Male circumcision is a common procedure, generally performed during the newborn period in the United States. In 2007, the American Academy of Pediatrics (AAP) formed a multidisciplinary task force of AAP members and other stakeholders to evaluate the recent evidence on male circumcision and update the Academy’s 1999 recommendations in this area. Evaluation of current evidence indicates that the health benefits of newborn male circumcision outweigh the risks and that the procedure’s benefits justify access to this procedure for families who choose it. Specific benefits identified included prevention of urinary tract infections, penile cancer, and transmission of some sexually transmitted infections, including HIV. The American College of Obstetricians and Gynecologists has endorsed this statement.
This policy automatically expired.
Systematic evaluation of English-language peer-reviewed literature from 1995 through 2010 indicates that preventive health benefits of elective circumcision of male newborns outweigh the risks of the procedure. 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.
The procedure is well tolerated when performed by trained professionals under sterile conditions with appropriate pain management. Complications are infrequent; most are minor, and severe complications are rare. Male circumcision performed during the newborn period has considerably lower complication rates than when performed later in life.
Although health benefits are not great enough to recommend routine circumcision for all male newborns, the benefits of circumcision are sufficient to justify access to this procedure for families choosing it and to warrant third-party payment for circumcision of male newborns. It is important that clinicians routinely inform parents of the health benefits and risks of male newborn circumcision in an unbiased and accurate manner.
Parents ultimately should decide whether circumcision is in the best interests of their male child. They will need to weigh medical information in the context of their own religious, ethical, and cultural beliefs and practices. The medical benefits alone may not outweigh these other considerations for individual families.
Findings from the systematic evaluation are available in the accompanying technical report. The American College of Obstetricians and Gynecologists has endorsed this statement.
Task Force on Circumcision
Susan Blank, MD, MPH, Chairperson
Michael Brady, MD, Representing the AAP Committee on Pediatrics AIDS
Ellen Buerk, MD, Representing the AAP Board of Directors
Waldemar Carlo, MD, Representing the AAP Committee on Fetus and Newborn
Douglas Diekema, MD, MPH, Representing the AAP Committee on Bioethics
Andrew Freedman, MD, Representing the AAP Section on Urology
Lynne Maxwell, MD, Representing the AAP Section on Anesthesiology
Steven Wegner, MD, JD, Representing the AAP Committee on Child Health Financing
Charles LeBaron, MD – Centers for Disease Control and Prevention
Lesley Atwood, MD – American Academy of Family Physicians
Sabrina Craigo, MD – American College of Obstetricians and Gynecologists
Susan K. Flinn, MA – Medical Writer
Esther C. Janowsky, MD, PhD
Edward P. Zimmerman, MS
American Academy of Pediatrics
This document is copyrighted and is property of the American Academy of Pediatrics and its Board of Directors. All authors have filed conflict of interest statements with the American Academy of Pediatrics. Any conflicts have been resolved through a process approved by the Board of Directors. The American Academy of Pediatrics has neither solicited nor accepted any commercial involvement in the development of the content of this publication.
All policy statements from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that time.
Gender Bias and Circumcision
The recent Policy Statement on Circumcision has been criticized for cultural bias, and it's critics have in turn been accused of the same thing. Whether or not either party is guilty of cultural bias, it is clear that both parties are guilty of gender bias. In weighing the evidence with regard to recommendation, no consideration whatever has been given to the consequences of transmitting HPV, a known cause of cervical cancer, or other STDs, to women or their offspring, nor was the pertinent literature reviewed in any depth.
Conflict of Interest:
Routine circumcision is insane
The evolution of mammals gained speed about 65 million years ago, when a meteorite fell on Yucatan and killed the dinosaurs. For all that we know, at that time, the mammals had a foreskin. If the mammal foreskin would be such a harmful piece of tissue as the pro circumcision lobbyists claim, it certainly would have fallen off during the 65 million years of evolution. However, mammals, including the human species, still have a foreskin. Rat is the most successful mammal on this planet. It has a foreskin. Evolution is merciless, and whatever mistakes it makes about the less important organs, such as the brain or stomach, it certainly knows best about the reproductive organs.
