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Tuesday, 28 August 2012

Circumcision - back on the chopping block

Circumcision protagonists and agonists alike will be filling the twitterverse and blogosphere with reaction and comment on the latest professional foray into the supposedly redundant flap of penile skin.  Certainly within hours of the American Academy of Pediatrics position statement, the media coverage was matched by blogs and retweets announcing and denouncing the recommendations.  The AAP website appeared to have been overwhelmed.  Such is the passion of the foreskin debate. 

To chop or not? Is a question that parents and professionals alike have grappled within over the decades, and the rationale ranges from religious expression and children’s rights through to prevention of cancer and HIV infection.  

Begin with the AAP statement and technical report AAP statement page with access to technical and lay documents  Note that the AAP take a cautiously supportive position stressing that there is more than science to the decision and ultimately the choice is up to parents.   The media reaction has jumped on the first statement, that current evidence is such that health benefits outweigh the risks. 

Circumcision rates in the US have been slowly decreasing and are about reported at about 60%.  While open to some question, Canadian rates may be half this based on the maternity experiences survey which likely was biased towards informed new mothers Maternity experiences survey page 267.  Other estimates would still put Canadian circumcision rates slightly higher, however as most provinces have delisted as an insured service, accurate statistics are lacking. Disconcertingly, the AAP statement quotes Canadian rates as unaffected by delisting with minimal actual documented support for the statement.

The evidence on which the benefits outweigh the risks is worth noting.

·        40-60% reduction in HIV acquisition in circumcised heterosexual males in Africa. 
·         No impact on males who have sex with males has been noted.
·         Reduced transmission of HPV and herpes simplex to female partners
·         No impact on syphilis, gonorrhea or Chlamydia transmission
·         Non-significant reductions in penile cancer, and any benefit disappears when phimosis is excluded as a condition that requires separate treatment.
·         A Ugandan/Kenyan study demonstrating less pain with intercourse for circumcised versus non-circumcised males. 
·         Good to fair evidence that North American sexual function is unaffected. 
·         A preponderance of evidence that circumcision protects against male UTI development, and perhaps the strongest argument in favour of the recommendation.

There are numerous flaws with the modelling that was used to predict a potential 15.7% reduction in US HIV lifetime risk in males. 

On preventing penile cancer, studies vary from estimates of 909 to 322,000 circumcisions required to prevent one case of penile cancer, and amongst these the complication rate would be respectively 2 to 644 infants. The case for preventing UTIs being more solid.  

The AAP statement appropriately cautiously interprets some aspects of the data and reinforcing informed parental decision making, it may also wander too far in coming to conclusions.  On the other hand, the evidence supporting circumcision as protective from certain diseases does seem to be mounting. 
Note there should be cautious application of the AAP analysis to the Canadian demographic given some important relevant differences in demography. The Canadian Pediatric Society is also maintaining a wary view of the AAP position New U.S. guidelines for male circumcision show health advantages

Of just as much interest, is the rapid migration of the ambivalent AAP messaging by the media, blogs and Tweets into polarized camps of support or opposition based on what were likely pre-existed biased positions. Thanks to the AAP for at least an attempt at applying scientific method to the debate, but it is okay occasionally to actually say "we don't know". 

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