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American Academy of Pediatrics News Release
AAP Releases Circumcision Statement (1989)
|FOR RELEASE: March 6, 1989
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The American Academy of Pediatrics (AAP) has released its statement on circumcision, concluding that the procedure has potential medical benefits and advantages, as well as inherent disadvantages and risks.
According to AAP president Donald Schiff, M.D., the Academy is recommending that the decision is one best made by parents in consultation with their physician.
"In addition to the medical aspects, other factors will affect the parents' decisions, including esthetics, religion, cultural attitudes, social pressures, and tradition," the AAP statement says.
Physicians should explain and discuss the benefits and risks of circumcision with parents, and informed consent should be obtained before the procedure is performed. [NOHARMM note: Parents should also be explained the important functions of the foreskin before they can make a truly informed decision.] Most male infants born in this country are circumcised in the newborn period, although the circumcision rate appears to be falling.
Since 1971, the AAP has maintained the position that there was no absolute medical indication for routine circumcision in the newborn. New information has recently appeared in the literature suggesting possible medical benefits from newborn circumcision. [NOHARMM note: These benefits remain 'possible,' not proven.] Summarized below are the main points of the AAP's new statement on circumcision, addressing the new evidence:
Urinary Tract Infections
Studies conducted at U.S. Army hospitals in 1985 involving more than 200,000 males showed greater than tenfold increase in urinary tract infections (UTI) in uncircumcised compared with circumcised male infants; moreover, as the rate of circumcision declined over the years, the incidence of urinary tract infection increased. [NOHARMM note: These studies, conducted by Thomas Wiswell, M.D., showed that even though the rate of UTI in intact (non-circumcised) male infants was 'tenfold' greater than in circumcised infants, the intact infant's risk of getting a UTI was only about 1%. This means that intact infants stand a 99% chance of NOT getting a UTI, while circumcision only slightly improved this chance. Circumcision does not prevent infants from getting a UTI. See Urinary Tract Infection and Circumcision. Excellent analysus by a doctor, with easy-to-read graphs.]
However, the AAP statement says: "It should be noted that these studies in Army hospitals are retrospective in design and may have methodological flaws. For example, they do not include all boys born in any single cohort or those treated as outpatients, so the study population may have been influenced by selection bias."
Circumcision "may result in decreased incidence of urinary tract infection. However, in the absence of well-designed prospective studies, conclusions regarding the relationship of urinary tract infection to circumcision are tentative," according to the statement. [NOHARMM note: In 1997, a an eight-year prospective study of UTI was published that concluded, "Regardless of circumcision status, infants who present with their first UTI at 6 months or less are likely to have an underlying genitourinary abnormality. In the remaining patients with normal underlying anatomy and UTI, we found as many circumcised infants as those who retained their foreskin." Bottom line: UTIs are caused by a defect in the urinary tract NOT the presence of a foreskin. See
The Incidence of Genitourinary Abnormalities in Circumcised and Uncircumcised Boys Presenting with an Initial Urinary Tract Infection by 6 Months of Age. Elizabeth R. Mueller, M.S.M.E., George Steinhardt M.D., Shahida Naseer M.D., Abstract 121, Pediatrics, September 1997, Vol. 100, page 580/supplement]
Cancer of the Penis
Circumcision has been shown to decrease incidence of cancer of the penis (a rare condition) among U.S. males. This condition occurs almost exclusively in uncircumcised men. Poor hygiene, lack of circumcision, and certain sexually transmitted diseases correlate with the incidence of penile carcinoma.
The decision not to circumcise a male infant must be accompanied by a lifetime commitment to genital hygiene to minimize the risk of developing penile cancer. [NOHARMM note: Circumcision does not absolve the circumcised male of a lifetime commitment to genital hygiene to prevent diseases. The intact genitals of the female must also be accompanied by a lifetime commitment to genital hygiene.]
Sexually Transmitted Diseases
"Evidence regarding the relationship of circumcision to sexually transmitted diseases is conflicting," the AAP statement says. "Although published reports suggest that chancroid, syphilis, human papillomavirus and herpes simplex type 2 infection are more frequent in uncircumcised men, methodologic problems render these reports inconclusive."
Evidence linking uncircumcised men to cervical carcinoma is also inconclusive, the statement notes. However, an increased incidence of cancer of the cervix has been found in sexual partners of uncircumcised men infected with human papillomavirus. [NOHARMM note: Circumcised men can also become infected with human papillomavirus and increase their female partners' risk of cervical carcinoma.]
The strongest predisposing factors in cervical cancer are a history of intercourse at an early age and multiple sex partners.
Pain and Behavioral Changes
Infants undergoing circumcision without anesthesia demonstrate physiologic responses suggesting that they are experiencing pain. Behavioral changes include a crying pattern indicating distress during the circumcision procedure and changes in activity (irritability, varying sleep patterns) and in infant-maternal interaction for the first few hours after circumcision. "These behavioral changes are transient and disappear within hours after the surgery," the statement notes.
Dorsal penile nerve block in appropriate doses may reduce the pain and stress of newborn circumcision. "However," according to the statement, "reported experience with local anesthesia in newborn circumcision is limited, and the procedure is not without risk." [NOHARMM note: It is clear to reasonable people that circumcision (the surgery and accompanying pain) and attempts at anesthesia both carry risks.]
Complications due to local anesthesia are rare and consist mainly of hematomas and local skin necrosis (death of tissue). "It would be prudent to obtain more data from large controlled series before advocating local anesthesia as an integral part of newborn circumcision," the statement says.
Complications, Contraindications, Hygiene, Infections
The exact incidence of postoperative complications is unknown, [NOHARMM note: Why is the medical community not documenting these?] but large series indicate that the rate is low, approximately 0.2 to 0.6 percent. [NOHARMM note: A 1993 report by Drs. Williams and Kapila indicates that a more realistic complication rate is 2%-10%. See Complications of Circumcision.]
Circumcision should only be performed on stable, healthy infants. It is contraindicated in an unstable or sick infant. It is prudent to wait until a premature infant meets criteria for discharge before performing circumcision.
Circumcision prevents phimosis (inability to retract the foreskin), paraphimosis (accumulation of fluid or swelling of the prepuce and glans), and balanoposthitis (inflammation of the prepuce and glans). [NOHARMM note: phimosis is a normal physiological condition, which is premature to diagnose before completion of penile development in late adolescence. See articles by Gairdner (1949), Øster (1968), Wright (1970), Wright (1994) and Kayaba (1996). Paraphimosis and balanoposthitis often result from premature retraction of the foreskin.] It is particularly important that uncircumcised boys be taught careful penile cleansing, the AAP statement notes. [NOHARMM note: it is important that all children, regardless of circumcision status or gender, be taught careful genital cleansing.]
The American Academy of Pediatrics is an organization of 37,000 pediatricians dedicated to the health, safety and well-being of infants, children, adolescents and young adults.
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