Current Circumcision Trends and Guidelines

Chapter

Abstract

Most consensus statements are made after clear consideration of the evidence at hand tempered by local politics. Routine circumcision was the norm in Great Britain, Canada, and the USA until after the Second World War. The early promoters of routine circumcision reflected the state of medicine in the late nineteenth century and were primarily influenced by anecdotal case reports, often of dubious nature. The reports of neonatal deaths from circumcision and the advent of the National Health Service before the end of the 1940s led Great Britain to abandon coverage for routine circumcision. It was more than 20 years later that Canada and Australia followed suit. The United States, for various reasons, took a different path, and following the First World War promoted routine circumcision, with an even stronger position following the Second World War. In 1999, to address the growing question as to the validity of routine circumcision, the AAP issued a policy statement that took the middle of the road, rather than polarized for or against. This policy has been revisited and revised based on new data as it accrues and last reaffirmed in 2005. That is, circumcision confers some medical benefit but not enough to call for its routine application.

Editors’ Note

Most consensus statements are made after clear consideration of the evidence at hand tempered by local politics. Routine circumcision was the norm in Great Britain, Canada, and the USA until after the Second World War. The early promoters of routine circumcision reflected the state of medicine in the late nineteenth century and were primarily influenced by anecdotal case reports, often of dubious nature. The reports of neonatal deaths from circumcision and the advent of the National Health Service before the end of the 1940s led Great Britain to abandon coverage for routine circumcision. It was more than 20 years later that Canada and Australia followed suit. The United States, for various reasons, took a different path, and following the First World War promoted routine circumcision, with an even stronger position following the Second World War. In 1999, to address the growing question as to the validity of routine circumcision, the AAP issued a policy statement that took the middle of the road, rather than polarized for or against. This policy has been revisited and revised based on new data as it accrues and last reaffirmed in 2005. That is, circumcision confers some medical benefit but not enough to call for its routine application.

Introduction

Since the popularization of circumcision in western culture, in the mid-nineteenth century, the potential benefits of the procedure have been met with pragmatic and ethical concerns, producing confusion for practitioners and parents alike. In response to this confusion, multiple medical organizations have released recommendations and guidelines in order to provide consensus opinions to those who counsel families and practice routine neonatal circumcision (NC). Unfortunately, these guidelines are not always consistent and often change with popular sentiment. Our goal here is to review the major arguments in favor of and opposed to neonatal circumcision that are put forth by medical organizations, to outline the current recommendations from the major medical organizations in western medicine, and to provide a consensus of these views that may be put into practice.

American Academy of Pediatrics

In many ways the American Academy of Pediatrics (AAP) policy statement on routine circumcision has been the standard bearer for US policy against which other positions have been metered.

In 1999, the American Academy of Pediatrics released its most recent Circumcision Policy Statement that was reaffirmed in 2005 [1, 2]. The statement, published in Pediatrics councils, is that although there are potential benefits of NC, there is not a preponderance of evidence mandating its routine practice.

This statement addresses several areas of potential benefit from NC, including prevention of urinary tract infection, penile cancer, and sexually transmitted diseases. With regard to urinary tract infection, it acknowledges that there is a tenfold increase in risk of UTI in uncircumcised males. This evidence is tempered by the exceedingly low absolute risk of UTI and the loss of effect after the first year of life. In addition, the studies showing lower rates of UTI are often not controlled for other factors such as prematurity and use inadequate collection techniques such as bagging for urine specimens.

The AAP statement also addresses penile cancer and concludes that rates of squamous cell carcinoma are three times lower in circumcised men. The statement does not justify circumcision based on this, because, as with the rates of UTI, rates of penile cancer in the United States are low. Therefore, the number of boys circumcised to prevent one case of cancer is very large.

The issue of sexually transmitted diseases, in particular HIV, is addressed in a single paragraph in the AAP policy statement. It acknowledges that there is evidence that uncircumcised men are at higher risk of contracting HIV and that there is a biological mechanism to explain this. It also comments, however, that behavioral risk factors “appear to be far more important risk factors in the acquisition of HIV infection than circumcision status.”

The AAP statement also points out several potential harms of the procedure. It sites a complication rate of 0.2–0.6%, but states that most of these complications are “minor”. These include bleeding, infection, poor cosmetic outcome, and, at the extreme, amputation of the glans penis. In addition, the AAP describes the inability to obtain informed consent and the need for ­adequate family counseling.

