On Monday, the American Academy of Pediatrics (AAP) publicly amended its position on circumcision for the first time in more than a decade, moving to support the procedure in light of recent research supporting its health benefits.
In a Circumcision Policy Statement published in Pediatrics, the organization listed the transmission of certain sexually transmitted infections (including HIV), prevention of urinary tract infections in the first year of life and penile cancers as some of the benefits of circumcision.
The AAP formed a multidisciplinary task force with other stakeholders in 2007 to evaluate recent research on male circumcision. The task force examined current English-language peer-reviewed literature from 1995 through 2010, with the intent of updating the 1999 recommendations on male circumcision, which took a neutral position on the procedure.
“Evaluation of current evidence indicates that the health benefits of newborn male circumcision outweigh the risks,” the statement abstract reads.
According to the task force, significant complications of circumcision are rare, and it does not “appear to adversely affect penile sexual function/sensitivity or sexual satisfaction.”
The full statement goes on to say that although health benefits are not great enough to recommend routine circumcision for all male newborns, the benefits of circumcision are sufficient to justify access for families choosing it. The AAP advises insurance payment of circumcision and said that parents are entitled to factual and nonbiased information about the procedure from their medical providers, with respect given for personal, religious and cultural preferences.
The American College of Obstetricians and Gynecologists also endorsed the statement.
Others were critical of AAP’s move to support circumcision, including Intact America, which puts the practice of routine neonatal male circumcision on par with female genital mutilation.
“The report presents highly selective information to promote the benefits of a useless and unethical surgery and completely ignores the rights of the child to an intact body,” said Georganne Chapin, founding executive director of Intact America, in a Monday release.
Intact America believes that “painful and medically unnecessary surgery to remove healthy genital tissue from non-consenting baby boys violates medical ethics and human rights.”
“[The AAP] is also ignoring the fact that circumcision is rare in Europe, with no negative health consequences, and that European politicians and physician groups – in increasing numbers – are calling for doctors to refuse to perform the procedure, on the basis that it is harmful and violates children’s rights and bodies,” said Chapin in a release from last week.
Several European cities have recently been in the news for controversial positions toward circumcision. In May, a Cologne district court in Germany ruled male circumcision of a boy unable to give consent as “bodily harm,” after a Muslim began bleeding after a doctor performed the procedure on him. Doctors were then asked to refrain from performing circumcisions for religions reasons until the law was clarified, despite the threat of non-professionals continuing to perform the procedures as per religious custom. Germany’s lower house of parliament then passed a resolution protecting religious male circumcision.
Hospitals in Switzerland and Austria followed suit to “ban” circumcision after the initial German ruling. The Vorarlberg province in Austria ordered state-run hospitals to stop performing circumcisions until the country could develop a uniform method for performing them that is supported by both Muslims and Jews.
This past Saturday, Danish Prime Minister Helle Thorning-Schmidt told Copenhagen-based Politiken daily the government was supporting an investigation whether non-medical circumcision violates its health code.
The Royal Dutch Medical Association opposes religious circumcision, claiming it might lead to medical and psychological complications.
“Our departure point is that you are cutting healthy flesh from a minor who has not consented to it,” Lode Wigersma, director of policy at the Dutch doctors’ group, told Bloomberg Businessweek. “When you remove that tissue, you can cause complications.”
A Danish study published last year in the International Journal of Epidemiology also points to an association between male circumcision and frequent sexual difficulties in both men and woman. However, 85 percent of the study’s circumcised participants had the procedure as adults.
The association says that if circumcision helps prevent HIV, parents should consider circumcision only after the male is sexually active and can decide for himself.
In February, the Swedish Paediatric Society called for a ban on non-medical circumcision stating children are unable to make a decision on the matter.
The Finnish Medical Association already opposes infant circumcision for non-medical reasons, stating that it risks the child’s health and “physical integrity.”
There were attempts to ban circumcision in San Francisco and Santa Monica, Calif. in July 2011, but a state judge blocked the ban, saying it was a state-licensed medical procedure. In October, Gov. Jerry Brown signed a law that prohibited local governments from legislating these types of actions.
The AAP’s decision might be at least partially economically motivated. Researchers predicted that if U.S. circumcision rates continue to drop at its current rate, it would cost the country in excess of $4.4 billion more in health expenses.
Roughly 55 percent of the 2 million boys born each year in the United States are circumcised, a decline from a high of 79 percent in the 1970s and 1980s, says epidemiologist and pathologist Aaron Tobian, professor at Johns Hopkins University School of Medicine. Rates in Europe average 10 percent, and, in Denmark, only 1.6 percent of infant males undergo the procedure.
Tobian lead a study, reported in the Archives of Pediatrics and Adolescent Medicine earlier this month, that projected if circumcision among men born in the same year dropped to European rates, there would be an expected 12 percent increase in HIV in men, 29 percent increase in human papillomavirus, nearly a 20 percent increase in herpes simplex virus, and approximately a 212 percent leap in the number of infant male urinary tract infections. The prevalence of several diseases would jump much higher among their female sexual partners.
“States that are trying to look for cost savings should also look at this study and see in the long term that eliminating male circumcision coverage is not advantageous,” said Tobian in U.S. News Weekly.
Using a computer model, researchers predict healthcare spending to increase by $313 per circumcision not performed. Cases of HIV in men would account for almost 80 percent of the increased costs.
In 2006, researchers from the Yale School of Medicine found that programs increasing adult male circumcision can significantly reduce the spread of HIV infection. Developing a mathematical model, they found that increasing adult male circumcision rates in Soweto, South Africa, by targeting 10 percent of uncircumcised adult men each year for five years, could prevent 32,000 infections and decrease 20-year HIV prevalence from 17 to 14 percent.
“It reduces transmission but will not provide complete protection from getting HIV,” said Yale medical student and public health doctoral candidate Kyeen Mesesan. “If widespread condom use decreased by 30 percent, for example, the circumcision program would prevent only 18,000 infections.”
For this reason, Mesesan said other sexual prevention tools still play an important role.
According to Chapin, the AAP task force report relies heavily on studies of sexually active African men and the role circumcision might play in reducing female-to-male transmission of the HIV virus. She says this is not surprising: The head of the task force is Dr. Susan Blank, director and assistant commissioner of the Bureau of STD (Sexually Transmitted Disease) Control for the New York City Department of Health and Mental Hygiene.
Dr. Michelle Storms, Assistant Clinical Professor at the Michigan State University College of Human Medicine and member of Intact America’s Board of Health professionals, also states that the AAP stacked its committee with members predisposed to supporting circumcision.
“This type of decision-making and skewed committee membership is abhorrent, unscientific and ultimately harmful to those people we should be most concerned with protecting our nation’s children,” she said in a letter calling on the AAP to retract its new technical report.
“The AAP Task Force has ignored the fact that European and other developed countries with extremely low rates of circumcision also have far lower rates of sexually-transmitted diseases than the United States, where circumcision rates are higher,” said Chapin.
“It is clear that the AAP is blind to the mounting worldwide movement against the genital cutting of boys,” she said. “This American physician organization is disregarding the risks and harms of the procedure.”