Stronger Evidence of Circumcision Benefits Drives AAP Policy Update

"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.