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.

To circ or not to circ

Jennifer asked about the medical evidence for and against circumcision: “A family doctor friend said there is new evidence (based on studies in S. Africa and New Zealand) suggesting that circumcisions for boys can reduce chances for HIV by 50%, and that uncircumcised men had 3x the incidence of STDs between the ages of 18-25. He said there is also strong evidence that circumcising males lowers the risk for UTIs, genital ulcer disease, penile cancer and HPV. Has the medical community changed their minds recently on recommending circumcisions as a preventative measure based on recent (limited) evidence?”

The current recommendation of the American Academy of Pediatrics (AAP) is that there is not sufficient evidence to support routine circumcisions on all baby boys. They acknowledge that cultural and religious factors are important and should be considered when making recommendations to parents. In other words, while the AAP agrees that there are medical benefits to circumcision, these don’t clearly outweigh the risks of the procedure. In the opinion of the AAP, it’s not a slam-dunk to circumcise.