Circumcision in the Family Practice

[mestielest]

Dear colleagues, what is the contemporary place of circumcision in the family practice in the US? Do FM residency includes training on circumcision? May anyone get interested if a training module is offered in another country (say Turkey)?

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[deleted87716]

I learned to do them in residency (Gomco, Mogen, and Plastibell), but never did any in private practice. I don't think it's a graduation requirement, but most residency educators consider it a core procedure for FM. I'm not sure it would be worth going overseas to learn how to do circs, however.

 

[SLC]

I learned them in residency, I do them now too. Tons of my Coresident refused to learn though, they were morally opposed. I traded them my termination training time (which I was uncomfortable doing) and I got tons of circumcision experience as a result.

 

[deleted87716]

I learned them in residency, I do them now too. Tons of my Coresident refused to learn though, they were morally opposed. I traded them my termination training time (which I was uncomfortable doing) and I got tons of circumcision experience as a result.

Your co-residents were morally opposed to circumcision, but OK with abortion...? That's ****ed up.

 

[SLC]

Your co-residents were morally opposed to circumcision, but OK with abortion...? That's ****ed up.

I tend to agree.

 

[VA Hopeful Dr]

Your co-residents were morally opposed to circumcision, but OK with abortion...? That's ****ed up.

No kidding. You and I are on different sides on that whole subject, so I think it says something that we agree on this.

 

[BigSib]

Performed many in residency and still do in practice. No idea what other countries are up to.

 

[FrustratedFamDoc]

I learned them in residency, I do them now too. Tons of my Coresident refused to learn though, they were morally opposed. I traded them my termination training time (which I was uncomfortable doing) and I got tons of circumcision experience as a result.

Holy ish that's pretty ass backwards.

I did plenty (circs, that is) in residency and in the next several months after I got out filling in for a local pediatrician. Haven't done one in years.

 

[septoplasty]

We were trained to them, had to do a minimum to meet 'graduation' requirements.

Never did any after that.. alot of this has politics/turf wars now too as Ob wants to do them, FM wants to do them, the Peds guys want to do them.

 

[SLC]

We were trained to them, had to do a minimum to meet 'graduation' requirements.

Never did any after that.. alot of this has politics/turf wars now too as Ob wants to do them, FM wants to do them, the Peds guys want to do them.

Yep, I only end up doing them because when I’m the hospitalist, I admit and then usually take the newborns in as new patients. We don’t do Circs in the hospital here, so I end up doing them in the office.

 

[Keona]

I am morally opposed. I did one during medical school and evaluated as I went forward and elected not to do during residency. I had to find another resident who would do procedure instead. I’d offer to do a nexplanon in place. I had one ob attending get really mad at me but everyone else was fine with it. I was never asked to participate in termination procedures but I do know other people who morally objected who were hard core pro choice. We did circs on ob, on continuity patients and the peds residents did in the Nicu.

 

[deleted87716]

I was never asked to participate in termination procedures but I do know other people who morally objected who were hard core pro choice.

That also makes no sense.

 

[Skindoc83]

I don’t understand what is morally reprehensible about circumcision. It decreases the risk of STDs and penile cancer. Seems like a no brainer to me

 

[SLC]

The NNT to prevent a case of penile cancer ranges from 900-300,000, with 2-600ish complications per cancer case prevented (complication rate in the US is about 1/500). The literature supports some reduction in the risk of some STDs - to be fair, incurable ones like HIV and herpes - by ~25%. I wouldn't call circumcision "morally reprehensible" by any means but I can certainly understand why somebody would think it's not worth doing. FWIW the AAFP, AAP, ACOG, and the AUA all say that the risks/benefit ratio is close enough that we should just let parents do what they feel most comfortable with and don't necessarily recommend doing it routinely.

Source: UpToDate

Yep, pretty modest benefits, pretty minimal risk (complications are overwhelmingly some post procedural bleeding controlled by local pressure or silver nitrate). Best to just let parents decide what they prefer.

Most people opposed cite it as body mutilation without consent of the patient. But I’ve never encountered a guy with circumcision regret.

People forget the benefit with respect to neonatal and geriatric UTI. 90% reduction in risk (though it’s an already very small risk) but UTI in this population can be catastrophic.

