Letters to the Editor Re: ST Sorokan, JC Finlay, AL Jefferies; Canadian Paediatric Society, Fetus and Newborn Committee, Infectious Diseases and Immunization Committee. Newborn male circumcision. Paediatr Child Health 2015;20(6):311-20.
Strengths and weaknesses in the 2015 Canadian Paediatric Society statement regarding newborn male circumcision. To the Editor; The latest statement from the Canadian Paediatric Society (CPS) regarding newborn male circumcision exhibits both strengths and weaknesses. Strengths include: 1. Acknowledgement that the foreskin is not redundant skin; that it “serves to cover the glans penis and has an abundance of sensory nerves”; that it is adherent at birth and may take several years to become fully retractile; that this is normal and should not be pathologized as phimosis; that true phimosis can be treated nonsurgically; 2. Acknowledgement that the absolute risk for urinary tract infections (UTIs) in boys is low; that it would take >100 circumcisions to prevent one case; that UTIs may be overdiagnosed in genitally intact boys; that UTIs can be treated nonsurgically; that “UTIs in children with normal kidneys do not [ordinarily] result in long-term sequelae”; 3. Acknowledgement that the absolute risk for female-to-male heterosexual transmission of HIV in countries such as Canada and the United States is low; that results from African trials involving adult men may not translate to newborn boys in developed countries; that circumcision does not reduce male-to-female transmission of HIV; that safe sex practices must continue to be emphasized; 4. Acknowledgement that penile cancer is rare in developed countries; that its association with intact male genitalia is primarily explained by the presence of phimosis; that human papilloma virus vaccines are expected to “dramatically decrease the incidence rate of cervical cancer”, thereby obviating a role for circumcision; 5. Acknowledgement that circumcision is painful; that this pain may have long-term adverse sequelae; that circumcision is a procedure with “lifelong consequences … performed on a [healthy] child who cannot give [his] consent”; that the “authority of substitute decision makers is … usually limited [to] interventions deemed to be medically necessary”; and that newborn male circumcision does not satisfy this condition. Weaknesses include:
1. Failure to engage seriously with the literature on negative sexual effects of circumcision (1-3). This includes a recent analytic review by Bossio et al (4), as well as several published critiques (5-7) of the studies by Kigozi et al (8) and Krieger et al (9), both of which studied adult rather than infant circumcision (the CPS authors conflate these in this passage); both of which involved insufficient follow-up for drawing long-term conclusions; and the latter of which did not use validated instruments (5-7). 2. Failure to state that the cited cost-effectiveness estimate concerning lifetime risk for HIV acquisition did not demonstrate cost savings for circumcision in the majority population of white males; Paediatr Child Health Vol 20 No 8 November/December 2015
3. Failure to explain the inclusion of a brochure by an Australian procircumcision lobbying group with no official status (10) as one of three 'selected resources', rather than the official brochure of the Royal Australasian College of Physicians (11), which advocates against neonatal circumcision; 4. Failure to consider analogous interventions in girls (12). The nontherapeutic removal of any amount of tissue from the female genitalia before an age of consent, including procedures that are less invasive than male circumcision, is a crime in Canada, notwithstanding any health benefits that may or may not ensue (13).
