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Strengths and Weaknesses in the 2015 Canadian Paediatric Society Statement Regarding Newborn Male Circumcision

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Abstract

In 2015, the Canadian Paediatric Society (CPS) updated its position statement on newborn male circumcision. Reaching a different conclusion from that of the American Academy of Pediatrics (AAP) in 2012, the CPS did not find that the benefits of the procedure outweigh the risks and harms. In this brief commentary, I discuss some of the main strengths and weaknesses of the latest CPS policy.
Strengths and weaknesses in the 2015 Canadian Paediatric Society
statement regarding newborn male circumcision
Brian D. Earp
University of Oxford
Abstract
In 2015, the Canadian Paediatric Society (CPS) updated its position statement on
newborn male circumcision. Reaching a different conclusion from that of the American
Academy of Pediatrics (AAP) in 2012, the CPS did not find that the benefits of the
procedure outweigh the risks and harms. In this brief commentary, I discuss some of the
main strengths and weaknesses of the latest CPS policy.
Published manuscript—author’s personal copy. Please cite as:
Earp, B. D. (2015). Strengths and weaknesses in the 2015 Canadian Paediatric
Society statement regarding newborn male circumcision. Paediatrics & Child
Health, 20(8), 433-434.
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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
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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;
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).
References
1. Frisch M, Lindholm M, Grønbæk M. Male circumcision and sexual function in men and
women: A survey-based, cross- sectional 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.
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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.
<https://members.racp.edu.au/page/paed- policy> (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.
... However, all three studies cited by the CPS authors were of men circumcised in adulthood, with inconsistent results. Two of the studies reported little negative impact on balance, but one employed non-validated self-report measures lacking in nuance, and neither had sufficient long-term follow-up (24, 119,120). Strangely, the third study actually reported "a decrease in masturbatory pleasure and sexual enjoyment after circumcision, indicating that adult circumcision adversely affects sexual function in many men, possibly because of complications of the surgery and a loss of nerve endings," contradicting the CPS summary (116). ...
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