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American Academy of Pediatrics Releases Revised Policy on Newborn Male Circumcision

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On August 27th, 2012, the American Academy of Pediatrics (AAP) released their updated policy on newborn male circumsion along with their updated technical report reviewing current research. This official statement follows a week or so of speculation in the media that the AAP’s new statement would fall on the side of supporting newborn male circumcision, stating that the benefits outweigh the risks.

The new policy statement replaces the last AAP recommendation on this topic released in 1999 (1). The just released statement makes the following recommendations:

  • Evaluation of 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.

  • Parents are entitled to factually correct, nonbiased information about circumcision that should be provided before conception and early in pregnancy, when parents are most likely to be weighing the option of circumcision of a male child.

  • Physicians counseling families about elective male circumcision should assist parents by explaining, in a nonbiased manner, the potential benefits and risks and by ensuring that they understand the elective nature of the procedure.

  • 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.

  • Parents of newborn boys should be instructed in the care of the penis, regardless of whether the newborn has been circumcised or not.

  • Elective circumcision should be performed only if the infant’s condition is stable and healthy.

  • Male circumcision should be performed by trained and competent practitioners, by using sterile techniques and effective pain management.

  • Analgesia is safe and effective in reducing the procedural pain associated with newborn circumcision; thus, adequate analgesia should be provided whenever newborn circumcision is performed.
    • Nonpharmacologic techniques (eg, positioning, sucrose pacifiers) alone are insufficient to prevent procedural and postprocedural pain and are not recommended as the sole method of analgesia. They should be used only as analgesic adjuncts to improve infant comfort during circumcision.

    • If used, topical creams may cause a higher incidence of skin irritation in low birth weight infants, compared with infants of normal weight; penile nerve block techniques should therefore be chosen for this group of newborns.

  • Key professional organizations (AAP, the American Academy of Family Physicians, the American College of Obstetricians and Gynecologists, the American Society of Anesthesiologists, the American College of Nurse Midwives, and other midlevel clinicians such as nurse practitioners) should work collaboratively to:
    • Develop standards of trainee proficiency in the performance of anesthetic and procedure techniques, including suturing;

    • Teach the procedure and analgesic techniques during postgraduate training programs;

    • Develop educational materials for clinicians to enhance their own competency in discussing the benefits and risks of circumcision with parents;

    • Offer educational materials to assist parents of male infants with the care of both circumcised and uncircumcised penises.

  • The preventive and public health benefits associated with newborn male circumcision warrant third-party reimbursement of the procedure.

As a result of research by the AAP Task Force commissioned for the purpose of updating their policy statemen, specific benefits from male circumcision were identified for the prevention of urinary tract infections, acquisition of HIV, transmission of some sexually transmitted infections, and penile cancer. Male circumcision does not appear to adversely affect penile sexual function/ sensitivity or sexual satisfaction. This task force was made up of AAP representatives from specialty areas, including anesthesiology/ pain management, bioethics, child health care financing, epidemiology, fetus and newborn medicine, infectious diseases (including pediatric AIDS), and urology. The Task Force also included members of the AAP Board of Directors and liaisons representing the American Academy of Family Physicians (AAFP), the American College of Obstetricians and Gynecologists (ACOG), and the CDC

Male circumcision consists of the removal of some or all of the foreksin (prepuce) from the penis. It is one of the most commonly performed procedures in the world and in the United States is most commonly done during the newborn period. The current estimated rate of male circumcision in the United States ranges from 42% to 80% among various populations.(2–6)

Circumcision rates were highest in the Midwestern states (74%), followed by the Northeastern (67%) and Southern states (61%). The lowest circumcision rates were found in the Western states (30%) (See Table 1)

Source: http://pediatrics.aappublications.org/content/early/2012/08/22/peds.2012-1990

The AAP discussed the ethical issues of newborn male circumcision, recognizing that the law allows parents or guardians to make medical decisions on behalf of the minors that they are responsible for, when provided unbiased information by a health care provider and taking into account cultural, religious, ethnic traditions and medical factors. The parents or guardians should be advised to take this into consideration. The AAP reccomends HCPs counseling families that are choosing to circumcise their male newborns to use a qualified medical provider in a medical facility rather than a traditional/religious provider in a nonmedical environment. There was also discussion on counseling parents about the potential risks of delaying the procedure beyond the newborn period, The AAP Task Force stated that there is less risk to the child when the procedure is done as a newborn.

