Circumcision Not Recommended

American Medical News, March 1999

Circumcision not routinely recommended,
new policy says.

Pediatricans say the procedure has benefits and risks,
and unbiased information should be given to parents.
Critics predict the procedure will become less common.

Diane M. Gianelli

Washington When the American Academy of Pediatrics issued its first statement on circumcision in 1971, the rate of infant boys in the United States getting the procedure was at an altime high: 85% to 90%. Since then the procedure has dropped to about 64%

Thanks to the academy's newest statement - which says that the medical benefits are not sufficiently compelling to recommend circumcision as routine newborn procedure - Ronald Goldman, Ph. D, says he expects to see the rate decrease further. And nothing could make him happier.

Dr. Goldman heads the Boston-based Circumcision Resource Center and is author of Circumcision: The Hidden Trauma. In recent years, he and an increasing number of others have mounted an increasing campaign propounding the benefits of the "intact" male and questioning the cultural and medical assumptions that lead, according to one critic, to the "equivalent of amputating a finger to avoid a hangnail."

The American Academy of Pediatrics is well aware of the divisive nature of the procedure. Carole M. Lannon, MD, MPD, chair of the AAP's task force on circumcision, said this issue has drawn more response than any other the 55,000-member group has dealt with in recent years.

So, in light of the debate over the procedures risks and benefits, she said, the academy decided to review the medical literature that was published on the topic since it issued its last statement in 1989.

Though none of the five statements issued since 1971 recommended routine circumcision, its pre-1989 ones stated that there was no absolute medical indication for it.

Its 1989 statement, however, cited new research that suggested circumcised males have fewer urinary tract infections and were at less risk for sexually tranmitted diseases. It concluded that the procedure had potential benefits, as well as risks, and said parents should be told of both before informed consent was obtained.

Studies show that during the first year of life, uncircumcised males have - at most - a one in 100 chance of developing a urinary tract infection, whereas circumcised males have about a one in 1,000 chance.

Research also indicates that uncircumcised men are more than three times more likely to get penile cancer than circumcised men. But according to the AAP, the cancer is very rare, with only nine or 10 cases per 1 million men diagnosed per year.

Research also indicates that circumcised males may be at reduced risk for STDs, the AAP, in its latest statement, concluded that "behavioral factors continue to be far more important in determining a person's risk of contracting sexually transmitted diseases than circumcision status."

Circumcision critics, including medical broadcaster, Dean Edell, MD, point out that the United States is the only country that routinely circumcises newborn males. They note that Australian, British and Canadian medical societies discourage the practice and that about 85% of the rest of the world is uncircumcised.

In addition, they say removal of the foreskin is unnecessary because it repairs no abnormality or removes no diseased tissue and is mutilating and because it robs the penis of its protective cover. Opponents say circumcision removes erogenous tissue and cite studies that claim uncircumcised men and their partners have more rewarding sexual experiences.

The new statement stops short of advising against the procedure. In fact, it says, "it is legitimate for parents to take into account cultural, religious, and ethnic traditions, in addition to medical factors, when making this choice."

Pain relief "essential"

The statement also recommended - for the first time - that pain relief be provided. Studies show that infants are receiving analgesia less than half of the time, Dr. Lannon said.

There is "considerable evidence," the report states, "that infants circumcised without analgesia experience pain and physiologic stress.

The report will be reviewed by the American College of Obstetricians and Gynecologists, whose members do the most hospital-based circumcisions. Pediatricians and family physicians are the other common providers. And in the Jewish community, religious ritual circumcisions are frequently performed by mohelim.

Critics are hoping insurers - most of whom, with the exception of Medicaid, cover the procedure - will stop paying for elective circumcisions.

According to Daniel Gollagher, author of the soon-to-be-published book, Circumcision: History of the World's Oldest Surgery, when the procedure stopped being covered by Britain's National Health Service after World War II, the rate of circumcision dropped in the United Kingdom from about 50% to less than 5%.

But U.S. insurers won't pull the plug on funding soon.

Chris Martin of the Chicago-based Blue Cross Blue Shield Assn., which covers one out of every four Americans, said that most of the insurers' 52 independent plans routinely cover elective circumcisions. He said that some will look at the new AAP position and discuss it, but he didn't predict any immediate change in policy.

Beverly Hayon of California-based Kaiser Permanente said the HMO routinely pays for the procedure and has no plans to drop the coverage.

Peter D. Rappo, MD, a Brockton, Mass., pediatrician said he always offered unbiased information about the procedure. But in 22 years of practice, "the breakdown has always been about 70% circumcised, 30% uncircumcised." He predicted the statement "may provoke more discussion but won't affect the numbers. "People don't come in waffling on this one."

Where he does expect to see change is in the pain control arena. And he said it will be the parents who force the issue. Although studies show most physicians still don't anesthetize the infant prior to the procedure, Dr. Rappo said he suspects the report will push the issue forward.

Though Dr. Rappo said he expects the numbers to stay about the same. Dr. Goldman predicted a decline. The AAP's earlier statements "didn't get the kind of front-page attention this statement is getting. This is ever getting on the late-night talk shows."

American Medical News
Chicago, IL 60610

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