Brian D Earp Visiting Scholar, The Hastings Center Bioethics Research Institute Garrison, New York, USA References
1. Frisch M, Lindholm M, Grønbæk M. Male circumcision and sexual function in men and women: A survey-based, crosssectional study in Denmark. Int J Epidemiol 2011;40:1367-81. 2. Bronselaer GA, Schober JM, Meyer-Bahlburg H, et al. Male circumcision decreases penile sensitivity as measured in a large cohort. BJU Int 2013;111:820-7. 3. Dias J, Freitas R, Amorim R, et al. Adult circumcision and male sexual health: A retrospective analysis. Andrologia 2014;46:459-64. 4. Bossio JA, Pukall CF, Steele S. A review of the current state of the male circumcision literature. J Sex Med 2014;11:2847-64. 5. Earp BD. Sex and circumcision. Am J Bioeth 2015;15:43-5. 6. Frisch M. Author's response to: Does sexual function survey in Denmark offer any support for male circumcision having an adverse effect? Int J Epidemiol 2012;41:312-4. 7. Boyle GJ. Does male circumcision adversely affect sexual sensation, function, or satisfaction? Critical comment on Morris and Krieger (2013). Advances Sex Med 2015;5:7-12. 8. Kigozi G, Watya S, Polis CB, et al. The effect of male circumcision on sexual satisfaction and function, results from a randomized trial of male circumcision for human immunodeficiency virus prevention, Rakai, Uganda. BJU Int 2008;101:65-70. 9. Krieger JN, Mehta SD, Bailey RC, et al. Adult male circumcision: Effect on sexual function and sexual satisfaction in Kimumu, Kenya. J Sex Med 2008;5:2610-22. 10. Earp BD, Darby RJ. Does science support infant circumcision? A skeptical reply to Brian Morris. Skeptic 2015;25:23-30. 11. Royal Australasian College of Physicians. Policy statement and brochure for parents. (Accessed November 10, 2015). 12. Earp BD. Female genital mutilation and male circumcision: Toward an autonomy-based ethical framework. Medicolegal and Bioeth 2015;5:89-104. 13. Earp BD. Do the benefits of male circumcision outweigh the risks? A critique of the proposed CDC guidelines. Front Pediatr 2015;3:1-6.
The authors respond; Thank you for your interest and comments on the 2015 CPS statement regarding newborn male circumcision. We reviewed several studies investigating the effects of circumcision on sexual function, and found the literature to be of varying quality, and demonstrated varying methodologies and outcome measures. A significant amount of this literature evaluates adult, rather than neonatal, circumcision, so is not directly applicable. There are two systematic reviews (1,2) that concluded that circumcision has no adverse effect on sexual function. A third review (3), similarly concluded that loss of the sensory receptors in the prepuce removed during circumcision does not appear to have any ©2015 Canadian Paediatric Society. All rights reserved
433
effect on sexual function or satisfaction. A recent survey involving Canadian men and women demonstrated minimal impact of circumcision status on sexual functioning (4). There are no Canadian studies exploring the cost effectiveness of newborn circumcision (5). It appears highly unlikely that routine circumcision would ever be cost effective in Canada. We stated that a United States Centers for Disease Control and Prevention study demonstrated significant variation in the lifetime HIV risk reduction with circumcision: 8% for white men compared with 21% for black men. This certainly affects the overall cost effectiveness for different populations. This difference is expressed in the number needed to treat to prevent one HIV infection – 1231 for white men compared with 65 for black men. The purpose of the selected resources was to provide additional information. We agree that there is conflicting information in the proposed Australian resource and, therefore, our online statement has been modified accordingly. The discussion of female genital alteration was beyond the scope of our guideline and the WHO has a clear statement regarding this subject (6). Male circumcision has limited health benefits, while female genital alteration is clearly detrimental to health and should never be condoned.
434
S Todd Sorokan, Jane C Finlay, Ann L Jefferies, Thierry Lacaze, Joan L Robinson; Canadian Paediatric Society, Fetus and Newborn Committee, Infectious Diseases and Immunization Committee
References
1. Tian Y, Liu W, Wang J-Z, Wazir R, Yue X, Wang K-J. Effects of circumcision on male sexual function: A systematic review and meta-analysis. Asian J Androl 2013;15:662-6. 2. Morris BJ, Krieger JN. Does male circumcision affect sexual function, sensitivity, or satisfaction – a systematic review. J Sex Med 2013;10:2644-57. 3. Cox G, Krieger JN, Morris BJ. Histological correlates of penile sexual sensation: Does circumcision make a difference? Sex Med 2015;3:76-85. 4. Bossio JA, Pukall CF, Bartley K. You either have it or you don’t: The impact of male circumcision status on sexual partners. Can J Hum Sex 2015;24:104-19. 5. Bossio JA, Pukall CF, Steele S. A review of the current state of the male circumcision literature. J Sex Med 2014;11:2847-64. 6. World Health Organization. Female genital mutilation. (Accessed November 10, 2015).
