Circumcision, revisited

The Pediatric Insider

© 2012 Roy Benaroch, MD

It’s been about four years since I last wrote about circumcision on the blog here, a post that led to quite a contentious series of responses. Though I had to block some of the most hateful comments, most of the people who responded were quite thoughtful and gave reasoned and passionate arguments from both sides.

What I said, basically, was that there are modest, genuine medical benefits of circumcision, and that it carries little serious risk. I encouraged health care providers to offer honest advice about the pros and cons of the procedure, letting parents make the final decision on circumcision.

This month, the AmericanAcademy of Pediatrics updated their 1999 recommendations on circumcision, stating that the evidence shows that newborn circumcision’s benefits outweigh the risks. Furthermore, access should be available for this procedure for families who choose it. They did not specifically endorse or state that circumcision should be performed on newborn boys.

The complete text of the Circumcision Policy Statement is here (along with links to many electronic responses), and since it’s brief I’m going to quote it in its entirety below. There is also an accompanying detailed technical report that contains about 250 references in support of the statement.

The AAP’s statement:

Systematic evaluation of English-language peer-reviewed literature from 1995 through 2010 indicates that preventive health benefits of elective circumcision of male newborns outweigh the risks of the procedure. Benefits include significant reductions in the risk of urinary tract infection in the first year of life and, subsequently, in the risk of heterosexual acquisition of HIV and the transmission of other sexually transmitted infections.

The procedure is well tolerated when performed by trained professionals under sterile conditions with appropriate pain management. Complications are infrequent; most are minor, and severe complications are rare. Male circumcision performed during the newborn period has considerably lower complication rates than when performed later in life.

Although health benefits are not great enough to recommend routine circumcision for all male newborns, the benefits of circumcision are sufficient to justify access to this procedure for families choosing it and to warrant third-party payment for circumcision of male newborns. It is important that clinicians routinely inform parents of the health benefits and risks of male newborn circumcision in an unbiased and accurate manner.

Parents ultimately should decide whether circumcision is in the best interests of their male child. They will need to weigh medical information in the context of their own religious, ethical, and cultural beliefs and practices. The medical benefits alone may not outweigh these other considerations for individual families.

Findings from the systematic evaluation are available in the accompanying technical report. The AmericanCollege of Obstetricians and Gynecologists has endorsed this statement.

Brief, factual, balanced. I welcome any reasonable replies.

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12 Comments on “Circumcision, revisited”

  1. Jessica Nye Says:

    What I’m not sure I understand about this is its ambivalence. If the health benefits of the procedure outweigh its risks, why is the AAP not outright recommending routine infant circumcision?

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  2. Dr. Roy Says:

    Jessica, this is the money quote:

    Although health benefits are not great enough to recommend routine circumcision for all male newborns, the benefits of circumcision are sufficient to justify access to this procedure for families choosing it and to warrant third-party payment for circumcision of male newborns.

    So they’re saying that there are benefits that outweigh risks, but the benefits are modest and don’t call for recommending circumcision routinely for all newborn males.

    Most of the news reports I’ve seen on this gloss over that point, and just say that the AAP has endorsed circumcision. In fact, the AAP statement is more nuanced. But nuance isn’t what most reporters are aiming for.

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  3. Elizabeth Rohan Says:

    But isn’t it true that most of the studies that support this statement were done in Africa, where HIV rates are very high and condom use is very low? So, how does this really speak us?

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  4. Elizabeth Rohan Says:

    …sorry, meant “speak to us”?

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  5. Dr. Roy Says:

    Elizabeth, most of the HIV prevention studies were done in Africa– but not all of them. And HIV is not rare in the USA– about 1.2 million Americans are infected, and 50,000 people become infected each year. If, as models predict, circumcision could reduce HIV transmission by about 16% (for all males), many parents would consider that worthwhile.

    Beyond HIV, though, there are many other STDs that can be prevented, including HPV and herpes.

    For details and references about these and other benefits, plus a well referenced review of the risks, read the technical document that accompanied the AAP recommendation: http://pediatrics.aappublications.org/content/130/3/e756.full.pdf.

