Circumcision: The Flap Over Foreskin Continues

Circumcision's health benefits are getting new scrutiny.

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The flap over a flap of skin—foreskin, to be precise—is heating up again, as two influential groups are re-examining the medical merits of circumcision in light of recent findings and are prepping to release new appraisals of the controversial procedure, a story in the Washington Post points out. Long a cultural and religious given, circumcision has increasingly become a medical issue, as growing evidence suggests that it may offer health gains, and to a greater degree than thought in the past. Opponents of circumcision nevertheless call the procedure unnecessary and compare it to female genital mutilation; many contend that it's child abuse and argue that parents should wait until boys are old enough to decide for themselves.

The Post story noted that the Centers for Disease Control and Prevention, which has never before issued public-health recommendations on circumcision, is expected to release a draft this summer and will most likely weigh in on whether newborns, and even adult males, should get snipped. The final version would serve solely as guidance to parents, individuals, and doctors, according to an agency spokeswoman, and not be a public-health mandate. Meanwhile, the Post added, the American Academy of Pediatrics is mulling over whether it should revise its policy on circumcision, adopted in 1999 and reaffirmed in 2005, which states: "Existing scientific evidence demonstrates potential medical benefits of newborn male circumcision; however, these data are not sufficient to recommend routine neonatal circumcision."

[For more background on the CDC and circumcision, read Should Circumcision Become Public Health Policy?]

It's unlikely that the AAP will adopt a more negative position, speculates Douglas Diekema, a member of the academy's task force on circumcision and head of education at the Treuman Katz Center for Pediatric Bioethics at Seattle Children's Hospital, because "there's a substantial amount of new data that's occurred in the last 10 years. Most of it's related to HIV and STDs and the impact of circumcision." Given that the data are strong enough to capture the CDC's attention, he says, "what most people are interested in is whether we will change our stance of one that's relatively neutral to one that's perhaps more in the direction of recommending the procedure and [make] the statement that there are medical benefits. That's what we're facing."

A review paper published last week in the Archives of Pediatrics & Adolescent Medicine summarized the latest evidence, including the results of highly publicized randomized trials in Africa finding that men who were circumcised as adults had a significantly lower risk of contracting HIV from an infected female partner—on the order of 50 to 60 percent lower—as well as a 30 percent lower risk of catching herpes and human papilloma virus. Female partners of circumcised men also appeared to be benefiting, with lower rates of bacterial infections and HPV, a major cause of cervical cancer, says Ronald Gray, a professor and expert on epidemiology and infectious disease at the Johns Hopkins Bloomberg School of Public Health and an author of the review paper who coconducted some of the African research. How much relevance the African trials hold for the United States, in terms of HIV prevention, is debated; in Africa, the virus is more prevalent and is largely spread through heterosexual rather than homosexual intercourse, as is the case here. "I think we can say that among heterosexual men in the U.S., the evidence is completely consistent with the African findings," says Gray. More research is needed, however, to see if circumcision can "definitively" cut the risk of infection in men who have sex with other men, his paper states.

Still, says Gray, on the issue of health benefits: "If you think of this as the scales of justice, I think that the evidence that we have accumulated in the past few years has tipped those scales, and I think parents really need to know." When asked about the purpose of his team's review paper, he says, "To be very honest, we wanted to hold [the AAP's] feet to the fire," so it will come up with guidelines for pediatricians and obstetricians that will fully inform parents and help them make a decision that's in the best interest of their baby. Pediatricians, he notes, are often faced with a dilemma since most of the benefits that are likely to accrue from circumcision, save for a potential reduction in urinary tract infections within a baby's first year of life, would occur in adulthood, when young men become sexually active. When weighing the risk of complications from circumcision against benefits that might not accrue for 20 years, pediatricians probably put greater emphasis on the short term, even though the risk to the infant is small, he says. (Other health benefits of circumcision apparently may include a reduced risk of developing penile cancer and no risk of experiencing a condition called "phimosis," when the foreskin painfully retracts, according to a patient advice sheet also published in last week's Archives.)

But the authors of another review paper published last week in the Annals of Family Medicine, which also included the African trials, reached a conclusion different from Gray's. While it may be tempting, based on those and other studies, to want to prescribe routine circumcision for all newborns in the name of prevention, the effectiveness of pre-emptive circumcision against things like sexually transmitted diseases "has not been comprehensively studied in neonates," the authors wrote. Thus, "it would be inappropriate to recommend widespread neonatal circumcision for this purpose." Furthermore, people considering circumcision for its proposed medical benefits "must be made aware of the lack of consensus" on the matter, even when it comes to adult circumcision, as well as the procedure's potential harms.

Circumcision is less risky when performed on newborns than on older children and adults, says Diekema. The most common complications are bleeding and infection, which tend to be minor and easily controlled, he says; tip-of-the-penis amputations have been known to occur, he says, though they're "extraordinarily rare" and mostly happen when the operation is done by untrained providers. Men may experience psychological side effects like "castration anxiety" or find themselves unhappy with the results, according to the Annals paper. Some opponents argue that circumcision exacts a lasting toll on men's sex lives, though Diekema says he finds in the data "no compelling reason to believe it impacts sexual satisfaction or dysfunction." However, adult circumcision may cause problems if men have sex before allowing their wound to heal properly.

What the CDC and AAP will ultimately say remains unknown, but the potential impact of their adopting more positive recommendations could be to spur more coverage by Medicaid, says Gray; in the decade since the AAP took its neutral position in 1999, U.S. News previously reported, Medicaid has ceased covering the cost of the operation in a number of states. The rate of infant circumcision in states without coverage is almost 25 percent lower than in states with coverage, Gray says, disadvantaging the disadvantaged.

For now, Diekema's advice to expecting parents is to find a good pediatrician and have a thorough conversation about the upsides and downsides of circumcision. "I don't think there is a wrong decision, but I do encourage parents to think about it—be aware of the risks and benefits," he says. "My preference would be that parents don't make a knee-jerk decision but make a thoughtful one." Gray agrees. "I don't want to impose my views on parents for something that is as culturally and sexually sensitive as this kind of surgery," he says. Since parents can't get the consent of their child, it's important that they act in the best interest of their child as they see it.

The bottom line for the circumcised? It's only partially protective against sexually transmitted infections, Gray says. "You've got to practice safe sex, period." Monogomy, he adds, also helps.

[Read U.S. News Health editor Bernadine Healy's take on the issue.]