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2013 JOURNAL OF UNIVERSAL SURGERY
Vol. 2 No. 1:2 doi: 10.3823/808
Our Site: http://www.imedpub.com/
Parental attitudes and practices about circumcision in Izmir, Turkey
Feyza Koc, MD1 , Sadik Aksit, Professor1 , Gokhan Koc, MD2, Oya Halicioglu, MD3, Yuksel Yilmaz, Associate professor 2 , Ozgur Cakmak, MD2, Huseyin Tarhan, MD2
1 Ege University Medical School, Department of Social Pediatrics, Izmir, Turkey 2 The Ministry of Health Tepecik Teaching and Research Hospital, Department of Urology, Izmir, Turkey 3 The Ministry of Health Tepecik Teaching and Research Hospital, Departments of Pediatrics, Izmir, Turkey Correspondence:
Gokhan Koc, M.D. The Ministry of Health Tepecik Teaching and Research Hospital, Department of Urology, Izmir, Turkey Tel: +90-232-4696969/1315
Parental attitudes and practices about circumcision in Izmir, Turkey
Background: The current study was carried out to investigate parental attitudes
and practices about circumcision in Izmir, Turkey.
Methods and Findings: This study was performed in two training hospitals
in Izmir. Questionnaires were filled out in face-to-face interviews with parents of 624 boys while waiting for their child’s well-child examination. Circumcision was generally performed by physicians (63.5%), in hospital conditions (52%), and primarily due to religious reasons (50.4%). We observed a statistically significant association between age of circumcision and educational status of both parents (p<0.05). Likewise, as the education level of both parents increased, the rate of circumcision performed by physicians also increased (p<0.05).
Conclusions: The traditional approach seems to be continued and circumcision
is often performed due to religious reasons in Turkey. So, the parents should be informed about the benefits and risks of circumcision and the importance of psychological influences when circumcised at older ages.
This article is available from: www.jusurgery.com
Key Words: Circumcision, Children, Parental attitudes,
Circumcision is the surgical removal of some or the entire foreskin of the penis. Circumcision is an ancient surgical procedure with a history of 15000 years.  One of every three men in the world is presumed to be circumcised.  Many studies in the literature showed that circumcision can protect from sexually transmitted diseases such as human immunodeficiency virus (HIV), syphilis, chlamydia, genital ulcer disease (GUD), herpes simplex virus (HSV), trichomonas © Copyright iMedPub
vaginalis and human papilloma virus (HPV), as well as diseases such as penile cancer and cervical cancer. [3-11] Because there are reports stating that neonatal circumcision decreases the incidence of urinary tract infections, circumcision in the neonatal period has gained importance in recent years.  Although neonatal circumcision is not recommended as a routine practice by the American Academy of Pediatrics, its medical benefits are clearly highlighted.  However, some minor and major complications can be seen in the neonatal circumcision. [14-17]
As the educational level of the mothers and fathers increased. Inform consent was obtained from all parents. Sev- 2 © Copyright iMedPub . General characteristics of the children and their families are seen in Table 1. Descriptive statistics for the socio-demographic data and chi-square test for the statistical differences were used. Even though clear information could not be obtained about the Results The study was conducted with 624 families. 40% of the children were circumcised after 6 years of age.1) 88 (14.9) 168 (26. so almost all of the Turkish men have been circumcised. by whom.9% of the mothers and 1% of the fathers were illiterate. The parents who had at least one male child were included in the study. Most of the families are from middle socio-economical class.4%). while 4 of them by other medical staff or traditional practitioner. 12 patients (5. Although the most common cause of circumcision was reported as religious. where and why it is to be performed. n (%) Economic status of family High Middle Low Mothers’ education No education Primary school Secondary school High school University Fathers’ education No education Primary school Secondary school High school University 6 (1. medical benefit was the primary reason. As the education level of both parents increased. 2 No. The parents who have an uncircumcised boy were excluded from the study. between January 2010 and August 2010. 