Circumcisions: Again

To the Editor.

The flurry of recent articles and commentaries addressing potential medical benefits of circumcision^1-4 provide much food for thought. I agree with the Academy's Task Force on Circumcision⁵ that the benefits of circumcision are not sufficient to recommend it routinely, that parents should be given accurate and unbiased information, and that procedural analgesia should be provided. It is unfortunate that the coverage in the lay press suggested that the AAP had changed its position to one opposing circumcision. A better headline would have read AAP Task Force notes benefits, risks of circumcision; urges anesthesia.

Nonetheless, I agree with Schoen, Wiswell, and Moses⁴ that the language used by the Task Force is partly responsible for this misunderstanding. The Task Force statement says: Existing scientific evidence demonstrates potential medical benefits; however, these data are not sufficient to recommend routine neonatal circumcision. In circumstances in which there are potential benefits and risks yet the procedure is not essential to the child's current well-being, parents should determine what is in the best interests of the child.

Although it is true that the benefits are potential in that most uncircumcised males will not develop conditions circumcision would have prevented, this is not the reason not to recommend it. We routinely recommend immunizations, car seat use, and safer sex, even though their benefits and risks are potential in the same way as those of circumcision and they also are not essential to the child's current well-being.

The key difference between circumcision and preventive interventions that the AAP does recommend is neither the quality of the evidence nor the absolute magnitude of the benefits; it is the nature of the intervention. Circumcision involves surgery to remove a natural part of the boy's body and alter its appearance forever. It is a procedure with considerable nonmedical significance in many cultures. Thus, although there are definite medical benefits that seem to outweigh the medical risks, I think it is appropriate for the AAP to refrain from routinely recommending it, because it is not solelya medical decision.

This being said, it is important not to exaggerate the known benefit of preventing urinary tract infections (UTIs). The degree to which urinary tract infections in infancy lead to hypertension and end-stage renal disease (ESRD) in adulthood is not known, but is almost certainly less than suggested by combining the results of the long-term studies cited by Wiswell.¹ Using those figures, if 2.2% of uncircumcised boys got UTIs and 44% of them developed renal scarring and 10% of those with scarring developed ESRD over the next 30 years, the 30-year risk of ESRD from infancy would be about 2.2% × 44% × 10%, or about 1 in 1000. In fact, according to the US Renal Data Service, ESRD in children younger than 20 years old has an annual incidence of only about 13 million per year, of which only about 2.7% is attributed to chronic pyelonephritis or reflux nephropathy.⁶ Over the next 25 years the annual incidence rises to 109 million per year, but the proportion attributed to chronic pyelonephritis or reflux nephropathy declines to 0.7%. Even if all the cases in males were attributable to UTIs in those who were uncircumcised, the 45-year risk would still be an order or magnitude lower than would be projected from the numbers cited by Wiswell.

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