Therefore, the claim, that there are health benefits in excising a piece of healthy tissue from the penis of a healthy neonate, is as absurd as would be the claim that amputating the left little finger of a neonate has health benefits. However, if you would make such an absurd claim, either of the prepuce or of the left little finger, you would have to provide the highest level of proof according to the principles of evidence based medicine. This means several randomized controlled studies performed by independent researchers, all having the same result. There is no such evidence, neither of the prepuce nor of the left little finger.
The AAP is having a "Circumcision task force". This is as absurd as having a task force for "The Routine Amputating of the Left Little Finger of a Neonate". Is the AAP insane? To an European Paediatric Surgeon it seems so.
Conflict of Interest:
Revised male infant circumcision policy: A disservice to Americans
The American Academy of Pediatrics (AAP) revised statement on male infant circumcision claims "the benefits of circumcision may exceed the risk of complications" but the AAP fails to recognize the sensory and mechanical function of the human foreskin. The foreskin is richly innervated, erogenous tissue which enhances sexual pleasure and it also provides a unique, linear gliding mechanism during sexual intercourse. In 2009, the College of Physicians and Surgeons of British Columbia stated "the foreskin is rich in specialized sensory nerve endings." In 2010, the Royal Australian College of Physicians stated "the foreskin is a primary sensory part of the penis, containing some of the most sensitive areas of the penis" and in the same year, the Royal Dutch Medical Association concluded "the foreskin is a complex erotogenic structure that plays an important role in the mechanical function of the penis during sexual acts." The AAP statement fails to consider the obstinate relationship between structure and function as it pertains to the foreskin; circumcision alters the structure of the penis which inevitably alters function. The long term harm and sexual side effects of circumcision have not been adequately studied.
The revised statement also claims "circumcision may decrease the risk of heterosexual HIV transmission" and is supported with selective evidence from randomized control trials from Kenya, Uganda and South Africa. These trials reveal a number of methodological weaknesses and they contradict larger demographic trends in global HIV prevalence. For instance, the United States has a high prevalence of circumcision, yet has a significantly higher rate of HIV infection compared with countries like Sweden and Japan where the prevalence of circumcision is very low. Behavioural factors greatly overshadow any potential protective effect of circumcision and should be the focus of effective and ethical prevention strategies. Even if the African trials were scientifically valid, the evidence can not be applied to justify infant circumcision in North America where the incidence of heterosexual HIV transmission is low.
The revised statement also claims "circumcision may decrease the risk of urinary tract infections" yet the AAP ignores the wealth of international medical evidence to the contrary. Even if circumcision provided complete protection against urinary tract infections, this practice could never be justified based on the ethical principle of proportionality - there are effective and less destructive therapies available for preventing and treating urinary tract infections which do not involve the prophylactic removal of healthy genital tissue.
The AAP's revised statement ignores the inherent conflict of circumcision with contemporary medical ethics. Infant circumcision violates the fundamental ethical principles of autonomy, beneficence and primum non nocere. Medical associations in the Netherlands, Finland, Sweden, Norway, Denmark, Germany and other countries have stated that there is no justification for performing the procedure without medical urgency. Medical associations in these countries are calling for the practice to stop due to ethical and human rights concerns. The AAP's new position statement does a disservice to American parents and children.
Respectfully, Christopher L. Guest M.D., F.R.C.P.C.
