The New York Times
August 27, 2012
Benefits of Circumcision Are Said to Outweigh Risks
The American Academy of Pediatrics has shifted its stance on infant male circumcision, announcing on Monday that new research, including studies in Africa suggesting that the procedure may protect heterosexual men against H.I.V., indicated that the health benefits outweighed the risks.
But the academy stopped short of recommending routine circumcision for all baby boys, saying the decision remains a family matter. The academy had previously taken a neutral position on circumcision.
The new policy statement, the first update of the academy’s circumcision policy in over a decade, appears in the Aug. 27 issue of the journal Pediatrics. The group’s guidelines greatly influence pediatric care and decisions about coverage by insurers; in the new statement, the academy also said that circumcision should be covered by insurance.
The long-delayed policy update comes as sentiment against circumcision 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. Critics succeeded last year in placing a circumcision ban on the ballot in San Francisco, but a judge ruled against including the measure.
In Europe, a government ethics committee in Germany last week overruled a court decision that removing a child’s foreskin was “grievous bodily harm” and therefore illegal. The country’s Professional Association of Pediatricians called the ethics committee ruling “a scandal.”
A provincial official in Austria has told state-run hospitals in the region to stop performing circumcisions, and the Danish authorities have commissioned a report to investigate whether medical doctors are present during religious circumcision rituals as required.
Officials with the Centers for Disease Control and Prevention in Atlanta, which for several years have been pondering circumcision recommendations of their own, have yet to weigh in and declined to comment on the academy’s new stance. Medicaid programs in several states have stopped paying for the routine circumcision of infants.
“We’re not pushing everybody to circumcise their babies,” Dr. Douglas S. Diekema, a member of the academy’s task force on circumcision and an author of the new policy, said in an interview. “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.’ ”
But opponents of circumcision say no one — not even a well-meaning parent — has the right to make the decision to remove a healthy body part from another person.
“The bottom line is it’s unethical,” said Georganne Chapin, founding director of Intact America, a national group that advocates against circumcision. “A normal foreskin on a normal baby boy is no more threatening than the hymen or labia on your daughter.”
In updating its 1999 policy, the academy’s task force reviewed the medical literature on benefits and harms of the surgery. It was a protracted analysis that began in 2007, and the result is a 30-page report, which includes seven pages of references, including 248 citations.
Among those are 14 studies that provide what the experts characterize as “fair” evidence that circumcision in adulthood protects men from H.I.V. transmission from a female partner, cutting infection rates by 40 to 60 percent. Three of the studies were large randomized controlled trials of the kind considered the gold standard in medicine, but they were carried out in Africa, where H.I.V. — the virus the causes AIDS — is spread primarily among heterosexuals.
Circumcision does not appear to reduce H.I.V. transmission among men who have sex with men, Dr. Diekema said. “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.
Two studies have found that circumcision actually increases the risk of H.I.V. infection among sexually active men and women, the academy noted.
Other studies have linked male circumcision to lower rates of infection with human papillomavirus and herpes simplex Type 2. But male circumcision is not associated with lower rates of gonorrhea or chlamydia, and evidence for protection against syphilis is weak, the review said.
The procedure has long been recognized to lower urinary tract infections early in life and reduce the incidence of penile cancer.
Although newborn male circumcision is generally believed to be relatively safe, deaths are not unheard of, and the review noted that “the true incidence of complications after newborn circumcision is unknown.”
Significant complications are believed to occur in approximately one in 500 procedures. Botched operations can result in damage or even amputation of parts of the penis, and by one estimate about 117 boys die each year.
Anesthesia is often not used, and the task force recommended that pain relief, including penile nerve blocks, be used regularly, a change that may raise the rate of complications.