Published online July 3, 2006
PEDIATRICS Vol. 118 No. 1 July 2006, pp. 385-387 (doi:10.1542/peds.2005-2881)
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COMMENTARY

Ignoring Evidence of Circumcision Benefits

Edgar J. Schoen, MD

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.


   ACKNOWLEDGMENTS
 
Editorial assistance was provided by the Medical Editing Service of the Permanente Medical Group Physician Education and Development Department.


   FOOTNOTES
 
Accepted Feb 10, 2006.

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.


   REFERENCES
TOP
 REFERENCES
 

  1. American Academy of Pediatrics, Task Force on Circumcision. Circumcision policy statement. Pediatrics. 1999;103 :686 –693[Abstract/Free Full Text]
  2. Schoen EJ. Ed Schoen, MD on Circumcision: Timely Information for Parents and Professionals From America's #1 Expert on Circumcision Berkeley, CA: RDR Books; 2005
  3. Ciesielski-Carlucci C, Milliken N, Cohen NH. Determinants of decision making for circumcision. Camb Q Healthc Ethics. 1996;5 :228 –236[Web of Science][Medline]
  4. Adler R, Ottaway MS, Gould S. Circumcision: we have heard from the experts; now let's hear from the parents. Pediatrics. 2001;107 (2). Available at: www.pediatrics.org/cgi/content/full/107/2/e20
  5. O'Brien TR, Calle EE, Poole WK. Incidence of neonatal circumcision in Atlanta, 1985–86. South Med J. 1995;88 :411 –415[Web of Science][Medline]
  6. Binner SL, Mastrobattista JM, Day MC, Swaim LS, Monga M. Effect of parental education on decision-making about neonatal circumcision. South Med J. 2002;95 :457 –461[Web of Science][Medline]
  7. Lyon J. Neonatal circumcision in Anchorage, 1985–1990. Alaska Med. 1992;34 :94 –95[Medline]
  8. Van Howe RS. Variability in penile appearance and penile findings: a prospective study. Br J Urol. 1997;80 :776 –782[Web of Science][Medline]
  9. Quayle SS, Coplen DE, Austen PF. The effect of health care coverage on circumcision rates among newborns. J Urol. 2003;170 :1533 –1536[CrossRef][Web of Science][Medline]
  10. Nelson CP, Dunn R, Wan J, Wei JT. The increasing incidence of newborn circumcision: data from the nationwide inpatient sample. J Urol. 2005;173 :978 –981[CrossRef][Web of Science][Medline]
  11. Schoen EJ. Re: the increasing incidence of newborn circumcision—data from the nationwide inpatient sample. J Urol. 2006;175 :394 –395; author reply 395[Medline]
  12. American Academy of Pediatrics, Committee on Fetus and Newborn. Standards and Recommendations for Hospital Care of Newborn Infants 5th ed. Evanston, IL: American Academy of Pediatrics; 1971
  13. Dean AL Jr. Epithelioma of the penis. J Urol. 1935;33 :252 –283
  14. 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: www.pediatrics.org/cgi/content/full/105/3/e36
  15. Stewart CM. Infections and related conditions. In: United States Army, Medical Department. Surgery in World War II: Urology. Washington, DC: Office of the Surgeon General and Center of Military History, United States Army; 1987:99 –146
  16. Thompson HC, King LR, Knox E, Korones SB. Report of the Ad Hoc Task Force on Circumcision. Pediatrics. 1975;56 :610 –611[Abstract/Free Full Text]
  17. Wiswell TE, Enzenauer RW, Holton ME, Cornish JD, Hankins CF. Declining frequency of circumcision: implications for changes in the absolute incidence and male to female sex ratio of urinary tract infections in early infancy. Pediatrics. 1987;79 :338 –342[Abstract/Free Full Text]
  18. American Academy of Pediatrics. Report of the Task Force on Circumcision [published correction appears in Pediatrics. 1989;84:761]. Pediatrics. 1989;84 :388 –391[Abstract/Free Full Text]
  19. Wiswell TE. John K. Lattimer lecture: prepuce presence portends prevalence of potentially perilous periurethral pathogens. J Urol. 1992;148 :739 –742[Web of Science][Medline]