Conflict of Interest:
1)A mandatory disclosure should be made whether the person conducting the study is himself circumscribed.Let us not be too sure of our science-- even Einstein missed discovering Quantum Mechanics even though it was right under his nose -- by his religious beliefs. 2)It is the mob (people around the baby, like father,religious person) who make the decision violating the Individual Rights of baby. 3)Any science which violates Individual Rights can only claim to be science is way similar to the shameful claim that dialectical materialism is a science. Again Aristotelian earth centric ideas was a "science" while violating the Individual rights of Galileo
Conflict of Interest:
Re:CIRCUMCISION ASSOCIATED WITH A REDUCTION IN RISK OF PROSTATE CANCER
As Dr Dickerman recorded, the significance of Wright's finding for men circumcised before sexual debut (OR 0.85, 95% CI, 0.73-0.99) was marginal. No significance was found between ever-circumcised men and never-circumcised men (0.87, 0.74-1.02), and men circumcised after sexual debut were slightly but non-significantly more likely to be diagnosed with prostate cancer than never-circumcised men (1.15, 0.75-1.77), so it is this that accounts for such correlation as was found. And as Dr. Gerald Chodak points out, the control group was not all known to be free of prostate cancer, but just assumed to be so, when undiagnosed prostate cancer (found on autopsy) is very common in older men.1
Even if the claim were valid, cutting parts off the genitals of babies to slighly reduce a cancer of old men commonly treated by watchful waiting is not good medicine. Yet this claim was widely publicised, like so many before it - and like so many cited in the AAP policy - as an indication for prophylactic circumcision of newborns.
1. Chodak, G, Circumcision Hype? Medscape Urology, http://www.medscape.com/viewarticle/760729 accessed September 16, 2012
Conflict of Interest:
I maintain the Intactivism Pages, www.circumstitions.com
CIRCUMCISION ASSOCIATED WITH A REDUCTION IN RISK OF PROSTATE CANCER
Circumcision before first sexual intercourse was associated with a 15% reduction in risk of prostate cancer (95% confidence interval [CL], 0.73-0.99) (1). Residents of Kings County, Washington, 88.3% Caucasian and 11.7% African-American, were evaluated and data from 1754 cases of prostate cancer were matched with 1645 controls. Multivariate logistic regression was used to establish the relative risk of prostate cancer by circumcision status. Infection and inflammation in the prostate may be important mechanisms that increase the risk of subsequent development of prostate cancer in some men. It has been demonstrated that circumcision reduces the risk for acquiring sexually transmitted diseases.
REFERENCES (1)WRIGHT JL, Lin DW, Stanford JL. Circumcision and the risk of prostate cancer. Cancer 2012; 118: 4437-4443.
Joseph D. Dickerman, M.D. Professor of Pediatrics University of Vermont College of Medicine Burlington, Vermont
Conflict of Interest:
Being honest about medical involvement that contravenes "first of all, do no harm"
Following the retraction of its policy on female genital mutilation in 2010 (1,2,3,4), the American Academy of Pediatrics (AAP) seems determined to court controversy again (5). What is puzzling is that apparently "new scientific evidence shows the health benefits of newborn male circumcision outweigh the risks of the procedure" - sufficient to justify third party payment and endorsement by the American College of Obstetricians and Gynaecologists - and yet "the benefits are not great enough to recommend routine circumcision for all newborn boys"(6).
The AAP dithers between envisioning neonatal circumcision as a benefit rather than 'the lesser of two [harms] evils' and cannot have it both ways: Either infant male circumcision is better for health and thus has a 'therapeutic' indication for all or it isn't - and has to be classified as 'cultural', 'religious', 'habitual', 'cosmetic' or 'mutilation'. Prophylactic pediatric surgery arguments are weak - we would not accept disease eradication via routine tonsillectomy or appendicectomy, for example, just because some children avoid problems later and certainly not without randomised trial evidence. There are no comprehensive and reliable statistics on the known, albeit rare, serious risks of death and damage (7, 8). The literature on circumcision complications is subject to underreporting and bias as it relies on case reports and is probably compounded for non-hospital procedures. If neonatal circumcision is beneficial, it should be recommended for all (accepting that parents do not have to take the advice). If it is not beneficial (or risky or harmful), then society can either (i) allow some leeway for parents to harm their infants (with or without medical collusion), or (ii) disallow it until boys are of an age to make their own decisions. The latter makes particular sense as most purported benefits relate to possibly preventing diseases and disorders, such as HIV acquisition, that will not occur until maturity.