For these reasons, the AAP concluded that although there may be some health benefit from circumcision, there is no clear evidence that this is profound enough to recommend its regular implementation by practitioners. It encourages health-care providers to offer unbiased information in an attempt to guide parents in their decision. Furthermore, the AAP statement affirms the parents’ (guardian’s) right to provide informed consent on behalf of their child:

In cases such as the decision to perform a circumcision in the neonatal period when there are potential benefits and risks and the procedure is not essential to the child’s current well-being, it should be the parents who determine what is in the best interest of the child. In the pluralistic society of the United States in which parents are afforded wide authority for determining what constitutes appropriate child-rearing and child welfare, it is legitimate for the parents to take into account cultural, religious, and ethnic traditions, in addition to medical factors, when making this choice.

While the AAP statement does not support the need for routine circumcision, it positively advocates the implementation of pain control for circumcision; “if a decision for circumcision is made, procedural analgesia should be provided.”

American Academy of Family Physicians

The American Academy of Family Physicians (AAFP) position of 2001, and reaffirmed in 2007 [3], is similar in context and tone to the AAP statement including the call for the use of anesthesia of neonatal circumcision:

“The AAFP Commission on Science has reviewed the literature regarding neonatal circumcision. Evidence from the literature is often conflicting and inconclusive. Most parents base their decisions whether or not to have their newborn son circumcised on nonmedical preferences (i.e. religious, ethnic, cultural, cosmetic). The American Academy of Family Physicians recommends physicians discuss the potential harms and benefits of circumcision with all parents or legal guardians considering this procedure for their newborn son.” … “If the decision is made to circumcise, anesthesia should be used.”

American Urological Association

The American Urological Association (AUA) policy statement of 1989 with a final revision in 2007 states that “neonatal circumcision has potential medical benefits and advantages as well as disadvantages and risks” [4]. It states that neonatal circumcision is relatively safe when performed by an experienced provider and that most complications are minor. Delayed complications of circumcision must be factored such as cicatricial buried penis, meatal stenosis, skin bridges, chordee, and poor cosmesis. In balance, it states that a properly performed circumcision prevents phimosis, paraphimosis, and balanoposthitis, and lowers incidence of penile cancer, urinary tract infections, and possibly sexually transmitted diseases. That is, “the risks and disadvantages of circumcision are encountered early whereas the advantages and benefits are prospective”.

Centers for Disease Control and Prevention

Though highly anticipated since 2009, the Centers for Disease Control and Prevention (CDC) has not published recommendations for or against routine circumcision. The CDC reports that circumcision has some protective value against genital ulcer disease and chlamydia, infant urinary tract infections, penile cancer, and cervical cancer in women (the latter two being associated with human papillomavirus, HPV).

The CDC is currently reviewing whether the sub-Saharan African studies can be extrapolated to the modes of HIV transmission seen in the USA and whether there is an adjunct prophylactic role for circumcision. In the mean time they take a tempered position: “individual men may wish to consider circumcision as an additional HIV prevention measure, but they must recognize that circumcision (1) does carry risks and costs that must be considered in addition to potential benefits; (2) has only proven effective in reducing the risk of infection through insertive vaginal sex; and (3) confers only partial protection and should be considered only in conjunction with other proven prevention measures.”

Canadian Pediatric Society

Canadian health organizations have largely opposed routine NC over the last 30 years. In 1989, the Canadian Pediatric Society commented that the evidence pertaining to STDs and UTI was not “sufficiently compelling to justify a change in policy” and revisited in 1996 [5]. This policy has discouraged neonatal circumcision since the 1970s. This position is also supported by the College of Physicians and Surgeons of British Columbia (CPSBC) position, released in 2009, which definitively states that the routine circumcision of neonates “is not recommended” and may even have human rights implications [6]. Though opposed to neonatal circumcision, the CPSBC cites CMA Code of Ethics, section 8, which protects parents from a provider who may deem circumcision an unacceptable practice: “If your personal beliefs dictate against infant male circumcision, this should be made known to your patients, with an offer of referral to another physician competent in performing the procedure.” Interestingly, despite such opposition from the medical establishment, a 2009 survey by the Public Health Agency of Canada, “What Mothers Say: The Canadian Maternity Experiences Survey,” reports that about one-third of responding mothers had their male child circumcised.

The Royal Australasian College of Physicians

In 1996, the Royal Australasian College of Physicians (RACP) acknowledged that rates of UTI, penile cancer, and HIV may be lower in ­circumcised males but that this does not support routine circumcision. Instead it recommended that the practice be delayed until the patient is old enough to make an “informed choice” [7].

