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婴幼儿男性包皮环切的益处据说大于风险
Benefits of Circumcision Are Said to Outweigh Risks

《纽约时报》2012-08-27 科学新闻

婴幼儿男性包皮环切的益处据说大于风险


By RONI CARYN RABIN

美国儿科学会已经转变了其在婴幼儿男性包皮环切术的立场。儿科学会周一宣布,新的研究,包括提示包皮环切术可以保护异性恋男人预防艾滋病毒的非洲研究,表明男性包皮环切对健康的益处大于风险。

但是,儿科学会突然停止了对所有男婴实施常规包皮环切的建议,说这样的决定仍然是一个家庭问题。儿科学会先前对待包皮环切采取中立的立场。

这项新的政策声明,儿科学会包皮环切政策10多年来首次更新,发表在今年8月27日出版的儿科杂志上。儿科学会的指南极大地影响了儿科护理和由保险公司支付的决定,儿科学会还在新的声明中表示,包皮环切应由保险公司支付。

这个拖延已久的政策更新正值美国和欧洲部分地区反对包皮环切的情绪正在加剧的时候。根据联邦估计,在美国的包皮环切率已由1999年的62.7%下降到2009年的54.5%。批评的声音持续到去年在旧金山选票上提出禁止包皮环切,但法官裁定不包括措施。

在欧洲,德国的政府伦理委员会上周推翻法院有关“切除孩子的包皮是‘严重的身体伤害’,因此是非法的”的裁决。德国的专业儿科医生协会称伦理委员会控制了“一个丑闻。”

奥地利的一位省级官员告诉在该地区的国营医院停止实施包皮环切术,丹麦当局已制定一份报告,以调查在宗教割礼仪式上是否按照要求有医生参加。

位于亚特兰大的美国疾病控制和预防中心的官员们,这几年一直在思考自己对包皮环切的建议,他们还在权衡中,对儿科学会的新立场拒绝发表评论。在美国有几个州的医疗补助计划已经停止支付例行的婴儿包皮环切。

“我们并没有促使大家让自己的孩子接受包皮环切,”儿科学会包皮环切专责组成员Douglas S. Diekema医生也是这项新政策的作者之一在接受采访时说。“这不是真的赞成-包皮环切。它处于中间。其实是赞成-选择,因为找不到一个更好的词。实际上,我们要说的是,‘这应该是提供给家长的一个选择。’”

但是,包皮环切的反对者们说,没有人 - 甚至没有一个善意的父母 - 有权作出决定从另一个人身上切除健康身体的一部分。

“底线是,它是不道德的,”全国性反对包皮环切的团体“完整的美国”的创建主任Georganne Chapin说,“一个正常的男婴身上的正常包皮并不比女孩的处女膜或阴唇有更大的威胁。”

在更新其1999年的政策过程中,儿科学会的专责组审查了包皮环切手术的益处与害处的医学文献。这是始于2007年的一场旷日持久的分析,其结果是一份30页的报告,其中包括占据7页纸的248条参考文献。

提供了专家们称为“公平”证据的其中14项研究表明,成年男性包皮环切能保护男性免受从女性伴侣获得性艾滋病毒感染,使感染率下降40%至60%。其中的3项研究为大规模随机对照试验,而此类研究在医学上被认为是金标准,但这些研究是在非洲完成的,那里造成艾滋病的艾滋病毒的传播主要是在异性性伴之间。

包皮环切似乎并不能减少HIV在男-男性交者之间的传播, Diekema医生说。 “包皮环切益处的程度,或其影响的程度,在像美国这样的一个地方,将明显小于在非洲这样的地方,”他说。

儿科学会注意到,有2项研究发现,包皮环切术实际上在性活跃的男性和女性中增加了艾滋病毒的感染风险。

评论说,其它研究已发现男性包皮环切与人乳头瘤病毒(HPV)和单纯疱疹病毒2型(HSV-2)的感染率较低相关。但是,男性包皮环切与较低的淋病或衣原体发病率无关,预防梅毒的证据也很弱。

包皮环切一直被认为能降低生命早期的婴幼儿尿路感染,也降低阴茎癌的发病率。

虽然一般认为新生儿男性包皮环切术相对安全,但是死亡并非前所未闻,评论指出,“真正的新生儿包皮环切术的术后并发症的发生率还不清楚。”

据认为,大约每500例手术会发生1例明显的并发症。拙劣的手术操作可能会导致损伤,甚至阴茎的部分切断,估计每年大约有117个男孩死亡。

通常不使用麻醉,专责小组建议常规使用包括阴茎神经阻滞麻醉来缓解手术疼痛,但是这个变化可能会升高并发症的发生率。□

http://www.nytimes.com/2012/08/27/science/benefits-of-circumcision-outweigh-risks-pediatric-group-says.html?_r=1




The New York Times


August 27, 2012

Benefits of Circumcision Are Said to Outweigh Risks

By RONI CARYN RABIN

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.



http://www.nytimes.com/2012/08/27/science/benefits-of-circumcision-outweigh-risks-pediatric-group-says.html?_r=1

 
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