The key question is whether the AAP brings the medical profession into disrepute when reading the scientific literature in an unsystematic way and legitimising non-therapeutic procedures by 'medicalisation'. Should we be suprised to find the practice supported by those with a cultural, religious or financial vested interest? The conflict of interest statements are not published with the policy. In the UK National Health Service, despite similar official equivocation (9,10) OB-GYNs do not perform neonatal circumcision and only 0.2% of newborn boys are circumcised (11). Female genital cutting or mutilation is illegal in the UK as well as the USA (12,13,14). Do newborn boys not deserve equal protection?
1. AAP Board of Directors Ritual Genital Cutting of Female Minors Pediatrics Vol. 126 ( 1) 191-192, July 1, 2010. 2. Strandjord SE. Opportunity for Education Plus Protection of Minors. Pediatrics eLetter published May 17 2010 http://pediatrics.aappublications.org/content/125/5/1088.short/reply#pediatrics_el_50347 3.Bewley S. Sincerity, retraction and apology. Pediatrics eLetter published June 1 2010. http://pediatrics.aappublications.org/content/125/5/1088.short/reply#pediatrics_el_50347 4.Bewley S. Female genital mutilation. BMJ 2010 Jun 2: 340:c2728. 5.AAP Task Force on Circumcision, Circumcision Policy Statement, Pediatrics 2012 Sept: 130:585-586 6. AAP Press Release August 27, 2012, http://www.aap.org/en-us/about-the-aap/aap-press-room/Pages/New-Benefits- Point-to-Greater-Benefits-of-Infant-Circumcision-But-Final-Say-is-Still-Up -to-parents-Says-AAP.aspx 7. Williams N. Complications of Circumcision. Br J Surg. 1993 Oct;80(10):1231 8. Circumcision Information and Resource Pages http://www.cirp.org/library/complications/ accessed September 6 2012 9. British Medical Association. The Law and ethics of male circumcision. Guidance for doctors. June 2006, http://bma.org.uk/practical-support-at- work/ethics/children accessed September 6 2012 10. British Association of Paediatric Surgeons, The Royal College of Nursing, The Royal College of Paediatrics and Child Health, The Royal College of Surgeons of England and The Royal College of Anaesthetists. Statement on Male Circumcision March 6, 2007 http://www.rcseng.ac.uk/media/medianews/statementonmalecircumcision 11. Cathcart P, Trends in paediatric circumcision and its complications in England between 1997 and 2003. Br J Surg. 2006 Jul;93(7):885-90 12. Ending female genital mutilation United Nations Resolution E/CN.6/208/L.2/Rev.1 http://www.un.org/womenwatch/daw/csw/csw52/AC_resolutions/Final%20L2%20ending%20female%20genital%20mutilation%20 -%20advance%20unedited.pdf accessed September 6 2012 13. Public Law No. 104-208, 30 September 1996 [Sections 579, 644, and 645]. 1995 Prevention
of Female Genital Mutilation Act, (USA) http://www.hsph.harvard.edu/population/fgm/usa.fgm.86.htm 14. Female Genital Mutilation Act 2003 (UK) http://www.legislation.gov.uk/ukpga/2003/31/contents
Conflict of Interest:
Conflicts of interest: None declared for SB. SS is Board Certified in Pediatric Hematology/Oncology and thus performs consultations on babies with bleeding complications of circumcision, including a couple of near-miss exsanguinations.
