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Stronger Evidence of Circumcision Benefits Drives AAP Policy Update

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Ob. Gyns. Support AAP Statement

"As obstetricians, we are charged with providing education to mothers about the health and welfare of their pregnancy. For those obstetricians like me who perform circumcisions, this new document provides evidenced-based information to our patients as they contemplate the circumcision procedure," Dr. David M. Jaspan said when asked to comment.


Dr. David M. Jaspan

"Many times we are asked, ‘Is the procedure necessary?’ We can now answer that there are specific benefits including ‘prevention of urinary tract infections, penile cancer, and transmission of some sexually transmitted infections, including HIV,’ " Dr. Jaspan said.

"I am in complete agreement with the new policy and believe that it is important that there are no impediments, financial or otherwise, to access to this procedure for families that request it," said Dr. Lindsay S. Alger.

"ACOG agrees with the AAP that the benefits of circumcision are sufficient to justify access to this procedure for families choosing it and to warrant third-party payment for circumcision of male newborns, although for cultural, ethical or religious considerations parents may choose not to have this procedure done," Dr. Alger said when asked to comment.

She also pointed to improvements in technique, including the use of local anesthesia, which makes circumcision safer and well-tolerated. "I have never seen a serious complication in over 35 years."

Dr. Jaspan is vice chairman and chief of gynecology in the department of obstetrics and gynecology at the Albert Einstein Medical Center in New York. He said he had no relevant financial disclosures.

Dr. Alger is professor of obstetrics, gynecology, and reproductive services at the University of Maryland and medical director of labor and delivery at the University of Maryland Medical Center, both in Baltimore. She said she had no relevant financial disclosures.

Changes to Financial Barriers Still Pending

The AAP Task Force summarized a complicated issue: the elective nature of circumcision, the importance of nonbiased counseling, the uniform use of analgesics to reduce procedural pain, and stressing the health and care of the newborn penis, whether circumcision is chosen or not. The recommendations reinforce and strengthen the 1999 AAP Circumcision Policy Statement and recommendation (Pediatrics 1999;103:686-93), but they went much further than that. They examined the areas of weakness in the previous recommendations and give credence to the rightful critics of the procedure.

Circumcision detractors have touted the procedure as "male genital mutilation," citing a decrease in penile sensation and sexual satisfaction upon removal of the prepuce, and questioned the ethics of an "informed consent process" that does not include "the patient," lacks a discussion of nonsurgical alternatives, and ignores potential adverse physical, sexual, and psychological effects. I believe the big difference in the current Task Force’s reports was that they make a point-by-point case for each of the above disadvantages. From my knowledge of the circumcision literature, I believe the Task Force’s literature search was exhaustive, and they do a fine job of summarizing the existing peer-reviewed literature.


Dr. Patrick J. Woodman

It will be interesting to see how Medicaid programs and third-party payers interpret the recommendation to "reduce or eliminate" financial barriers that prevent parents from having the choice to circumcise their male infants. The report notes that uninsured clients are about 20% less likely to choose circumcision than do those who have coverage. As of 2009, 15 states did not cover newborn male circumcisions in their Medicaid programs, and 2 others had variable coverage, according to the report. Denying coverage disproportionately affects groups that are at greater risk for HIV and other sexually transmitted infections and also are overly represented in the Medicaid population: African American and Hispanic males. Since a recent Centers for Disease Control and Prevention report concluded that newborn circumcision is a societal cost-effective HIV prevention program (PLoS ONE 2010;5:e8723), efforts by state Medicaid programs to limit payment disproportionately affects those that could benefit most from circumcision.

Patrick J. Woodman, D.O., is a urogynecologist, associate professor of obstetrics and gynecology, and is chief of specialty care at Marian University College of Osteopathic Medicine in Indianapolis. He said that he has no disclosures pertinent to the story.


 

FROM PEDIATRICS

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.

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