 

[deleted87716]

I have no strong feelings one way or the other. I've treated plenty of balanitis in un-circ'd patients, and have sent plenty of adults to urology for circs due to phimosis, so there are definitely advantages to losing the foreskin in infancy.

 

[mestielest]

I don’t understand what is morally reprehensible about circumcision. It decreases the risk of STDs and penile cancer. Seems like a no brainer to me

I cannot review all the stuff from PubMed now. However, I can express my views, beliefs, and experiences that are based on my 8 years of practice in urology.

Morally:

- In Torah, circumcision has a solid place. Therefore it is hard to say that circumcision should not be routinely carried out. More or less, clinical guidelines are affected by this situation. Even though one may have evidence to oppose the routine neonatal circumcision, it is impossible to declare that a holy text is wrong or at least a particular order of a belief should be abandoned.

- Circumcision is not a rule in Islam. It is more a tradition. However, most of the Muslim world believes that all Muslim men should be circumcised.

The same thing applies to Muslims. If one shares the evidence (if any) opposing circumcision a regular Muslim will think that he is an anti-islamist, not a scientist.

- Loss of circumcision practice in Christian world is probably due to losing the geographical bound with the Middle East.

- My point of view: I think circumcision should not be a routine procedure. I also think that it is just some kind of Middle East tradition, nothing more. If it will be carried out, the boy should be at least able to defend himself and contribute to the circumcision decision. Thus, going under a circumcision should be voluntarily.


My views on the practice:
Neonatal circumcision:

- There is a great gap between the evidence and the practice. Academy is mostly out of "circumcision business" while people who has a vast amount of cases are not publishing even a letter. Even if one wants to share his experience he will probably get rejected by an editor who barely carried out ten circumcisions last year because the lack of prospective design or not using a validated questionnaire. I often see that journal are more prone to publish results of mass circumcisions in HIV-endemic area than personal case series.
- It is hard to defend a surgical procedure involving the genitalia, even if it is a small procedure with rare complications, with questionable benefit and low NNT.
- I think in the developed world circumcision has no benefits. We are swimming in antibiotics pool. Notebook sized USG workstations are in the personal-budget range. Still performing routine circumcisions in contemporary practice is really an over-treatment.
- For HIV-endemic areas, it is mandatory.

Adult or late-adolescent circumcision:
- Completely different issue. To fight against STI, I think the first choice is condoms. However, circumcision has an indispensable role in people who are in adult movie industry or have several partners.

A special problem in my country and aim of our association:
- In Turkey, performing a circumcision is only restricted to physicians. Anyone who carry out a procedure should be charged with violation of the body integrity as well as child-abuse due to the current act of law. Unfortunately, most of the circumcisions are still carried out by traditional-circumciser (sometimes barbers etc) or health-staff (there was previously male clerks in the turkish health-care system who are now working as nurse). The results are not always bad. However it is illegal and some faults are extreme. Thus, we initiated The Circumcision Medicine Association in Turkey to generate some kind of attention on the issue.

 

[mestielest]

The NNT to prevent a case of penile cancer ranges from 900-300,000, with 2-600ish complications per cancer case prevented (complication rate in the US is about 1/500). The literature supports some reduction in the risk of some STDs - to be fair, incurable ones like HIV and herpes - by ~25%. I wouldn't call circumcision "morally reprehensible" by any means but I can certainly understand why somebody would think it's not worth doing. FWIW the AAFP, AAP, ACOG, and the AUA all say that the risks/benefit ratio is close enough that we should just let parents do what they feel most comfortable with and don't necessarily recommend doing it routinely.

Source: UpToDate

Completely agree: we should just let parents do what they feel most comfortable with and don't necessarily recommend doing it routinely.

