As officials with the American Academy of Pediatrics crafted their statement on circumcision, a highly anticipated show of qualified support for the procedure released Monday, they were fully aware that their report would come under fire.
Though the new report concludes that the decision of whether or not to circumcise an infant boy should be made by informed parents, the pediatricians group offered more support for the procedure than ever before. It cites several new studies that found benefits to circumcision, especially in preventing future sexually transmitted diseases.
Many critics of circumcision immediately challenged the report’s conclusions. The Circumcision Resource Center, which publishes a book called “Circumcision, The Hidden Trauma,” said the new AAP statement is the result of a “pro-circumcision bias” deeply rooted in American medicine and American culture.
Douglas Diekema, who served on the AAP task force that wrote the report and who specializes in pediatric bioethics at the Seattle Children’s Research Institute, said the group expected as much.
“For individuals who have decided that circumcision is wrong, no amount or quality of data will put these questions to rest. It is always possible to find potential weaknesses in any study. What the AAP report does is provide a critical assessment of all of the studies that have been done to date. There are clearly many studies of good quality that demonstrate that circumcision has potential medical benefits.”
Diekema agreed to explain more about the newly charged atmosphere around circumcision and how the task force came to its conclusions.
An edited version of our Q&A is below:
JD: Why issue a new report on circumcision now?
DD: It’s standard practice for the AAP to revisit all of its policies on a regular basis. The previous policy statement on newborn male circumcision was first approved in 1999. It was revisited in 2005, but the depth and breadth of studies looking at the relationship between circumcision and HIV and other sexually transmitted infections were not strong enough at that time to warrant a revision, so the existing policy was reaffirmed. Since that time, new scientific knowledge has accumulated about the medical benefits of newborn circumcision. In order to maintain a current policy, it was important that the scientific literature be reviewed and the policy updated.
If new studies suggest that circumcision can be medically beneficial, why did the AAP not recommend it outright?
Even when something in medical practice may benefit a patient, the level of benefit may not be so overwhelming that it would lead to a universal recommendation. Other factors may come into play in those situations, like the cost of the procedure, the parents’ values, or other nonmedical factors. In the case of circumcision, the likelihood that the benefits would accrue to an individual child are relatively small, and it seems reasonable that a child’s parents should be weighing the risks and benefits of the procedure in consultation with their physician.
In what areas, specifically, are you expecting pushback and from whom?
Most of the pushback will come from individuals and groups who are opposed to circumcision. Among other things, they claim that there are no medical benefits to circumcision. This is simply not supported by the data, which clearly shows that there are some potential medical benefits to circumcision.
The risks of an adverse event during circumcision are very low when performed by an experienced practitioner using sterile technique and adequate pain control, and the AAP task force concluded that the potential benefits outweigh these risks.
Others argue that circumcision should be delayed until a boy has attained the legal age of consent and can make the decision for himself.
While parents should consider that option, behavioral health surveys show that most young males become sexually active before the age of majority, so by delaying circumcision until males reach the age of majority, they would lose some of the protective benefit of circumcision. According to the CDC, almost 40% of 9th grade males in 2011 reported already having had sexual intercourse. Also, they would not benefit from circumcision’s demonstrated protection against urinary tract infections during the first year of life.
Just as importantly, circumcision in an older patient is more difficult and the complication rate is considerably higher. The safest time to perform circumcision is during the newborn period.
Is there a concern among pediatricians that this report will alienate the anti-circumcision folks and isolate them from the medical community (as has happened with some anti-vaccine folks?)
Pediatricians want to do what is best for their patients. The AAP policy and technical report on circumcision is intended to provide physicians with an assessment of the scientific knowledge we have about circumcision so that they can best counsel parents. That is more important than what certain groups might think about the report.
Anything else you think parents should know about the report and the process of preparing it?
The report was based on a thorough review of the medical literature. Whether or not to circumcise a baby boy is an important decision for parents, and it should be made thoughtfully. The child’s physician can help parents make that decision by sharing with parents the potential benefits along with the potential harms of circumcision. In addition, parents who decide to circumcise their child should make sure that the procedure is performed by trained personnel under sterile conditions with adequate pain control.
What are your thoughts on circumcision and whether the new AAP report may change minds about the procedure?