Prevalence of male circumcision, according to self-report; United States, 1999–2004 Source: http://pediatrics.aappublications.org/content/early/2012/08/22/peds.2012-1990.full.pdf+html

The AAP does acknowledge that this procedure is elective and the parents should be informed that this is considered an elective procedure.

The AAP Task Force, in their technical report, shares their current literature review and research findings that provided for the basis of each of the current recommendations. Additionally, the technical report discusses studies that provide information on risks and complications of this elective procedure. The technical report is a comprehensive review of the information the AAP used to formulate their current recommendations and I encourage you to not only read it for your own information, but to have it available as a resource for parents who are looking for the full statement and the research behind it.

Future Research is Needed

The Task Force identified important gaps in their knowledge of male circumcision and urges the research community to seriously consider these gaps as future research agendas are developed. Although it is clear that there is good evidence on the risks and benefits of male circumcision, it will be useful for this benefit to be more precisely defined in a US setting and to monitor adverse events. Specifically, the Task Force recommends additional studies to better understand:

photo licensed by creative commons Nina Matthews Photography

  • The performance of elective male circumcisions in the United States, including those that are hospital- based and nonhospital-based, in infancy and subsequently in life.
  • Parental decision-making to develop useful tools for communication between providers and parents on the issue of male circumcision.
  • The impact of male circumcision on transmission of HIV and other STIs in the United States because key studies to date have been performed in African populations with HIV bur- dens that are epidemiologically dif- ferent from HIV in the United States.
  • The risk of acquisition of HIV and other STIs in 0- to 18-year-olds, to help inform the acceptance of the procedure during infancy versus deferring the decision to perform circumcision (and thus the procedure’s benefits) until the child can provide his own assent/consent. Because newborn male circumcision is less expensive and more widely available, a delay often means that circumcision does not occur. It will be useful to more precisely define the prevention benefits conferred by male circumcision to inform parental decision-making and to evaluate cost-effectiveness and benefits of circumcision, especially in terms of numbers needed to treat to prevent specific outcomes.
  • The population-based incidence of complications of newborn male circumcision (including stratifications according to timing of procedure, type of procedure, provider type, setting, and timing of complications [especially severe and non- acute complications]).
  • The impact of the AAP Male Circumcision policy on newborn male circumcision practices in the United States and elsewhere.
  • The extent and level of training of the workforce to sustain the availability of safe circumcision practices for newborn males and their families.

The Role of The Childbirth Educator

The decision of whether to circumcise a male newborn is frequently made early in the pregnancy and even before conception.(7-9) In a cross-sectional study of parents of 55 male infants presenting to a family practice clinic for a well-child visit, 80% of parents reported that the circumcision decision was made before a discussion occurred with the clinician about this issue. Only 4% of parents reportedly discussed circumcision with their clinician before the pregnancy.(6) This finding is substantiated by the 2009 AAP survey of 1620 members with a response rate of 57%, in which most respondents reported that parents of newborn male patients generally do not seek their pediatrician’s recommendation regarding circumcision; only 5% reported that “all” or “most” parents “are uncertain about circumcision and seek their recommendation” about the procedure. (10) There is fair evidence that parental decisions about circumcision are shaped more by family and socio- cultural influences than by discussion with medical clinicians or by parental education.(7, 11)

The AAP states that parents are entitled to factually correct, nonbiased information about circumcision and should receive this information from clinicians before conception and/or early in pregnancy, which is when they are making choices about circumcision.