1:2 doi: 10. Data related with the rate and type of medical complications could not be obtained clearly.8) 202 (32.2) 46 (7. in hospital conditions (52%).4) Methods This study was carried out in two major training hospitals. ( Table 4). while 72. because relevant information was collected from families instead of medical records of the patients.iMedPub Journals 2013 JOURNAL OF UNIVERSAL SURGERY Vol.1%) were intervened. All of the children from high economic status were circumcised in hospitals. however.0 was used for statistical analysis. and primarily due to religious reasons (50. This study was done in accordance with the principles of the Declaration of Helsinki 2008.7% of them believed the same for penile cancer. When educational status of the parents was considered. Most of the people are Muslim in Turkey.1%) patients.0) 138 (22. for the families with high economic status. We observed a statistically significant association between age of circumcision and educational status of both parents (p<0. Family incomes below this sum were defined as a low-income family. Some features of circumcision and influence of some socio-demographic characteristic on the age of circumcision are shown in Table 2 and 3. Circumcision was generally performed by physicians (63. the rate of circumcision performed in hospitals also increased (p<0. Families were questioned about their most important reason for performing circumcision and asked to indicate just one single reason. was defined as middle income. Monthly income. Questionnaires were filled out in face-to-face interviews with parents of 624 boys (1 month to 12 years old) while waiting for their child’s well-child examination.05). as regards to when. we aimed to survey parental attitudes and current circumcision practices in Turkey. A P value of <0.5%). Table 1.05). however. in Izmir.6) 18 (2. While only 7% of children were circumcised in the first moth of life.imedpub.05). In the present study.3823/808 Our Site: http://www.4) 34 (5. Median age of circumcision was 5 years (1 month to 12 years old). 2. The subsistence wage according to national poverty criteria is currently 430 $ equivalent Turkish Liras. Regarding late intervention.9) 56 (9. Economic status of the family was classified based on monthly income. The income above this level was defined as high income SPSS version 16. the higher the age of children at circumcision.com/ Circumcision is a common practice among Jewish and Muslims in the world. enty-seven percent of the parents believed that circumcision could protect children from sexually transmitted diseases. which is the third largest city of Turkey.1) 170 (27. there was no statistically significant difference between groups (P>0. the rate of circumcision performed by physicians also increased (p<0.4) 544 (87.0) 180 (28.2) 222 (35.05 was considered statistically significant. General characteristics of the children and the ir families. In general.05). Early intervention due to hemorrhage after circumcision was reported in 5 (2. which was between the subsistence wages and up to three-fold of the subsistence wage. the lower the education level of parents. One of these 5 patients was circumcised by a physician.
iMedPub Journals 2013 JOURNAL OF UNIVERSAL SURGERY Vol.4 16.2 < 0.8 13.7 11.5 45.1 6.4 0 36.3) 155 (24.com/ Table 2.0 43.7 6.6 30. 2 No.5) 159 (25.05 5.9 12.3 9.05 9.8 9.6) 68 (10.5) 324 (52.05 2-6 m 7 m-3 y 4 -6 y >6 y P value © Copyright iMedPub 3 .2 18.5 2.2 6.1) 53 (8.9 14.3 42.7 68.6 18.3 36.7 18.0 35.4 23.0) 77 (12.3823/808 Our Site: http://www.0) 397 (63.3 14.8 >0.4 28.6 14.6 26.6 45.7 8. Age of circumcision 0-1 m Economic condition High Middle Low Mothers’ education Primary school / no education Secondary school High school University Fathers’ education Primary school / no education Secondary school High school University Values are percent.8) 97 (15.4 21.3 0 14.7 12.6) 252 (40.1 35.9) 43 (7. Characteristics Age of circumcision 0-1 m 2-6 m 7 m-3 y 4-6 y >6y Person performing circumcision Physician Other medical person Traditional practitioners Place of circumcision Hospital Outpatient clinics Other Reason for circumcision Religious Medical Traditional 314 (50.4 6.0) 63 (10.4 24.2 < 0.3 27.3 9.9 0 23.imedpub.3 0 9. 1:2 doi: 10. Influence of some socio-demographic characteristic on the age of circumcision.5 12.3 56.2 34.8 18. 9.4) 257 (41.7 0 5.3) n (%) Table 3.5 5.0) 237 (38. Some characteristics of circumcision practice.4 31.9 61.
