Circumcision

Pediatricians can address controversial topics—such as circumcision—with families while incorporating scientific information, as well as the parents’ unique social and cultural background.

BACKGROUND

Circumcision remains a controversial topic in America, which can make it a challenge for pediatricians to discuss with families. How should a pediatrician approach this topic, using evidence-based medicine, while taking into account the family’s culture and preferences?

With maturity comes the realization that there is much we do not know, and the facts we thought were certain in the past will change even within our lifetimes.

  • Newer pediatricians, however, desirous of knowledge and certainty, often believe the facts they know are certain, constant, and must guide all decisions without family or cultural input.
  • As pediatricians, we realize there are many topics we should counsel parents about and must recognize that we are unable to read and evaluate all the information that is available.
  • Given the changing fund of knowledge over time, the overwhelming amount of information available, and the differences in family background and culture, we can:
  • Use evidence-based medicine for much of the information we provide parents.
  • Realize there is a wide spectrum of “normal” that can accommodate most parenting philosophies.
  • Use this approach with many “controversial” topics, including co-sleeping, alternative immunization schedules, alternative diets, and the use of integrative medicine.

PROMOTING STRONG, STABLE FAMILIES

We should acknowledge that parents, except in the most extreme circumstances, should be allowed to make decisions for their child.

SCIENTIFIC RESEARCH

The American Academy of Pediatrics (AAP) has revised its recommendations on circumcision several times over the past 40 years as new research has demonstrated the medical benefits of this procedure.

  • In 1975, the AAP stated there was no medical indication or benefit from circumcision.(1)
  • The Circumcision Policy Statement was revised in 1999 to state “existing scientific evidence demonstrates potential medical benefits of newborn male circumcision.”(2)
  • In 2012, the Circumcision Policy Statement was revised to state, “Evaluation of current evidence indicates that the health benefits of newborn male circumcision outweigh the risks and that the procedure’s benefits justify access to this procedure for families who choose it. Specific benefits identified included prevention of urinary tract infections, penile cancer, and transmission of some sexually transmitted infections, including HIV.”(3)
  • In 2012, the AAP Task Force on Circumcision identified the following benefits of neonatal male circumcision: decreased risk of urinary tract infection in the first year of life, decreased risk of adult penile cancer, and decreased risk of acquisition of HIV and some other sexually transmitted infections (STIs).(4)

In December 2014, the Centers for Disease Control released a draft stating, “Health care providers should inform all uncircumcised adolescent and adult males that male circumcision reduces, but does not eliminate, the risk of acquiring HIV and some STIs during heterosexual sex.”(5)

The risks of neonatal circumcision include bleeding and infection, as well as later development of meatal stenosis. A review of 1.4 million male circumcisions between 2001 and 2010 showed an overall adverse event rate of less than 0.5%.(6)

In 1975, the AAP stated there was no medical indication or benefit from circumcision. (1)

The Circumcision Policy Statement was revised in 1999 to state “existing scientific evidence demonstrates potential medical benefits of newborn male circumcision.” (2)

In 2012, the Circumcision Policy Statement was revised to state, “Evaluation of current evidence indicates that the health benefits of newborn male circumcision outweigh the risks and that the procedure’s benefits justify access to this procedure for families who choose it. Specific benefits identified included prevention of urinary tract infections, penile cancer, and transmission of some sexually transmitted infections, including HIV.” (3)

In 2012, the AAP Task Force on Circumcision identified the following benefits of neonatal male circumcision: decreased risk of urinary tract infection in the first year of life, decreased risk of adult penile cancer, and decreased risk of acquisition of HIV and some other sexually transmitted infections (STIs). (4)

In December 2014, the Centers for Disease Control released a draft stating, “Health care providers should inform all uncircumcised adolescent and adult males that male circumcision reduces, but does not eliminate, the risk of acquiring HIV and some STIs during heterosexual sex.” (5)

The risks of neonatal circumcision include bleeding and infection, as well as later development of meatal stenosis. A review of 1.4 million male circumcisions between 2001 and 2010 showed an overall adverse event rate of less than 0.5%. (6)

THE CONVERSATION

During your rotation in the well-baby nursery, parents of a newborn boy ask you for your advice: “Would you circumcise your son?” How should you respond?

It is best not to answer this question, for at least two reasons:

The decision whether or not to circumcise is one of the very first decisions parents will make for another individual.

  • The parents may have discussed what color to paint a room or what car to purchase, but this may be the first decision they will make directly for their child (or any other person).
  • The way the parents communicate and reach a decision may demonstrate their ability to problem solve, thus providing the pediatrician with insight as to how to monitor the family dynamics.

The decision to circumcise is most often based on personal criteria—whether the father is circumcised and parental religious beliefs.

  • Several articles investigating the circumcision decision process have confirmed that the amount of medical information a parent receives does not often affect the decision.
  • Therefore, medical information provided by an unbiased pediatrician will not often be used in parental decision making.

Given the personal and intimate nature of this decision, it is important that the pediatrician not impose his or her own bias into the parental discussion.

The pediatrician should be knowledgeable in the benefits and risks of neonatal circumcision as noted above. The pediatrician may want to state his or her opinion that the benefits outweigh the risks (if this opinion is held).

Instead of offering an answer, direct the question back to the parents and make them aware that this is an important first decision they will be making for their son, so it is important for them to practice their problem-solving skills.

Acknowledge that most parents base their decisions on non-medical, personal information. This is often very liberating for parents who may feel guilty for not evaluating medical information more carefully or for choosing circumcision “just” because the father is circumcised.

REFERENCES

  1. American Academy of Pediatrics, Committee on Fetus and Newborn. Report of the ad hoc task force on circumcision. 1975;56:610-611.
  2. American Academy of Pediatrics, Task Force on Circumcision. Circumcision policy statement. 1999;103(3):686.
  3. American Academy of Pediatrics, Task Force on Circumcision. Circumcision policy statement. 2012;130(3):585-586. https://www2.aap.org/sections/urology/Circumcision_TechnicalReport2012.pdf
  4. Task Force on Circumcision. Technical report—male circumcision. 2012;130(3):e756-e785. https://www2.aap.org/sections/urology/Circumcision_TechnicalReport2012.pdf
  5. Draft CDC recommendations for providers counseling male patients and parents regarding male circumcision and the prevention of HIV infections, STIs, and other health outcomes. http://www.cdc.gov/nchhstp/newsroom/docs/MC-factsheet-508.pdf
  6. El Bcheraoui C, Zhang X, Cooper CS, Rose CE, Kilmarx PH, Chen RT. Rates of adverse events associated with male circumcision in U.S. medical settings, 2001 to 2010. JAMA Pediatr. 2014;168(7):625-634.