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CDC Male Circumcision Recommendations Represent a Key Public Health Measure

Thursday, 11th of January 2018

http://www.ghspjournal.org/content/5/1/15.long#sec-5     

 

CDC Male Circumcision Recommendations Represent a Key Public Health Measure

Brian J Morris, John N Krieger and Jeffrey D Klausner

Global Health: Science and Practice March 2017, 5(1):15-27; https://doi.org/10.9745/GHSP-D-16-00390

Frisch and Earp, opponents of male circumcision, have criticized draft recommendations from the CDC that advocate counseling men and parents of newborn boys in the United States about the benefits and risks of male circumcision. We provide a rebuttal to Frisch and Earps criticisms and contend that the recommendations are entirely appropriate and merit consideration for policy development.

After an extensive evaluation of the scientific evidence, the United States Centers for Disease Control and Prevention (CDC) released draft policy recommendations in December 2014 affirming male circumcision (MC) as an important public health measure.^1–3 The CDCs summary¹ (Box 1) was accompanied by a 61-page literature review.² The CDC supported the 2012 American Academy of Pediatrics (AAP) infant MC policy^4,5 (Box 2) and recommended that providers: (1) give parents of newborn boys comprehensive counseling about the benefits and risks of MC; (2) inform all uncircumcised adolescent and adult males who engage in heterosexual sex about the significant, but partial, efficacy of MC in reducing the risk of acquiring HIV and some sexually transmitted infections (STIs) through heterosexual sex, as well as about the potential harms of MC; and (3) inform men who have sex with men (MSM) that while it is biologically plausible that MC could benefit MSM during insertive sex, MC has not been proven to reduce the risk of acquiring HIV or other STIs during anal sex.³

BOX 1

U.S. Centers for Disease Control and Preventions Summary of Its Draft Male Circumcision Recommendations¹

These recommendations are intended to assist health care providers in the United States who are counseling men and parents of male infants, children and adolescents in decision-making about male circumcision. Such decision-making is made in the context of not only health considerations, but also other social, cultural, ethical, and religious factors. Although data have been accumulating about infant male circumcision for many years, clinical trials conducted between 2005–2010 have demonstrated safety and significant efficacy of voluntary adult male circumcision performed by clinicians for reducing the risk of acquisition of human immunodeficiency virus (HIV) by a male during penile-vaginal sex (“heterosexual sex”). Three randomized clinical trials showed that adult male circumcision reduced HIV infection risk by 50–60% over time. These trials also found that adult circumcision reduced the risk of men acquiring two common sexually transmitted infections (STIs), herpes simplex virus type-2 (HSV–2) and types of human papilloma virus (HPV) that can cause penile and other anogenital cancers, by 30%. Since the release of these trial data, various organizations have updated their recommendations about adult male and infant male circumcision.

BOX 2

Conclusions of the 2012 Circumcision Policy Statement by the American Academy of Pediatrics Task Force on Circumcision³

Systematic evaluation of English-language peer-reviewed literature from 1995 through 2010 indicates that preventive health benefits of elective circumcision of male newborns outweigh the risks of the procedure. Benefits include significant reductions in the risk of urinary tract infection in the first year of life and, subsequently, in the risk of heterosexual acquisition of HIV and the transmission of other sexually transmitted infections.

The procedure is well tolerated when performed by trained professionals under sterile conditions with appropriate pain management. Complications are infrequent; most are minor, and severe complications are rare. Male circumcision performed during the newborn period has considerably lower complication rates than when performed later in life.

Although health benefits are not great enough to recommend routine circumcision for all male newborns, the benefits of circumcision are sufficient to justify access to this procedure for families choosing it and to warrant third-party payment for circumcision of male newborns. It is important that clinicians routinely inform parents of the health benefits and risks of male newborn circumcision in an unbiased and accurate manner.

Parents ultimately should decide whether circumcision is in in the best interests of their male child. They will need to weigh medical information in the context of their own religious, ethical, and cultural beliefs and practices. The medical benefits alone may not outweigh these other considerations for individual families.