9 20. in hospital conditions (52%). we found that circumcision was generally performed by physicians (63.3%.3 Outpatient Clinics Other Reason for circumcision Religious Medical Traditional Person performing circumcision Physician Other medical person Traditional practitioners underlying reasons.6 p=0. Circumcision is performed more common for religious reasons in Jewish and Muslim societies.0 25.  In a comprehensive retrospective study conducted with 30000 children.1 27.3 3. Circumcision is a common and simple surgical procedure.3 3. In our study.5 11.7 p<0.05 22.9 6.8 52. 2 No.  Particularly neonatal circumcision has recently become very popular in countries such as Africans and the USA.6 31.1 0 27.8 75. and very serious complications such as penile amputation may be seen.  Intraoperative complications such as hemorrhage.6 36.  In our study. Influence of some socio-demographic characteristic on where.  About 62% of newborns in the United States have already been circumcid. pain. One of every three men in the world is estimated to be circumcied.05 26.6 72.2% in the non-circumcised group. for medical reasons as in African countries.7 58.2 57. meatal ulcer.3 100 47.4%.5 31.7 55. Low incidence of neonatal circumcision might be primarily due to religious reason for the circumcision.3 100 60.2 7.7 p<0.imedpub.3 2. 67% of the families declared that they refused any surgical intervention at neonatal period.1 13.9 23.9 52.7 79.7 68.5 42.3823/808 Our Site: http://www.4 p=0.7 28. and meatal steno- 4 © Copyright iMedPub .9 30.07 0 41.7 60. wound infection.9 47.5 35.4%) in Izmir.4 18.7 39.3 36.3 18.7 11.8 25.3 0 2.7 28.3 p=0. skin bridges between penile shaft and glans penis.8 5.6 14.4 53.1 14.0 54.5%).2% in the first year of life as in the circumcised group.1 8.9 69.62 9.4 45.7 54.14 0 11. 1:2 doi: 10.8 48.5 38.5 63.9 45.4 1. The most common period of circumcision was after 6 years of age with the rate of 40. and also getting more popular worldwide.7 57.19 12.7 42. and why circumcision was performed Place of circumcision Hospital Economic condition High Middle Low Mother’s education Primary school / no education Secondary school High school University Father’s education Primary school / no education Secondary school High school University 35.0 7.iMedPub Journals 2013 JOURNAL OF UNIVERSAL SURGERY Vol.2 86.7 9. Local anesthesia was used in all of the circumcision practices performed outside the hospital.0 5. the rate of circumcision in the first six months of life was 19. Religious reasons were identified as the most frequent cause of circumcision in 50% of cases.22 8. insufficient resection.9 18.5 p<0.4 57. by whom.4 9.9 0 10.com/ Table 4.05 62.05 Values are percent 51. and primarily due to religious reasons (50.4 13.6 p=0.0 37.6 12. Discussion In the present study.3 32.6 43. Postoperative complications like pain.4 9.1 54.0 41.9 12.8 37.3 73. American Academy of Pediatrics reported that urinary tract infections were ten folds reduced by neonatal circumcisn. Turkey. occasionally leading to complications with different rates of 1% to %.2 45.4 51. the most frequent cause leading to late interventions was identified as meatal stenosis.8 14.8 36.5 28.6 25.1 p<0. Schoen elreported reported a urinary tract infection rate of 0.3 p=0. because of its benefits on the decrease both in the frequency of urinary tract infections throughout the first year of life and the transmission of HIV among heterosexual n.4 45. but that of 2.
The place that the circumcision is performed is also important in terms of complications. according to the general surgical principles. Yet.4% by other physicians. median age of circumcision was found to be 6 years. In our study. under sterile conditions. the necessity of anesthesia or analgesia during the procedure and the importance of psychological influences of circumcision at lder ages.imedpub. Therefore. 2 No.  In our study. Our study has some limitations as the study population may not fully represent the whole Turkish population. and 10. In a previous study carried out by Sahiet al  in Turkey about 10 years ago. where and why circumcision should be performed is noted as important factors. while 30% of significant bleeding was reported in the second group. at which period of lifecycle.  reported a complication rate of 73%. being important factors reducing complications. 38% were done in other places. there was a prejudice against neonatal circumcision in all family groups. 1:2 doi: 10.6% by other medical staff. but higher education level of the parents has generally got a tendency to the earlier ages for circumcision.iMedPub Journals 2013 JOURNAL OF UNIVERSAL SURGERY Vol. Neonatal circumcision may lead to relatively less complications. it seems that we should encourage families to have their children have circumcised in hospitals. Our study indicated that nothing changed after 10 years and educational levels did not seem to affect the traditional approach to circumcision in Turkey. by whom.  compared children being circumcised during the first month of life and 3-9 months of life and found no complications in the group circumcised in the first month of life. The rate of complications after circumcisions by medical staff has been reported as 0-12%. In a retrospective study of 407 children being circumcised under non-sterile conditions other than hospitals. No conflict of interest and no financial support or relationships. Therefore.9% by traditional circumcisers. 22% by urologists and 2. The main reasons for circumcision were religious and traditional. Age of circumcision might be another factor affecting frequency of complications. while performed by non-medical staff it is up to 63%.5%. the parents should be fully informed about the benefits and risks of circumcision when performed at certain ages. However. [14-17] From this point of view. So.com/ sis may also occur. our results indicate that even in the Izmir. Only 15% of children were circumcised before 1 year of age. Moreover.6% of circumcisions were performed by pediatric surgeons. we observed that 52% of cases were circumcised in hospitals. even leading to more serious complicatis. 25.3823/808 Our Site: http://www. even if performed by physicians or other experienced medical staff. 75. the third largest city of Turkey. 63. Circumcision in the neonatal period usually does not need sutures and recovery occurs faster in this period. none of the parents of uncircumcised boys reported that they would not have their children circumcised. © Copyright iMedPub 5 . Economic status of the family does not significantly influence decisions about circumcision.5% of cases were circumcised by physicians. the traditional approach is common. Horowitz eal. and a hospitalization rate of 1. Atikeler eal. Among physicians. it is highly important to perform circumcision in hospitals.
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