DUDLEY SETH DANOFF, M.D., F.A.C.S.
The highly respected and authoritative American Academy of Pediatrics (AAP) has changed its position on infant male circumcision. Several studies in Africa suggesting that the procedure may protect heterosexual men against HIV brought the academy to conclude that the health benefits of infant circumcision outweigh the risks.
The conundrum, however, is that the academy stopped short of recommending routine circumcision for all baby boys, saying the decision remains a family matter. For decades, families made the choice based on religious, moral, and ethical principles that were, at best, ethereal. The academy had previously taken a neutral position on circumcision.
It has been more than a decade since the AAP has issued a policy statement regarding newborn circumcision. The new statement, which appears in the journal Pediatrics, is important because the group’s guidelines greatly influence pediatric care and decisions about coverage by insurers. The academy said that circumcision should be covered by insurance.
The academy’s new policy position seems to be in direct conflict with the sentiment against circumcision, which is gaining strength in the United States and parts of Europe.
Circumcision rates in the United States declined to 54.5 percent in 2009 from 62.7 percent in 1999, according to one federal estimate. Last year, a ban on circumcision was placed on the ballot in San Francisco, but a judge ruled against including the measure.
In Germany, a government ethics committee recently overruled a court decision that removing a child’s foreskin was “grievous bodily harm” and therefore illegal. However, Germany’s Professional Association of Pediatricians called the ethics committee ruling “a scandal.”
In Austria, a provincial official told state-run hospitals in the region to stop performing circumcisions.
In the United States, the Medicaid programs in several states have stopped paying for the routine circumcision of infants. Furthermore, the Centers for Disease Control and Prevention has been examining the issue for several years, but it has not yet issued a position on circumcision recommendations or comments regarding the AAP’s new policy statement.
Dr. Douglas S. Diekema, a member of the academy’s task force on circumcision and main author of the new policy, said, “This is not really pro-circumcision. It falls in the middle. It’s pro-choice, for lack of a better word. Really, what we’re saying is, ‘This ought to be a choice that’s available to parents.’”
Taking the opposite view is Georganne Chapin, founding director of Intact America, a national group that advocates against circumcision. “The bottom line is it’s unethical,” said Chapin. “A normal foreskin on a normal baby boy is no more threatening than the hymen or labia on your daughter.” Opponents of circumcision are vocal and maintain that no one—not even a well-meaning parent—has the right to decide to remove a healthy body part from another person.
The AAP updated its 1999 policy after the academy’s task force reviewed the medical literature on the benefits and possible harms of the surgery. The review began in 2007 and was completed in 2012. It included 248 citations in a 30-page report involving 14 studies that experts characterize as fair evidence that circumcision in adulthood protects men from HIV transmission from a female partner, cutting infection rates by 40 to 60 percent. The three largest studies were carried out in Africa, where HIV is spread primarily among heterosexuals.
According to Dr. Diekema, circumcision does not appear to reduce HIV transmission among men who have sex with men. “The degree of benefit, or degree of impact, in a place like the U.S. will clearly be smaller than in a place like Africa,” he said.
Conversely, two studies reviewed have found that circumcision actually increases the risk of HIV infection among sexually active men and women.
Although male circumcision is not associated with lower rates of gonorrhea or chlamydia or even syphilis, circumcision has been linked to low rates of infection with human papillomavirus and herpes simplex type 2.
One thing is certain: there is virtually no incidence of penile cancer reported in circumcised males, and the procedure has long been recognized as a factor in lowering urinary tract infections in early life.
The question of complications is always brought up, but the true incidence of complications after newborn circumcision is unknown. The procedure is relatively safe, but deaths are not unheard of, the review noted. The complication rate is about one in 500 procedures, and most complications are minor. Although rare, severe damage or even amputation of parts of the penis can occur.
The new policy statement by the AAP certainly carries considerable weight and may convince more families that newborn circumcision is advantageous, but clearly that decision remains controversial to its very core.