Circumcision Report is Flawed
The American Academy of Pediatrics circumcision report has many serious deficiencies. It ignores effects of circumcision pain on infants, two dozen surgical risks including death, functions of the foreskin, connections between circumcision and erectile dysfunction, trauma of circumcision, psychological harm to men, using condoms to prevent STDs, conflicts with its own bioethics committee, lack of true informed consent, and unknown harms that have not been studied. Instead it continues the endless search for a medical "benefit" that started in the late 1800s. Circumcision is a solution in search of a problem.
The AAP report also conflicts with circumcision positions in other countries that recommend against circumcision or are discussing restricting it. Other countries recognize the inherent physical, sexual, and psychological harm of circumcision and that it violates medial ethics to cut off a natural, healthy, functioning body part. Ignore the report. Just watch a circumcision video and trust your feelings.
Conflict of Interest:
Re:The Recommendation for universal newborn male circumcision is an overgeneralization
Dr Gupta, in his response to the AAP Policy statement, implies that the Academy recommends universal newborn male circumcision, when in fact the policy statement clearly does not make that recommendation. Rather, the Academy's Policy states is that the data justifies the risks compared with benefits, leaving parents free to choose. Asked by parents, I would now be able to report that the Academies (of Pediatrics and Ob/Gyn) feel that cicumcision is acceptable, and that benefits outweigh risks. If asked for my own professional opinion, I would recommend that purely elective circumcision be done as a newborn, or deferred until a male can decide for himself at age 18 years or older.
Conflict of Interest:
The Recommendation for universal newborn male circumcision is an overgeneralization
While the data presented in some of the studies cited in this technical report are incontrovertible1, it is unclear if they can be extrapolated to populations that are at low risk for HIV infection and other STD. In the United States the prevalence of HIV infection and STDs varies widely among people of different races and ethnicities. For example, the prevalence of HIV infection among whites is 224.3 per 100,000, as compared to 1,715.1 per 100,000 in African Americans and 2700 per 100,000 in the African studies.2,3 The population attributable risk of HIV and STD in uncircumcised males is likely to be lower in populations where the prevalence of HIV is lower and higher numbers will be needed to treat to prevent one case.3 With regard to UTI in male infants, prevalence data on UTIs are based upon either clinic or ED studies of febrile infants and are not population prevalence.4 UTI is found in about 8% of febrile males below the age of 3 months and this proportion falls sharply thereafter and the sex ratio reverses.4 Extapolating the data to all newborns, febrile or non-febrile will lead to a lot of unnecessary circumcisions. Rates of UTI in infants are also affected by race with African Americans having a significantly lower rate than White Americans in a metanalysis.4 The rates in Asian and Pacific Islanders and other races and ethnicities are not well known. Whether the risk of STDs and UTIs can be mitigated by proper foreskin hygiene has not been studied with controlled trials. Hygiene habits are a modifiable behavior even among high risk populations.5 The recommendation for universal male circumcision is premature until effectiveness of circumcision over good penile hygiene is studied in a randomized controlled trial. Your recommendation for pediatricians to offer circumcision to every male newborn is an overgeneralization. Thankfully you acknowledge that some families do not opt for circumcision of religious and identity reason (a significant number in the United States and an even more significant number in Europe and other countries), and offer guidance for them about caring for an uncircumcised penis.
