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Monday, August 27, 2012 - Page updated at 09:00 p.m.
Circumcision benefits outweigh risks, pediatrics report says
By Carol M. Ostrom
Seattle Times health reporter
Thirteen years ago, when the nation's pediatricians produced a policy on circumcision of newborn boys, it was all of eight pages long and, many felt, a wishy-washy assessment that didn't make a recommendation one way or the other.
The latest policy of the American Academy of Pediatrics (AAP), released Monday, covers 30 pages — with 248 footnotes — and firmly concludes the health benefits of circumcision outweigh the risks, so insurers should pay for it.
Still, the academy's task force, which included Dr. Doug Diekema, a medical ethics expert at Seattle Children's, stopped short of calling for routine circumcision of all newborn boys, saying instead that fully informed parents should decide.
"In our estimation, the benefits actually outweigh the harms," Diekema said, including conferring some protection against urinary-tract infections, heterosexual acquisition of HIV, some sexually transmitted diseases and penile cancer.
But many of those dangers are relatively rare, he conceded, and circumcision is hardly a magic shield, in any case. "That's part of the reason the Academy did not go so far as to recommend routinely circumcising male boys."
Nevertheless, the new policy has infuriated anti-circumcision groups, who say — as a German court did recently — that circumcising without consent inflicts bodily harm, violating a child's rights.
John Geisheker, executive director of Doctors Opposing Circumcision, a Seattle-based organization, said his group was "horrified that our work of 17 years may just have evaporated."
Circumcision, which was once the default choice of parents in the U.S., has become increasingly controversial over the past several decades. In the late 1990s, with pediatricians unable to cite health benefits and critics calling the surgery "barbaric" and "life-altering," rates dropped precipitously.
Geisheker said many other English-speaking countries have essentially abandoned the procedure with no detectable deterioration in health outcomes. "There are zero circumcised children in New Zealand these days, and somehow they struggle through the day. What does that say? Are American penises defective at birth?"
Geisheker also questioned health-care spending on the procedure, which removes the foreskin, the skin covering the tip of the penis. In the U.S., circumcision is often done before a newborn leaves the hospital. "Why is the AAP championing this unnecessary surgery during a crisis of necessary care for our children?"
Another anti-circumcision organization, Intact America, headquartered in New York, said the AAP "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."
The AAP task force acknowledged it was taking into account non-health reasons that parents may want to circumcise an infant.
In a pluralistic society, where parents are given wide authority in child-rearing and welfare, "it is legitimate for the parents to take into account their own cultural, religious and ethnic traditions, in addition to medical factors, when making this choice," the task force wrote.
Circumcision of males is a religious duty in Jewish and Islamic traditions.
In general, the AAP policy says, the law respects the right of parents to make decisions on behalf of their children, except when they are "clearly contrary to the best interests of the child or place the child's health, well-being or life at significant risk of serious harm."
Diekema said the task force was not arguing that "religious benefits trump medical harms." Rather, he said, it concluded the medical benefits outweighed or at least equaled the risks.
The new policy statement and accompanying technical report, meant to help guide pediatricians and parents, urged parents to ensure a provider performing circumcision — whether medical or religious — has adequate training, takes proper measures to avoid infection and uses good pain control.
"For me, that was a big deal," Diekema said. "There are lots of ethical issues wound in and around this circumcision issue. But the one clear one is that the procedure shouldn't be done in a way that causes pain to the baby. We have an absolute obligation to do it using good pain control."
In addition, elective circumcision should be performed only if the infant is stable and healthy, the AAP said.
In general, the report said, the true incidence of complications after newborn circumcision is unknown, in part because the definition of "complication" is fuzzy and there are differing standards for determining whether a later problem is in fact a circumcision complication.
It appears that significant acute complications are rare, the AAP said, occurring in about one in 500 newborn circumcisions — a conclusion disputed by anti-circumcision groups.
In the West, Diekema said, circumcision rates are particularly low — an estimated 30 percent, which is still higher than many European countries, Australia or New Zealand, according to studies.
Low rates have a snowball effect, causing parents who want the baby to "look like dad" to also weigh the likelihood a circumcised boy will look different from most of his classmates.
Costs of the procedure, which range from $216 to $601 across the country, may be an issue, the AAP said.
Newborns who are circumcised are much more likely to have private insurance, which typically covers the procedure.
Washington is one of 18 states where Medicaid does not cover circumcision.
Diekema said the AAP concluded there should not be a financial barrier for low-income parents. "In some ways, it's an equity issue," he said.
Jim Stevenson, the state Medicaid spokesman, said Washington's Medicaid coverage decisions are based on scientific research, and the new AAP study likely would be reviewed with other findings. The program has a process for requesting coverage based on evidence, he said.
In a recent study, Johns Hopkins researchers predicted that if U.S. circumcision rates, now about 55 percent, fell to 10 percent, it could add $4.4 billion in avoidable health-care costs over the next decade.
Carol M. Ostrom: 206-464-2249 or email@example.com. On Twitter @costrom.
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