Findings from the systematic evaluation are available in the accompanying technical report. The American College of Obstetricians and Gynecologists has endorsed this statement.

The CDC has a mandate to use the best available evidence to inform the public on interventions for disease prevention. In the case of early infant MC, there are few public health interventions in which the scientific evidence in favor is now so compelling. Despite this, opponents of MC do not accept the CDCs position. Two prominent opponents, Frisch and Earp, published arguments that led them to conclude that “from a scientific and medical perspective, current evidence suggests that circumcision is not an appropriate public health measure for developed countries such as the United States.”⁶

Here, we critically assess the evidence used by Frisch and Earp to support their thesis and respond to their main criticisms (summarized in Box 3).

BOX 3

Criticisms of the U.S. Centers for Disease Control and Preventions Draft Male Circumcision Recommendations and Responses

In a recently published article, Frisch and Earp⁶ oppose the 2014 draft MC recommendations from the U.S. Centers for Disease Control and Prevention (CDC),³ referring to what they believe are “numerous scientific and conceptual shortcomings.” Here, we quote these 7 criticisms by Frisch and Earp and provide our response to each criticism.

1. Failure to provide a thorough description of the normal anatomy and functions of the penile structure being removed at circumcision (i.e., the foreskin)Response: There seems to be no need for the CDC to provide a thorough description of the anatomy and functions of the foreskin.
2. Failure to consider the intrinsic value to some men of having an unmodified genital organResponse: While some men may believe there is “an intrinsic value to having an unmodified genital organ,” those men should be made aware of the risks posed by their foreskin.
3. Undue reliance on findings from sub-Saharan Africa concerning circumcision of adult males (as opposed to infants or children)Response: The evidence shows the CDC is correct in concluding that findings from sub-Saharan Africa concerning circumcision of adult males for protection against heterosexually-acquired HIV and certain other STIs also apply to men in the United States. The findings also apply to boys when they grow up. Moreover, the cumulative lifetime benefit is greatest if circumcision is performed early in infancy since early infant circumcision is simpler, more convenient, and carries lower risk than when performed later, and circumcision confers immediate protection against urinary tract infections, phimosis, balanitis, and, when older, specific STIs and genital cancers. MC also protects the female partners, as confirmed in randomized controlled trials.
4. Uncritical reliance on a prima facie implausible benefit-risk analysis performed by a self-described circumcision advocateResponse: The benefit-risk analysis used by the CDC is based on the best current evidence relevant to the United States, and the results are plausible.
5. Reliance on misreported statistics to downplay the problem of pain in the youngest of boysResponse: While procedural pain can occur during circumcision, the evidence cited by the CDC indicates that, with use of local anesthetic, pain is negligible in the first week of a boys life. Frisch and Earp misconstrue pain statistics to overplay the issue of pain.
6. Reliance on incomplete register data to assess the frequency of short-term post-operative complications associated with circumcision, leading to a likely underestimation of their true frequencyResponse: By selective citation and misrepresentation of findings, Frisch and Earp overstate the frequency of short-term postoperative complications associated with MC while ignoring data from large high-quality studies such as those published recently by CDC researchers.
7. Serious underestimation of the late-occurring harms of circumcision presenting months to years after the operation (most notably meatal stenosis).Response: Frisch and Earp selectively cite small, outdated, weak studies, often involving traditional circumcisers, and misrepresent data while ignoring large, high-quality studies. As a result, they overestimate the frequency of meatal stenosis occurring years after the MC procedure.

MC confers immediate and lifelong protection against numerous medical conditions (Box 4).^{1,2,4,5,7–9} For example, MC protects against a number of STIs including HIV, and it partially protects against oncogenic types of human papillomavirus (HPV)^10–15 that together with phimosis, balanitis, and smegma are major risk factors for penile cancer,^10,16–18 as shown in meta-analyses that found 12-, 4-, and 3-fold statistically significant higher risks of penile cancer for phimosis, balanitis, and smegma, respectively.¹⁶ Infancy is the ideal time for MC and there are cogent reasons why it should not be delayed until the boy or man can make up his own mind¹⁹