Vidya Bhushan Gupta, MD, MPH, FAAP Professor of Clinical Pediatrics New York Medical College
1. American Academy of Pediatrics. Circumcision Policy Statement. Pediatrics. 1999 (reaffirmed in 2005) and again on August 27, 2012;103:686 -693. 2. HIV prevalence estimates in the United States, 2006. MMWR. 2008;57:1073 -1076. 3. Wawer MJ, Makumbi F, Kigozi G, Serwadda D, Watya S, Nalugoda F, Buwembo D, Ssempijja V, Kiwanuka N, Moulton LH, Sewankambo NK, Reynolds SJ, Quinn TC, Opendi P, Iga B, Ridzon R, Laeyendecker O, Gray RH. Circumcision in HIV-infected men and its effects on HIV transmission to female partners in Rakai, Uganda: a randomized controlled trial. Lancet. 2009;374:229-237. 4. Shaikh N, Morone NE, Bost JE, Farrell MH. Prevalence of urinary tract infection in childhood: a meta-analysis. Pediatr Infect Dis J. 2008;27:302 -328 5. Schneider JA, Dude A, Dinaker M, Kumar V, Laumann EO, Holloway-Beth A, Oruganti G, Saluja GS, Chundi V, Yeldandi V, Mayer KH. General hygiene, sexual risk behaviour and HIV prevalence in truck drivers from Andhra Pradesh, South India: implications for prevention interventions. Int J STD AIDS. 2009; 20:39-45. 6. Brady MT. Newborn circumcision: routine or not routine, that is the question. Arch Pediatr Adolesc Med. 2010;164:94-6. 7. Krueger H, Osborn L Effects of hygiene among the uncircumcised. J Fam Pract 1986; 22:353-355
Conflict of Interest:
How about the simple fact that there is absolutely no penile cancer in circumcised males? How about because the transmission of HPV is much reduced by circumcised males, thus presenting less of a hazard to females? How about because circumcised males transmit less HIV and other STDs? Scientifically it's a "no brainer." Also, 4000 years of Judaism proves that there is no danger to the health of males of an entire cultural group. I'm less familiar with Moslems, but I think that they would testify to the same benefit. The movement against circumcision has been much more about politics than about a scientific approach to the health of the male who is circumcised...as well as the sexual partners of such patients. I find no compelling scientific and empiric evidence at all that supports a ban such as the AAP once attempted, and which is now in place in several European nations.
Conflict of Interest:
The New AAP Circumcision Policy: Wrong in Fact and Law
The American Academy of Pediatrics asserts that the health benefits of newborn male circumcision outweigh the risks, that parents have the right to make the circumcision decision for religious, cultural, or other reasons, and that insurance such as Medicaid should pay for it. The AAP is wrong on all counts.
As to the facts, the surgery risks catastrophic injury and death (which the AAP has never acknowledged), and harms all boys and men without conferring any real benefits. Among other disadvantages, it is painful, irreversibly amputates living tissue, radically alters the appearance of the penis, destroys normal sexual function (as anyone can see), removes the most sensitive parts of the penis, reduces penile girth and length, and leaves a scar. It does not benefit infants, who are not at risk of penile cancer or STD's, and men must still wash and practice safe sex to avoid those diseases.
As a legal matter, the rule is that physicians cannot operate on healthy children. Boys, like girls and adults, have absolute rights under the common law, constitutional law, and human rights law to bodily and hence to genital integrity, to be free from harm, and to choose their own religion or no religion. Physicians cannot take orders from parents for reasons having nothing to do with medicine. Physicians and parents also cannot lawfully circumcise boys because men rarely choose circumcision for themselves. In fact, physicians and parents have a legal duty to protect boys from circumcision.
As to Medicaid, it only covers necessary health care, not elective cosmetic surgery. Medicaid claims for circumcision are false claims against the government.
We condemn the AAP's new circumcision policy. We call for more than a retraction. The AAP should tell its physicians to stop cutting body parts off of our helpless, trusting, vulnerable children.
Conflict of Interest:
Every time I read one of these I ask the same question, and I never get a good response.
Where is your analysis on the correlation between aggressive children being predisposed to playing violent games?
Why does the game make the child aggressive? Why isn't it the already aggressive child being drawn to the game?
Frankly, any study on this matter that is done via survey, can be considered a joke. The confidence in the conclusions being made is shocking.
Lastly, I leave you with this. Why are video games under such a microscope? There are a lot of football and hockey playing children out there that never play video games but are far more aggressive than any video game player.
Sounds like lot of time, money, effort, wasted on trying to prove something that cant be proven using the methods that have been tried to date. It's not an important subject. It's a sensational subject.
Quit your jobs.
Conflict of Interest: