Male circumcision ban defeated; health benefits lauded

Infant male circumcision has long been a controversial issue in the United States, with supporters highlighting the health benefits and opponents comparing it to forced genital mutilation.

In recent years, the opponents have become increasingly vocal and organized, some health professionals say.

The latest controversy occurred in San Francisco. Circumcision opponents collected more than 10,000 signatures to bring a proposal before voters to ban circumcising men younger than 18 unless medically necessary.

County of San Francisco Superior Court of California Judge Loretta M. Giorgi on July 27 struck the measure from the ballot. On Oct. 2, Gov. Jerry Brown signed legislation that prevents local authorities from prohibiting or restricting male circumcision.

The same week, an editorial by Johns Hopkins University researchers published in the Oct. 5 issue of The Journal of the American Medical Association highlighted the medical benefits of circumcision (link).

The authors cited previous research that shows circumcised men are up to 60% less likely to contract HIV from a female partner than adult males who have not had the procedure.

The editorial said studies found that male circumcision also lowers men's risk of acquiring genital herpes by more than 30% and reduces their chances of contracting high-risk human papillomavirus by up to 35%. Infant males who are circumcised are less likely to get urinary tract infections than those who do not have the procedure, the editorial said.

Any ban on neonatal circumcision would deny religious freedoms to Jews and Muslims, who consider it a ritual obligation, the editorial stated.

Questioning the advantages

Circumcision opponents question the validity of some of the studies cited in the editorial because they were halted early. The Centers for Disease Control and Prevention said the studies ended after an analysis found a significant reduction in male participants' risk for HIV infection from circumcision.

Those opposed to the procedure also say the potential for surgical complications from infant male circumcision is one reason to prohibit circumcision.

But Aaron A.R. Tobian, MD, PhD, lead author of the JAMA editorial, said the complication rate for infants is less than 1%. For adult males, the risk of complications increases to as much as 4%, said Dr. Tobian, assistant professor of pathology at Johns Hopkins School of Medicine in Baltimore.

The American Medical Association says the decision for neonatal circumcision should be determined by parents in circumstances in which the procedure is not essential to the child's current well-being. "To make an informed choice, parents of all male infants should be given accurate and unbiased information and be provided the opportunity to discuss this decision," AMA policy states.

Pediatrician Douglas Diekema, MD, MPH, a member of the American Academy of Pediatrics' Task Force on Circumcision, encourages physicians to be aware of both sides of the issue.

"There are some very real preventive benefits [of circumcision]. The data is pretty clear about that," said Dr. Diekema, a professor of pediatrics at the University of Washington. "There also are risks associated with circumcision, but most are minor."

The controversy surrounding infant male circumcision is fueled, in part, by a neutral position of some in the medical community, physicians say. For example, the AAP in 2005 reaffirmed its 1999 statement that there is insufficient data to recommend routine neonatal circumcision.

If the procedure is not essential to the child's well-being, "parents should determine what is in the best interest of the child," the academy says.

A new AAP position statement on the procedure is expected to be issued in 2012, Dr. Diekema said. The committee, which included bioethicists, family physicians, infectious disease experts, pediatricians and urologists, reviewed hundreds of studies on the health benefits and risks of infant male circumcision.

There has been a lot of new data on the health benefits since the last AAP statement was issued, "and there was no question that the [academy's] statement needed to be updated," Dr. Diekema said.

"Hopefully, the statement we come out with will be a resource for physicians when they talk to families."