
Research and Education Association on Circumcision Health Effects
Des Moines, IA 50393

REFERENCES

1. No significant benefits to circumcision. Associated Press, March 1, 1999
2. Circumcision no longer recommended. USA Today, March 2, 1999
3. Van Howe RS Is circumcision healthy? No. Priorities. 1997; 9:25-29
4. American Academy of Pediatrics, Task Force on Circumcision. Circumcision policy statement. Pediatrics. 1999;103:686-693 [references 90-94]
5. Cancer Incidence in Five Continents, published first by the International Union Against Cancer, later by the International Agency for Research on Cancer division of the World Health Organization. 1966 (Volume 1) to 1997 (Volume 7)
6. Maden C, Sherman KJ, Beckmann AM, History of circumcision, medical conditions, and sexual activity and risk of penile cancer. J Natl Cancer Inst. 1993; 85:19-24 [Abstract/Free Full Text]

To the Editor.

The March 1999 issue of Pediatrics had a "Circumcision Policy Statement" from the AAP. It stated: "The procedure is not essential to the child's current well-being."

So that the readership should be able to make their own informed evaluation, we want to present the preoperative findings of a case series.

The cohort involves 480 recent Russian immigrants who requested a bris (ritual circumcision). They ranged in age from 11/2 month to 66 years. Their mean age was 23.8 years. The circumcisions were performed on an outpatient basis under a local anesthetic.

The following are their pre-bris findings: Table 1 identified the following according to the mohel: 85 had phimosis; their prepuce could not be retracted unless forced or dilated. Two adult patients came in for a bris after having developed phimosis secondary to inflammation and infection. (Phimosis in adult uncircumcised males has previously been noted by Whelan.¹ He reported that 25/48 [52%] had phimosis and in 10/48 [20%] of the cases it caused secondary pain during coitus. In our cohort 85/480 [17.7%] had phimosis.) 160/480 had a tight frenulum that bent the glans upon erection, forming a frenular chordee also known as glandular or skin chordee. (Frenular chordee can cause dyspareunia secondary to pain during coitus. Such findings have previously been noted. Griffin and Kroovand² found (20/70) a 28.5% incidence of frenular chordee. Whelan¹ found (10/48) a 20% incidence of short frenulum (frenular chordee). In our cohort we found (160/480) a 33.3% incidence of frenular chordee. By lysing the frenulum during the bris, the condition was relieved.¹ Four patients had hypospadias and declined repairs, 29 had balanitis, 4 had posthitis, 6 had balanoposthitis, 2 had condylomata, 2 had major congenital bridges, 3 had a shpora (a foreign body implant in the prepuce, which was the macho symbol in the gulag prison system), and 3 had balanitis xerotica obliterans with secondary male dyspareunia. Urinary tract infections were pretreated by pediatricians. Patients with penile carcinoma did not come to this program.

  The "Circumcision Policy Statement" declared: "The procedure is not essential to the child's current well-being." Children become adults. Considering the above long-term findings in the uncircumcised remedied by adult circumcision, it follows that routine newborn circumcision is a prudent prophylactic measure.

  The "Circumcision Policy Statement" mentioned the Gomco clamp, the Plastibell device, and the Mogen clamp and recommended using analgesia to minimize pain. We should mention the authentic traditional Jewish neonatal bris (ritual circumcision), the fastest and most humane. Unlike the others, clamps or hemostats are not permitted, so the infant does not suffer from the pain associated with crushing tissue.³ Excision time is about 1 second and the entire procedure takes about 10 seconds. The wound heals naturally by second intention. Hemorrhaging and other complications are rare.⁴ With the authentic traditional bris, it is more humane not to subject the infant to a local anesthetic.³ Jewish patients interested in this technique should be referred to a mohel (ritual circumciser) who is adept at performing the authentic traditional bris.

