Infant circumcision: Evidence, policy, and practice

A recent article on ‘routine’ infant male circumcision (IMC)1 argues that the debate about IMC is stuck and that it is time the polarised belligerents compromise down the middle. … But how realistic is that? We disagree that the debate about IMC is deadlocked. Unlike many previous reviews, the 2012 American Academy of Pediatrics (AAP) adopted a meticulous policy process and carefully reviewed the evidence.2 It stated that benefits exceed risks, so justifying access, recommended accurate, unbiased scientific information for parents to help in their decision, it be performed by trained, competent practitioners using sterile techniques and effective pain management, and that ‘the preventive and public health benefits associated with newborn IMC warrant third-party reimbursement’.2 This milestone in the long-running debate was soon followed by similar draft recommendations by the Centers for Disease Control and Prevention (CDC), which reported benefits exceed risks by 100 to 1.3 A Canadian Paediatric Society position statement only recognised, ‘a benefit for some boys in high-risk populations and circumstances’.4 This stemmed from a faulty risk-benefit analysis that omitted several major benefits and overstated certain risks by ignoring high-quality CDC and UK data. The CPS policy's ‘Selected resources’ section does however recommend the brochure for parents available on the Circumcision Academy of Australia website (http://www.circumcisionaustralia.org). Professors in law, ethics and medicine found that failure to accurately inform parents of the benefits and risks of IMC may be regarded as a violation of human rights and should be deemed unethical.5 Although ‘most paediatric surgeons in Australia recommend delaying the procedure until the infant is over 6 months of age and then performing the procedure in hospital under general anaesthesia’,1 general anaesthesia adds to risks and costs, delay means exposing the boy to risk of urinary tract infections common in early infancy, and only private hospitals and practitioners perform elective IMC, so disadvantaging poor families. The CDC cited a study reporting negligible neonatal/infant pain score with local anaesthesia in the first week of life, but higher pain thereafter.6 The reason suggested was the increase in foreskin size, thickness and blood supply at 1–4 months (‘mini-puberty of infancy’).6 We agree with Jansen that providers be given better training in pain management. But instead of the present situation, clearly what is needed in Australia is realistic Medicare rebates for IMC and a repeal of the ban on IMC in public hospitals in all states and territories. That is a compromise we could live with. We would also want the next RACP review to follow a process as transparent and impressive as that followed by the AAP and CDC.

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