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  6. Elizabeth Rohan Says:

    Thanks, Dr. Roy.

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  7. Jessica Nye Says:

    So is circumcision unique in that its benefits aren’t considered significant enough to recommend it routinely, yet they’re sufficient to warrant third party payment for the procedure? Or is it common for insurances to pay for procedures with modest enough benefits that they aren’t routinely recommended, and whether they’re performed or not is based on the patient (or parent’s) preference? Are most “elective” surgeries like this?

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  8. Dr. Roy Says:

    Jessica, there are many circumstances where procedures or treatments are elective– in fact, I would say the majority of concerns and illnesses that drive patients to my office are things that would get better anyway, without treatment, but we elect to treat anyway for comfort, convenience, reassurance, or to reduce the chance of complications (even if that chance is small). Whether insurance pays for these isn’t usually based on whether the treatment is absolutely necessary (though for some big-ticket items, insurance may indeed want some kind of reassurance on that point.)

    A somewhat-similar situation occurred for a few years with the HPV vaccine for boys. It had a “permissive” recommendation, meaning that parents may wish to choose it, and the AAP endorsed 3rd party payment even thought it wasn’t recommending it for everyone. Earlier this year, once more evidence accumulated, the AAP rec changed to a stronger genuine endorsement of HPV vaccines for boys: https://pediatricinsider.wordpress.com/2011/10/30/hpv-vaccine-for-men-a-maybe-becomes-a-yes/

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  9. Jessica Nye Says:

    Ugh, this makes me sad because I didn’t have my two boys circumcised based on my impression that it was more of a cosmetic preference and that there weren’t significant health benefits. Now my boys are 2 and 4, and I’m pretty sure at their ages the risks WOULD outweigh the benefits. I wish now that I’d had them circumcised as newborns.

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  10. mayamarkov Says:

    Jessica, as far as I know, the main alleged health benefit of circumcision for pre-pubertal males is decreasing the risk of infant urinary tract infection. Once your boys are out of infancy, I think circumcision wouldn’t have brought them any significant benefits until they become sexually active, when presumably they can opt for the procedure themselves.
    (The word “alleged” hints at my European disbelief in circumcision benefits at any age.)

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  11. Tony Says:

    The technical report doesn’t support the abstract in at least one key way. The abstract states that the benefits outweigh the risks, which is an absurd notion to present as fact. It is not fact. It’s a subjective evaluation unique to each person making the (non-therapeutic) judgement about his body based on his preferences. As the technical report notes (on page 759) with a different implication from the stupidly confident abstract, “[r]easonable people may disagree, … how the potential medical benefits and potential medical harms of circumcision should be weighed against each other.” That’s correct because the way a male values – or would have valued – the trade-offs for his normal, health foreskin may differ greatly from the way his parents value(d) the trade-offs.

    The existence of possible benefits is merely the scientific question. It answers nothing for the ethical question involved in permanently applying that science to a healthy child’s body, especially when less invasive methods for achieving the same possible benefits exist. The male must live with the circumcision. His foreskin belongs to him, and should not be surgically altered/removed for his parents’ preference(s) as long as it’s healthy. Logic requires the opposite conclusion from the one the Task Force reached.

    The abstract’s summary is also absurd because it and the technical report basically ignore the reality that losing the foreskin is itself a cost of the surgery. Even if this cost is merely aesthetic, it matters. The AAP’s omission of this guaranteed cost of the surgery by limiting its discussion to potential benefits and potential harms is indefensible.

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  12. Dale Says:

    I am a 68 year old man that was circumcised at birth with no procedural complications but has endured the psychological and physical loss caused by this irreversible amputation all my life.

    I will agree that there may be an acceptable trade-off of benefits for procedural risks for the infant boy. What I don’t agree with is no one ever thinks about the lifelong effects of altering the genitals of a child, both emotionally and the physical pleasures of the man so inflicted with this unnecessary procedure of removing healthy functional body parts.

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