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New Data Support Long-Term Health Benefits of Male Circumcision

From Medscape Medical News
New Data Support Long-Term Health Benefits of Male Circumcision
Fran Lowry
Authors and Disclosures

January 4, 2010 — The American Academy of Pediatrics (AAP) policy on newborn male circumcision, initiated in 1999 and reaffirmed in 2005, states that data are insufficient to recommend routine neonatal circumcision. However, recent results from 3 randomized trials showing that it prevents sexually transmitted infections suggest that it is time to revise this policy to fully reflect these benefits, according to a review published in the January 2010 issue of the Archives of Pediatric and Adolescent Medicine.

“During the past 4 years, substantial new data have been published on the health benefits of circumcision,” write Aaron A. R. Tobian, MD, from Johns Hopkins University School of Medicine, Baltimore, Maryland, and colleagues. “While the historical evidence strongly suggests that male circumcision reduces urinary tract infections and penile inflammatory disorders in infants, we reviewed the more recent evidence with regard to effects on sexually transmitted infections (STIs) in adulthood.”

To evaluate the effect of circumcision on HIV prevention, the researchers analyzed 3 randomized controlled trials of more than 10,000 men from South Africa, Kenya, and Uganda.

The trials enrolled HIV-negative men to circumcision on enrollment or after 21 to 24 months, and all 3 trials demonstrated that male circumcision significantly decreased male heterosexual HIV acquisition by 53% to 60%, despite differences in age eligibility criteria, urban or rural settings, and surgical procedure.

Results Prompted New WHO/UNAIDS Recommendations

Because of this new evidence, the World Health Organization (WHO), together with the Joint United Nations Program on HIV/AIDS (UNAIDS), recommended that male circumcision be provided as an important intervention to reduce heterosexually acquired HIV in men, the study authors report.

The trials also found that male circumcision decreased herpes simplex virus type 2 (HSV-2) acquisition by 28% to 34% and the prevalence of human papillomavirus (HPV) by 32% to 35% in men.

Among female partners of circumcised men, bacterial vaginosis was reduced by 40% and Trichomonas vaginalis infection was reduced by 48%, the study authors write.

The study authors note that the rates of neonatal circumcision complications are between 0.2% and 0.6% of operations performed. The most common complications are bleeding and local infection, which are controlled with pressure and wound care or antibiotics. Other complications, such as phimosis and concealed penis, adhesions, fistula, meatitis, meatal stenosis, and injury to the glans, are extremely rare.

They add that there was no evidence of change in sexual behavior after circumcision in the African randomized controlled trials. “Thus, there are risks to neonatal circumcision, but serious long-term complications are extremely rare,” the study authors write.

“The rare short-term risks of neonatal circumcision need to be weighed against the potential benefits accrued in infancy and childhood (eg, reduction of urinary tract infections), the longer-term benefits that may accrue in adolescence and adulthood (eg, reduced risks of HIV, HSV-2, and HPV), as well as possible benefits to female sexual partners of circumcised men (eg, reduced bacterial vaginosis and trichomonas),” Dr. Tobian and colleagues write.

Medicaid does not cover the cost of male circumcision in 16 states, and the lack of coverage particularly affects disadvantaged minorities, who have the highest risk for HIV and sexually transmitted diseases. “These socioeconomically disadvantaged groups could benefit most if Medicaid covered the costs of neonatal circumcision. Thus, the AAP’s policy has important implications for the health of disadvantaged minorities,” they write.

They conclude that it is time for the AAP policy to fully reflect current data.

Coverage for Circumcision

In an accompanying editorial, Michael T. Brady, MD, from Nationwide Children’s Hospital in Columbus, Ohio, writes that the study authors have provided a very objective review of the available data. Although the 3 randomized trials were performed in Africa, “it is clear that circumcision does offer health benefits, even in the United States,” he notes.

The current evidence on the health benefits of circumcision is adequate enough to include circumcision in medical coverage provided by Medicaid or commercial insurance providers, Dr. Brady points out. “This is particularly relevant since over the past decade many state Medicaid programs have discontinued payment for circumcision.”

He concludes that recommendations for routine newborn circumcision will need to wait for well-designed studies that verify its cost-effectiveness for the individual and/or society. “With available data, we are not there yet, but we may be getting closer.”

Dr. Tobian and Dr. Brady have disclosed no relevant financial relationships.

Arch Pediatr Adolesc Med. 2010;164:78-84, 94-96.

http://www.medscape.com/viewarticle/714553

Views: 3051

Comment by Debby Bruck on January 5, 2010 at 2:11am
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Benefits of Male Circumcision --> http://j.mp/5NQKtk #HWC

Thank you Dr Nambison. This is an ancient ritual practice. Maybe they knew something we are just substantiating today through medical research and scientific studies.
Comment by Gina Tyler DHOM on January 6, 2010 at 1:43pm
Improved understanding of the normal anatomy of the infant foreskin means there is now rarely a therapeutic indication for infant circumcision,1 and the procedure is not supported by international medical opinion.2 Ritual (non-therapeutic) male circumcision, however, continues unchecked throughout the world, long after female circumcision, facial scarification, and other ritual forms of infant abuse have been made illegal.