 

[birchswing]

Some of these arguments are extraordinarily similar to those used by proponents of female genital cutting (which does exist in hospitals in the US performed by doctors, both in terms of XX females born with "too large" of clitoris or in the case of MDs practicing khatna in midwestern states). The 1997 federal ban of female genital cutting was just found to be unconstitutional in a case of a doctor performing female genital cutting in Michigan. That does not mean that it is legal. It means that it has the same legal protections as male circumcision at a federal level. It can still be considered battery, but the specific federal law distinguishing female genital cutting as a separate crime was found to be unconstitutional. There isn't a tenable legal framework going forward that does not involve autonomy/consent rather than sex/gender. Legal scholars have already argued that circumcision (without the individual's consent) as it exists today is already illegal under existing law regarding battery. Under current case law (after the Michigan ruling), many states without female genital cutting laws can only regulate female genital cutting under existing battery law, which is the same purview these legal scholars consider male circumcision to fall under.

 

[Hamhock]

Your co-residents were morally opposed to circumcision, but OK with abortion...? That's ****ed up.

Really?
I think "morally opposed" is poor diction. "OK with abortion" isn't much better.
That said, I am one of those people you would apparently be shocked by. I can explain if needed, but let's start with:
Why are these two procedures even linked? What do they have to do with each other?
Completely different worlds!
HH

 

[Hamhock]

it is impossible to declare that a holy text is wrong or at least a particular order of a belief should be abandoned.
.

WTF?
It's very easy to declare a holy text wrong, never mind "impossible".
Furthermore, beliefs, when shown to be wrong, are and should be abandoned all of the time.
Maintenance of a false belief is delusion.
Is earth flat?
This is elementary epistemology.
HH

 

[deleted87716]

Completely different worlds!

Indeed. I'd be interested in hearing you explain why a foreskin has more value than a human life.

 

[mestielest]

Some of these arguments are extraordinarily similar to those used by proponents of female genital cutting (which does exist in hospitals in the US performed by doctors, both in terms of XX females born with "too large" of clitoris or in the case of MDs practicing khatna in midwestern states). The 1997 federal ban of female genital cutting was just found to be unconstitutional in a case of a doctor performing female genital cutting in Michigan. That does not mean that it is legal. It means that it has the same legal protections as male circumcision at a federal level. It can still be considered battery, but the specific federal law distinguishing female genital cutting as a separate crime was found to be unconstitutional. There isn't a tenable legal framework going forward that does not involve autonomy/consent rather than sex/gender. Legal scholars have already argued that circumcision (without the individual's consent) as it exists today is already illegal under existing law regarding battery. Under current case law (after the Michigan ruling), many states without female genital cutting laws can only regulate female genital cutting under existing battery law, which is the same purview these legal scholars consider male circumcision to fall under.

First, I want to say again that I am against circumcision in babies. It should be carried out in adults or late adolescents that can understand the pros and cons of the procedure. On the other hand the dilemma of such an approach is prohibiting the performance a religious ritual. Freedom of belief is also guarented by the constitutions. So, freedom of belief and medical ethics clash at this point.

 

[deleted87716]

First, I want to say again that I am against circumcision in babies. It should be carried out in adults or late adolescents that can understand the pros and cons of the procedure.

Parents can consent to a child's medical treatment until adulthood (typically 18 years old), including sex-reassignment surgery in some cases. Why is circumcision any different?

 

[SLC]

First, I want to say again that I am against circumcision in babies. It should be carried out in adults or late adolescents that can understand the pros and cons of the procedure. On the other hand the dilemma of such an approach is prohibiting the performance a religious ritual. Freedom of belief is also guarented by the constitutions. So, freedom of belief and medical ethics clash at this point.

Less complications when done in neonatal stage.

 

[Hamhock]

Parents can consent to a child's medical treatment until adulthood (typically 18 years old), including sex-reassignment surgery in some cases. Why is circumcision any different?

Sex assignment surgery is -- to the best of my knowledge -- never considered prior to the ability to communicate one's wishes.

Circumcision, as most commonly practiced in the US, is completely different. I am surprised this distinction requires clarification.

HH

 

[deleted87716]

Sex assignment surgery is -- to the best of my knowledge -- never considered prior to the ability to communicate one's wishes.

Where have you been...? Sex-change treatment for kids on the rise

 

[Hamhock]

Indeed. I'd be interested in hearing you explain why a foreskin has more value than a human life.

I never said foreskin was more important than a human life. I wouldn't say that. Please avoid using straw man rhetoric. Such technique is used by reactionaries or those who are not interested in dialogue seeking common ground or truth.

