News in Science

Benefits of circumcision 'outweigh risks'

Circumcision debate The health benefits of infant circumcision outweigh the risks of the surgery, according to new guidelines from the American Academy of Pediatrics.

But the influential physician's group has fallen short of a universal recommendation of the procedure for all infants, saying that parents should make the final call.

The change was prompted by scientific evidence that suggests circumcision can reduce the risk of urinary tract infections in infants and cut the risk of penile cancer and sexually transmitted diseases, including HIV and the human papillomavirus or HPV, which causes cervical and other cancers.

Although the AAP's 1999 statement was fairly neutral, the new statement, published on Monday in the journal Pediatrics, comes down in favour of the procedure, saying the health benefits of newborn male circumcision "justify access to this procedure for families who choose it."

"We're not saying you have to have it," says Dr Andrew Freedman, a paediatric urologist at Cedars-Sinai Medical Center in Los Angeles, who chaired the AAP's circumcision task force.

"We're saying if a family thinks it is in the child's best interests, the benefits are enough to help them do that."

Based on a review of more than 1000 scientific articles, the task force says male circumcision does not appear to adversely affect penile sexual function, sensitivity of the penis or sexual satisfaction.

The AAP says parents should be given unbiased information about the procedure and be allowed to make the call on their own.

Growing debate

Circumcision, the surgical removal of the foreskin of the penis, is a ritual obligation for infant Jewish boys, and is also a common rite among Muslims, who account for the largest share of circumcised men worldwide.

Others have adopted the practice due to potential health benefits, but those advantages have become the subject of debate, including recent efforts to ban circumcision in San Francisco and Germany.

In a statement issued on Friday in anticipation of the guidelines, the anti-circumcision group Intact America said most of the studies underlying the new guidelines are based on research done on adult men in Africa.

"The task force has failed to consider the large body of evidence from the developed world that shows no medical benefits for the practice, and has given short shrift, if not dismissed out of hand, the serious ethical problems inherent in doctors removing healthy body parts from children who cannot consent," says Georganne Chapin, the group's executive director.

Dr Douglas Diekema, a paediatric bioethicist from the Seattle Children's Research Institute and the University of Washington who served on the task force, says the group considered a wide range of ethical issues, including pain experienced by the child and whether parents have the right to make the decision without the child's consent.

"There is no decision you can make that doesn't potentially put a child at risk. If you choose to circumcise, there is a risk he'll grow up to be a man who wishes he wasn't circumcised," Diekema says.

Diekema says waiting until the child is older to make the choice about circumcision would lose much of these early benefits, and because the foreskin is thicker in a teen than in an adolescent, the procedure carries more risks.

"I really don't think there is an easy answer," he says.

What was clear, Diekema says, was the issue of pain.

"We were unanimously agreed that it's inappropriate to do this procedure without adequate pain control. That, in many ways, is one of the biggest ethical issues," he says.

Australian debate

According to the Royal Australasian College of Physicians (RACP), the circumcision rate in Australia and New Zealand has fallen in recent years, and currently 10-20 per cent of newborn male infants are circumcised.

The College has been criticised by some doctors for having a bias against infant circumcision.

In a statement to the media College spokesperson Dr David Forbes defended the College's policy on infant circumcision.

"The RACP Infant Male Circumcision Position Statement, is evidence-based, and balanced, utilising both international and local research to come to a conclusion that the frequency of diseases modifiable by circumcision, the level of protection offered by circumcision, and the complication rates of circumcision in Australia and New Zealand do not warrant routine circumcision of healthy infant boys in Australia and New Zealand," says Forbes.

"The RACP notes that the American Academy of Paediatrics emphasises the long term benefits of circumcision, but does not recommend routine circumcision of all boys," adds Forbes.

"However it is reasonable for parents to weigh the benefits and risks of circumcision and to make the decision whether or not to circumcise their sons."

Professor Roger Short, of the University of Melbourne, who is interested in HIV prevention welcomes the new statement.

"In view of the manifold new-found health benefits of male circumcision, including reducing the risk of prostate cancer in American men, and the proven 60 per cent reduction in HIV infection in men, it is shameful that Australia is not following the World Health Organization's promotion of male circumcision," says Short.

"I do not think that male circumcision should be compulsory, but it should certainly be made available in our major hospitals at minimal cost to those parents who wish to give their newborn boy maximal protection for the rest of his life from a variety of life-threatening disorders, such as prostate cancer, penile cancer, and HIV infection."