Rabbi Jacob Shechet, Mohel
Private Practice
Newborn, Adult and Special Bris
Los Angeles, CA 90046

Barton Tanenbaum, MD, FACS
Private Practice of Urology and Surgery
UrologyUSC School of Medicine
Los Angeles, CA 90057

REFERENCES

1. Whelan P Male dyspareunia due to short frenulumindication for adult circumcision. Br Med J. 1977; 2:1633-1634
2. Griffin AS, Kroovand RI Frenular chordee: implications and treatment. Urology. 1990; 35:133-134 [CrossRef][Medline]
3. Shechet J, Fried SM, Tanenbaum B Letter. JAMA. 1998; 279:1170
4. Shechet J, Fried SM. Traditional Jewish circumcision technique of Bris. Am Fam Physician. 1996;53-4:1070-1072

To the Editor.

As a board-certified urologist and mohel (ritual circumciser), I find the recent AAP "Circumcision Policy Statement" misleading and confusing. It is a difficult task to review all of the ethical and medical data and still try to appease everyone with an opinion about circumcision. Stating that the AAP now cannot recommend routine circumcision was unnecessary because the AAP has never recommended routine circumcision, even when there was less evidence of benefits. A better conclusion may have read, "Though the data supporting circumcision continues to support it, we choose to remain neutral on the subject. The decision should be made by the parents based on neutral and unbiased informed consent."

The present statement will confuse many pediatricians and encourages those opposed to circumcision. In today's litigious environment, physicians best serve their patients by remaining neutral and merely presenting facts in a nonjudgmental manner.

Also distressing was the use of the word amputation, a favorite buzz word of anticircumcision advocates, instead of excision. Although correct from a dictionary point of view, this word is rarely used in surgical dictation as it was used in the report. In over 25 years of urologic practice, the only time I used this word was when I did have to amputate a noncircumcised penis for carcinoma.

With ongoing accumulation of data that favors circumcision, I see no reason to continue to appease the anticircumcision advocates. Circumcision is a preventive health measure, but I do not personally champion its universal acceptance. On the other hand, the anticircumcision rhetoric is anecdotal at best. The AAP serves its constituency best by not catering to any extremist groups.

Samuel A. Kunin, MD, FACS
Tarzana, CA 91356

To the Editor.

The recent AAP circumcision policy report¹ contains a few statements that merit comment. In reference to a study by Taylor et al,² the report states: "One study suggests that there may be a concentration of specialized sensory cells in specific ridged areas of the foreskin." The cautious wording is puzzling. Taylor's investigation does not "suggest" that there "may be" specialized nerve endings in the ridged band of the foreskin: it conclusively documents this fact. The report also neglects to acknowledge the relevant fact that there additionally exists a large number of anatomical studies on preputial innervation. In a classic series of studies of the sensory innervation of the foreskin, Winkelmann, for example, concludes that the foreskin is a specific erogenous zone.^3-5 Bazett et al's anatomical investigation,⁶ likewise, documented the foreskin's rich array of sensory end-organs that convey fine gradations of touch and temperature. The conclusion to be drawn from this literature is that the impressive innervation of the inner and outer surfaces of the foreskin contrasts sharply with the limited sensory investment of the glans penis, which is characterized primarily by simple, unencapsulated free nerve endings, incapable of detecting and conveying sensations other than deep pressure or pain.⁷ It is irrelevant, of course, whether the loss of aggregate penile sensory capacity occasioned by amputation of the foreskin seems not to impair erectile function or fertility.

The report also cites a "study" by Masters and Johnson that alleges "no difference in exteroceptive and light tactile discrimination on the ventral or dorsal surfaces of the glans penis between circumcised and uncircumcised men." First, the "study" actually says: "Routine neurologic testing for both exteroceptive and light tactile discrimination were conducted on the ventral and dorsal surfaces of the penile body [emphasis added], with particular attention directed toward the glans. No clinically significant difference could be established between the circumcised and the uncircumcised glans during these examinations." Second, it would seem to be a breach of scientific principles to accept uncritically the validity of a "study" that was never published in a peer-reviewed journal, being only sketchily described in 4 sentences in the best-seller Human Sexual Response.⁸ The study design, materials, methods, cohort details, and numerical analyses are undisclosed. Among other lacunae, they never define "routine neurologic testing," present the numerical data allegedly yielded by this "testing," or reveal how they analyzed the data. Third, this "study" has little bearing on the question of the sensory deficit caused by circumcision. The real issue is not the effect on the glans but the effect on the foreskin, because that is the part amputated. A meaningful study would investigate the difference in the quantitative and qualitative sensory capacity between the circumcision scar of circumcised males and both the inner and outer surfaces of the foreskin of intact males. Elementary deduction, however, can predict the results of such a study in advance.

