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Dr. Grahame Smith The Childrens Hospital at Westmead

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1 Dr. Grahame Smith The Childrens Hospital at Westmead
Circumcision Dr. Grahame Smith The Childrens Hospital at Westmead

2 History Undertaken for many thousands of years

3 Why Originally a hygiene measure A ritual, religious
Enhance/decrease sexual performance Prevent masturbation (Brigman)

4 Current position statements
RACP/RACS 2010 Not recommended routinely American Academy of Pediatrics 2012 Justified for families that choose it Canadian Pediatric Society 1989 Not recommended None recommend routine circumcision

5 Strongly opposed Finland Netherlands Germany
In February 2010, a Jewish couple were fined for causing bodily harm to their then infant son who was circumcised in 2008 by a mohel brought in from the UK. Normal procedure for persons of Jewish faith in Finland is to have a locally certified mohel who works in Finnish healthcare perform the operation. In the 2008 case, the infant was not anesthetized and developed complications that required immediate hospital care. The parents were ordered to pay 1500 euros in damages to their child Netherlands Germany Dec 2012; law passed explicitly permitting non-therapeutic circumcision to be performed under certain conditions (religious)

6 Risk & cognitive error 1

7 Risk & cognitive error 2

8 Risk & cognitive error summary
We fear snakes and not cars We fear spectacular, unlikely events Plane crash versus car crash We underestimate our risk of disease We don’t interpret statistics well

9 Thought processes Thought Hats Religious - faith * Science* - evidence

10 Arguments for Religious, social, “cultural freedom” Prevent
Penile cancer HIV Other STDs UTIs

11 Medical indications Recurrent UTIs – 1% children
Foreskin increases UTI risk 5 – 10 times Phimosis (pathological) – 1% children Recurrent balanitis – 1% children

12 Invalid reasons Reduced sexually transmitted disease
HIV, Herpes, HPV etc. Safe sex practices cheaper & more effective May be valid in areas with high HIV incidence HPV vaccine a better alternative Penile cancer (1: 100,000) too rare to worry about UTIs – example to follow

13 Risk benefit analysis for UTIs
Assume complication rate 2% (1% - 10%) 1000 well children circumcised => 8 less UTIs, 20 complications 1000 Children with UTIs => 250 UTIs prevented, 20 complications

14 And further risk Circumcision may decrease female pleasure during intercourse O’Hara & O’Hara - surveyed 138 women. Of that group 20 (14.5%) preferred non-intact circumcised sexual partners while 118 or (85.5%) preferred intact non-circumcised sexual partners. This means that about 6 out of 7 women preferred intact non-circumcised partners while about 1 out of seven preferred non-intact circumcised partners

15 Contra indications Abnormal penis Systemic Hypospadias Epispadias
Buried penis Systemic Coagulopathy Increased anesthetic risk

16 Risks Early Pain Infection Bleeding Fistula Glans amputation
Loss of penis Death

17 Risks Late Meatal stenosis Poor cosmetic result
Skin tags, suture sinuses Buried penis

18 Risks Theoretical Sued or prosecuted Legally, parents may not consent for an operation for a child when such a decision is not in the child’s best interest.

19 Care of the normal foreskin

20 Infancy and childhood Nothing required
Forceful retraction may cause injury and phimosis

21 After puberty Retract and clean each day

22 Phimosis - physiological
Treatment not needed Responds well to Betnovate ½ cream

23 Phimosis – pathological
Responds to Betnovate ½ cream – rarely Tacrolimus May be carcinogenic Circumcision usually curative

24 Phimosis and buried penis
Megaprepuce

25 Paraphimosis

26 Tight frenulum

27 Foreskin adhesions

28 Foreskin lumps

29 Smegma

30 Smegma - more

31 Circumcision complications
Multiple Happen even in the best of hands Incidence = 5 to 10%

32 Buried penis

33 Shaft to glans adhesions

34 Meatal stenosis

35 Shortage of skin

36 Amputation glans

37 Conclusion Don’t circumcise unless there is a medical indication (benefits outweigh the risk) If there is an indication, it’s a good operation

38 References https://www.racp.edu.au/page/paed-policy
(against) (pro) O’Hara K, O’Hara J. The effect of male circumcision on the sexual enjoyment of the female partner. BJU Int 1999;83 Suppl 1:79–84.

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