The law and principles pertaining to child protection should apply equally to both sexes, so why do society and the medical profession collude with this unnecessary mutilating practice?

Ritual male circumcision is an ancient religious rite for Muslims and Jews, and the crux of this debate revolves around the primacy of parental religious conviction versus the primacy of the human rights of the child, the preservation of its bodily integrity, and its right of self determination.

In addition to religious justification, there have been many spurious and now unsupported health claims for circumcision—including the prevention of penile cancer, masturbation, blindness, and insanity3—most of which, like reduction in HIV transmission identified more recently, relate to adult sexual behaviour and not to the genital anatomy or best interest of a child.

Male genital mutilation is not a risk-free procedure. There are potential anaesthetic risks, and the short term risk of bleeding and infection associated with any surgical procedure.4 Longer term potential complications include pain on erection, penile disfigurement, and psychological problems.5 A recent report shows that the non-circumcised adult penis is more sensitive than the circumcised penis, largely because the five most sensitive areas, identified in the study, are removed during circumcision.6 This implies a reduction in future sexual sensitivity for circumcised adults. Far from being a harmless traditional practice, circumcision damages young boys.


Legal protection
Article 24(3) of the UN convention on the rights of the child commits all ratifying states to "take all effective and appropriate measures with a view to abolishing traditional practices prejudicial to the health of children" and article 19(1) says: "States shall take all appropriate legislative administrative social and educational measures to protect the child from all forms of physical or mental violence, injury or abuse."7

UK courts have interceded in the past to protect the best interests of children whose parental belief systems have put children at risk. However, male circumcision remains lawful if both parents consent.8910 Since the Human Rights Act has been implemented, however, single parental consent has been found to be insufficient to show that the procedure is in the child’s best interest.11

As far as female genital mutilation is concerned, in the United States the Federal Prohibition of Female Genital Mutilation Act states that in applying the law, "no account shall be taken . . . that the operation is required as a matter of custom or ritual." These terms are closely mirrored in the UK Female Genital Mutilation Act 2003. Both the US and the UK legal systems therefore discriminate between the sexes when it comes to protecting boys and girls from damaging ritual genital mutilation.

The UK’s General Medical Council abdicates all responsibility for male circumcision to society as a whole,12 but in June 2007 the BMA, which had previously offered general guidance,13 decided that "any decision to provide medical or surgical treatment to a child, or any decision to withhold medical or surgical treatment from a child, should: consider the ethical, cultural and religious views of the child’s parents and/or carers, but without allowing these views to override the rights of the child to have his/her best interests protected."14

Male circumcision was not specifically mentioned, but it cannot be in the best interest of a child to be subjected, without its consent, to an irreversible surgical procedure, often without anaesthetic, which will provide no medical benefit but which has proved adverse consequences both in terms of potential complications for some and reduced penile sensation in adulthood for all.


Religious perspective
Some faiths view male circumcision, often done by people who are not medically qualified, as important for entering a covenant with their God. However, given the age of the children involved it cannot be said that this covenant is freely entered into by the individual concerned.

In the US, elements of the Jewish community are beginning to rethink this issue.15 They suggest bringing Jewish boys into the covenant symbolically, with the potential for the child to be circumcised when old enough to consent to the procedure himself. Muslims already circumcise boys at an older age, and further delay to allow the child to consent could equally be considered. How much stronger would that covenant be, when entered into by a fully competent young man with full knowledge of its religious implications and the potential risks involved.

The unpalatable truth is that logic and the rights of the child play little part in determining the acceptability of male genital mutilation in our society. The profession needs to recognise this and champion the argument on behalf of boys that was so successful for girls.






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Reference

British Association of Paediatric Surgeons, Royal College of Nursing, Royal College of Paediatrics and Child Health, Royal College of Surgeons of England and Royal College of Anaesthetists.
Comment by Gina Tyler DHOM on January 6, 2010 at 1:47pm
Comment by Gina Tyler DHOM on January 6, 2010 at 2:16pm
a few more links; FACTUAL information not information based on mothergoose theory!
www.doctorsopposingcircumcision.org
www.noharm.org
www.cirp.org
http://www.cirp.org/library/disease/
www.stopthecut.org
Comment by Gina Tyler DHOM on January 8, 2010 at 12:41pm
more on the factual data; www.nocirc.org
Comment by Gina Tyler DHOM on January 8, 2010 at 12:50pm
Paul Fleiss MD comments on Circumcision;
Babies are a miracle. They come complete and perfect with all their functional parts ready to develop into a total human being. It is our job as parents, teachers, and others to guide them in growth and development to become the best they can be - to become intelligent, compassionate, healthy individuals in mind, body, and spirit.