In 2010, the Royal Australasian College of Physicians published an updated policy reaffirming their position against routine infant circumcision: “the frequency of diseases modifiable by circumcision, the level of protection offered by circumcision and the complication rates of circumcision do not warrant routine infant circumcision in Australia and New Zealand. However it is reasonable for parents to weigh the benefits and risks of circumcision and to make the decision whether or not to circumcise their sons” [8]. Though against routine circumcision as a matter of policy, the RACP states emphatically that where the parents choose circumcision for their infant male child, analgesia must be provided: “Infant circumcision without analgesia is unacceptable practice in Australia and New Zealand.”

In New Zealand, circumcision is defined as a restricted activity (Health Practitioners Com­petency Assurance Act, 2003) and may only be carried out by a medical practitioner, whereas in Australia, both lay and medical practitioners may perform circumcisions.

British Medical Association and British Association of Pediatric Surgeons

In England, the consensus of medical bodies has been similar to that in Canada. Both the British Medical Association (BMA) and the British Association of Pediatric Surgeons (BAPS) have expressed that there is “rarely a clinical indication for circumcision” [9]. These organizations raise the question of valid consent and ethical concerns in making a decision for a newborn male. They hedge on the potential impact of Human Rights Act [10]: “If it was shown that circumcision where there is no clinical need is prejudicial to a child’s health and wellbeing, it is likely that a legal challenge on human rights grounds would be successful.” They require that both parents must give consent. If the child is old enough to express person views, they must be taken into account. That said, the BMA emphasizes the role of parents as advocates for the child’s best interest: “… the BMA believes that parents should be entitled to make choices about how best to promote their children’s interests, and is for society to decide what limits should be imposed on parental choices … Male circumcision is not grounded in statute, however judicial review assumes that, provided both parents consent, non-therapeutic male circumcision is lawful.”

Royal Dutch Medical Association (KNMG)

Of all the points of view listed herein, the KNMG takes the strongest position in opposing nontherapeutic circumcision: “The KNMG calls for a dialogue between doctors’ organisations, experts and the religious groups concerned in order to put the issue of non-therapeutic circumcision of male minors on the agenda and ultimately restrict it as much as possible” [11]. Their position is that the complications of circumcision are significant and therefore outweigh grounds other than direct medical/therapeutic: “Contrary to what is often thought, circumcision entails the risk of medical and psychological complications. The most ­common complications are bleeding, infections, meatus stenosis (narrowing of the urethra) and panic attacks.” and “Non-therapeutic circumcision of male minors is contrary to the rule that minors may only be exposed to medical treatments if illness or abnormalities are present, or if it can be convincingly demonstrated that the medical intervention is in the interest of the child, as in the case of vaccinations.” and “Non-therapeutic circumcision of male minors conflicts with the child’s right to autonomy and physical integrity.” Finally, the KNMG equates, in a legal sense, male circumcision with “female genital mutilation” but fears the prohibition of the former would lead to the use of lay practitioners. Despite this opposition to circumcision, the KNMG does hold that circumcision is a surgical procedure that is covered by the Individual Healthcare Professions Act. Where circumcision is provided, it must be done by a doctor and under local or general anesthesia.

World Health Organization

“Male circumcision should be recognized as an additional important step in curbing heterosexually acquired HIV in men” – March 2007 (UN News Centre). The World Health Organization (WHO) is highly engaged in remedying the HIV epidemic, especially in sub-Saharan Africa. In addition to counseling safer behavior and early initiation of antiretroviral therapy, circumcision, especially in high prevalence areas, is recommended [12]. This is due largely to the evidence that circumcision has been shown to reduce the risk of transmission of HIV by as much as 60%. Because rates of HIV are so high in areas of sub-Saharan Africa, this reduction translates into the subsidence of HIV transmission in a profound number of people: “Modeling studies suggest that male circumcision in sub-Saharan Africa could prevent 5.7 million new HIV cases and three million deaths over 20 years.” [13] Though currently the bulk of circumcisions in the HIV eradication programs are performed on adult males, there is a new push to extend this to newborns where the procedure is considered safer and less expensive. Accordingly, the WHO has published a guide for infant male circumcision [14].

It should be noted that several countries and regions of sub-Saharan Africa have developed their own policy statements on circumcision.

Summary

Outside of strategic regions in sub-Saharan Africa, no call for routine circumcision has been made by any established medical organizations or governmental bodies. The range of positions is from “some medical benefit/parental choice” in the United States, to “essential no medical benefit/parental choice” in Great Britain, to “no medical benefit/physical and psychological trauma/parental choice” in the Netherlands.