Frederick M. Hodges, MSt Oxon
Wellcome Unit for the History of Medicine
University of Oxford
Oxford OX2 6PE, United Kingdom

Paul M. Fleiss, MD, MPH
Los Angeles, CA 90027

REFERENCES

1. American Academy of Pediatrics, Task Force on Circumcision Circumcision policy statement. Pediatrics. 1999; 103:686-693
2. Taylor JR, Lockwood AP, Taylor AJ The prepuce: specialized mucosa of the penis and its loss to circumcision. Br J Urol. 1996; 77:291-295 [CrossRef][Medline]
3. Winkelmann RK The cutaneous innervation of the newborn prepuce. J Invest Dermatol. 1956; 26:53-67 [Medline]
4. Winkelmann RK The erogenous zones: their nerve supply and significance. Proc Staff Mayo Clin. 1959; 34:39-47
5. Bourlond A, Winkelmann RK L'innervation du prépuce chez le nouveau-né. Arch Belg Derm Syph. 1965; 21:139-156 [Medline]
6. Bazett HC, McGlone B, Williams RG, Depth, distribution and probable identification in the prepuce of sensory end-organs concerned in sensations of temperature and touch; thermometric conductivity. Arch Neurol Psychiatry. 1932; 27:489-517
7. Halata Z, Munger B The neuroanatomical basis for the protopathic sensibility of the human glans penis. Brain Res. 1986; 371:205-230 [CrossRef][Medline]
8. Masters WH, Johnson VE. Human Sexual Response. Boston, MA: Little, Brown and Company; 1966:190

To the Editor.

Within the context of a discussion regarding differing infant male circumcision rates around the world, the American Academy of Pediatrics' recent policy statement on circumcision¹ states that in Canada approximately 48% of males are circumcised, citing as a reference for this figure a 1970 article from an Australian medical journal.²

However, recent data indicate that the current Canadian rate is considerably lower than that in the early 1970s. Statistics Canada reports a newborn circumcision rate for fiscal 1993-1994 of 24.5%.³ The Canadian Institute for Health Information, which in 1994 took over the national Hospital Morbidity Database from Statistics Canada, reports that in fiscal 1996-1997 circumcision was performed as a primary procedure on <17% of Canadian male neonates.⁴

John Antonopoulos
Circumcision Information Resource Centre
Montreal, Quebec H2L 4Y5, Canada

REFERENCES

1. American Academy of Pediatrics Task Force on Circumcision Circumcision policy statement. Pediatrics. 1999; 103:686-693
2. Leitch IO Circumcision: a continuing enigma. Aust Paediatr. 1970; 6:59-65
3. Statistics Canada. Hospital Morbidity Database (up to fiscal 1993-1994)
4. Canadian Institute for Health Information. CIHI Hospital Morbidity Database (fiscal 1994-1995 to the present)

To the Editor.

It was with great interest that we read the recent "Circumcision Policy Statement" from the American Academy of Pediatrics.¹ That statement has provoked a great deal of attention to the issue of newborn circumcision in the popular media. In response to one such article, published in a local newspaper, one of us, a member of the AAP, wrote a letter to the editor critical of the opinion that the main determinant of whether parents should circumcise their infant son is the circumcision status of the father. That letter, in turn, led to a response from the other one of us telling of the experiences of some members of his family that had resulted from the inadequate education of uncircumcised boys and their parents. As mentioned in the policy statement, "Various studies suggest that genital hygiene needs to be emphasized as a preventative health topic throughout a patient's lifetime."¹

A 90-year-old man was required to have a circumcision because of a lifelong neglect of his uncircumcised penis. It took the surgeon 2.5 hours to correct the damage that had been done. This man had 2 sons, neither of whom had ever been circumcised. Because of their father's experience they began to compare notes.

