Circumcision: The Controversy Continues

Mother and son. (iStockphoto)
Mother and son. (iStockphoto)

“What advice should a physician give to parents considering whether or not to have their baby circumcised?” asks Dr. Jeff Blackmer. Dr. Blackmer is a Director of Ethics at the Canadian Medical Association (CMA). His column appears in the Bulletin of the CMA which is part of the Canadian Medical Association Journal (CMAJ February 5, 2013).

The Canadian Paediatric Society (CPS) evaluates scientific evidence and sets guidelines in matters affecting children’s health. Since 1996, CPS has advised physicians that circumcision of newborn should not be routinely performed as there was no medical benefit. This, of course, has not changed the practice. Some parents request circumcision for their sons for religious reasons or family tradition.

In August, 2012 the American Academy of Pediatrics (AAP) updated its 1999 policy on circumcision to say that there are some medical benefits to having the procedure. Circumcision lowers risk of urinary tract infection, cancer of the penis, and sexually transmitted infection. Blackmer says that CPS is reviewing the evidence and may release an updated statement.

In 2011, Dr. Noni MacDonald, Section Editor of CMAJ wrote an article in the CMAJ under the title, “Male circumcision: get the timing right.” (CMAJ April 19, 2011). Dr. Noni MacDonald is a Professor of Paediatrics and of Computer Science at Dalhousie University with a clinical appointment in Paediatric Infectious Diseases at the IWK Health Centre in Halifax Canada. She is the former Dean of Medicine at Dalhousie University.

“The most commonly performed surgical procedure in the world – male circumcision – is done for therapeutic, prophylactic, religious, cultural and social reasons. Discussions of male infant circumcision for health reasons are always split,” says MacDonald in her article.

Those who support circumcision say that there are significant potential health benefits including a decreased risk for some sexually transmitted infections, a decrease in HPV-related penile cancer and reduced phimosis and paraphimosis (tightness of the foreskin).

Those who oppose circumcision say that the procedure is not without likely complications – about 1.5 per cent – and it is a painful procedure for the newborn.
Medical organizations in western countries have discouraged infant circumcision for many years. MacDonald asks, “The question now is whether the findings from the randomized trials of adult male circumcision in sub-Saharan Africa that show circumcision halves the risk of acquiring HIV and decreases risk for HSV-2 (a herpes simplex virus that can cause genital herpes) and high-risk HPV in heterosexual African adult men push these organizations to change their positions on routine infant circumcision.”

MacDonald adds, “… none of the sub-Saharan African studies examined infant circumcision; all involved adult male circumcision. There is no new evidence that infant circumcision provides any added benefit to the neonate, infant or young child with respect to HIV and HPV protection. The potential benefit from circumcision only begins to accrue when the male becomes sexually active.”

The dilemma is: if the infant is not going to benefit from circumcision until he is sexually active then should we offer circumcision during peripubertal time? Would the male adolescent be willing to go through the procedure? Currently, infants have no choice. The choice for them is made by their parents.

The World Health Organization agrees there is evidence that male circumcision significantly reduces the risk of HIV acquisition by men during penile-vaginal sex, but also state that circumcision only provides partial protection and should not replace other interventions to prevent transmission of HIV.

Well, what is the conclusion? I will quote Dr. Blackmer from his ethics corner column mentioned earlier. It says, “Some parents will always choose circumcision, some will always reject it, and some will decide based solely on the evidence.” The only thing a physician can do is present the evidence and let the parents make the decision.

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