Benefits of circumcision outweigh risks, US pediatrics group says

Doctors, however, fall short of a universal recommendation of the procedure for all infants.

CHICAGO: The American Academy of Pediatrics has issued new guidelines saying the health benefits of infant circumcision outweigh the risks of the surgery, but the influential physician's group has fallen short of a universal recommendation of the procedure for all infants, saying that parents should make the final call.

The change was prompted by scientific evidence that suggests circumcision can reduce the risk of urinary tract infections in infants and cut the risk of penile cancer and sexually transmitted diseases, including HIV and the human papillomavirus or HPV, which causes cervical and other cancers.

Although the AAP's 1999 statement was fairly neutral, the new statement, published on Monday in the journal Pediatrics, comes down in favour of the procedure, saying the health benefits of newborn male circumcision "justify access to this procedure for families who choose it."

"We're not saying you have to have it," said Dr. Andrew Freedman, a pediatric urologist at Cedars-Sinai Medical Center in Los Angeles who chaired the AAP's circumcision task force.

"We're saying if a family thinks it is in the child's best interests, the benefits are enough to help them do that," he said.

Based on a review of more than 1,000 scientific articles, the task force said male circumcision does not appear to adversely affect penile sexual function, sensitivity of the penis or sexual satisfaction.

The AAP said parents should be given unbiased information about the procedure and be allowed to make the call on their own.

But the group did say it is imperative that those performing circumcision are adequately trained, that they use sterile techniques and offer effective pain management.

Growing debate

Circumcision, the surgical removal of the foreskin of the penis, is a ritual obligation for infant Jewish boys, and is also a common rite among Muslims, who account for the largest share of circumcised men worldwide.

The wider US population adopted the practice due to potential health benefits, but those advantages have become the subject of debate, including recent efforts to ban circumcision in San Francisco and Germany.

In Germany, the debate over circumcision has landed in the courts. Last week, an unnamed doctor in Germany filed charges against a rabbi for performing ritual circumcisions on infant boys, two months after a court in Cologne angered Jews and Muslims by banning the practice.

In the United States, the new guidelines may begin to turn the tide on infant circumcision, which has begun to fall in recent years as insurers have balked at paying for a procedure without a strong medical justification.

In as many as 18 US states, the Medicaid program for the poor has stopped paying for the procedure, a trend some doctors fear could significantly increase US health costs because of  increased cases of urinary tract and HIV infections.

"The American Academy of Pediatrics had formerly been on the discouraging side," said Dr Peter Richel, chief of pediatrics, at Northern Westchester Hospital in Mount Kisco, New York.

"If, indeed, we can cut down on a greater incidence statically of HIV or HPV, then I am certainly all for that."

'Short shrift'

In a statement issued on Friday in anticipation of the guidelines, the anti-circumcision group Intact America said most of the studies underlying the new guidelines are based on research done on adult men in Africa.

"The task force has failed to consider the large body of evidence from the developed world that shows no medical benefits for the practice, and has given short shrift, if not dismissed out of hand, the serious ethical problems inherent in doctors removing healthy body parts from children who cannot consent," said Georganne Chapin, the group's executive director.

Dr Douglas Diekema, a pediatric bioethicist from the Seattle Children's Research Institute and the University of Washington who served on the task force, said the group considered a wide range of ethical issues, including pain experienced by the child and whether parents have the right to make the decision without the child's consent.

"There is no decision you can make that doesn't potentially put a child at risk. If you choose to circumcise, there is a risk he'll grow up to be a man who wishes he wasn't circumcised," Diekema said.

Diekema said waiting until the child is older to make the choice about circumcision would lose much of these early benefits, and because the foreskin is thicker in a teen than in an adolescent, the procedure carries more risks.

"I really don't think there is an easy answer," he said.

What was clear, Diekema said, was the issue of pain.

"We were unanimously agreed that it's inappropriate to do this procedure without adequate pain control. That, in many ways, is one of the biggest ethical issues," he said.

Rabbi Shmuel Goldin of the Ahavath Torah congregation in Englewood, New Jersey, and president of the Rabbinical Council of America, said circumcisions done for religious purposes do not typically involve pain medication, but he noted that the procedure is quick and has a long tradition of success.

"We've performed it for centuries with no adverse effects to our children."

Even so, he worries about the lawsuits in Germany trying to ban circumcision.

"For us, it is such a critical component of our religious life that an attempt to eradicate it is an attempt to eradicate our religion. To have this happening in Germany, given our history, is particularly saddening to us."