Using an evidence-based approach, the American Academy of Pediatrics' (AAP) Task Force on Circumcision developed the "Circumcision Policy Statement,"[1] published in the March 1999 issue of Pediatrics. A special article by Schoen et al[2] responding to this policy statement is published in this month's issue. These authors would have preferred a report recommending routine circumcision for all newborn males and base their assessment of the Task Force report on this advocacy position.
There is no disagreement between the Task Force and the authors over the fact that there are potential medical benefits to circumcision. There is disagreement over the magnitude of these beneficial effects. The Task Force found the evidence of low incidence, high-morbidity problems not sufficiently compelling to recommend circumcision as a routine procedure for all newborn males. However, the Task Force did recommend making all parents aware of the potential benefits and risks of circumcision and leaving it to the family to decide whether circumcision is in the best interests of their child.
The process of informed consent in all pediatric cases should include a complete explanation of the benefits and risks of any procedure. When a procedure or treatment is not essential to a child's current well-being, a parent has no obligation to consent to it. Circumcision falls into that group of procedures that have potential medical benefits and some risks and should be evaluated by each family in the context of their personal beliefs and values as well as their ethnic, cultural, and religious practices. The Task Force respects the role of parents as decision-makers for their newborns and recommends that physicians discuss with parents the potential benefits as well as risks of circumcision so that parents can decide whether circumcision is in the child's best interests.
The Task Force report contains a balanced discussion of the benefits of the procedure as well as the risks. This statement was carefully reviewed and unanimously approved by the more than 10 Academy subcommittees asked to critique it: the Committee on Bioethics, the Committee on Fetus and Newborn, the Section on Perinatal Pediatrics, the Section on Urology, the Committee on Pediatric AIDS, the Committee on Practice and Ambulatory Medicine, the Section on Epidemiology, the Section on Clinical Pharmacology and Therapeutics, the Committee on Drugs, the Section on Anesthesiology, the Committee on Infectious Diseases, and the Section on Infectious Diseases, as well as the AAP's Board of Directors. This policy statement is in agreement with the statements of professional medical societies of the United Kingdom, Canada, and Australia.
The following relate to selected specific issues raised by the authors. Our comments were forwarded to these authors, who chose to not incorporate these suggested changes in their manuscript.
The authors imply that the media interpreted the report to recommend against circumcision. Numerous media reports noted that the Academy has never advocated routine circumcision and accurately described the recommendations in the report. The authors also imply that the Task Force analysis was incomplete and did not include important material, which is actually discussed in the report.
The authors suggest that there was "interdisciplinary imbalance" on the Task Force -- however, 2 of the subspecialty areas they suggest be included actually were represented (internal medicine and urology). The authors also imply that the Task Force did not consider their views in developing its report. This is incorrect as each of the authors communicated with members of the Task Force, some on multiple occasions. The Task Force also heard from a broad range of people who oppose circumcision. The conclusions of the Task Force report were established by a careful, methodical, and deliberate review of all the evidence including expert opinion, and the recommendations were based on peer-reviewed evidence from the medical literature.
The phrase "slightly lower risk" does not appear in the Task Force statement in relation to the risk of urinary tract infection (UTI). The references in one paragraph of the UTI section (see page 689 of the Task Force report in the March 1999 issue) were out of order, causing confusion. We appreciate the opportunity to correct this. This section should read:
Initial retrospective studies suggested that uncircumcised male infants were 10 to 20 times more likely to develop UTI than were circumcised male infants.62 (References 63, 64, and 67 also should have appeared at the end of this statement after reference 62). ... More recent studies using cohort and case-control design also support an association, although reduced in magnitude.63,64,67,70-72 (The references at the end of this statement should have appeared as follows: 67, 71, and 72 only.) ... These studies have found a three to seven times increased risk of UTI in uncircumcised infant males compared with that in circumcised male infants.
The authors did not consider the recent population-based cohort study of 58 000 Canadian infants (reference 72) that noted an increased risk of 3.7 in hospital admission for UTI in uncircumcised infant males younger than 1 year of age compared with circumcised infant males. The Task Force report supports the association between UTI and circumcision status, although reduced in magnitude from earlier estimates.
Conclusions
In summary, the Task Force would like to reiterate its conclusions:
Existing scientific evidence demonstrates potential medical benefits of newborn male circumcision; 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. To make an informed choice, parents of all male infants should be given accurate and unbiased information and be provided the opportunity to discuss this decision. If a decision for circumcision is made, procedural analgesia should be given.
Abbreviations
AAP, American Academy of Pediatrics; UTI, urinary tract infection.
References
- American Academy of Pediatrics, Task Force on Circumcision. Circumcision policy statement. Pediatrics 1999; 103: 686-693
- Schoen EJ, Wiswell TE, Moses S. New policy on circumcision--cause for concern. Pediatrics 2000; 105: 620-623
