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PEDIATRICS Vol. 111 No. 6 June 2003, pp. 1490-1491

It’s Wise to Circumcise: Time to Change Policy

Edgar J. Schoen, MD
Kaiser Permanente Medical Center
Oakland, CA 94611-5693
USA

To the Editor.—

Since 1999, when the American Academy of Pediatrics (AAP) Task Force on Circumcision published its report,1 new data have accumulated that reinforce the preventive health advantages of newborn circumcision: protection against severe infant urinary tract infection (UTI),2 against penile cancer,3,4 against human immunodeficiency virus (HIV) infection,5 against penile dermatoses (eg, lichen planus and eczema)6—including the mechanism by which the foreskin predisposes to HIV infection7—and against balanoposthitis and phimosis. Observations from Sweden8,9 and from the United States10 indicate a higher prevalence of UTI in uncircumcised male infants than previously reported. Circumcision also improves genital hygiene throughout life, particularly during infancy and old age.

Powerful new data indicate that circumcision protects against penile acquisition of human papilloma virus (HPV) and that this protection reduces prevalence of cervical cancer in female partners of circumcised men.11 Uncircumcised men were about 3 times as likely to have penile HPV, and female partners of promiscuous uncircumcised men with HPV had a statistically significantly increased risk for cervical cancer.11,12

Findings linking the uncircumcised state to cervical cancer11,12 and recent data on multiple medical benefits of newborn circumcision2–6,8–10,13–17 make untenable the AAP position opposing routine circumcision.1 That 1999 statement has been criticized as both misleading and internally inconsistent.18 One inconsistent aspect of the AAP report is that it opposed routine circumcision despite listing 6 evidence-based benefits of newborn circumcision (protection against UTI, penile cancer, HIV infection, balanoposthitis, and phimosis; and ease of genital hygiene) and only 1 documented disadvantage (possibility of rare minor surgical complications).1

Social and sexual advantages of circumcision also have been shown. In a survey of California parents,19 those who chose not to have their newborn boys circumcised were later more likely to be dissatisfied than those who chose circumcision, and parents who decided against the procedure believed that they had been inadequately informed about it. In Texas, 85% of parents chose newborn circumcision20; having a circumcised father and highly educated parents were strong factors in this choice.

On the subject of adult circumcision, 1 study showed no adverse effects on sexual function,21 and another study reported that 50% of men circumcised as adults believed that they had benefited from circumcision and that 62% were satisfied with the results.22 These findings support earlier reports of improved sexual function in circumcised men23 and more sexual satisfaction in female partners of circumcised men,24 mainly because of improved genital hygiene.

Analysis of lifetime effects of newborn circumcision has been hampered by compartmentalization into specialized research interests: internists and others concerned with infectious disease focus on studying sexually transmitted diseases (STDs) in young men; pediatricians focus on severe UTI in infants and on phimosis, balanoposthitis, and genital hygiene in children; penile cancer and hygiene problems occurring more commonly during old age are thus considered mainly in that context. These age-specific advantages of circumcision are rarely consolidated into a comprehensive picture of disease prevention from birth through old age.

Parents of newborn boys should be aware of the lifelong health implications of circumcision status. To properly counsel these parents, pediatricians should be aware of the increasing documented medical evidence favoring newborn circumcision. On the basis of this evidence—much of it published since the 1999 AAP report—the AAP should reassess its position of not routinely recommending circumcision for male newborns.

ACKNOWLEDGMENTS

Trinh T. To, BS, assisted with research of the topic. The Medical Editing Department of Kaiser Foundation Hospitals provided editorial assistance.

REFERENCES

  1. American Academy of Pediatrics, Task Force on Circumcision. Circumcision policy statement. Pediatrics.1999; 103 :686 –693. (American Academy of Pediatrics. Circumcision Information for Parents. Elk Grove Village, IL: American Academy of Pediatrics; 1999)[Abstract/Free Full Text]
  2. Wiswell TE. John K. Lattimer lecture: prepuce presence portends prevalence of potentially perilous periurethral pathogens. J Urol.1992; 148(2, pt 2) :739 –742[Web of Science][Medline]
  3. Schoen EJ, Oehrli M, Colby CJ, Machin G. The highly protective effect of newborn circumcision against invasive penile cancer. Pediatrics.2000; 105(3) . Available at: http://www.pediatrics.org/cgi/content/full/105/3/e36
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  7. Patterson BK, Landay A, Siegel JN, et al. Susceptibility to human immunodeficiency virus-1 infection of human foreskin and cervical tissue grown in explant culture. Am J Pathol.2002; 161 :867 –873[Abstract/Free Full Text]
  8. Jakobsson B, Esbjorner E, Hansson S. Minimum incidence and diagnostic rate of first urinary tract infection. Pediatrics.1999; 104 :222 –226[Abstract/Free Full Text]
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  11. Castellsague X, Bosch FX, Munoz N, et al. Male circumcision, penile human papillomavirus infection, and cervical cancer in female partners. N Engl J Med.2002; 346 :1105 –1112[Abstract/Free Full Text]
  12. Adami HO, Trichopoulos D. Cervical cancer and the elusive male factor [editorial]. N Engl J Med.2002; 346 :1160 –1161[Free Full Text]
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  16. Rodriguez-Soriano J, Vallo A, Quintela MJ, Oliveros R, Ubetagoyena M. Normokalaemic pseudohypoaldosteronism is present in children with acute pyelonephritis. Acta Paediatr.1992; 81 :402 –406[Medline]
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  18. Schoen EJ, Wiswell TE, Moses S. New policy on circumcision—cause for concern. Pediatrics.2000; 105 :620 –623[Free Full Text]
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  24. Williamson ML, Williamson PS. Women’s preferences for penile circumcision in sexual partners. J Sex Educ Ther.1988 Fall/Winter;14 :8 –12
PEDIATRICS (ISSN 1098-4275). ©2003 by the American Academy of Pediatrics

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