Circumcision Patient Consent Form

Pediatric Services
Informed Consent for Surgical Procedure

Form 4a · Rev. 1.2
To be completed before procedure

Consent for Circumcision

Newborn Male: Non-Therapeutic / Elective Procedure

Patient

Date of birth

Age

Date

1. Procedure to be performed

Circumcision: surgical excision of the prepuce (foreskin), the tissue covering the glans of the penis.

2. Indication for procedure

No medical condition requiring surgical intervention has been diagnosed in this patient. This procedure is being requested on an elective, non-therapeutic basis.

3. Risks and potential complications

As with any surgical procedure, risks include but are not limited to:

Bleeding
Infection
Pain
Scarring or unsatisfactory cosmetic appearance
Removal of too little skin (may require a second procedure) or too much skin (may result in painful erections)
Adhesions between the remaining skin and the glans, sometimes requiring later correction
Meatal stenosis (narrowing of the urinary opening): occurs in studies that specifically screen for it at rates meaningfully above the baseline rate in boys who are not circumcised
Injury to the glans or urethra (rare, but reported)
Anesthetic or analgesic complications, where sedation or local anesthetic is used
In rare cases, complications requiring hospitalization, blood transfusion, or further surgery
In extremely rare cases, death has been reported in association with this procedure

The overall complication rate across large pooled studies of elective circumcision is approximately 3.3%. Meatal stenosis is not included in that figure: studies designed specifically to detect it find it in a substantial minority of circumcised boys, and it is very uncommon in boys who are not circumcised.

Parent/guardian has reviewed the risks above

4. Expected downsides of a successful procedure

Section 3 describes outcomes that may or may not occur. The outcomes below are not complications: they occur in every case where the procedure is completed as intended, and are not a sign anything went wrong.

Permanent removal of the prepuce, including the ridged band, a band of tissue at the junction of its outer and inner surfaces with a high concentration of nerve endings specialized for light touch. This tissue cannot be regrown or replaced.
Permanent loss of the gliding action the prepuce provided against the shaft during erection and intercourse.
Permanent exposure of the glans. No longer covered, it gradually keratinizes (thickens and toughens) rather than remaining a protected, moist surface.
A visible surgical scar at the site of removal.

Parent/guardian understands these outcomes are certain, not risks

5. Expected benefits

Expected benefits before he could have a say

Circumcision is associated with a reduction in the incidence of urinary tract infection in infancy, from approximately 1% to approximately 0.1%, on the order of 111 procedures performed for each infection prevented.

Expected benefits arriving later in life, after he could have had a say

Note: Circumcision has NOT been shown to provide statistically significant protection against HIV or other sexually transmitted infections in the largest cohort studies conducted in countries comparable to this patient's, including national cohorts of over 800,000 men in Denmark and over 550,000 men in Ontario, Canada.

Circumcision is associated with a reduced lifetime risk of penile cancer, a rare cancer with a median age at diagnosis of age 68.

A circumcised penis requires marginally less time to wash, saving on the order of a few seconds per shower.

6. Alternatives, including non-treatment

The alternative to this procedure is to not perform it. The foreskin separates from the glans naturally over a period of months to years in almost all boys and requires no specific care beyond routine external washing during this time. No treatment is required for this natural process, and it is not evidence of a medical problem.

This procedure remains available to the patient at any later date in his life, should he choose it, with his own informed consent. No later procedure can restore tissue removed at this stage.

7. Consent of the patient

The patient is a newborn and is not capable of providing or withholding consent. No proxy measure fully substitutes for his own informed decision.

The best available indication of the preference he might express, if he could: in populations where the decision is left to the individual rather than made in infancy, it is overwhelmingly declined.

8. Financial interest disclosure

This procedure is billable separately from the birth admission under its own procedure code. The physician who recommends this procedure is frequently the same physician who performs it and is compensated for doing so.

9. Acknowledgment

I have read and understand the information above, including the risks, downsides, benefits, and alternatives described in Sections 3 through 8. I have had the opportunity to ask questions, and my questions, if any, have been answered to my satisfaction. I understand this procedure is elective, is not medically necessary for this patient, and cannot be undone. I am consenting on behalf of a person who has not been, and cannot be, consulted. I understand that, statistically, he would be unlikely to choose this for himself if left intact. I understand that no national or international pediatric or medical association — including the American Academy of Pediatrics, the Canadian Paediatric Society, the Royal Dutch Medical Association, the British Medical Association, and the Royal Australasian College of Physicians — recommends this procedure be performed routinely on newborn males in the absence of a diagnosed medical condition.

Parent / Legal Guardian Signature

Date

Physician Signature

Date

Patient Signature (not obtainable; patient is a newborn)

Date

Form 4a (composite, for illustration only)Not a record of an actual encounter