I found it interesting that research indicated that most parents have most likely made a decision on newborn male circumcision prior to participating in any childbirth classes that they may be attending. I also know that talking about circumcision in a childbirth class can be a sticky, uncomfortable and emotional discussion for both attendees and educators. It may be difficult but it is important to share information on this topic in the same way that we share other information about pregnancy, labor, birth and parenting; providing resources, sources of information and avenues for additional information that the parents can access later for information.

I invite you to share your thoughts on the new AAP recommendation on newborn male circumcision and how you discuss this topic in your childbirth classes. Do you avoid speaking about it altogether because it makes you uncomfortable? How do you bring it up? What do you do when the topic becomes emotional amongst participants? Will you change what you do based on this newly released recommendation? I invite discussion but ask that you follow Science & Sensibility’s policy on participation and keep all comments polite and respectful. – SM

References

  1. American Academy of Pediatrics. Circumcision Policy Statement. Task Force on Circumcision. Pediatrics. 1999;103(3):686– 693. Reaffirmation published on 116(3): 796
  2. Centers for Disease Control and Prevention (CDC). Trends in in-hospital newborn male circumcision—United States, 1999-2010. MMWR Morb Mortal Wkly Rep. 2011;60(34): 1167–1168
  3. Warner L, Cox S, Kuklina E, et al. Updated trends in the incidence of circumcision among male newborn delivery hospitalizations in the United States, 2000-2008. Paper presented at: National HIV Prevention Conference; August 26, 2011; Atlanta, GA
  4. Overview of the Healthcare Cost and Utilization Project (HCUP). Rockville, MD: Agency for Healthcare Research and Quality; 2009. Available at: www.hcup-us. ahrq.gov/overview.jsp
  5. Nelson CP, Dunn R, Wan J, Wei JT. The increasing incidence of newborn circumcision: data from the nationwide inpatient sample. J Urol. 2005;173(3):978–981
  6. Xu F, Markowitz LE, Sternberg MR, Aral SO. Prevalence of circumcision and herpes simplex virus type 2 infection in men in the United States: the National Health and Nutrition Examination Survey (NHANES), 1999-2004. Sex Transm Dis. 2007;34(7): 479–484
  7. Tiemstra JD. Factors affecting the circumcision decision. J Am Board Fam Pract. 1999;12(1):16–20
  8. Walton RE, Ostbye T, Campbell MK. Neonatal male circumcision after delisting in Ontario. Survey of new parents. Can Fam Physician. 1997;43:1241–1247
  9. Ciesielski-Carlucci C, Milliken N, Cohen NH. Determinants of decision making for circumcision. Camb Q Healthc Ethics. 1996;5 (2):228–236
  10. American Academy of Pediatrics. Periodic Survey of Fellows: Counseling on Circumcision. Elk Grove Village, IL: American Academy of Pediatrics; 2009
  11. Binner SL, Mastrobattista JM, Day MC, Swaim LS, Monga M. Effect of parental education on decision-making about neonatal circumcision. South Med J. 2002;95 (4):457–461

American Academy of Pediatrics, Childbirth Education, Circumcision, informed Consent, Newborns, Parenting an Infant, Research , , , , , , , ,

  1. avatar
    Lynn
    August 27th, 2012 at 21:32 | #1

    There are numerous flaws in the AAP’s stance. It talks about the mogen clamp (one of the three most popular methods of infant circumcision) but fails to mention that the clamp was not invented by a medical professional, the mogen clamp has caused at least 6 penile amputations (resulting in over $25 million in successful lawsuits), and the company which produces mogen clamp went bankrupt after victims were awarded millions of dollars. It also cites a study that shows male circumcision increases transmission of HIV from men to women but fails to mention that. The bottom line is that the AAP should just be flat out ashamed of themselves for publishing this garbage.