  20. Shaw KN, Gorelick M, McGowan KL, Yakscoe NM, Schwartz JS. Prevalence of urinary tract infection in febrile young children in the emergency department. Pediatrics. 1998;102 (2). Available at: www.pediatrics.org/cgi/content/full/102/2/e16
  21. Schoen EJ, Bhatia S, Ray GT, Clapp W, To TT. Transient pseudohypoaldosteronism with hyponatremia-hyperkalemia in infant urinary tract infection. J Urol. 2002;167 :680 –682[CrossRef][Web of Science][Medline]
  22. Moses S, Plummer FA, Bradley JE, Ndinya-Achola JO, Nagelkerke NJ, Ronald AR. The association between lack of male circumcision and risk for HIV infection: a review of the epidemiological data. Sex Transm Dis. 1994;21 :201 –210[Web of Science][Medline]
  23. Halperin DT, Bailey RC. Male circumcision and HIV infection: 10 years and counting. Lancet. 1999;354 :1813 –1815[CrossRef][Web of Science][Medline]
  24. American Academy of Pediatrics. Circumcision Information for Parents Elk Grove Village, IL: American Academy of Pediatrics; 1999
  25. Schoen EJ, Wiswell TE, Moses S. New policy on circumcision: cause for concern. Pediatrics. 2000;105 :620 –623[Free Full Text]
  26. Schoen EJ, Colby CJ, Ray GT. Newborn circumcision decreases incidence and costs of urinary tract infections during the first year of life. Pediatrics. 2000;105 :789 –793[Abstract/Free Full Text]
  27. Wiswell TE. The prepuce, urinary tract infections, and the consequences. Pediatrics. 2000;105 :860 –862[Free Full Text]
  28. Zorc JJ, Levine DA, Platt SL, et al. Clinical and demographic factors associated with urinary tract infection in young febrile infants. Pediatrics. 2005;116 :644 –648[Abstract/Free Full Text]
  29. Drain PK, Smith JS, Hughes JP, Halperin DT, Holmes KK. Correlates of national HIV seroprevalence: an ecologic analysis of 122 developing countries. J Acquir Immune Defic Syndr. 2004;35 :407 –420[Web of Science][Medline]
  30. Short RV. The HIV/AIDS pandemic: new ways of preventing infection in men. Reprod Fertil Dev. 2004;16 :555 –559[CrossRef][Medline]
  31. Auvert B, Taljaard D, Lagarde E, Sobngwi-Tambekou J, Sitta R, Puren A. Randomized, controlled intervention trial of male circumcision for reduction of HIV infection risk: the ANRS 1265 trial. PLoS Med. 2005;2 :e298[CrossRef][Medline]
  32. Mallon E, Hawkins D, Dinneen M, et al. Circumcision and genital dermatoses. Arch Dermatol. 2000;136 :350 –354[Abstract/Free Full Text]
  33. Castellsagué 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]
  34. Castellsagué X, Peeling RW, Franceschi S, et al. Chlamydia trachomatis infection in female partners of circumcised and uncircumcised adult men. Am J Epidemiol. 2005;162 :907 –916[Abstract/Free Full Text]
  35. Collins S, Upshaw J, Rutchik S, Ohannessian C, Ortenberg J, Albertsen P. Effects of circumcision on male sexual function: debunking a myth? J Urol. 2002;167 :2111 –2112[CrossRef][Web of Science][Medline]
  36. Fink KS, Carson CC, DeVellis RF. Adult circumcision outcomes study: effect on erectile function, penile sensitivity, sexual activity and satisfaction. J Urol. 2002;167 :2113 –2116[CrossRef][Web of Science][Medline]
  37. Bluestein CB, Eckholdt H, Arezzo JC, Melman A. Effects of circumcision on male penile sensitivity [abstract]. J Urol. 2003;169 :324[CrossRef][Web of Science][Medline]
  38. Senkul T, Iseri C, Sen B, Karademir K, Saracoglu F, Erden D. Circumcision in adults: effect on sexual function. Urology. 2004;63 :155 –158[CrossRef][Web of Science][Medline]
  39. American Academy of Pediatrics. AAP publications retired and reaffirmed. Pediatrics. 2005;116 :796[Free Full Text]
PEDIATRICS (ISSN 1098-4275). ©2006 by the American Academy of Pediatrics

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