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AAP and Circumcision: What's a Parent to Think?





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


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.”


PENILE CANCER


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.”


THE RISKS


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.


Peggy O'Mara  (101 Posts)

Peggy O’Mara founded Mothering.com in 1995 and is currently its editor-in chief. She was the editor and publisher of Mothering Magazine from 1980 to 2011. The author of Having a Baby Naturally; Natural Family Living; The Way Back Home; and A Quiet Place, Peggy has lectured and conducted workshops at Omega Institute, Esalen, La Leche League International, and Bioneers. She is the mother of four.

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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





Comments (53)

Just a quick request (as I agree with Peggy on the content of the blog post)...would you mind changing the photo or at least warning people that when they click through that there will be a photo of a baby being circumcised? My imagination is more than good enough--I don't need a relatively traumatic visual to go with the article.
"...the risk of penile cancer in the US is 1%, or 1 in 100,000." Shouldn't that be 0.001%?
'wishin'&hopin', I witnessed my both of my son's circs in person. The pic you find distressing is barely showing anything - no blood, just a crying baby and tools. Nothing compared to what I saw done to my second son. He was given anaesthesia, which must not have worked, the cutting went around and around while he screamed himself hoarse and then threw up violently afterwards, and then could not be calmed enough to nurse. (The first son had a simple snip which he slept through!) I will live with my regret over both of their circs till my dying day, and my sons will have to live with their surgically altered bodies till their dying day. My husband wanted them to 'look like everyone else, look like daddy'. Now I realize how stupid and superficial that idea was. I do NOT look forward to the day I have to talk to my sons about what we (all) decided to do to them when they were defenseless infants.
I appreciate this article in its impartiality (for the most part). Thank you for commenting on the facts and not attempting to illicit an emotional response to convince parents one way or the other. It is distressing to see that in most cases, when researching this topic, too many people are so far convinced one way or the other, that the information is not presented in a objective manner. This is extremely distressing to me as I prefer sound, solid arguments when I research topics such as this.
I agree. My stomach is upset. I realize that the photo is probably placed for shock value. However, I think anyone reading Mothering magazine is probably reading with an open-mind. Although there is an emotional piece wrapped up in circumcision, it is not relevant to the facts of the article. Thank you.
My older son is intact. He now has a stepbrother the same age. When my husband and I were having a heated discussion about whether or not to circumsize our baby when he was born, the older boys started asking questions. We were very open with them. The concensus of the boys was that we should not alter their baby brother, and that doing so to "look his dad" would be "stupid." Neither boy remembers ever seeing their dad's penis, and probably would have simply thought it look different by virtue of being a grown man's, and hairy. The conversation ended with my preteen stepson asking his dad why he was "mean enough" to have the procedure done to him. "Why couldn't you have left mine alone too?" In the end we chose to circumsize our newborn, as my husband researched it and felt very strongly. I think parents need to be informed and thoughtful.
I cannot help but wonder when reading about circumcision why it is no one talks about some of the negative effects of circumcision? What about the loss of sensitivity for the man during sex? What about the callous that has to develop over the glans to protect the very sensitive membrane covering the head of the penis? What about the job of the foreskin to maintain lubrication of the glans and allow free movement of the penile shaft during sexual intercourse? What about skin bridges and/or scarring that causes the penis to bend during erection to the right or to the left? Why does no one ever talk about that?...
I agree completely! While researching circumcision I found the same to be true. Most websites and/or documents were either for or against it and presented info as such.
I am aware that this picture is "tame" (I've attended a bris and seen a variety of surgical procedures), but do feel that folks should be aware when they "click" that they will be seeing a photo of a screaming baby experiencing a circ...in the forums most folk are kind enough to alert others that what they are writing may be "triggering", I wish this blog post had the same warning.
Agreed. ...and how about the affect this has on a circumscribed man's partner and their sexual relationship? Yes, these facts are important too.
