* New guidelines stop short of universal recommendation
* Parents should make the final call, group says
By Julie Steenhuysen
CHICAGO, Aug 27 The American Academy of
Pediatrics has issued new guidelines saying the health benefits
of infant circumcision outweigh the risks of the surgery, 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 favor 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," said Dr. Andrew
Freedman, a pediatric 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," he
Based on a review of more than 1,000 scientific articles,
the task force said male circumcision does not appear to
adversely affect penile sexual function, sensitivity of the
penis or sexual satisfaction.
The AAP said parents should be given unbiased information
about the procedure and be allowed to make the call on their
But the group did say it is imperative that those performing
circumcision are adequately trained, that they use sterile
techniques and offer effective pain management.
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.
The wider U.S. population 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 Germany, the debate over circumcision has landed in the
courts. Last week, an unnamed doctor in Germany filed charges
against a rabbi for performing ritual circumcisions on infant
boys, two months after a court in Cologne angered Jews and
Muslims by banning the practice.
In the United States, the new guidelines may begin to turn
the tide on infant circumcision, which has begun to fall in
recent years as insurers have balked at paying for a procedure
without a strong medical justification.
In as many as 18 U.S. states, the Medicaid program for the
poor has stopped paying for the procedure, a trend some doctors
fear could significantly increase U.S. health costs because of
increased cases of urinary tract and HIV infections.
"The American Academy of Pediatrics had formerly been on the
discouraging side," said Dr. Peter Richel, chief of pediatrics,
at Northern Westchester Hospital in Mount Kisco, New York.
"If, indeed, we can cut down on a greater incidence
statically of HIV or HPV, then I am certainly all for that."
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,"
said Georganne Chapin, the group's executive director.
Dr. Douglas Diekema, a pediatric bioethicist from the
Seattle Children's Research Institute and the University of
Washington who served on the task force, said 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 said.
Diekema said 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 said.
What was clear, Diekema said, 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 said.
Rabbi Shmuel Goldin of the Ahavath Torah congregation in
Englewood, New Jersey, and president of the Rabbinical Council
of America, said circumcisions done for religious purposes do
not typically involve pain medication, but he noted that the
procedure is quick and has a long tradition of success.
"We've performed it for centuries with no adverse effects to
Even so, he worries about the lawsuits in Germany trying to
"For us, it is such a critical component of our religious
life that an attempt to eradicate it is an attempt to eradicate
our religion. To have this happening in Germany, given our
history, is particularly saddening to us."
(Reporting by Julie Steenhuysen; Editing by Lisa Shumaker)