By Katie Kerwin McCrimmon
The American Academy of Pediatrics (AAP) has reversed decades of advice on circumcision and now says that the benefits of the procedure outweigh the risks.
The first policy statement on circumcision since 1999 has triggered angry reactions from opponents who called on the influential group to immediately retract the policy recommendation.
Since the 1970s, the AAP had said circumcisions were not medically necessary. Removing the foreskin of the penis from infant boys is an ancient Jewish and Islamic tradition, but circumcision rates have been declining in the U.S. and even in Israel. An increasing number of global health officials has raised concerns about the health impacts of circumcision and the thorny ethical problem of removing an infants body part when he is too young to consent.
The AAP statement, however, said that new research shows circumcising infants can decrease the risks of those boys being infected with HIV, genital herpes, HPV and syphilis. The influential group that represents 60,000 U.S. pediatricians stopped short of recommending routine circumcision, but called on public and private health insurance programs to cover the procedure for families who choose it.
In Colorado, the largest private health insurance company in the state, Anthem Blue Cross and Blue Shield, which has about 950,000 members has always covered circumcisions and will continue to do so, said company spokeswoman, Joyzelle Davis.
Medicaid circumcisions in Colorado
- 2011 Lawmakers voted to halt Medicaid-covered circumcisions
- Fiscal Year 2010-11 Medicaid covered circumcisions for 6,634 infants out of 13,876 male newborns, or 47.8 percent. Cost: $376,862
- Fiscal Year 2009-10 Medicaid covered circumcisions for 6,920 infants out of 14,315 male newborns, or 48.3 percent.
Source: Colorado Department of Health Care Policy and Financing
Ultimately, this is a decision that parents will have to make, said Dr. Susan Blank, chair of the task force that authored the AAP policy statement. Parents are entitled to medically accurate and non-biased information about circumcision, and they should weight this medical information in the context of their own religious, ethical and cultural beliefs.
Its unclear whether pediatricians and family physicians, many of whom have strong opinions on circumcision, will heed the advice of the AAP task force.
A spokeswoman for the AAP in Colorado did not return calls on Monday to comment on how pediatricians here would respond.
In 2011, Colorado joined 17 other states in barring Medicaid funding of circumcisions. A bill introduced in the Colorado legislature earlier this year would have reinstated funding, but was defeated after a coalition of budget hawks, anti-circumcision activists and health professionals successfully argued that circumcision is cosmetic and potentially harmful and that taxpayers should not fund it.
Because of the AAPs new recommendations, the debate over public funding of circumcisions could resurface in the 2013 session, but lawmakers in cash-strapped states have not been eager to increase their spending on public health programs. Legislative fiscal analysts had estimated that restoring Medicaid funding circumcisions would cost Colorado taxpayers about $230,000 a year.
Gillian Longley, a registered nurse from Louisville and an anti-circumcision activist with the Circumcision Information Resource Center of Colorado (NOCIRC), believes many health professionals will ignore the AAP statement and that increasing concern about the practice will spur reconsideration.
The AAP is very out of step with what the rest of the world is saying, Longley said. Multiple medical, legal and human rights bodies in Europe and Australia are discussing the ethically problematic nature of circumcision. They are looking at the same evidence that the AAP has (reviewed). And they have concluded that there is no convincing reason to do this either for health prevention or for hygiene.
Longley said the AAP based the new policy recommendations about the health benefits of circumcision on studies of adult men in Africa, where studies by the Bill and Melinda Gates Foundation have found that circumcision can prevent HIV transmission.
Longley believes its totally inappropriate to extrapolate results from adult Africans to newborns in the U.S.
Its irrelevant to us in the U.S., Longley said.
First, HIV transmission in Africa is generally the result of heterosexual sex whereas in the U.S., transmission is still most common among men who have sex with men. Second, she said very few studies have been done to better understand the functions of the foreskin or to analyze adverse reactions from botched circumcisions.
In Colorado, some low-income families are delaying circumcisions until they can come up with the cash to pay for the procedures. Doctors at hospitals in the Denver metro area are seeing some cases of babies who have been circumcised older than usual at about a month or six weeks of age and are seeing some who are returning to hospitals with excessive bleeding.
Longley said no one in the U.S. tracks the negative impacts of circumcision.
Its very disingenuous and ethically unsupportable for a policy-making body to make such a strong statement that the benefits clearly outweigh the risks when we dont know the risks. No one is looking for the risks, Longley said.
Physicians in Colorado spoke out both for and against circumcision when public funding was debated earlier this year. Among those who supported it were Sen. Irene Aguilar, D-Denver, who is also and internal medicine doctor for Denver Health. Aguilar framed circumcision as a social justice issue, saying that if wealthy parents have the ability to get their babies circumcised, the poor should also have that right.
As a physician, I dont try to influence parents one way or the other, Aguilar said. People make this decision based on religious and cultural reasons.
She said she found some of the evidence convincing that infant boys who dont get circumcised have higher rates of urinary tract infections and that adult men who are uncircumcised and live in poverty have higher rates of sexually transmitted disease.
Another physician testified against circumcision. Dr. Jennifer Johnson is a family physician who works with Medicaid and uninsured patients at Clinica Family Health Services. She used to do circumcisions and recently stopped doing them.
This is not a necessary procedure, Johnson said. Its a healthy, normal body part.
There are a lot of medical needs in our population. We have no business using limited health care dollars on a medically unnecessary cosmetic procedure.
Longley of Colorado NOCIRC said perhaps the most persuasive new argument against circumcision is coming from opponents of genital mutilation who have been fighting to protect adolescent girls in Africa and who now believe male children deserve the same protection.
It all comes down to the same ethical bottom line, said Longley. The child is a human being and has the same human rights as any other human adult. That includes the right to have a whole human body.