We have two boys, both of whom are circumcised. My husband and I talked about it very earnestly when we were pregnant with our first, read all the research, and made our decision based on what we consider to be an educated and thoughtful study of the matter. Because the research is so benign on both sides every one needs to remember that is is a personal decision made by the parents and should be respected as such. I don't judge my friends who don't circumcise their children but because it's so trendy right now not to do it I have had quite a few associates accuse me of things like "genital mutilation", "child abuse" and other extremely offensive things. I don't know any grown circumcised men who hold long lasting resentful towards their parents for snipping the tip. I doubt my boys will ever really think about it. In my book it's on par with something like ear piercing. I probably wouldn't pierce my infant daughter's ears but I don't care if other people want to do it to theirs.
Intricate nerve-endings preclude circumcision being likened to earlobe piercing.
A story about babies being circumcised should be illustrated with a picture of a baby being circumcised - close up and in detail would be even better. Enough of these bananas, Egyptian papyri, babies' feet, and kitchen utensils! If they could be illustrated with videos of babies being circumcised - there are plenty on YouTube - the rate of circumcision would plummet.
That's the annual risk. The lifetime risk is well under 1 in 1000 or 0.1%, meaning even if it was 100% protective - and it isn't - that's 999 circumcisions, with all their risks and harm, wasted.
To this day bonafide peer-reviewed medical research has not clearly proved that routine circumcision of newborns signifcantly prevents disease ( definitely not enough to actually recommend this surgery on a routine basis; the AAP still does not recommend it). If there are diseases there are doctors who observe that these can in many cases be treated equally well by antibiotics. Eye infection, nose bleed and hangnail can readily be prevented by removing those body parts but why would someone do that? Some very renowned doctors have argued effectively that the human foreskin may serve healthy immunological and sexual functions to the male and that cutting it off is counterproductive in the maintenance of health. Bottom line is that most of the world's boys are left intact with no detriment to health because of it. In the view of some, this is a cultural issue and not a health one. Personal decision means the baby and he does not want it done for obvious reasons; there are no really sound reasons on why it should be done on a routine basis without clear medical indication. It is difficult for many people around the world to understand why it should be done on a routine basis given the pain and trauma involved to the neonate apparent in the photo. It is puzzling for many people to contemplate and seems counterintuitive.
I have to say, I have heard the "ear piercing" argument a few times before-- and,while I too would never pierce someone's ears (ie a child) until they were ready to make their own decision about it, ear piercing is NOT to be compared to cutting off a piece of your child's anatomy without their consent. I myself didn't get my ears pierced until I was in my 20's and remember a slight prick, not a gut-wrenching pain that may have caused me to not be able to eat, throw up, etc. I also stopped wearing earings and my holes closed up, as though it had never happened! Cutting a newborn and piercing one's ears like comparing is apples and oranges. I also would like to say that as a parent educator/teacher of young children, circumcsion is often discussed and I have had conversations with men who ARE upset with their parents for "snipping the tip" (or cutting part of their body off, as I see it) There have been very difficult conversation about this. If you do the research, you will actually find many support groups out there.
Then allow me to introduce myself, Robynn. I'm a grown man who STRONGLY resents his parents for having circumcised him. There are many of us out there, who feel sexually violated because of this. Most of us speak out anonymously online because we're afraid of being shamed in public. The "snip" you talk about ends up being 6 square inches of erogenous, specialized tissue, nearly 50% of the skin on the human penis. People who cut their sons should be aware they made a terrible, terrible mistake. It needs to stop. Now.
Robynn most men will not talk about what has happened to us. I for one, am beyond mad at being cut and have been since I found out I was cut! Imagine, being a boy and finding out that someone cut your penis! As a father, I could never do something so drastic to my son (and he is intact)
Robynn most men will not talk about what has happened to us. I for one, am beyond mad at being cut and have been since I found out I was cut! Imagine, being a boy and finding out that someone cut your penis! As a father, I could never do something so drastic to my son (and he is intact). What gives a parent the right to surgically remove a body part for no medical reason? I don't understand the thinking in this country that it's a parents right! It makes me want to throw up! And yes, I have suffered greatly from my botch circumcision. How would you feel if you tore and bleed when sexual aroused?
And who has the tip cut off? Mine was way more than just the tip!
Mothering › Blog Posts › AAP and Circumcision: What's a Parent to Think?