The American Academy of Pediatrics (AAP) issued a new policy statement on the medical circumcision of infants today. A multi-disciplinary work group was created in 2007 to update the AAP’s recommendation and their statement has long been anticipated.
The new policy claims that the benefits of infant circumcision outweigh the risks, but falls just short of recommending the procedure. Instead, the AAP leaves the decision up the parents, as it has done since 1989. A survey of AAP members found that parents do not seek their pediatrician’s recommendation about the procedure, but instead are more influenced by family and sociocultural influences.
CIRCUMCISION ON THE DECLINE.
One of the sociocultural influences the AAP may be referring to is the overall declining rate of circumcision worldwide. In Europe, for example, only about 10% of men are circumcised, and those mostly for religious reasons.
The social acceptance of circumcision is less in Europe than in the US. In a recent German case, for example, the court ruled that circumcision constituted an act of inflicting bodily harm, comparing it to female genital mutilation, widely banned in Europe. Several regions of Switzerland and Austria have made it illegal to perform circumcisions, and Scandinavian countries are considering doing the same.
Circumcision is on the decline in the US as well. According to the National Inpatient Sample (NIS), 57% of male newborns born in hospitals were circumcised from 1998 to 2005. In the Western states, the rate has dropped to 30%. Along with this decline, has come a parallel decline in insurance coverage for the procedure; increasingly, circumcision is looked upon as elective.
CIRCUMCISION AND INSURANCE
A 2011 study found that insurance coverage for circumcision varies. Private insurance provides far broader coverage than do Medicaid programs. In fact, Medicaid programs in 17 states do not cover circumcision at all and circumcision rates fall when a procedure is not covered by Medicaid
Sixty-one percent of circumcisions are paid for by private insurance; 36% are paid for by Medicaid, and 3% are paid for by parents—at a cost of between $250 and $500. As a result of the cost, parents covered by private insurance are 2.5 times more likely to choose circumcision than parents who pay for it themselves.
Insurance coverage for circumcision is a significant cornerstone of the new AAP circumcision policy, and one of the few substantive changes from past policies: “The preventive and public health benefits associated with newborn male circumcision warrant third-party reimbursement of the procedure.”
According to the new AAP statement, the “preventive and public health benefits” “…include significant reductions in the risk of urinary tract infection in the first year of life and, subsequently, in the risk of heterosexual acquisition of HIV and the transmission of other sexually transmitted infections.”
URINARY TRACT INFECTIONS
A 2005 meta-analysis estimated the risks of circumcision to include haemorrhage and infection and to occur at a rate of about 2% of circumcisions. According to the analysis, urinary tract infections occur in “normal boys” at a rate of about 1%, but at a much higher rate among high risk boys. The analysis concludes, “Assuming equal utility of benefits and harms, net clinical benefit is likely only in boys at high risk of UTI.”
In 2012, there were 1,570 new cases of penile (and other genital) cancer in the US. Like UTIs, the risk of penile cancer in the US is 1%, or 1 in 100,000. According to the National Cancer Institute, some, but not all, observational studies suggest that newborn male circumcision is associated with a decreased risk of penile cancer. However, when diagnosed early, penile cancer is highly curable.
SEXUALLY TRANSMITTED DISEASE (STD)
A new study, conveniently released the week before the publication of the new AAP circumcision statement, claims huge increases in future health care costs from the treatment of STDs if the rate of US circumcision falls to the European level. However, the study assumes that newborn circumcision prevents STDs and this has not been proven.
The studies that support a correlation between circumcision and a reduction in STDs, have been done among adult African men. It is unclear if the benefits of circumcision would be the same in newborn babies as they are in adult men. In addition, the African studies only show efficacy for penile-vaginal sex, not the primary mode of HIV sexual transmission in the US.
The CDC is more cautious than the AAP in response to these African HIV studies and suggests the possible benefit of circumcision for men in similar settings, not babies: “Accordingly, male circumcision, together with other prevention interventions, could play an important role in HIV prevention in settings similar to those of the clinical trials.”
A 2000 study examined the records of 354,297 boys born in Washington state hospitals from 1987 to 1996 and found that there was a complication in one of every 476 circumcisions, the most common being intraoperative bleeding and damage to the penis. According to the study’s author, Dr. Dimitri Christakis, ”Now, I can tell parents that one in 500 circumcised children may suffer a complication, and one in 100 children may derive a benefit. But people will weigh that differently. However, the vast majority of children will gain no medical benefit nor suffer any complication as a result of circumcision.”
In addition to the risks of bleeding, infection and disfigurement. is the risk of loss of penile sensation. According to pediatrician Paul Fleiss, MD, “Circumcision desensitizes the penis radically.”
WHAT’S A PARENT TO THINK?
While the new AAP policy on circumcision addresses anaesthesia, informed consent, and ethics in new ways, its primary purpose appears to be to ensure continued insurance reimbursement for circumcision, for without it circumcision in the US will continue to plummet as it did in England when coverage was withdrawn. Circumcision is the most common childhood surgery in the US and revenues from the procedure are in the hundreds of millions of dollars. In addition to revenue from the procedure itself, private hospitals sell infant foreskins for use in bio-tech research and cosmetic preparations.
It’s important to remember that nothing has really changed. The AAP still does not recommend circumcision and it never has. The AAP recommends breastfeeding, Vitamin D for babies, and no TV for toddlers, but not circumcision. Apparently, though the benefits of circumcision might outweigh the risks, the benefits are not compelling enough to actually recommend the procedure, only its reimbursement.
As parents we have to ask ourselves hard ethical questions about circumcision. If we are looking at the question from a religious perspective, our introspection will be personal and private. If we are looking at it from a medical perspective, we will have to weigh possible future benefits for our son—providing he is heterosexual, at high-risk for UTIs, and slow to seek medical care—against certain present risk.
Think it over. Regardless of your decision, someday you will have to explain it to your son.
Tags: American Academy of Pediatrics, CDC, circumcision, Dr. Dimitri Christakis, HIV, Medicaid, National Cancer Institute, National Inpatient Sample, Paul Fleiss, penile cancer, STDs, urinary tract infections