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Circumcision in the United States—the debate continues
  1. H BAUCHNER, MD US Associate Editor

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    In 1999, the American Academy of Pediatrics (AAP) released its most recent policy on newborn male circumcision.1 Because circumcision occurs in the context of cultural, religious, and societal norms, and is regrettably a painful procedure, it is a controversial subject. The AAP report was widely covered in the popular press and, subsequently, there have been many letters to the editor,2as well as a stinging rebuke of the report published inPediatrics.3

    The highlights of the report are as follows:

    • Circumcision conveys protection against urinary tract infections, penile cancer, and various sexually transmitted diseases.

    • Circumcision is a painful procedure for which the newborn should receive analgesia.

    • “Existing scientific evidence demonstrates potential medical benefits of newborn male circumcision; however, these data are not sufficient to recommend routine neonatal circumcision. In the case of circumcision, in which there are potential benefits and risks, yet the procedure is not essential to the child's current wellbeing, parents should determine what is in the best interest of the child.”1

    Subsequent criticisms of the report have focused on the following:

    • The report understates the protective effect of circumcision against penile cancer and sexually transmitted diseases.

    • The AAP task force should have been more forceful in delineating the medical benefits of circumcision and the comment “not essential to the child's wellbeing”, should not have been included in the report.

    It is not clear to me how often parents ask paediatricians what they believe are the risks and benefits of circumcision. I believe that most parents make the decision to circumcise their child in the context of their religion, culture, and heritage, and that most pay only minimal attention to other factors. It is always difficult to present information about risks and benefits to parents in a balanced manner, free of our own biases, particularly when the data are imprecise.

    I believe that the report will encourage clinicians to provide analgesia for circumcision. The medical community has come a long way in appreciating that newborns and young infants experience pain, and many parents (and physicians) now appreciate that pain is associated with circumcision. The task force states that analgesia is safe and effective and should be provided for the procedure. They recommend a eutectic mixture of local anesthetics (EMLA cream), dorsal penile nerve block, or a subcutaneous ring block. They specifically state that neither sucrose nor acetaminophen (paracetamol) provide adequate analgesia.

    We have not seen the last of the debate about circumcision in the United States. The AAP revisits the issue approximately every 10 years—so stay tuned.

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