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COMMENTARY |
Departments of Pediatrics and Genetics, Kaiser Permanente Medical Center, Oakland, California
Abbreviations: AAP, American Academy of Pediatrics • UTI, urinary tract infection
The American public remains resolute in its support of newborn circumcision despite negative recommendations from the American Academy of Pediatrics (AAP).1 The great majority of males in the United States are circumcised: prevalence of circumcision is 80% to 85%2 as measured by published values from Georgia, Texas, California, Colorado, Alaska, Wisconsin, and Missouri.3–9 Circumcision prevalence not only is high but seems to be increasing.10 Between 1988 and 2000, the US newborn circumcision rate increased by 12.8%, an increase that has been attributed to "an increased recognition of the potential medical benefits of circumcision" by the general public.10(p978) The increase in circumcisions is most apparent in mid-America states with the fewest immigrants,6,10,11 because most immigrants, particularly Hispanics, are not circumcised. The 80% to 85% US circumcision rate observed in practice contrasts with the 55% to 65% rate reported in statistics collected from birth centers across the nation.6,10 The explanation for this difference is that the published results of national statistical surveys represent only coded diagnoses obtained from birth centers; the reported figures do not include males who are circumcised at a later date for religious, medical, or personal reasons or who received newborn circumcision that was not coded.5,7
The original position of the AAP was established with an erroneous statement in 1971, when the AAP Committee on Fetus and Newborn in a single sentence stated that "there are no valid medical indications for circumcision in the neonatal period."12(p110) The anonymous authors seem to have been unaware of multiple published studies, mainly in the urologic literature, that showed that circumcision protected against penile cancer, balanoposthitis, and phimosis. Multiple published studies had shown that circumcision essentially eliminates the otherwise-possible development of invasive penile cancer.13,14 During the North African desert campaign of World War II, >146000 servicemen were hospitalized with foreskin-related disorders, mainly balanoposthitis, paraphimosis, and phimosis; US Army urologists stated: "Had these patients been circumcised before induction, this total would probably have been close to zero."15(p146) In 1975, instead of admitting the existence of valid indications for newborn circumcision as revealed in the body of the report, the AAP Ad Hoc Task Force on Circumcision simply changed the wording to "there is no absolute medical indication for routine circumcision of the newborn."16(p611) This anticircumcision policy remained in place until 1987, when Wiswell et al17 showed a 10- to 20-fold protective benefit of newborn circumcision against severe urinary tract infections (UTIs) in the first year of life. A new AAP task force was appointed, which I chaired. Published in 1989,18 our findings did indeed confirm medical benefits to circumcision as well as possible complications, and we stated that these benefits and complications should be pointed out to parents. In the 1989–1999 decade, multiple studies confirmed the beneficial effect of newborn circumcision in preventing infant UTIs19–21 and transmission of HIV.22,23 The safety and efficacy of local anesthesia were established also.
With this appearance of more benefits and less risks, an update was considered necessary. A 1999 task force was therefore appointed, and a new report was issued. Unbelievably, however, this report took a step backward by issuing an anticircumcision message despite additional compelling studies favoring newborn circumcision.1 The conclusions in the report belied the evidence contained in the body of the report. Proven benefits such as prevention of infant UTIs, balanoposthitis, and phimosis and the acknowledged protection against HIV were referred to as "potential benefits" that were concluded to be "not sufficient to recommend routine neonatal circumcision."1(p693) Although a table issued by the AAP in 1999 listed 6 evidence-based benefits and 1 risk (the rare [0.2%–0.6%] and usually minor risk of surgical complications),24 no benefit-to-risk ratio was offered to allow parents to decide the issue for themselves. In light of the multiple benefits and only minor risks, it is difficult to understand how the 1999 AAP task force reached its conclusions. The report was challenged25 but to no avail.
Since 1999, further convincing data have documented the preventive health benefits of circumcision. Published reports have confirmed a protective effect against infant UTIs,26–28 HIV acquisition,23,29–31 penile cancer,14 and penile dermatoses,32 and local anesthesia has become the standard of care. New, important evidence-based advantages of circumcision have been established. Most notable has been the finding that uncircumcised men are 3 times more likely than circumcised men to carry the human papilloma virus,33 the infectious agent involved in development of genital cancer (cervical cancer in women and penile cancer in men). Cervical cancer is of special importance because, particularly in underdeveloped countries, this disease is a leading cause of cancer death in women. Hundreds of thousands of women in the world die annually from cervical cancer, and evidence shows that male circumcision could markedly reduce this number.33 Most recently, an international study from 5 different countries found that chlamydia infection is 
3 times more common in female partners of uncircumcised men than in female partners of circumcised men.34 In addition, particularly in the past 3 to 4 years, objective studies comparing sensitivity and sexual pleasure in circumcised versus uncircumcised men and evaluating measures of sexual pleasure before and after adult circumcision35–38 have concluded that no clinically significant difference exists between the circumcised and uncircumcised states. This result should come as no surprise in view of the complex psychological, neurologic, chemical, hormonal, and circulatory cascade involved in sexual activity.
Since publication of the misleading 1999 AAP task force conclusions, compelling evidence has accumulated warranting acknowledgment that the multiple medical benefits of newborn circumcision far outweigh the minor risks of the procedure. This updated evidence of benefits includes studies confirming the preventive effect of circumcision against HIV,23,29–31 penile cancer,14 and infant UTI26,28 and new evidence of protection against penile dermatoses,32 human papilloma virus,33 cervical cancer,33 and chlamydia infection.34 Nonetheless, in 2005 the AAP reaffirmed the 1999 policy,39 in effect suppressing all the evidence published since then. According to both the current position of the AAP and the reference list provided in the task force report, the last relevant reference on the health benefits of circumcision occurred in 19981; all the many convincing studies published during the past 7 years have been ignored. It is time for the AAP to acknowledge the evidence and to catch up to the American public.
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ACKNOWLEDGMENTS |
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FOOTNOTES |
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Address correspondence to Edgar J. Schoen, MD, Departments of Pediatrics and Genetics, Kaiser Permanente Medical Center, 280 W MacArthur Blvd, Oakland, CA 94611. E-mail: edgar.schoen{at}kp.org
The author has indicated he has no financial relationships relevant to this article to disclose.
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REFERENCES |
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 TOP REFERENCES |
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This article has been cited by other articles:
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  E. J. Schoen Rebuttal: Should newborns be circumcised?: YES Can Fam Physician, January 1, 2008; 54(1): 22 - 22. [Full Text] [PDF]
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E. J. Schoen Should newborns be circumcised?: YES Can Fam Physician, December 1, 2007; 53(12): 2096 - 2098. [Full Text] [PDF]
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E. J. Schoen Faut-il circoncire les nouveau-nes?: OUI Can Fam Physician, December 1, 2007; 53(12): 2100 - 2102. [Full Text] [PDF]
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 J. D. Dickerman Circumcision in the Time of HIV: When Is There Enough Evidence to Revise the American Academy of Pediatrics' Policy on Circumcision? Pediatrics, May 1, 2007; 119(5): 1006 - 1007. [Full Text] [PDF]
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P. Flynn, P. Havens, M. Brady, P. Emmanuel, J. Read, L. Hoyt, L. Henry-Reid, R. Van Dyke, and L. Mofenson Male Circumcision for Prevention of HIV and Other Sexually Transmitted Diseases Pediatrics, April 1, 2007; 119(4): 821 - 822. [Full Text] [PDF]
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