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CommonHealth: A New Policy Cites Benefits Of Infant Circumcision

In this photo provided by the University of Colorado Hospital, Katie Medley holds her newborn son Hugo Jackson Medley at the hospital in Aurora, Colo. in July. (AP/University of Colorado Hospital)

In this photo provided by the University of Colorado Hospital, Katie Medley holds her newborn son Hugo Jackson Medley at the hospital in Aurora, Colo. in July. (AP/University of Colorado Hospital)

In their updated policy statement released on Monday, the American Academy of Pediatrics stated that the health benefits of circumcision outweigh the risks of the procedure.

The AAP press release outlined the known benefits of infant circumcision:

According to a systematic and critical review of the scientific literature, the health benefits of circumcision include lower risks of acquiring HIV, genital herpes, human papilloma virus and syphilis. Circumcision also lowers the risk of penile cancer over a lifetime; reduces the risk of cervical cancer in sexual partners, and lowers the risk of urinary tract infections in the first year of life.

Despite their new statement, the AAP acknowledged that parents’ decision to circumcise isn’t so cut and dry:

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.

The AAP’s revised stance on circumcision touched off a new round of debate around the procedure, leaving parents possibly more confused about what’s best for their boys.

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Rachel Zimmerman explained the nuanced shift in the American Academy of Pediatrics’ stance on circumcision:

Back in 1999, the AAP had issued their earlier recommendations on circumcision – basically it was neutral. So what they did on Monday was come back to this issue and basically say the health benefits outweigh the risks. They say that the health benefits, for instance, decreased number of urinary tract infections, penile cancer, lower rates of transmission of some sexually transmitted infections (notably HIV) justify circumcision, but they can’t recommend that for all babies. The bottom line is that parents should decide for themselves what’s best for their children.

Zimmerman also noted the AAP’s stance could affect whether insurance covers circumcision:

They say the health benefits are enough to warrant insurance coverage for the procedure, which they had not stated in the earlier recommendations, so that’s a big difference. Government insurance, Medicaid, had also used the lack of AAP backing for this procedure as a justification for not covering the procedure in certain states.

About half of infant boys in the United States are circumcised, but that percentage was much higher a generation ago. Dr. Wang gave a few reasons for that decline:

That estimate comes from the Centers for Disease Control and Prevention, which is based primarily on hospital circumcisions done, so it possibly underestimates the total number of circumcisions done in the United States. But certainly that is a steady decline and a much smaller percentage compared to 40 years ago — and even 50 years ago — when the circumcision rate was probably up to about almost 100%. A lot of that downward shift has to do with some interesting cultural and historical changes over the time. But it also has a lot to do with research that’s been coming in over the course of the last 20 or 30 years or so that casts doubt on the significant health benefits of circumcision. They basically have shown — on the whole — boys who are circumcised really aren’t that much healthier than boys who are uncircumcised.

There have been some studies examining circumcision and HIV, and these have played a key role in informing policy recommendations, Dr. Wang explained:

The game changer happened about five or six years ago with clinical trials done in sub-Saharan Africa where they took uncircumcised adult men and gave them the opportunity to have the circumcision. When they followed those men through time, they found that those particular men had a 50% reduction in acquiring HIV compared to men who were uncircumcised. Those things have sort of tilted the balance towards being able to say there is a more significant health benefit that parents should be aware of.

The studies conducted were in an entirely different context compared to the United States. Are the results therefore applicable to the American context?

That is why you’ve seen such a delay from that onset of those studies to this current set of recommendations from the AAP. How do you justify adult men in a third world country where HIV is that much more prevalent versus newborns in developed countries where HIV is not so prevalent? I think that’s the difficulty in being able to make a full recommendation saying that circumcision could potentially prevent HIV. I think people are afraid to make that connection because we haven’t really done those studies yet — in looking at newborns in particular.

Zimmerman points out the nature of the circumcision controversy:

Let’s not forget what this is about: This is involving pain and a newborn and cutting the foreskin of the penis – it’s a serious choice you have to make as a parent.

Dr. Wang reflected on how the new AAP policy statement will modify his approach to talking with patients:

Up until yesterday, I had the same mantra that I go through with parents. And now, today, I have to sort of finagle that and add the caveat, “Well, you know what, there is a little bit more health benefit, so we are kind of encouraging it — but the decision is still yours. And I still want you to think more about family health, social and religious reasons to balance all of that together for your decision for wanting or not wanting it.”

At the end of the day, Dr. Wang reminded us that it’s all about making an informed decision, weighing the benefits and the risks:

Let’s not forget this is a surgery. This is not a procedure without risk. So all the things we associate with surgery — things like bleeding and infection and, in this particular case, damage to the area you’re cutting into, damage to the penis — are always going to be possible. And that’s what I impart to the parents…“Yeah, there could be benefits to circumcision. Let’s also remember there are risks involved, too.”

 


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