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Should OB/GYNs Perform Male Circumcision?

YES Lee P. Shulman, MD   Male circumcision remains highly controversial among those who do not consider it a religious matter. Much of this discussion involves whether the procedure has health benefits for men, and whether any such benefit justifies the small risk of complications. Studies suggest that male circumcision is associated with a decreased risk for sexually transmitted infections, including human immunodeficiency virus and cervical cancer.1,2 However, the question here is not whether circumcision should be performed, but rather who should perform it. Among observant Jews, male circumcision is performed by mohelim. These individuals may be physicians trained in circumcision who receive ritual instruction, or trained lay people. Currently, however, the vast majority of circumcisions are performed for nonreligious reasons, and are thus carried out by physicians. I am a mohel. I was trained in male circumcision as a resident, and subsequently received ritual instruction. Accordingly, I believe that OB/GYNs should perform circumcision—for the present, at least. Their specialty alone provides training for its residents to perform this procedure and manage its complications. I do not believe that OB/GYNs are necessarily better equipped to perform circumcision than pediatricians, urologists, or other clinicians. Indeed, in my experience the best practitioners of this procedure are the lay mohelim. However, where religion is not a consideration, it is important for women and families to have easy access to medical professionals who know the risks and benefits of circumcision and have the clinical skills. In actuality, I find many of the arguments about which specialty is best (or worst) suited to perform circumcision to be ridiculous—eg, pediatricians and general practitioners have few surgical skills; OB/GYNs donÍt take care of newborns; urologists usually perform adult circumcisions. As most successful mohelim are trained rabbis with no medical background, such contentions are absurd. Physicians need to determine which specialties are ready to take on male circumcision and the related family counseling, and include appropriate instruction in their training. Although serious risks of male circumcision are uncommon, all physicians can contact a specialist for assistance. Indeed, all of the prospective specialties have the requisite expertise. Obstetrician/gynecologists should continue to offer male circumcision because they have been trained to do so. However, I see no reason why pediatricians and other specialists could not incorporate similar training into their residency programs. The goal is to provide more trained, experienced professionals for families who seek this service and optimal care for the male newborns who undergo circumcision. Lee P. Shulman, MD, is professor, Department of Obstetrics and Gynecology, and head, Section of Reproductive Genetics, Feinberg School of Medicine, Northwestern University, Chicago, IL. References Drain PK, Halperin DT, Hughes JP, Klausner Bailey RC. Male circumcision, religion, and infectious diseases: an ecologic analysis of 118 developing countries. BMC Infect Dis. 2006;6:172. Drain PK, Smith JS, Hughes JP, Halperin DT, Holmes K. Correlates of national HIV seroprevalence: an ecologic analysis of 122 developing countries. J Acquir Immune Defic Syndr. 2004;35(4):407-420.

NO Timothy R.B. Johnson, MD   As a resident in the 1970s, I well remember facing the nursery line-up of newborns in plastic restraining devices after a full night on call. I would perform 10 to 15 circumcisions under the watchful eyes of a stern, starched head nurse; it was part of the job and a rite of passage. I learned this procedure as a fourth-year medical student, where pediatricians had responsibility for circumcisions and ñtaughtî use of the Gomco clamp with a safety-pin modification. Without any further direct resident training, this was just another of those ñsee-do-teachî procedures. Obstetrician/gynecologists are the default providers of routine newborn male circumcision by virtue of skill, availability, and proximity. Now, however, it is time for OB/GYNs to stop this practice. We are trained to provide health care for women; care of newborn/pediatric patients is not within our purview unless they require gynecologic consultation. Just as the title of this journal is The Female Patient, male patients have no place in our practice. Training, competency, continuing education, and best-practice standards are important requisites for any procedure. Although circumcision is a relatively simple procedure with few complications, keeping current with advances (eg, new analgesics) can be a challenge. More importantly, providing adequate informed consent to patients is also a requirement—one that cannot be fulfilled reliably by OB/GYNs and busy residents. The only valid reason for OB/GYNs to continue performing circumcision is the financial benefit.1 Considering the time/reimbursement ratio, though, it is hardly worth the effort. The idea that attending physicians can simply look over a shoulder during ñkey portions of the procedureî or that it can be passed off to junior residents with minimal training is no longer tenable. More attention must be given to both the training process and the quality of care. In the United States and most of the developed world there is little justification for routine newborn circumcision. Indeed, ACOG supports the current position of the American Academy of Pediatrics: ñExisting scientific evidence demonstrates potential medical benefits of newborn male circumcision; however, these data are not sufficient to recommend routine neonatal circumcision.î2 The potential role of circumcision domestically and globally in the prevention of human immunodeficiency virus transmission is a new consideration, but minimally relevant to a discussion of who should perform it.3 This procedure is best left to those who care for newborns (pediatricians, pediatric surgeons, pediatric urologists), and/or those who provide comprehensive care (family physicians). The OB/GYN should no longer act as the default provider of newborn male circumcision. Timothy R.B. Johnson, MD, is Bates professor and chair, Department of Obstetrics and Gynecology, University of Michigan Medical School, Ann Arbor; and Arthur F. Thurnau professor, professor of WomenÍs Studies, and research professor in the Center for Human Growth and Development, University of Michigan, Ann Arbor. References Johnson TR, Pituch K, Brackbill EL, Wan J, van de Ven C, Pearlman MD. Why and how a department of obstetrics and gynecology stopped doing routine newborn male circumcision. Obstet Gynecol. 2007;109(3):750-752. American College of Obstetricians and Gynecologists. Committee on Obstetric Practice. Committee on Obstetric Practice.ACOG Committee Opinion. Circumcision. Number 260, October 2001. Obstet Gynecol. 2001;98(4): 707-708. Gray RH, Kigozi G, Serwadda D, et al. Male circumcision for HIV prevention in men in Rakai, Uganda: a randomised trial. Lancet 2007;369(9562):657-666.