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Circumcision: trends and guidelines

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Circumcision: Trends and Guidelines

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Circumcision: trends and guidelines

  1. 1. 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.
  2. 2. 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.
  3. 3. 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.
  4. 4. • 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.
  5. 5. • 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.
  6. 6. • 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.”
  7. 7. 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
  8. 8. • 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.”
  9. 9. 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.
  10. 10. • 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”.
  11. 11. 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).
  12. 12. • 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.”
  13. 13. 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.
  14. 14. 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”.
  15. 15. • 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.”
  16. 16. 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.
  17. 17. • “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
  18. 18. 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”.
  19. 19. • 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.
  20. 20. 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.
  21. 21. • 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.
  22. 22. • 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.
  23. 23. 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.
  24. 24. • 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.
  25. 25. • 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.
  26. 26. 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.
  27. 27. • 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.

Circumcision: Trends and Guidelines

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