Greater Benefits of Infant Circumcision

Commentary: Benefits extend into adulthood, says Johns Hopkins adolescent medicine specialist

Arik Marcell

Johns Hopkins Adolescent Medicine Specialist Arik Marcell, M.D., M.P.H., outlines circumcision's medical benefits.

The American Academy of Pediatrics (AAP) recently published (Pediatrics, September 2012) a policy statement on the medical circumcision of male newborns. While determining that the procedure’s benefits outweigh its risks, AAP does not go so far as to recommend universal newborn circumcision, saying instead that the decision should be left to parents “to make in the context of their religious, ethical and cultural beliefs.”

The preventive and public health benefits associated with newborn male circumcision, however, “warrant third-party reimbursement of the procedure,” including Medicaid, says AAP. It goes on to recommend that circumcision in infancy be performed by “trained and competent providers, using sterile techniques and effective pain management.”

Circumcision is the surgical removal of the foreskin, a flap of skin that covers the tip of the penis. The first revision of its circumcision stance in 13 years, the AAP’s new policy takes into account significant studies, including a recent one from Johns Hopkins, that link circumcision to decreased risk over a lifetime for some forms of cancer, including penile and cervical, and the spread and heterosexual acquisition of HIV, human papilloma virus (HPV), genital herpes and syphilis. Much of the new scientific research, since the previous AAP policy of 1999, has taken place in Africa, where the prevalence of sexually transmitted infections, HIV in particular, is high and increasing.

Such newly and widely documented health benefits, says the AAP in related literature, are great enough that the insurance should cover the cost of circumcision, “which would increase access to the procedure for families who choose it.”

A recent Johns Hopkins study (Archives of Pediatrics & Adolescent Medicine, online, Aug. 20) goes further. Declining rates of U.S. infant male circumcision will lead to dramatically higher rates of sexually transmitted disease and related cancers in men and their female partners, researchers warn, and add up to more than $4.4 billion in avoidable costs if circumcision rates in the U.S., now averaging 55 percent (down from 76 percent in the 1970s and 1980s), drop to levels now seen in Europe (around 10 percent on average) over the next decade.

Commentary: Q&A with Arik V. Marcell, M.D., M.P.H.

An adolescent medicine expert at Johns Hopkins Children’s Center, Arik Marcell, M.D., M.P.H., discusses the AAP update on circumcision, and the medical case for this procedure in a newborn.

Why did the AAP think it was necessary to update its circumcision policy?
Newer evidence has accumulated that had not been previously considered by the AAP in its review of benefits and costs of circumcision, including that of its benefit in decreasing HIV and STD transmission. The new policy is based on a thorough review of the available scientific evidence, which shows clearer health benefits than had previously been understood. The most significant changes since the last recommendation in 1999 are new studies demonstrating a protective effect of circumcision against acquiring several sexually transmitted diseases, including HIV, genital herpes, human papillomavirus (the virus that causes genital warts, cancer of the penis and cancer of the cervix) and syphilis. The new AAP policy states that the strength of the data is sufficient enough that the Academy advocates the procedure be covered by insurance, also not discussed in the prior (1999) statement. The scientific evidence indicates that the health benefits of newborn male circumcision outweigh the risks, it adds. This is a stronger statement regarding the medical benefits of circumcision than was included in the 1999 statement, reflecting the scientific evidence that has emerged since then.

Do you see medical consequences in your uncircumcised adolescent patients?
Yes. For example, uncircumcised male teens and young adults may be less likely to notice symptoms of STDs, because of the foreskin covering. I’ve seen many uncircumcised male patients during routine physical examinations who have asymptomatic discharge from the urethra due to either gonorrhea or Chlamydia that would have otherwise gone undiagnosed. This is a threat to the health of the male as well as his partners since STDs can cause ascending infections into the reproductive tract. We’re still accumulating evidence about the role of bacteria that accumulates under the foreskin that may be shared between sexual partners. Bacterial vaginosis may be an example of this. Another concern includes addressing issues about foreskin hygiene and among males in the first year of life higher risk of urinary tract infections.

So, the benefits of circumcision extend to adulthood?
Yes. We have substantial science to show why it’s beneficial – not only in early life but later in life when the individual becomes sexually active – with lower risk of acquiring HIV, syphilis, human papillomavirus, and genital herpes, lower risk of cervical cancer in sexual partners and lower risk of penile cancer over a lifetime. The African studies found that being circumcised reduces by approximately 50 percent the risk of HIV transmission.

What do you say to those who, in public forums, equate circumcision with female genital mutilation?
The two procedures are not the same at all. Female genital cutting is mutilation and is not circumcision. The scientific evidence of female genital cutting indicates only harm and no health benefits. In male circumcision, the anatomy and procedure is different. Male circumcision has been shown scientifically to provide benefits to the person being circumcised, and has a proven track record for safety when conducted by a trained health professional using sterile procedure.

How would you advise parents considering circumcision for their newborn?
Parents make many important decisions for their children on a daily basis and this is one of them. I would recommend they consult their child’s pediatrician, consider the scientific evidence about the risks and benefits of the procedure, and then weigh this with their own ethical and religious beliefs to make this decision. Behavioral health studies show most males start having sex before 18. Delaying circumcision until the age of majority, males would lose some of the protective benefit of circumcision, not benefit from circumcision’s demonstrated protection against urinary tract infections during the first year of life, and may experience more complications if performed later in life compared to the newborn period when the procedure is safest to perform.

Arik V. Marcell, M.D., M.P.H., is a nationally recognized expert in the field of preventive health and medical services for adolescent men and young adults. He directs adolescent services and the Title X Program at the Harriet Lane Clinic at Johns Hopkins Children’s Center. He is on faculty in the Division of General Pediatrics and Adolescent Medicine and the Departments of Pediatrics and Population, Family & Reproductive Health at The Johns Hopkins University.