Paediatr Child Health Vol 20 No 8 November/December 2015
Strengths and weaknesses in the 2015 Canadian Paediatric Society statement regarding newborn male circumcision. To the Editor; The latest statement from the Canadian Paediatric Society (CPS) regarding newborn male circumcision exhibits both strengths and weaknesses. Strengths include: 1. Acknowledgement that the foreskin is not redundant skin; that it “serves to cover the glans penis and has an abundance of sensory nerves”; that it is adherent at birth and may take several years to become fully retractile; that this is normal and should not be pathologized as phimosis; that true phimosis can be treated nonsurgically; 2. Acknowledgement that the absolute risk for urinary tract infections (UTIs) in boys is low; that it would take >100 circumcisions to prevent one case; that UTIs may be overdiagnosed in genitally intact boys; that UTIs can be treated nonsurgically; that “UTIs in children with normal kidneys do not [ordinarily] result in long-term sequelae”; 3. Acknowledgement that the absolute risk for female-to-male heterosexual transmission of HIV in countries such as Canada and the United States is low; that results from African trials involving adult men may not translate to newborn boys in developed countries; that circumcision does not reduce male-to-female transmission of HIV; that safe sex practices must continue to be emphasized; 4. Acknowledgement that penile cancer is rare in developed countries; that its association with intact male genitalia is primarily explained by the presence of phimosis; that human papilloma virus vaccines are expected to “dramatically decrease the incidence rate of cervical cancer”, thereby obviating a role for circumcision; 5. Acknowledgement that circumcision is painful; that this pain may have long-term adverse sequelae; that circumcision is a procedure with “lifelong consequences … performed on a [healthy] child who cannot give [his] consent”; that the “authority of substitute decision makers is … usually limited [to] interventions deemed to be medically necessary”; and that newborn male circumcision does not satisfy this condition. Weaknesses include:
1. Failure to engage seriously with the literature on negative sexual effects of circumcision (1-3). This includes a recent analytic review by Bossio et al (4), as well as several published critiques (5-7) of the studies by Kigozi et al (8) and Krieger et al (9), both of which studied adult rather than infant circumcision (the CPS authors conflate these in this passage); both of which involved insufficient follow-up for drawing long-term conclusions; and the latter of which did not use validated instruments (5-7). 2. Failure to state that the cited cost-effectiveness estimate concerning lifetime risk for HIV acquisition did not demonstrate cost savings for circumcision in the majority population of white males; Paediatr Child Health Vol 20 No 8 November/December 2015
3. Failure to explain the inclusion of a brochure by an Australian procircumcision lobbying group with no official status (10) as one of three 'selected resources', rather than the official brochure of the Royal Australasian College of Physicians (11), which advocates against neonatal circumcision; 4. Failure to consider analogous interventions in girls (12). The nontherapeutic removal of any amount of tissue from the female genitalia before an age of consent, including procedures that are less invasive than male circumcision, is a crime in Canada, notwithstanding any health benefits that may or may not ensue (13).