However, I will continue, as that this type of response has become so common in our American discourse, that I suspect your response was just a "mental reflex", analogous to the patellar reflex.

In response, I would again start with the underlying problem with this connection: there is none. I am unable to find a connection or reason to contrast/compare circumcision with abortion. Once this is understood, I think it is clear that one's views regarding abortion and circumcision also unrelated.

HH

 

[deleted87716]

I never said foreskin was more important than a human life. I wouldn't say that. Please avoid using straw man rhetoric. Such technique is used by reactionaries or those who are not interested in dialogue seeking common ground or truth.

Bull****. You've alluded to the fact that you think abortion is fine, but circumcision is wrong, but you've failed to explain your reasoning. I'm still waiting.

Of note, I never tried to connect the two. That was somebody else. But, since you chimed in...

 

[Hamhock]

Where have you been...? Sex-change treatment for kids on the rise

You still haven't explained how circs are any different.

I have been typing in response to the other discussion. I can't seem to respond quickly enough with two discussions going on.

Regarding the link you provided for this discussion, I find no mention of "sex-change" treatments for any child who is unable to communicate her wishes.

Yes, there was some cheap shock journalism used that mentions a parent's recollection of what an 18mo child said. This is, of course, was not the reason for any "sex-change" operation. Please.

Also, the circumcisions were are talking about here are performed on infants, who can't say even one word, never mind complete sentences.

HH

 

[deleted87716]

Regarding the link you provided for this discussion, I find no mention of "sex-change" treatments for any child who is unable to communicate her wishes.

Who said anything about "communicating their wishes" (aside from you)? The legal basis for circumcision (and every other medical treatment in children) has to do with the age of consent.

Yes, there was some cheap shock journalism used that mentions a parent's recollection of what an 18mo child said. This is, of course, was not the reason for any "sex-change" operation. Please.

"...cheap shock journalism..." Dude, it's ****ing CBS News!

 

[Hamhock]

Bull****. You've alluded to the fact that you think abortion is fine, but circumcision is wrong, but you've failed to explain your reasoning. I'm still waiting.

Of note, I never tried to connect the two. That was somebody else. But, since you chimed in...

Wow, I must learn to type faster. I can't keep up with this post rate.

I have indeed alluded to the fact "that I think abortion is fine" (not the words I would choose; but the concept is one I have alluded to). To jump from "abortion" to the "value of human life", even for the most ardent fundamentalist, is not acceptable. That is what generated my response.

I will again state that one's views of circumcision and abortion are in now way connected. Agreed? Once you agree to that, I think it is easy to see why anyone could be:

(excuse the terms; they are only used for efficiency)
pro-abortion/pro-circ
pro-abortion/anti-circ
anti-abortion/pro-circ
anti-abortion/anti-circ

You must be able to see why anyone could fit in any of those categories right? And, that is why it is not "*****ed up."

That's ****ed up.

 

[deleted87716]

To jump from "abortion" to the "value of human life", even for the most ardent fundamentalist, is not acceptable.

Huh...? If you aren't aborting a human life, what exactly are you aborting...?

I'm less interested in "categorizing" people or ideas than I am in people being able to logically and rationally explain their reasoning for believing or doing something.

 

[Hamhock]

Who said anything about "communicating their wishes" (aside from you)? The legal basis for circumcision (and every other medical treatment in children) has to do with the age of consent.



"...cheap shock journalism..." Dude, it's ****ing CBS News!

Yes, I am the one who mentioned communicating one's wishes. I said this in response to the posters, including you (see quote below) who implied they didn't see a difference between circumcision and "sex-change" surgery. The most obvious difference (and there are more) is that sex-change procedures are (occasionally) pursued in children who can communicate. The majority of circumcisions (that we are discussing here) are not performed on children who can communicate wishes. You asked for a distinction and I provided it; that's all.

Parents can consent to a child's medical treatment until adulthood (typically 18 years old), including sex-reassignment surgery in some cases. Why is circumcision any different?

HH

 

[Hamhock]

Huh...? If you aren't aborting a human life, what exactly are you aborting...?

I'm less interested in "categorizing" people or ideas than I am in people being able to logically and rationally explain their reasoning for believing or doing something.

