AAP: Circumcision Decision Belongs To Parents

by Heidi Green
August 31, 2012

“To cut, or not to cut?” It may sound glib, but when it comes to newborn boys and circumcision, that is the question—and it’s one that the vast majority of parents struggle with, from the moment they realize they are expecting a child.

When the American Academy of Pediatrics (AAP) looked at this question in 1999, it took a neutral stance on the issue, concluding that “[e]xisting scientific evidence demonstrates potential medical benefits of newborn male circumcision; however, these data are not sufficient to recommend routine neonatal circumcision.” In 2005, the AAP reaffirmed its position.

In 2007, however, the AAP convened a multidisciplinary task force to take yet another look at the data. Their review culminated in the release of a new Circumcision Policy Statement (published alongside a 32-page Technical Report.) The new policy shifts the tone to one of support for neonatal circumcision, stating “[e]valuation of the current evidence indicates that the health benefits of newborn male circumcision outweigh the risks, and the benefits of newborn male circumcision justify access to this procedure for those families who choose it.” (More about circumcision can be found elsewhere on baby gooroo.)

The recent findings
The AAP Task Force on Circumcision responsible for the current policy included AAP specialists, members of the AAP Board of Directors, and liaisons from other leading health groups, including the American Academy of Family Physicians (AAFP), the American College of Obstetricians and Gynecologists (ACOG), and the Centers for Disease Control and Prevention (CDC).

The Task Force identified eight questions related to male circumcision:

• What is the current epidemiology of male circumcision in the U.S.?
• What are the most common procedures and techniques?
• What best supports the parental decision-making process?
• What is the association between male circumcision and both morbidity and sexual function/satisfaction?
• What is the impact of anesthesia and analgesia?
• What are the common complications and the complication rates?
• What workforce issues affect newborn male circumcision?
• What are the trends in financing and payment for elective circumcision?

The group looked at English-language, peer-reviewed analytic studies published from 1995 through 2010; 1,031 articles were included in the review. The Task Force conducted a review of the literature based on the American Heart Association’s template for evidence evaluation, which was supplemented by an independent review of an AAP-contracted physician and doctoral-level epidemiologist.

According to the AAP, neonatal circumcision reduces the risk of urinary tract infections (UTIs) for infants and, later in life, the risk of HIV and other sexually transmitted infections. The benefits, it argues, are “sufficient to justify access to this procedure for families choosing it and to warrant third-party payment for circumcision of male newborns.”

The risks of circumcision are few, according to the AAP, which states that “[t]he procedure is well tolerated when performed by trained professionals under sterile conditions with appropriate pain management.” Complications are described as infrequent and largely minor in nature, including bleeding, infection, and pain.

The AAP acknowledges the ethical concerns when parents choose elective surgery for their healthy newborn (see more on the controversy here on baby gooroo.) However, the group argues, “parents or guardians are empowered to make health care decisions on their [children’s] behalf … parents and physicians each have an ethical duty to the child to attempt to secure the child’s best interest and well-being.” Circumcision is one area in which “[r]easonable people may disagree,” and the AAP encourages every family to consider the medical benefits and risks in light of their own “social, cultural, religious, and familial benefits and harms.”

Who should pay for the elective procedure?
Reimbursement of circumcision ensures “[p]reventive and public health benefits,” the AAP states, and insurance companies ought to cover the cost. Whether this statement will persuade health care payers to reimburse remains to be seen; Medicaid programs in 18 states and some health insurance companies stopped paying for the procedure after the AAP released its 1999 policy statement. An editorial co-authored by Annie Leibowitz, Phd and Katherine Desmond, MS in a recent issue of Archives of Pediatrics and Adolescent Medicine calls upon third-party payers to assume the cost of circumcision, stating, “It is now time for federal Medicaid programs to consider reclassifying male circumcision from an ‘optional’ service to one that state Medicaid plans will cover for those parents who choose the procedure for their newborn sons.”

Among the studies they cite is a cost-assessment piece from the same journal issue, in which data analysts present projected costs of reduced circumcision rates. Estimating that cases of HIV, human papillomavirus, herpes simplex virus type 2, infant UTIs, bacterial vaginosis, and trichomoniasis would all increase if American society reduced its male circumcision rate to 10 percent (Europe’s rate), the authors project net expenditure per annual birth cohort of $505 million. Over 10 annual cohorts, the total would exceed $4.4 billion. If it’s the money that matters, by this argument at least, third-party payers seem to have a vested interest in covering male circumcision.

Weighing the benefits and risks of circumcision
In the 1970s, about 80 percent of male babies were circumcised after birth; as of 2010, the Centers for Disease Control and Prevention say that number has dropped to about 55 percent.

Based on its review of the recent literature, the AAP Task Force recommends:

• Circumcision should be available to families who choose it for their newborn boys. It should be performed only on stable, healthy babies by “trained and competent practitioners … using sterile techniques and effective pain management.” Nonpharmacologic pain relief, such as positioning and sucrose pacifiers, may be used in conjunction with pain medicine but should not be used as the only source of pain relief.
• Physicians should explain the benefits and risks, and should address the elective nature of the procedure. They should provide “factually correct and nonbiased information,” ideally before conception and early in pregnancy, when families are engaged in decision-making.
• Parents should “weigh the health benefits and risks in light of their own religious, cultural, and personal preferences, as the medical benefits alone may not outweigh these other considerations for individual families.”
• Health care providers should instruct new parents in the care of their baby boy’s penis, whether it is circumcised or not.
• Provider groups (AAP, AAFP, ACOG, the American Society of Anesthesiologists, the American College of Nurse Midwives, and others) should collaborate to develop standards of training, post-graduate programs, and educational materials for clinicians and parents alike.
• Insurance companies should reimburse for newborn circumcision.

The AAP’s policy statement has been endorsed by ACOG, with that organization’s liaison to the task force noting that the group “support[s] the idea that parents choosing circumcision should have access to the procedure.” Despite ACOG’s endorsement, the AAP policy has unleashed a firestorm of controversy, particularly from those who saw the group’s earlier policy as a bold step away from a procedure many view as unnecessary. As of this writing, the AAP’s Facebook note about the policy update has received well over 2,000 comments, almost uniformly negative.

Opinions may vary about the tone and measure of the AAP’s statement, but one thing is for sure: the circumcision decision is one no parent should take lightly.