  2. August 30th, 2012 at 11:51 | #2

    The AAP says “It is normal to have a little yellow discharge or coating around the head of the penis in the first week.” Yes this coating will be the scar thickened mucosa as outlined and quantified in Sorrells et al. preliminary study on Adult Male Penile Sensitivity Study which also included non surgically restored men. Bluntly speaking any gay man can tell you how much rougher is the texture of the circumcised glans compared to the intact.

    http://intactnews.org/node/91/1310657919/obgyn-chairman-calls-end-quotcontroversialquot-routine-infant-circumcision-obgyn-
    OB/GYN chairman calls for end to “controversial” routine infant circumcision in OB/GYN profession.

    http://ije.oxfordjournals.org/content/early/2011/06/13/ije.dyr104.short?rss=1 “Male circumcision and sexual function in men and women: a survey-based, cross-sectional study in Denmark” A recent study in
    Denmark found circumcised men have a much higher rate of sexual problems.

    http://www.ncbi.nlm.nih.gov/pubmed/21492404 Research also finds circumcised men are five times more likely to suffer from premature ejaculation.

    http://research.cirp.org/news1.html John Taylor, heart specialist and world’s penis researcher and expert says in his 2009 October Newsletter: (snip) Until we do know more, extreme care should be taken to avoid any insult to the neonatal body that might upset interlinked respiratory and cardiac rhythms. Circumcision for no obvious medical reason is somewhere near the top of a list of don`ts; after circumcision, babies are in a state of pain and shock; they become quiet and respiration often slows. Now with some knowledge of fetal physiology, you can figure out the rest of the story.
    As with the heart, the development of the prepuce can be seen in the context of the wider development of a system of tissues. The preceding newsletter outlines one set of possibilities, reflexes triggered by movement of the prepuce and glans affecting events (reflex contractions) at the base of the penis. It is ridiculous to suggest, as many do, that the prepuce is an isolated tissue that developed in the absence of any other penile influence. So what is the final message? Simply that interference with one tissue or even a nutrient bloodflow might have knock-on effects, from sudden death to bedraggled sexual reflexes in later life, that are difficult to predict without a much-improved and more sophisticated knowledge of human anatomy and physiology.
    —————————–
    The Glans-Ridged Band Dyad
    There are two levels of sexual receptors in the penis. The ridged band is a ring of innervated tissue just inside the tip of the foreskin, while the corona is the rounded base of the glans. On the top of the penis, there are more receptors in the corona while on the underside of the penis there are more receptors in the ridged band. This unequal distribution of nerve endings works in tandem to heighten sensation awareness. When the ridged band in the foreskin is completely removed (circumcision) this connection is disrupted and the increased sexual sensations are lost. Like going from stereo to mono.

    Cold/Taylor-the presence of smegma preputii is a rare finding; in a prospective examination of 4521 uncircumcised boys, only 0.5% had smegma.

    Dr. John Taylor penile and heart researcher – Sexual Function of the Dartos Muscle (loosely):
    Upon erection the Dartos muscle tenses creating a one-piece solid skin tube, where any action on the penile shaft is transferred to act on the erogenous Taylor’s Ridged Band and through its loop to the Frenulum, this action it transferred to act on the erogenous Frenulum, together the male’s sexual nexus. No action on the shaft is wasted on these sexual structures.
    Circumcision always removes all of the erogenous Taylor’s Ridged Band and part to all of it’s connecting Frenulum. Having this hangman’s noose of the male’s sexual receptors missing no longer keeps the whole of the penile Dartos muscle tense. With tension gone, all action on the erect penile shaft is wasted to act on the Ridged Band and Frenulum. Action must be applied directly to the Frenulum remnant, if any remains. Meaning the intact has the whole penile skin area to activate the erogenous receptors whereas the circumcised if lucky has just the short narrow string, the frenulum remnant and scarred and keratinized glands coronal erogenous receptors.