Must respond to a trauma code. This answer takes a bit of time and I have already shown that I can't respond quickly enough.

To be continued...
HH

 

[mestielest]

Parents can consent to a child's medical treatment until adulthood (typically 18 years old), including sex-reassignment surgery in some cases. Why is circumcision any different?

The answer is simple. Because it is not a treatment in most of the cases. It is either a religious ritual (it is arguably whether a family holds right to make a change in their babies body that will sustain lifelong due to their belief or not), traditional procedure, or a preventive intervention with low NNT. Sex-reassignment surgery depends on comprehensive evaluations with shared decisions. It is completely different.

 

[deleted87716]

The answer is simple. Because it [circumcision] is not a treatment in most of the cases.

Your definition. Not the legal definition.

Sex-reassignment surgery depends on comprehensive evaluations with shared decisions

Again, your definition, not the legal definition. Sex-reassignment surgery can legally be performed without the patient's (child's) consent due to parental consent laws.

 

[mestielest]

My experience is different. I always favor performing circumcision on school-kids. I carry out circumcision while they are playing PES and talking with me. I can also avaid the obsessive parents who are always asking why the head of the penis is still purple or why they go inside the skin everytime.

 

[mestielest]

Your definition. Not the legal definition.

It can be. However, it is clear that in neonatal circumcision we remove some part of penile tissue from babies who have no symptoms.

 

[mestielest]

Must respond to a trauma code. This answer takes a bit of time and I have already shown that I can't respond quickly enough.

To be continued...
HH

Have a nice code

 

[deleted87716]

It can be. However, it is clear that in neonatal circumcision we remove some part of penile tissue from babies who have no symptoms.

"No symptoms" isn't relevant. PARENTAL CONSENT.

 

[deleted87716]

My experience is different. I always favor performing circumcision on school-kids. I carry out circumcision while they are playing PES and talking with me. I can also avaid the obsessive parents who are always asking why the head of the penis is still purple or why they go inside the skin everytime.

 

[mestielest]

"No symptoms" isn't relevant. PARENTAL CONSENT.

So this is the main difference between sex-reassignment.

In children who are candidates for sex-reassignment surgery we can declare a pathology. In newborn who are consented by their parents to circumcision, mostly we cannot.

 

[deleted87716]

So this is the main difference between sex-reassignment.

In children who are candidates for sex-reassignment surgery we can declare a pathology. In newborn who are consented by their parents to circumcision, mostly we cannot.

Again..."pathology" isn't relevant. PARENTAL CONSENT.

 

[mestielest]

It's very funny to perform a circumcision in a 10 years old boy who comes to the clinic well informed by his parents. He accepts the local anesthesia well and also checks whether it is ok himself. Then, he responds to my questions on pain-check and then play with his iPhone during the procedure.

 

[mestielest]

Again..."pathology" isn't relevant. PARENTAL CONSENT.

So what should be our response to parents who give an informed consent to remove the ear-lobe of their baby?

 

[deleted87716]

So what should be our response to parents who give an informed consent to remove the ear-lobe of their baby?

My first question would be, "Why?"

 

[mestielest]

Your definition. Not the legal definition.



Again, your definition, not the legal definition. Sex-reassignment surgery can legally be performed without the patient's (child's) consent due to parental consent laws.

You can carry out sex-reassignmet only after documenting some medical situations. I don't now the law in the US but in Turkey you also need a shared decision of pediatric endocrinologist, genetics, pediatric surgeon, pediatric urologist etc. You cannot perform a sex-reassignment in a healthy kid due to parents' consent.

 

[mestielest]

My first question would be, "Why?"

Because they believe that it is an order from the supreme being. Why not?

 

[deleted87716]

You can carry out sex-reassignmet only after documenting some medical situations. I don't now the situation in the US bur in TUrkey you also need a shared decision of pediatric endocrinologist, genetics, pediatric surgeon, pediatric urologist etc. You cannot perform a sex-reassignment in a healthy kid due to parents' consent.

I have no interest in discussing legality outside the US.

 

[deleted87716]

Because they believe that it is an order from the supreme being. Why not?

SRSLY...? Can you provide a link, or did you just pull that out of your...er, ear?