Circumcision is one of the oldest and most common surgical procedures. About 30% of the worlds male population is circumcised according to the World Health Organization. Under strict Jewish religious law, male circumcision must be performed on the eighth day after birth, either in a hospital or by a mohel, who is often a trained rabbi. In the Muslim religion, it is a tradition that boys are circumcised later in life.
Decreased US rates of infant male circumcision have been seen over the last 20 years. While there was an increase from 48% in 1991 to 61% in 2000, the rate has fallen to 56% in 2008. Some sources quote rates as low as 32%. There has also been a decline in insurance coverage for the procedure, further impacting on the decision for elective newborn medical circumcision. However, models have shown that continuing decreases in circumcision will not only increase certain sexually related diseases but also increase the medical expenditures for both men and women who contract conditions that can potentially be reduced by circumcision.
The American Academy of Pediatrics (AAP) updated their policy statement in 2012 on male infant circumcision and this was also endorsed by the American College of Obstetricians and Gynecologists. They noted that stronger evidence of medical benefit outweighs the risks of the procedure and access to circumcision is justified if the family chooses it. The procedure can reduce the risk of urinary tract infections, penile cancer and sexually transmitted infections such as HIV, HPV, herpes and syphilis but not gonorrhea. The rate of HIV infection can be decreased as much as 60% with circumcision. Previously, the American Urological Association has noted that neonatal circumcision is generally safe when performed by an experienced operator on healthy infants with a low incidence of serious complications.
Based on the potential benefits, some countries are encouraging the widespread adoption of circumcision. Kenya is attempting to have over 1 million men between the ages of 15 and 49 circumcised by the end of 2013. Free clinics and the extensive training of nurses and other health care providers in the procedure has taken place. The program is focused primarily on fighting the AIDS epidemic. While there is strong cultural bias not to be circumcised, it is becoming more accepted.
Some groups such as the non-profit Circumcision Resource Center are critical of any form of male circumcision. In response to the AAP policy they stated that “the circumcision literature reflects the pro-circumcision bias of circumcised American researchers who seek to find benefits and avoid studying the harms of circumcision”. They also express concern over unrecognized psychological and social aspects of this practice.
Is childhood male circumcision a criminal act? Recently a German court stated that the procedure violates a “fundamental right to bodily integrity” and that “the body of the child is irreparably and permanently changed by a circumcision”. The case involved a 4-year-old Muslim boy who was circumcised at the request of his parents. Of note, the physician who performed the procedure was tried on two occasions for inflicting grievous bodily harm. Fortunately, he was acquitted both times. The case caused many German doctors to stop performing infant circumcision.
While the US or Canadian governments are unlikely to legislate on circumcision, lawmakers worldwide are becoming increasingly engaged in this discussion. In Sweden, all circumcisions must be carried out within the first 2 months by a properly registered physician using an anesthetic. Norway and The Netherlands have proposed that religious groups replace formal circumcision with some type of alternative symbolic ritual. Prompted by a 2011 ballot initiative in San Francisco, California passed a law preventing local municipalities from banning all male circumcision. The New York City Board of Health just passed a regulation requiring formal parental consent before an infant can undergo a specific form of Orthodox Jewish ritual circumcision where the circumciser uses his mouth to remove blood from the incision. Some claim this is an unconstitutional infringement of their religious freedom.
Urologists must closely follow this ongoing controversy due to the obvious impact on our specialty. This is not only important from a religious, social, and patient care standpoint but from a malpractice perspective as well. Infant male circumcision remains a choice, albeit controversial, that families should be able to choose freely should they decide it is either spiritually or medically right for their child. Criminalization of this elective procedure, when performed by qualified individuals with informed consent, should not be tolerated.
Leonard G. Gomella, MD Thomas Jefferson University Philadelphia, PA
© The Canadian Journal of Urology™; 19(6); December 2012