A baby is born into an imperfect world, yet he or she is pure and full of trust. A baby's wants and needs are simple. A baby needs nourishment - not only physical, but emotional nourishment. S/he wants to he held and hugged and loved and kissed and touched, to hear music - soothing and gentle sounds - like those produced by a harp, cello, or human voice.

It seems absurd that today we choose to mutilate a significant percentage of our newborn infants. As a young medical student in the 1960s, I learned the technique of performing the surgical procedure of male circumcision. It was not difficult to learn this procedure, and I very rapidly became expert at removing the foreskin from a newborn. I was able to do circumcisions in a very short amount of time - four or five minutes. I did this at the parents' request, and I was oblivious to the infant's cry.

Several years later into my pediatrics career, after having performed perhaps a hundred circumcisions, I became aware of the newborn's pain that I had somehow managed to put out of my consciousness. I now know that every baby that I circumcised cried and that I never responded to their pain. I then decided I was on their side; my job was to protect babies, not harm them. It was only then that I began my study of the foreskin, how it is unlike any tissue found elsewhere in the human body and accordingly, has special functions. The doctors and others performing this procedure on newborn babies do not know the pain they are causing nor do they appreciate the functions of that unique bit of tissue.

Billy Ray Boyd, in writing this book, will have a profound impact on a ritual more than 2,000 years old that has been based on superstition, tradition, and religious beliefs, with little basis in medicine. This book will change outmoded methods of thinking. Parents, doctors, and religious leaders will learn from this book and come away from it with regret that this procedure was done to them and done by them.

It is understandable that parents, doctors, and religious leaders have always wanted what is best for their children. It is only by changing this practice that we will stop hurting our babies in a manner that cannot be good for them. Circumcision not only destroys an important part of anatomy and, therefore, the male's physiology, but also psychologically and emotionally damages them.

Infants do feel pain. This has been proven without a doubt in many recent studies. To continue to perform this procedure on our babies without medical justification is a practice that should and will end. This book will make that end come sooner rather than later.

Paul M. Fleiss, M.D.


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Paul Fleiss, M.D., has been a practicing pediatrician in Hollywood(USA) for over thirty years. He has treated over 30,000 patients, including the children of some of Hollywood's most famous stars. Dr. Fleiss is an Assistant Clinical Professor of Pediatrics at College of Osteopathic Medicine of the Pacific, and a lecturer at UCLA School of Public Health. He is on the medical advisory board for La Leche League International and also on the advisory board for the National Organization of Circumcision Information Resource Centers.
Comment by Amy L. Lansky on January 8, 2010 at 2:45pm
I probably should chime in on this, since I am Jewish and had both my sons circumsized for religious reasons. But I just wanted to point this out:

a) Female circumcision deprives women of sexual satisfaction and that seems to be the intention. That is VERY different than male circumcision. Men would, of course, never intentionally set up a practice that deprived them of their sexual satisfaction! I agree that these people may have known that there were some benefits.

b) I have seen a circumcision done by a doctor in a hospital, and I would say that it is barbaric and scary compared to my experience with Jewish circumcision in my home with both my sons. There is a man called a "mohel" who does it -- that's his job -- and he's obviously an expert at it, whereas most doctors are not. The Jewish circumcision method is different (I can describe it if you like), it is quick, and it seemed to be relatively painless to my sons. The only part when they cried was when they were breaking the adhesions between the glans and the penis, but the actual cutting happened in 1 second. There was barely a fuss. Within 10 seconds they were quiet and nursing and happy. They had no problem. There were never any restrictions on the baby's limbs, they were always held.

In contrast, what I saw in the hospital was a long belabored cutting process with the infant held down in bonds and screaming for 10-15 minutes. It was horrifying!
Comment by Gina Tyler DHOM on January 8, 2010 at 3:24pm
Hi Amy Thanks for your comment. With all due respect here are a few links on this subject of circumcision from the religious point of view.
http://jewishcircumcision.org/
http://www.udonet.com/circumcision/christian.html
http://www.quran.org/circumcision.htm#against
Comment by Gina Tyler DHOM on January 8, 2010 at 3:46pm
if you have trouble with these links try
www.cirp.org
go to religious issues-all 3 of the above prior links can be found here
Comment by Danny Quaranto on January 9, 2010 at 8:07am
Interesting, all of the comments are from women. I'm still traumatized. I want my foreskin back. We should at least be given the option of being buried with out foreskin so that we can go out of this world with all of the parts we came in with :). If it served no use, then we should not have been born with it.

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