The American Academy of Pediatrics (AAP) has recently updated its position on infant circumcision, saying “the health benefits of newborn male circumcision outweigh the risks,” and the Canadian Paediatric Society (CPS), the corresponding organization in this country, may follow in the months to come.
The AAP’s previous policy had identified only “potential” health benefits. The revised policy is based on a survey of medical literature that found definite preventative and public health benefits.
The task force evaluated new studies on HIV acquisition and found that circumcised heterosexual men are less likely to acquire the disease from infected female partners than uncircumcised men are.
According to one statement by the World Health Organization (WHO), circumcision “reduces the risk of female-to-male sexual transmission of HIV by approximately 60 per cent.”
In priority regions of Africa, the WHO has initiated a five-year voluntary circumcision campaign, with a goal of an 80 per cent circumcision rate among adult men and infants. It hopes to reduce new HIV infections by 50 per cent by 2015.
Circumcision may also help prevent syphilis. On the other hand, the AAP task force found no connection between circumcision and rates of chlamydia and gonorrhea, the two most common sexually transmitted infections (STIs) in the United States. Another area where circumcision probably doesn’t help is penile cancer, which is declining worldwide anyway, says the AAP, regardless of the rate of circumcision in various countries.
However, circumcised boys are much less likely to develop urinary-tract infections (UTIs), the AAP notes. “The majority of UTIs in males occur during the first year of life. In children, UTIs usually necessitate a physician visit and may involve the possibility of an invasive procedure and hospitalization.”
Boys and men aren’t the only ones who benefit. There’s evidence that their female partners are protected as well from conditions such as bacterial vaginosis and human papillomavirus (HPV), one of the most common STIs in the United States, which can also lead to cervical cancer.
A 2002 study in the New England Journal of Medicine also found a small “protective effect” against cervical cancer for female partners of circumcised men.
Dr. Neil Pollock, a Vancouver doctor who specializes in circumcision, explains that the foreskin’s inner lining can act as an entry point for viruses that cause STIs, such as HIV, HPV and herpes, or bacteria such as E. coli, which cause urinary tract infections.
“When you remove the foreskin, you remove that entry point into the body.”
The AAP says the foreskin may also “trap” these “pathogens and secretions and favour their survival and replication.”
While it still doesn’t endorse routine circumcision, the AAP now recommends reimbursement from insurers if parents opt for the procedure. In Canada, routine circumcision isn’t funded by government medicare. In Ontario, it was delisted in 1994.
The current CPS position, updated in 1996, says that “evidence of the benefits and harms of circumcision is so evenly balanced that it does not support recommending [newborn] circumcision as a routine procedure.”
“We expect to release a revised statement in six to 12 months, but until then our current position stands,” a CPS spokesperson told The CJN.
Pollock says that “prior positions by the CPS viewed risks and benefits as more evenly balanced… their new position may be much more supportive.”
A 1975 CPS statement referred to circumcision as an “obsolete operation,” though this language was omitted in recent documents.
Newborn circumcision offers far lower rates of complications such as bleeding and infection than when it’s done later in life, Pollock says. “The procedure [on a newborn] can be comfortably and painlessly done by skilled doctors using local anesthetic,” instead of a hospital stay and general anesthetic for an adult.
Both the CPS and the AAP emphasize pain relief. The new AAP statement says “[n]onpharmacologic techniques (e.g., positioning, sucrose pacifiers) alone” can’t prevent pain, and it recommends better educational materials to help parents make the decision. Anti-circumcision forces have rallied against the AAP statement. Dr. Christopher Guest, a Barrie radiologist who co-founded the Children’s Health and Human Rights Partnership, dedicated to “ending non-therapeutic genital surgery on children in Canada,” calls the AAP’s evidence “selective,” using trials that “reveal a number of methodological weaknesses.”
Others argue that STI-related health benefits only apply to developing nations.
Guest also believes that the AAP “fails to recognize the sensory and mechanical function of the human foreskin.”
However, the AAP task force found “no statistically significant differences… between circumcised and uncircumcised men in terms of sexual sensation and satisfaction,” and said that “sexual function is not adversely affected.”
The AAP recommends finding providers with adequate training and sterile techniques, and avoiding “mouth-to-penis contact during circumcision,” a wound-clearing practice known as metzitzah b’peh that is used mainly among haredim. Pollock believes that “after this strong support… by the AAP – which only came after careful review of thousands of recently published scientific papers – it would be very difficult for the CPS to adopt anything but a more supportive stance.”
Will new evidence change anything for the Jewish community?
“Yes and no,” Pollock says.
“We always did this [circumcision] as a sign of the covenant between God and the Jewish people… however, [the AAP statement] makes it harder for the secular world to pressure us to cease our customs – as was done recently by a German court – when the world discovers that what we have been practising…. for religious reasons makes great medical sense as well.”