Circumcision References. Circumcision and the AAP. Circumcision (click on refs)

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1 Circumcision and the AAP Edgar Schoen, MD Clinical Professor of Pediatrics, Emeritus, UCSF June 5, 2010 UCSF Advances in Clin. Peds Circumcision 2010 Evidence- Based Benefits UTI HIV Balanoposthitis Phimosis/Paraphimosis Genital Hygiene Human Papilloma Virus Penile Cancer Cervical Cancer Herpes simplex II Penile dermatoses Valid urine spec Evidence Based Risks Surgical complications Rare ( %) and usually minor Circumcision References (click on refs) EDGAR SCHOEN, M.D. CIRCUMCISION, SEX, GOD AND SCIENCE, 2009, BOOKSURGE- reference section De Bruyn,G. Circ and HIV/STDS, Expert Rev. Anti Inf Ther 8(1); 23-31,

2 Old Testament Genesis, Chapter 17 God said to Abraham, the covenant between me and you and your offspring to follow which you shall keep: throughout the generations every male among you shall be circumcised at the age of eight days. New Testament Luke, Chapter 2, Verse 21 Circumcision of Jesus And when eight days were completed for the circumcision of the child, his name was called Jesus, the name given by the angel before he was conceived in the womb. 2

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4 Early U.S. Circumcision Dr Peter Remondino Prominent San Diego MD History of Circumcision...(1891), Origins of American Circumcision ( ) 1. Recommendation of leading physicians Clinical observations- penile cancer, cervical cancer, STIs, local infections, phimosis 2. Open minded Americans/Immigrants Freed from rigid old world social/class order. New life, new ways 3. Emphasis on cleanliness genital hygiene 4. Acceptance by middle/upper classes 4

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6 Medical Department, U.S. Army, Surgery in WW II [Patton, JF - Urology (1987) p 145] Hospital admissions for paraphimosis, phimosis, balanitis, and condyloma acuminata during totaled 146,793. Had these patients been circumcised before induction, this total would probably have been close to zero. 6

7 DEAN, A.J., J UROL 1935;35: cases penile cancer - Memorial Hospital, N.Y. Average age 50 years (24-81 yrs) - 22% < 40 yrs None had newborn circumcision 37 circumcised later in life for phimosis, paraphimosis or severe irritation None were Jews - although a large proportion of the patients at Memorial Hospital are Jews and Jews have no racial immunity to epidermoid cancers in other parts of the body. Estimated Total % American Males Circumcised Newborn Hospital (coded) 65% Newborn Hospital (uncoded) 10% Post-neonatal (KP, Finland) 8% Estimated total 83% 7

8 Xu, F. et al ( CDC) Prevalence of Circumcision in the US- NHANES 2006, XVI Intl AIDS Conf Overall 79% Non-Hispanic Whites 89 % Non-Hispanic Blacks 78 % Mexican Americans 41% Newborns - Window of Opportunity 1. Newborns adaptable and programmed for stress 2. Resilient-Intense, rapid reaction with quick recovery 3. High levels of stress hormones epinephrine/norepinephrine cortisol thyroxin testosterone Newborns - Window of Opportunity cont. 4. Endogenous pain protection- endorphin responsiveness to sucrose 5. Ease of surgery. Thin foreskin - no sutures needed 6. Rapid healing 7. Many experienced operators 8

9 Post Newborn Circumcision More difficult than in newborns (egs sutures) More complications 10X (5%vs..5%) Fewer experienced operators More likely to use general anesthesia Healing is slower More expensive (10x) Circumcision Policy- Original Sin (AAP 1971 Single line, no evidence,? Author) There are no valid medical indications for circumcision in the neonatal period. (from Care of the Newborn, before Clothing, Committee of the Fetus & Newborn) 9

10 Circumcision Policy- More Confusion (AAP Task Force Members) Medical benefits prevention of penile cancer and local foreskin disorders. Ease of genital hygiene. There is no absolute medical indication for routine circumcision of the newborn. (Committee of the Fetus and Newborn) Urinary Tract Infections < Age1 Year 12 Studies ( ) Uncircumcised 10x Risk Circumcision Benefits vs. Risks (AAP Task Force Members) Evidence- Based Benefits Penile cancer prevention Balanoposthitis prevention Phimosis prevention UTI prevention Genital Hygiene Evidence Based Risks Surgical complications Rare ( %) and usually minor Pain Counsel on Risks and Benefits, Parents Choose 10

11 The HIV/AIDS Tragedy 1980 s On HIV/AIDS Epidemic, Africa Family Transmission - father to mother to baby 20 million deaths, 40 million affected HIV Acquisition > 40 Studies ( ) Uncircumcised 2 4x Risk 3 RCTs ( ) (50-60% protection ) 1999 AAP Circumcision: Information for Parents Reasons to Choose Slightly lower UTI risk Lower penile CA risk Slightly lower HIV risk Prevents foreskin infection Prevents phimosis Easier genital hygiene Reasons not to Choose Surgery risks. Complications rare and usually minor Belief that foreskin protects tip of penis Belief that circumcision decreases sexual pleasure Can teach people proper hygiene 11

12 Circumcision Benefits vs. Risks (AAP Task Force Members) Evidence- Based Benefits Penile cancer Balanoposthitis Phimosis Ease of genital hygiene UTI HIV Evidence Based Risks Surgical complications Rare ( %) and usually minor Potential benefits not sufficient to recommend not necessary for current well being AAP Task Force on Circumcision (Pediatrics 1999, 103:686) Media Response: Circumcision Loses a Key Endorsement (Washington Post). Circumcision Benefits Disputed (Chicago Sun Times). Pediatricians Turn Away from Circumcision (CNN). Circumcision Opponents Energized by About Face of Academy of Pediatrics (Forward). Concern About 1999 AAP Task Force Report (Schoen et al. Pediatrics 2000:620-3) Anti-circumcision jargon- amputation of the foreskin Six documented evidence-based benefits referred to as potential benefits Six benefits vs 1 risk (complications- rare and usually minor ) not sufficient to recommend newborn circumcision. What would be sufficient? 12

13 Pediatrics September AAP Circumcision, Policy Reaffirmed JACKSON POLLOCK CIRCUMCISION (1946) 13

14 Circumcision 2010 Evidence- Based Benefits Penile Cancer Balanoposthitis Phimosis/Paraphimosis Genital Hygiene UTI HIV Human Papilloma Virus Herpes simplex II Cervical Cancer Penile dermatoses Valid urine spec Evidence Based Risks Surgical complications Rare ( %) and usually minor Summary/Conclusions Circumcision is an important lifetime preventive health measure. The multiple evidence-based health benefits far outweigh the minor risks. The newborn period is the ideal time for circumcision. Policy statements of the AAP have been misleading, confusing, biased and deceptive, and have deprived poor children of a choice for circumcision. Evidence has been ignored and misrepresented. Stay tuned for pending CDC/AAP policy changes. 14