Expectant parents face many anxieties in preparing for a child. For those who have a son, there is an extra complication: deciding whether to keep his foreskin or have it snipped off.
On 27 August, a report by the American Academy of Pediatrics (AAP) concludes for the first time that, overall, boys will be healthier if circumcised1. The report says that although the choice is ultimately up to parents, medical insurance should pay for the procedure. The recommendation, coming from such an influential body, could boost US circumcision rates, which, at 55%, are already higher than much of the developed world (see ‘Cuts by country’). “This time around, we could say that the medical benefits outweigh the risks of the procedure,” says Douglas Diekema, a paediatrician and ethicist at the University of Washington, Seattle, who served on the circumcision task force for the AAP, headquartered in Elk Grove Village, Illinois.
The recommendation is also sure to stir up debate. The practice of circumcision cuts deeper than the body, tapping into religious rituals and cultural identities. What is a harmless snip to some signifies mutilation to others. And in the developing world, many see it as an essential life-saving measure. Condoms are more effective at preventing disease, but are not used consistently.
Diekema says that the task force’s reviews of the latest medical evidence allowed it to make stronger policy recommendations than it did in 1999 and 2005. Perhaps the most powerful evidence in favour of circumcision comes from randomized controlled trials in South Africa2, Kenya3 and Uganda4. These found that, for men who have sex with women, circumcision reduced the risk of infection with HIV. (No protection was observed for men who have sex with men.) The South African and Ugandan trials also found that circumcision reduced infection rates for human papillomavirus (HPV) and herpes. The World Health Organization has already made circumcision part of its HIV-prevention strategy in sub-Saharan Africa, with a goal to circumcise 20 million men by 2015.
The AAP found that, in addition to preventing sexually transmitted infections, circumcision could reduce the rates of urinary tract infections and penile cancer, probably because the foreskin harbours infectious microbes as well as the immune cells targeted by HIV. The most common complications of circumcision — oozing, bleeding and infection — occur in 2% or fewer circumcisions and are easily treated. More serious complications are exceedingly rare, says Diekema. The task force also found no strong evidence that circumcised babies grew up with more urinary difficulties or sexual problems.
Gert van Dijk, an ethicist at the Royal Dutch Medical Association in Utrecht, the Netherlands, thinks that the AAP has underestimated the potential harm of circumcision. He says that it should only be performed when men are old enough to give consent, and disagrees with the AAP that circumcisions are simplest and safest when performed on infants. The very idea of asking whether circumcisions are beneficial is strange to Europeans, van Dijk says. “The integrity of the body is an important thing. We would never amputate a healthy part of a child.”
Van Dijk notes that the benefits cited in the African studies do not apply to the Netherlands, where HIV transmission is rare and occurs mainly through sex between men and through needle-sharing among drug users.
Rowena Hitchcock, president of the British Association of Paediatric Urologists, says that she is disappointed with the AAP policy because it recommends an “irreversible, mutilating surgery”. She says that her organization is considering a review of its current policy, which recommends circumcision for infants who are at severe risk of urinary tract infections, because the evidence of medical benefit is not definitive.
The number of circumcisions required in order for the wider population to avoid disease may explain some of the national differences in policies and rates. Most men are unlikely to get the infections that circumcisions protect against, so they will not see a direct benefit.
But the cumulative benefits can add up. An analysis published last week by researchers at Johns Hopkins University in Baltimore, Maryland, found that the cost of performing circumcisions and treating complications would be tiny in comparison to the savings from the resulting lower rates of HIV, HPV, herpes and urinary tract infections, as well as from lower rates of bacterial vaginosis and trichomoniasis in women5. Each circumcision that is not performed costs the US health-care system US$313, the researchers estimate.
However, national customs may have a bigger role than economic decisions, says David Gollaher, a medical historian at the California Healthcare Institute in La Jolla, who has studied the history of circumcision. Insurance cover sends a signal that a procedure is medically appropriate, he says, which would reinforce existing inclinations in the United States towards action and intervention. “We do a lot more surgeries than anyone else, so circumcision fits into the pattern of doing more,” he says.
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