Brian D Earp Visiting Scholar, The Hastings Center Bioethics Research Institute Garrison, New York, USA References
1. Frisch M, Lindholm M, Grønbæk M. Male circumcision and sexual function in men and women: A survey-based, crosssectional study in Denmark. Int J Epidemiol 2011;40:1367-81. 2. Bronselaer GA, Schober JM, Meyer-Bahlburg H, et al. Male circumcision decreases penile sensitivity as measured in a large cohort. BJU Int 2013;111:820-7. 3. Dias J, Freitas R, Amorim R, et al. Adult circumcision and male sexual health: A retrospective analysis. Andrologia 2014;46:459-64. 4. Bossio JA, Pukall CF, Steele S. A review of the current state of the male circumcision literature. J Sex Med 2014;11:2847-64. 5. Earp BD. Sex and circumcision. Am J Bioeth 2015;15:43-5. 6. Frisch M. Author's response to: Does sexual function survey in Denmark offer any support for male circumcision having an adverse effect? Int J Epidemiol 2012;41:312-4. 7. Boyle GJ. Does male circumcision adversely affect sexual sensation, function, or satisfaction? Critical comment on Morris and Krieger (2013). Advances Sex Med 2015;5:7-12. 8. Kigozi G, Watya S, Polis CB, et al. The effect of male circumcision on sexual satisfaction and function, results from a randomized trial of male circumcision for human immunodeficiency virus prevention, Rakai, Uganda. BJU Int 2008;101:65-70. 9. Krieger JN, Mehta SD, Bailey RC, et al. Adult male circumcision: Effect on sexual function and sexual satisfaction in Kimumu, Kenya. J Sex Med 2008;5:2610-22. 10. Earp BD, Darby RJ. Does science support infant circumcision? A skeptical reply to Brian Morris. Skeptic 2015;25:23-30. 11. Royal Australasian College of Physicians. Policy statement and brochure for parents. (Accessed November 10, 2015). 12. Earp BD. Female genital mutilation and male circumcision: Toward an autonomy-based ethical framework. Medicolegal and Bioeth 2015;5:89-104. 13. Earp BD. Do the benefits of male circumcision outweigh the risks? A critique of the proposed CDC guidelines. Front Pediatr 2015;3:1-6.
The authors respond; Thank you for your interest and comments on the 2015 CPS statement regarding newborn male circumcision. We reviewed several studies investigating the effects of circumcision on sexual function, and found the literature to be of varying quality, and demonstrated varying methodologies and outcome measures. A significant amount of this literature evaluates adult, rather than neonatal, circumcision, so is not directly applicable. There are two systematic reviews (1,2) that concluded that circumcision has no adverse effect on sexual function. A third review (3), similarly concluded that loss of the sensory receptors in the prepuce removed during circumcision does not appear to have any ©2015 Canadian Paediatric Society. All rights reserved
433
effect on sexual function or satisfaction. A recent survey involving Canadian men and women demonstrated minimal impact of circumcision status on sexual functioning (4). There are no Canadian studies exploring the cost effectiveness of newborn circumcision (5). It appears highly unlikely that routine circumcision would ever be cost effective in Canada. We stated that a United States Centers for Disease Control and Prevention study demonstrated significant variation in the lifetime HIV risk reduction with circumcision: 8% for white men compared with 21% for black men. This certainly affects the overall cost effectiveness for different populations. This difference is expressed in the number needed to treat to prevent one HIV infection – 1231 for white men compared with 65 for black men. The purpose of the selected resources was to provide additional information. We agree that there is conflicting information in the proposed Australian resource and, therefore, our online statement has been modified accordingly. The discussion of female genital alteration was beyond the scope of our guideline and the WHO has a clear statement regarding this subject (6). Male circumcision has limited health benefits, while female genital alteration is clearly detrimental to health and should never be condoned.
434
S Todd Sorokan, Jane C Finlay, Ann L Jefferies, Thierry Lacaze, Joan L Robinson; Canadian Paediatric Society, Fetus and Newborn Committee, Infectious Diseases and Immunization Committee
References
1. Tian Y, Liu W, Wang J-Z, Wazir R, Yue X, Wang K-J. Effects of circumcision on male sexual function: A systematic review and meta-analysis. Asian J Androl 2013;15:662-6. 2. Morris BJ, Krieger JN. Does male circumcision affect sexual function, sensitivity, or satisfaction – a systematic review. J Sex Med 2013;10:2644-57. 3. Cox G, Krieger JN, Morris BJ. Histological correlates of penile sexual sensation: Does circumcision make a difference? Sex Med 2015;3:76-85. 4. Bossio JA, Pukall CF, Bartley K. You either have it or you don’t: The impact of male circumcision status on sexual partners. Can J Hum Sex 2015;24:104-19. 5. Bossio JA, Pukall CF, Steele S. A review of the current state of the male circumcision literature. J Sex Med 2014;11:2847-64. 6. World Health Organization. Female genital mutilation. (Accessed November 10, 2015).
Paediatr Child Health Vol 20 No 8 November/December 2015
