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Publication Date: 
December, 1989
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The American Academy of Pediatrics (AAP) has released its statement on circumcision, concluding that the procedure has potential medical benefits and advantages, as well as inherent disadvantages and risks.

According to AAP president Donald Schiff, M.D., the Academy is recommending that the decision is one best made by parents in consultation with their physician.

\"In addition to the medical aspects, other factors will affect the parents' decisions, including esthetics, religion, cultural attitudes, social pressures, and tradition,\" the AAP statement says.

Physicians should explain and discuss the benefits and risks of circumcision with parents, and informed consent should be obtained before the procedure is performed. Most male infants born in this country are circumcised in the newborn period, although the circumcision rate appears to be falling.

Since 1971, the AAP has maintained the position that there was no absolute medical indication for routine circumcision of the newborn. New information has recently appeared in the literature suggesting possible medical benefits from newborn circumcision. Summarized below are the main points of the AAP's new statement on circumcision, addressing the new evidence:

Urinary Tract Infections Studies conducted at U.S. Army hospitals in 1985 involving more than 200,000 males showed a greater than tenfold increase in urinary tract infections in uncircumcised male infants; moreover, as the rate of circumcision declined over the years, the incidence of urinary tract infection increased.

However, the AAP statement says: \"It should be noted that these studies in Army hospitals are retrospective in design and may have methodological flaws. For example, they do not include all boys born in any single cohort or those treated as outpatients, so the study population may have been influenced by selection bias.\"

Circumcision \"may result in a decreased incidence of urinary tract infection. However, in the absence of well-designed prospective studies, conclusions regarding the relationship of urinary tract infection to circumcision are tentative,\" according to the statement.

Cancer of the Penis Circumcision has been shown to decrease the incidence of cancer of the penis (a rare condition) among U.S. males. This condition occurs almost exclusively in uncircumcised men. Poor hygiene, lack of circumcision, and certain sexually transmitted diseases all correlate with the incidence of penile carcinoma.

The decision not to circumcise a male infant must be accompanied by a lifetime commitment to genital hygiene to minimize the risk of developing penile cancer.

Sexually Transmitted Diseases \"Evidence regarding the relationship of circumcision to sexually transmitted diseases is conflicting,\" the AAP statement says. \"Although published reports suggest that chancroid, syphilis, human papillomavirus and herpes simplex virus type 2 infection are more frequent in uncircumcized men, methodological problems render these reports inconclusive.\"

Cervical Cancer Evidence linking uncircumcised men to cervical carcinoma is also inconclusive, the statement notes. However, an increased incidence of cancer of the cervix has been found in sexual partners of uncircumcised men infected with human papillomavirus.

The strongest predisposing factors in cervical cancer are a history of intercourse at an early age and multiple sex partners.

Pain and Behavioral Changes Infants undergoing circumcision without anesthesia demonstrate physiological responses suggesting that they are experiencing pain. Behavioral changes include a cry pattern indicating distress during the circumcision procedure and changes in activity (irritability, varying sleep patterns) and in infantmaternal interaction for the first few hours after circumcision. \"These behavioral changes are transient and disappear within hours after surgery,\" the statement notes.

Local Anesthesia Dorsal penile nerve block in appropriate doses may reduce the pain and stress of newborn circumcision. \"However,\" according to the statement, \"reported experience with local anesthesia in newborn circumcision is limited, and the procedure is not without risk.\"

Complications due to local anesthesia are rare and consist mainly of hematomas and local skin necrosis (death of tissue). \"It would be prudent to obtain more data from large controlled series before advocating local anesthesia as an integral part of newborn circumcision,\" the statement says.

Complications, Contraindications, Hygiene, Infections The exact incidence of postoperative complications is unkown, but large series indicate that the rate is low, approximately 0.2 to 0.6 percent. The most common complications are local infection and bleeding.

Circumcision should only be performed on stable, healthy infants. It is contraindicated in an unstable or sick infant. It is prudent to wait until a premature infant meets criteria for discharge before performing circumcision.

Circumcision prevents phimosis (inability to retract the foreskin), paraphimosis (accumulation of fluid and swelling of the prepuce and glans), and balanoposthitis (inflammation of the prepuce and glans). It is particularly important that uncircumcised boys be taught careful penile cleansing, the AAP statement notes.

The American Academy of Pediatrics is an organization of 37,000 pediatricians dedicated to the health, safety and well-being of infants, children, adolescents and young adults.

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