The older son had been given instruction as a very young boy on how to keep himself clean, and did so all his life. The younger son was not so instructed and did not follow the necessary practice. On the occasion of his first physical examination when he went into the service, the army doctor took one look at the young man's corroded penis and severely reprimanded him and instructed him on how to keep himself clean. Since then, after over 30 years, he has had no problem in that area.

Both the problem the father experienced and the potential problem of the younger son were attributable to the lack of parental instruction and the follow-up that would ensure the proper hygienical attention paid by each man to himself.

We feel that pediatricians should promote, that parents of uncircumcised boys should be educated in, and that strong emphasis should be placed on the proper care of the uncircumcised penis.

This education should emphasize both the need for genital hygiene as a preventive health topic and the natural history of the progression from physiologic phimosis to an easily retractible foreskin, a process which, in a small percentage of boys, may not be fully complete until adolescence.²

Randy Rockney, MD
Department of Pediatrics
Brown University
Hasbro Children's Hospital
Providence, RI 02903

Al Taylor
147 Williams St
Providence, RI 02906

REFERENCES

1. American Academy of Pediatrics, Task Force on Circumcision Circumcision policy statement. Pediatrics. 1999; 103:686-693
2. Gairdner D Fate of the foreskin: a study of circumcision. Br Med J. 1949; 2:1433-1437

To the Editor.

We praise the American Academy of Pediatrics (AAP) Task Force on Circumcision's recent policy statement on neonatal circumcision, especially the strong endorsement of the use of anesthesia.¹ We feel the viewpoint of clinicians who perform circumcisions and have conducted research in the field may add a different perspective to the policy statement.

There has been much criticism from those who feel the statement was too "anticircumcision" and those who alternatively feel that the statement was not "anticircumcision" enough. This criticism, coming from both sides of the issue, is an indication of the balance in the Task Force's work. Circumcision is a controversial issue and many people feel strongly about it. There are many issues on which the AAP has taken strong stands such as immunizations and safety issues. The data on the benefits of circumcision are not compelling enough to influence parents to have their sons circumcised (as they are to encourage MMR and DTaP). Instead, parents should be given information and then be allowed to make their own decision. Many will ask the physician for their viewpoint, and if noncoercive, it is appropriate to give one's perspective. We encourage medical groups and hospitals to develop a specific informed consent that parents sign detailing the pros and cons of the procedure as well as the risks, benefits, and complications. However, if the parents make an informed decision, the doctor should support it, whether it is for or against having their son circumcised.

When the parents' decision is in favor of circumcision, the Task Force has strongly endorsed the use of anesthesia to minimize the pain and stress of the procedure. We feel this is essential, especially because experience has shown that relatively simple, safe, and effective anesthesia for newborn circumcision is readily available. However, we feel there is insufficient data to endorse the use of the ring block over dorsal penile nerve block (DPNB). There are only 3 peer-reviewed studies of ring block anesthesia with a total of 42 patients receiving the block with 3 different techniques.^2-4 In these studies, ring block or local injections have been variously placed halfway along the shaft³ and at the distal shaft near the attachment of the foreskin.² This last technique was associated in some cases with considerable foreskin edema, which made it difficult to visualize anatomic landmarks and place the circumcision clamp.^2,5

In contrast, DPNB has been used since 1978 and more than 15 000 patients have received this anesthesia without significant complications at our hospital. There are more than 20 studies detailing the safety and efficacy of DPNB. Although we feel it is important for physicians to use the method of anesthesia with which they are most comfortable and have the greatest success, the DPNB has the longest, safest track record and is an excellent choice.⁶ It is also important to remember that minimizing the pain and stress of circumcision goes beyond the use of anesthesia to include other modalities such as oral sucrose, comforting the infant during the procedure, and using comfortable positioning.⁶

The results of a recent survey found that only 56% of family practitioners and 25% of obstetricians use anesthesia for circumcision compared with 71% of pediatricians.⁷ We strongly encourage the American Academy of Family Physicians and the American College of Obstetricians and Gynecologists to also adopt strong endorsements for the use of anesthesia for all newborn circumcisions.