    Circumcision cuts off 65%-85% of the male’s sexual receptors (85% when the frenulum is cut or scraped off infant). This leaves 15% sexual receptors located in the glans corona where it’s overpowered by the more populous pain/thermal receptors, ratio 5% to 95%. It is this case that men report “If I felt anymore sensitivity, I think I would die of a heart attack!” (Larry David) Circumcision changes the way, means, and type of sensations felt. Circumcision sexually handicaps.

  3. avatar
    Kat
    August 30th, 2012 at 16:23 | #3

    I am a woman thinking to become pregnant, married to a circumcised man. As atheists there’s no pressure of religion. I’ve made it clear that I’m against circumcision for the reason that I don’t want any bits cut off my baby. Husband has not directly addressed his true feelings but will once I become pregnant. I see here that delaying circumcision until adulthood is not any safer. This is dissapointing as “baby can choose any procedure he wants when he’s 20″ is the back-door to arguments against my position. I certainly hope in 20 years we have the medical technology to do plastic surgery on male genitals safely. Many surgical procedures are already done on genitals; I imagine the bulk of the risk lies in anasthesia.
    One thing I’m not sure how to bring up is the sexual sensation. I live in America and of the two dozen or so lovers I’ve had, only one was uncircumcised. Vaginal sex with that man was better with that man because of his foreskin. He wasn’t a notably good lover otherwise, just enthusiastic. There’s just more “going on down there” with intact parts. The previous commenter mentioning gay men’s opinion on the foreskin also hints to the differences. My circumcised lover was very sensitive to touch on his penis. Other lovers including my husband like painful, rough sensations much more than gentle. The head of the erect penis itself is also different- more akin to the soft smoothness of very aroused clitoral area, than to the slightly-scaly bulge of a circumcised glans. How do I address my own experience with my husband? I don’t relish telling him his penis gives me less sensation than some ex.
    For me going at the genitals that will become that smooth, nerve-filled sexual center with a scalpel seems barbaric and wrong. “Popular opinion” is not nearly enough to sway me. Medical hemming and hawing doesn’t really convince me either. STDs can be avoided even by a teenager – I never caught anything and I was dumb for years.
    One other thing not mentioned is the sexism of the whole idea. Many left-leaning people like myself and this blog feel than female genital mutilation / removal of the clitoris / modification of the labia / female circumcision is ‘just wrong’. In a non medical context it’s horrifying, and when done in a hospital by request is either the work of a troglodyte doctor or a patient too ignorant to know better. Let’s just say FGM is wrong– isn’t male circumcision just MGM and naturally also wrong? Or FGM if it’s just removal of the inner labia in a hospital with analgesia is ok, foreskin removal is ok, everything is fine lets all remove bits of our offspring for sociocultural reasons. Is it that FGM is done on older girls, who suffer at least weeks of pain, and we can imagine that? Can’t we imagine genital pain on a little infant boy is exactly the same?
    So what I have concluded is removal of the foreskin from infant boys is sexist, in that Americans expect men to look a certain way, which is clearly oppressive as the expectation is we cut bits off our infants. Sexism is wrong, no one deserves to have bits cut off or attached to them against their will.
    Clearly if my husbad does want our baby circumcised, he’s going to need all nine months to convince me.

  4. avatar
    Karen
    November 2nd, 2012 at 08:29 | #4

    Kat, I’m a bit behind in reading this article but I wanted to say that as far as the supposed medical benefits go, everything that circ is supposed to prevent can also be prevented by other means – namely, breastfeed your baby and don’t retract the foreskin. There has been a lot of hype about circ preventing STIs, but even circumcised men still have to wear condoms. Also, it’s important to note that as women, we experience vastly more vaginal infections than men do, yet we don’t break baby girls’ hymens or alter them surgically for “preventative” measures.

    As far as convincing your husband goes, maybe he wishes he had been left intact? Or wonders what it would be like? Perhaps he could be convinced to use Senslip for a while and regain part of what he’s missing? That alone might be enough to convince him not to sexually cripple his own child.

    Best wishes on your future babies!

  1. September 5th, 2012 at 04:00 | #1