Circumcision: Trends and Guidelines

2. Introduction
• Since the popularization of circumcision in western
culture, in the mid-nineteenth century, the potential
benefits of the procedure have been met with
pragmatic and ethical concerns, producing confusion
for practitioners and parents alike.
• In response to this confusion, multiple medical
organizations have released recommendations and
guidelines in order to provide consensus opinions to
those who counsel families and practice routine
neonatal circumcision (NC).
• Unfortunately, these guidelines are not always
consistent and often change with popular sentiment.

3. Our goal here is
• to review the major arguments in favor of and
opposed to neonatal circumcision that are put
forth by medical organizations,
• to outline the current recommendations from
the major medical organizations in western
medicine, and
• to provide a consensus of these views that
may be put into practice.

4. American Academy of Pediatrics
• In 1999, the American Academy of Pediatrics
released its most recent Circumcision Policy
Statement that was reaffirmed in 2005.
• The statement, published in Pediatrics
councils, is that although there are potential
benefits of NC, there is not a preponderance
of evidence mandating its routine practice.

5. • This statement addresses several areas of
potential benefit from NC, including
 prevention of urinary tract infection(tenfold
increase in risk of UTI in uncircumcised males)
 penile cancer (three times lower in
circumcised men).
 sexually transmitted diseases.

6. • The AAP statement also points out several
potential harms of the procedure.
• It sites a complication rate of 0.2–0.6%, but
states that most of these complications are
“minor”.
• These include bleeding, infection, poor
cosmetic outcome, and, at the extreme,
amputation of the glans penis.

7. • In conclusion: the AAP statement that the
parents should be persons the determine
what is in the best interest of the child.
• “if a decision for circumcision is made,
procedural analgesia should be provided.”

8. American Academy of Family
Physicians
• The American Academy of Family Physicians
(AAFP) position of 2001, and reaffirmed in
2007, is similar in context and tone to the AAP

9. • Most parents base their decisions whether or not
to have their newborn son circumcised on
nonmedical preferences (i.e. religious, ethnic,
cultural, cosmetic).
• The American Academy of Family Physicians
recommends physicians discuss the potential
harms and benefits of circumcision with all
parents or legal guardians considering this
procedure for their newborn son.
• “If the decision is made to circumcise,
anesthesia should be used.”

10. American Urological Association
• The American Urological Association (AUA) policy
statement of 1989 with a final revision in 2007
states that “neonatal circumcision has potential
medical benefits and advantages as well as
disadvantages and risks” .
• It states that neonatal circumcision is relatively
safe when performed by an experienced provider
and that most complications are minor.

11. • Delayed complications of circumcision must be
factored such as cicatricial buried penis, meatal
stenosis, skin bridges, chordee, and poor cosmesis.
• In balance, it states that a properly performed
circumcision prevents phimosis, paraphimosis, and
balanoposthitis, and lowers incidence of penile
cancer, urinary tract infections, and possibly sexually
transmitted diseases.
• That is, “the risks and disadvantages of circumcision
are encountered early whereas the advantages and
benefits are prospective”.

12. Centres for Disease Control
and Prevention
• Though highly anticipated since 2009, the Centers for
Disease Control and Prevention (CDC) has not
published recommendations for or against routine
circumcision.
• The CDC reports that circumcision has some protective
value against genital ulcer disease and chlamydia,
infant urinary tract infections, penile cancer, and
cervical cancer in women (the latter two being
associated with human papillomavirus, HPV).

13. • The CDC recognize that circumcision:
• (1) does carry risks and costs that must be
considered in addition to potential benefits;
• (2) has only proven effective in reducing the risk
of infection through insertive vaginal sex; and
• (3) confers only partial protection and should be
considered only in conjunction with other proven
prevention measures.”

14. Canadian Pediatric Society
• Canadian health organizations have largely opposed routine NC
over the last 30 years.
• In 1989, the Canadian Pediatric Society commented that the
evidence pertaining to STDs and UTI was not “sufficiently
compelling to justify a change in policy” and revisited in 1996.
• This policy has discouraged neonatal circumcision since the 1970s.
• This position is also supported by the College of Physicians and
Surgeons of British Columbia (CPSBC) position, released in 2009,
which definitively states that the routine circumcision of neonates
“is not recommended” and may even have human rights
implications.

15. The Royal Australasian College
of Physicians
• In 1996, the Royal Australasian College of
Physicians (RACP) acknowledged that rates of
UTI, penile cancer, and HIV may be lower in
circumcised males but that this does not support
routine circumcision.
• Instead it recommended that the practice be
delayed until the patient is old enough to make
an “informed choice”.