Ultimately, a number of factors play a role in the position on circumcision that a medical organization will take. In areas such as sub-Saharan Africa, where HIV rates are extremely high and recent evidence suggests a prophylactic value, there will be strong motivation to circumcise as many males as possible. Where circumcision is viewed as having nominal or no medical value, then only social, cultural, and religious factors will drive the practice. In fact, all policy statements reviewed, regardless of its position on circumcision, have made allowances for parental choice in support of their cultural or religious preference. Furthermore, some policy makers take the position that in such cases, circumcision should be covered by state health programs to discourage the use of lesser trained lay practitioners.

In places where the government or health insurances do not cover circumcision, the incidence is low or tends to decline. For example, the rates of circumcision and the support of this practice have fallen drastically in Great Britain once the government funded health care stopped covering circumcision. Moreover, the demographic distribution of circumcision in the United States is significantly affected by insurance and state (Medicaid) coverage such that a socioeconomic divide is apparent, which gives enhanced meaning to the have and have-nots.

In light of the most recent research on whether or not and to what extent circumcision has prophylactic value in preventing the transmission of HIV and HPV, many organizations have established new review committees. Thus, this review may well be dated.

References

  1. 1.
    American Task Force on Circumcision, American Academy of Pediatrics. Circumcision policy statement. Pediatrics. 1999;103(3):686–93.CrossRefGoogle Scholar
  2. 2.
    American Academy of Pediatrics. AAP publications retired and reaffirmed. Pediatrics. 2005;116(3):796.CrossRefGoogle Scholar
  3. 3.
    American Academy of Family Physicians. Circumcision: position paper on Neonatal Circumcision. 2007. http://www.aafp.org/online/en/home/clinical/clinicalrecs/children/circumcision.html. Reaffirmed Aug 2007.
  4. 4.
    American Urological Associate. Policy statements: circumcision. 2007. http://www.auanet.org/content/guidelines-and-quality-care/policy-statements/c/circumcision.cfm. Revised May 2007.
  5. 5.
    Canadian Paediatric Society. Neonatal circumcision revisited. CMAJ. 1996;154(6):769–80.Google Scholar
  6. 6.
    The College of Physicians and Surgeons of British Columbia. Resource manual: circumcision (Infant Male). 2009. Updated Sept 2009.Google Scholar
  7. 7.
    The Australian College of Paediatrics. Position statement: routine circumcision of normal male infants and boys. Parkville: Australian College of Paediatrics; 1996.Google Scholar
  8. 8.
    The Royal Australasian College of Physicians. Circumcision of infant males. Sydney: Royal Australasian College of Physicians; 2010.Google Scholar
  9. 9.
    British Medical Association, Department of Medical Ethics. The law and ethics of male circumcision: guidance for doctors. London: British Medical Association; 2006.Google Scholar
  10. 10.
    Parliament of the United Kingdom, Human Rights Act. 1998. http://www.legislation.gov.uk/ukpga/1998/42/contents.
  11. 11.
    Royal Dutch Medical Association (KNMG). Non-therapeutic circumcision of male minors. Utrecht: Royal Dutch Medical Association (KNMG); 2010.Google Scholar
  12. 12.
    World Health Organization. Global health sector strategy on HIV/AIDS 2011–2015. 2011.Google Scholar
  13. 13.
    Would Health Organization (WHO) and Joint United Nations Programme on HIV/AIDS (UNAIDS). WHO and UNAIDS announce recommendations from expert consultation on male circumcision for HIV prevention. 2007.Google Scholar
  14. 14.
    World Health Organization and Jhpiego Corporation. Manual for early infant male circumcision under local anaesthesia. Geneva: World Health Organization; 2010.Google Scholar
  15. 15.
    Centers for Disease Control and Prevention. Male ­circumcision and risk for HIV transmission and other health conditions: implications for the United States. 2008. http://www.cdc.gov/hiv/resources/factsheets/circumcision.htm. Feb 2008.
  16. 16.
    Public Health Agency of Canada. What mothers say: the Canadian maternity experiences survey. Ottawa: Public Health Agency of Canada; 2009.Google Scholar

Copyright information

© Springer-Verlag London 2012

Authors and Affiliations

  • Micah Jacobs
    • 1
  • Richard Grady
    • 2
  • David A. Bolnick
    • 3
  1. 1.Department of UrologyUniversity of TexasDallasUSA
  2. 2.Department of UrologyUniversity of Washington School of Medicine – Seattle Children’s HospitalSeattleUSA
  3. 3.Department of UrologyUniversity of Washington – Seattle Children’s HospitalSeattleUSA

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