Howard Stang, MD, and Leonard Snellman, MD
HealthPartners White Bear Lake Clinic
White Bear Lake, MN 55110

Patricia Fontaine, MD
University Family PhysiciansSmiley's Clinic
Minneapolis, MN 55406

Lawrence M. Condon, MD
HealthPartners Woodbury Clinic
Woodbury, MN 55125

REFERENCES

1. American Academy of Pediatrics, Task Force on Circumcision Circumcision policy statement. Pediatrics. 1999; 103:686-693
2. Masciello AL Anesthesia for neonatal circumcision: local anesthesia is better than dorsal penile nerve block. Obstet Gynecol. 1990; 75:834-838 [Abstract/Free Full Text]
3. Lander J, Brady-Fryer B, Metcalfe JB, Comparison of ring block, dorsal penile nerve block, and topical anesthesia for neonatal circumcision: A randomized clinical trial. JAMA. 1997; 278:2157-2162 [Abstract]
4. Hardwick-Smith S, Mastrobeattista JM, Wallace PA, Ring block for neonatal circumcision. Obstet Gynecol. 1998; 91:930-934 [Abstract]
5. Lenhart JG, Lenhart NM, Reid A, Chong BK Local anesthesia for circumcision: which technique is most effective? I Am Board Fam Pract. 1997; 10:13-19
6. Stang HJ, Snellman LW, Condon LM, et al. Beyond dorsal penile nerve block: a more humane circumcision. Pediatrics. 1997;100(2). URL: http://www.pediatrics.org/cgi/content/full/100/2/e3
7. Stang HJ, Snellman LW. Circumcision practice patterns in the United States. Pediatrics. 1998;101(6). URL: http://www.pediatrics.org/cgi/content/full/101/6/e5

In Reply.

The Task Force on Circumcision appreciates the comments expressed in the letter by Dr Stang and his colleagues.

Drs Stang, Snellman, Fontaine, Condon, and Herschel discuss specific analgesic techniques. The Task Force reiterates the importance of universal utilization of pain management in all cases where circumcision is performed. We recognize that the dorsal penile nerve block has been used successfully for many years. EMLA cream and ring block are relatively new techniques with demonstrated analgesic properties. Those who perform circumcisions should be able to use one of these 3 options for every infant.

The anecdotes outlined in the letter from Dr Rockney and Mr Taylor reinforce the Task Force recommendation that "genital hygiene needs to be emphasized as a preventive health topic throughout a patient's lifetime."

The 7-year-old described by Dr Preiser needs nothing done. Adhesions that form after circumcision separate spontaneously over time. Dr Preiser also asks about appropriate hygiene of an intact or uncircumcised penis. The Academy brochure on this topic states: "The foreskin does not fully retract for several years and should never be forced. The uncircumcised penis is easy to keep clean by gently washing the genital area while bathing. There is no need for any special cleansing, such as with cotton swabs or antiseptics. Later, when the foreskin fully retracts, boys should be taught how to wash underneath the foreskin every day. Teach your son to clean his foreskin by

• Gently pulling it back away from the head of the penis,
• Rinsing the head of the penis and inside fold of the foreskin with mild soap and warm water, and
• Pulling the foreskin back over the head of the penis."

Drs Andersson and Kunin both emphasize that parents of male children should be given accurate and unbiased information regarding circumcision. We agree with Dr Kunin that "the decision should be made by parents based on neutral and unbiased informed consent," and the Task Force report supports this view.

We acknowledge Dr Fleiss and Hodges' concerns regarding the lack of peer review in the Masters and Johnson report.

Dr Bartman asks about female genital mutilation. The critical distinction between female genital mutilation and male circumcision is the potential medical benefits of male circumcision. These potential benefits warrant a parental role in decision making about this procedure. In addition, it should be noted that the AAP Committee on Bioethics did review and approve the policy statement.

Carole M. Lannon, MD, MPH
Chair, AAP Task Force on Circumcision