16. • In 2010, the Royal Australasian College of Physicians
published an updated policy reaffirming their position
against routine infant circumcision:
• “the frequency of diseases modifiable by circumcision,
the level of protection offered by circumcision and the
complication rates of circumcision do not warrant
routine infant circumcision in Australia and New
Zealand.
• However it is reasonable for parents to weigh the
benefits and risks of circumcision and to make the
decision whether or not to circumcise their sons”.
• “Infant circumcision without analgesia is
unacceptable practice in Australia and New Zealand.”

17. British Medical Association and British
Association of Pediatric Surgeons
• Both the British Medical Association (BMA)
and the British Association of Pediatric
Surgeons (BAPS) have expressed that there is
“rarely a clinical indication for circumcision”.
• These organizations raise the question of valid
consent and ethical concerns in making a
decision for a newborn male.

18. • “If it was shown that circumcision where there
is no clinical need is prejudicial to a child’s
health and wellbeing, it is likely that a legal
challenge on human rights grounds would be
successful.” They require that both parents
must give consent.
• If the child is old enough to express person
views, they must be taken into account. That
said, the BMA

19. Royal Dutch Medical Association
(KNMG)
• Of all the points of view listed herein, the KNMG
takes the strongest position in opposing
nontherapeutic circumcision:
• “The KNMG calls for a dialogue between doctors’
organisations, experts and the religious groups
concerned in order to put the issue of non-
therapeutic circumcision of male minors on the
agenda and ultimately restrict it as much as
possible”.

20. • Their position is that the complications of circumcision
are significant and therefore outweigh grounds other
than direct medical/therapeutic: “Contrary to what is
often thought, circumcision entails the risk of medical
and psychological complications.
• The most common complications are bleeding,
infections, meatus stenosis and panic attacks.” and
“Non-therapeutic circumcision of male minors is
contrary to the rule that minors may only be exposed
to medical treatments if illness or abnormalities are
present,
• Where circumcision is provided, it must be done by a
doctor and under local or general anesthesia.

21. World Health Organization
• “Male circumcision should be recognized as an
additional important step in curbing
heterosexually acquired HIV in men” – March
2007 (UN News Centre).
• The World Health Organization (WHO) is highly
engaged in remedying the HIV epidemic,
especially in sub-Saharan Africa.
• In addition to counseling safer behavior and early
initiation of antiretroviral therapy, circumcision,
especially in high prevalence areas, is
recommended.

22. • In fact, all policy statements reviewed, regardless
of its position on circumcision, have made
allowances for parental choice in support of their
cultural or religious preference.
• Furthermore, some policy makers take the
position that in such cases, circumcision should
be covered by state health programs to
discourage the use of lesser trained lay
practitioners.

23. • In places where the government or health insurances
do not cover circumcision, the incidence is low or tends
to decline. For example, the rates of circumcision and
the support of this practice have fallen drastically in
Great Britain once the government funded health care
stopped covering circumcision.
• Moreover, the demographic distribution of
circumcision in the United States is significantly
affected by insurance and state (Medicaid) coverage
such that a socioeconomic divide is apparent, which
gives enhanced meaning to the have and have-nots.

24. Summary
• Outside of strategic regions in sub-Saharan
Africa, no call for routine circumcision has been
made by any established medical organizations or
governmental bodies.
• The range of positions is from “some medical
benefit/parental choice” in the United States, to
“essential no medical benefit/ parental choice” in
Great Britain, to “no medical benefit/physical and
psychological trauma/parental choice” in the
Netherlands.

25. • Ultimately, a number of factors play a role in
the position on circumcision that a medical
organization will take.
• In areas such as sub-Saharan Africa, where HIV
rates are extremely high and recent evidence
suggests a prophylactic value.
• In places where the government or health
insurances do not cover circumcision, the
incidence is low or tends to decline.

26. • Where circumcision is viewed as having
nominal or no medical value, then only social,
cultural, and religious factors will drive the
practice.
• Furthermore, some policy makers take the
position that in such cases, circumcision
should be covered by state health programs
to discourage the use of lesser trained lay
practitioners.

27. Islam and Circumcision
• Although circumcision is not mentioned in the
Qur’an , Muslims everywhere regard it as
essential. This practice is attributed to the
Prophet of Islam.
• Among the different schools of Islamic law, some
consider male circumcision obligatory while the
majority recommends it.
• Despite differences of opinion, none consider it a
precondition of being a Muslim. As a result, it is
not a prerequisite for any person converting to
Islam.

28. • The Age for Circumcision: During the time of
the Prophet Muhammad (pbuh) circumcision
was done for boys at the time of their Aqiqah
(on the seventh day or later on).
• It is considered sensible to perform
circumcision before the age of puberty where
boys start praying regularly.