How you counsel parents regarding their ultimate decision about male infant circumcision could change based on a new policy statement from the American Academy of Pediatrics.

The academy points to stronger evidence of health benefits that outweigh the risks of the procedure in an updated circumcision policy statement (Pediatrics 2012 Aug. 27;130:585-86). Data support the prevention of urinary tract infections, penile cancer, and transmission of some sexually transmitted infections, including HIV, for example, based on a systematic review of the medical literature.

The final decision lies with parents. However, the evidence is now strong enough to justify access to circumcision and third-party insurance payment for all families who choose the procedure, the American Academy of Pediatrics stated.

"What we suggest is that, having reviewed the literature, especially incorporating the new data on HIV acquisition, we feel that circumcision does have a lot of benefit and some very modest risk," Dr. Andrew Freedman, a member of the AAP Task Force on Circumcision, said in an interview. "Overall, the benefits are probably greater than the risks, or at least great enough that for a family that wishes to have a circumcision, we feel they should be allowed to have a circumcision."

"However, the benefits are not so great that we are advocating a universal recommendation. We’re not suggesting everyone should have a circumcision," added Dr. Freedman, who is vice chair of pediatric surgical services and director of pediatric urology at Cedars-Sinai Medical Center in Los Angeles.

The task force recognized that the medical considerations are just one part of the decision making process, Dr. Freedman said. "For families, this cuts across other paradigms: the ethnic, the religious, and the aesthetic."

Pediatricians play a vital role in counseling families. Dr. Freedman suggested physicians read the technical report that accompanies the policy statement (Pediatrics 2012 Aug. 27;130:e756-85) for "a very robust discussion of the scientific data that I think will be very helpful to pediatricians counseling [families] about circumcision, to provide them with the most relevant data from the literature review."

The health benefits of circumcision include lowering the risk of urinary tract infections in the first 2 years of life (Pediatr. Infect. Dis. J. 2008;27:302-8).The literature review also indicates the procedure lowers the risk of acquiring HIV (PLoS One 2010;5:e8723); genital herpes (CDC fact sheet, Jan. 31, 2012); and human papillomavirus virus (Lancet 2011;377:209-18). To a lesser extent, the evidence also suggests a protective effect against syphilis (Lancet Infect Dis. 2009;9:669-77).

The task force also considered evidence that circumcision can lower the risk of penile cancer over a lifetime (Int. J. Cancer. 2005;116:606-116); and the risk of cervical cancer in sexual partners (N. Engl. J. Med. 2002;346:1105-12).

There is a lot of partisanship regarding circumcision, Dr. Freedman said. "People are for it or against it, and they don’t recognize the AAP is not in that game. We are just trying to do a fair, scientific review of the data and put the medical aspect into context."

"What we’ve tried to do is add clarification because it’s a nuanced policy. The old policy was as well, but people did not appreciate that," he said. "People tended to want to see the policy as a ‘yes or no’ vote on circumcision."

"Everyone [on the task force] approached it from the standpoint that we should start without any preconceived bias. Let the data drive where it goes." Once task force members identified the relevant issues, accumulated the research, presented it to each other, and discussed the findings, "we reached consensus pretty easily," he said.

The policy statement updates the previous policy on circumcision that the AAP published in 1999 and reaffirmed in 2005.

The Circumcision Resource Center, a critic of circumcision, responded to the AAP policy statement by saying, "The circumcision literature reflects the pro-circumcision bias of circumcised American researchers who seek to find benefits and avoid studying the harms of circumcision. ... The United States is the only country in the world that circumcises many of its male infants for nonreligious reasons." It then counters some specific points covered in the AAP policy with its own views in a statement on its website.*

The American College of Obstetricians and Gynecologists endorsed the AAP policy statement and the technical report. ACOG provided a liaison member to the task force, as did the American Academy of Family Physicians and the Centers for Disease Control and Prevention.

The Agency for Healthcare Research and Quality’s National Inpatient Sample data from 1988 to 2008 reveal that the rate of circumcision performed during newborn male delivery hospitalizations rose from 48% in 1988-1991, to 61% in 1997-2000, then fell to 56% in 2000-2008. This does not include out-of hospital circumcisions and thus underestimates the rate of male circumcisions in the first month of life.

Dr. Freedman said that he had no relevant financial disclosures.

* This story was updated with new information on 8/29/2012.

Stronger Evidence of Circumcision Benefits Drives AAP Policy Update