Will male circumcision guidance reverse trends in the procedure?

The American Academy of Pediatrics, by adopting a more positive position on infant male circumcision, is aiming to remove health and cost barriers to the procedure.

The guidance, which was posted online Aug. 27 in Pediatrics, says the health benefits of infant male circumcision outweigh the potential risks and recommends that physicians give expectant parents factual, nonbiased information about the possible advantages and drawbacks of the procedure. The AAP calls for insurers to cover infant male circumcision and encourages medical organizations to work together to develop standards of proficiency in circumcision techniques, such as suturing, and to create tools that help educate doctors about the latest data on the issue.

This marks a shift from the organization’s more neutral position, published in 1999 and reaffirmed in 2005, which said there were “potential medical benefits” of infant male circumcision. The 1999 statement did not address coverage of the procedure by health insurers.

“For health care professionals who are going to be responsible for educating patients, [the updated report] provides them with a lot of rich information with which to do that,” said Andrew L. Freedman, MD, a member of the AAP’s task force on circumcision who helped write the guidance.

However, the current guidance stops short of suggesting routine circumcision for all infant boys, partly because evidence of its health benefits is not strong enough to warrant it being a medical necessity, Dr. Freedman said. AAP changed its position, though, because of growing evidence that infant male circumcision could have positive health effects.

Let parents decide

The AAP encourages physicians to ensure that families understand that infant male circumcision is an elective procedure. The updated statement also accounts for the fact that male circumcision is not purely a medical decision, but includes aesthetic, cultural and religious factors as well, Dr. Freedman said.

“We recognize our ethical obligation is in the best interest of the child, and we don’t have the ability to judge the best interest of the child across all those paradigms,” said Dr. Freedman, a pediatric urologist at Cedars-Sinai Medical Center in Los Angeles. “If [families] want the procedure, they can justify getting it. If they don’t want it, they don’t have to have it.”

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 well-being.

The AAP was spurred to re-examine the issue in 2007 as mounting evidence linked higher prevalence of male circumcision to lower rates of herpes simplex virus type 2, HIV, human papillomavirus, penile cancer and urinary tract infections. The organization formed an eight-person multidisciplinary task force to examine the recent evidence on male circumcision.

The AAP’s change in position was supported by some physicians and researchers who have found benefits to infant male circumcision. “This [new report] is very important and good news,” said Aaron A.R. Tobian, MD, PhD, an assistant professor of pathology at Johns Hopkins School of Medicine in Baltimore.

Dr. Tobian was lead author of a study, published online in Archives of Pediatrics & Adolescent Medicine, that shows the U.S. could end up paying $4.4 billion in avoidable health costs in 10 years’ time if infant male circumcision rates dropped as low as in Europe. The study, which was not a part of AAP’s review, said 55% of the 2 million males born in the United States are circumcised each year, compared with only 10% in Europe. The study said higher costs largely would result from increased rates of STDs, including HIV and herpes, among uncircumcised men and their partners. Circumcision prevents the buildup of bacteria and viruses in skin folds.

The study said U.S. infant male circumcision rates have declined from a high of 79% in the 1970s and 1980s. Likely contributing to the decline is the decision of 18 state Medicaid plans to drop insurance coverage for routine circumcisions, said an editorial in the same journal issue.

If all state Medicaid plans stop covering the procedure, only about 38.5% of newborn males will be circumcised, said a study on 417,282 infant boys, published in the January 2009 issue of the American Journal of Public Health.

“The groups that Medicaid covers are precisely those that experience the greatest prevalence of HIV and other [sexually transmitted infections], which male circumcision can effectively avert,” the Archives of Pediatrics & Adolescent Medicine editorial said. “In this way, state policies are building in future health disparities that these disadvantaged children will face as adults.”

Some disagreements

However, some opponents of circumcision question the accuracy and validity of the data on which the AAP based its updated statement and report.

Intact America, a New York nonprofit against infant circumcision, is demanding that the AAP retract its report “on the basis that it is inaccurate, biased and misleading,” among other charges.

Dr. Freedman said such backlash was expected. He said the AAP task force went out of its way in the technical report “to be inclusive, comprehensive and transparent as to the quality of the evidence.”

“As a practicing pediatric urologist, 20% of the patients I will see today are here because of something related to their circumcision,” Dr. Freedman said. “The procedure has some modest benefits and some modest risks.”

Families shouldn’t “feel like they’re harming their child no matter what they decide to do.”