The Case for Neonatal Male Circumcision: An Interview with Aaron Tobian, MD, PhD

Less than a decade ago, Aaron Tobian, MD, PhD, would not have been a proponent of male circumcision. But now the benefits of this procedure are undeniable to the Johns Hopkins Center for Global Health pathologist, who has studied the matter extensively both in the United States and in Uganda. Dr. Tobian spoke with Renal & Urology News hours after returning from his most recent trip to sub-Saharan Africa.

Are you promoting circumcision for all male newborns, or are you just more concerned that people are considering the proper evidence in making a decision?

Dr. Tobian: It has been well known for a long time that male circumcision reduces urinary tract infections among infants. However, the other benefits of male circumcision have not been clear up until about the last 10 years.

Three randomized controlled trials have demonstrated that male circumcision reduces multiple sexually transmitted infections. However, the American Academy of Pediatrics (AAP) has not revised its policy since these trials have been published, and increasing numbers of states have eliminated Medicaid insurance coverage for male circumcision.

What is the current policy of the AAP?

Dr. Tobian: The current policy states that they're equivocal on male circumcision—they say that there aren't major benefits, but there aren't major risks, either.  However, when they discuss the sexually transmitted infections, they say the data are complex and conflicting. The medical benefits of male circumcision to reduce sexually transmitted infections are overwhelming clear since the publication of the first randomized trial in 2005.

How can a whole organization of professionals come to this conclusion, which you find erroneous?

Dr. Tobian: Primarily the American Academy of Pediatrics focuses on young children, whereas sexually transmitted infections are more of an issue as an adult. So I think the AAP is focusing on the short term and not the whole life span. However, they are in the process of revising their policy.

We primarily want to clarify the evidence and correct misconceptions about male circumcision. There are clearly benefits of male circumcision: It reduces HIV, genital herpes, and human papillomavirus [HPV] in men. In female partners, it reduces bacterial vaginosis, trichomoniasis, and human papillomavirus, which causes cervical cancer.

What do you see as the greatest misconception about male circumcision held by health care professionals?

Dr. Tobian: I think most healthcare professionals know that male circumcision reduces urinary tract infections among male infants. The rate of urinary tract infections among infants is low, so they think overall there's not a huge benefit for male circumcision. However, they are less aware of the randomized trial data, which are relatively new and shows that male circumcision has a substantial impact on reducing common sexually transmitted infections.

When you are interacting with colleagues, what is the general sense you get about the medical community's stance on male circumcision?

Dr. Tobian: I think most people outside of the HIV field think that male circumcision is fine, but there are not substantial benefits.

In a recent JAMA editorial (2011;306:1479-1480), you and Ronald H. Gray, MD, MSc, expressed that it is important for circumcision to occur early in life rather than have the male wait until adulthood to make the decision, as proponents of a ban on circumcision would prefer. What is your main reason for taking this position?

Dr. Tobian: There are multiple reasons to be circumcised as a neonate compared to an adult. One is that neonatal male circumcision provides some benefits during childhood, such as reduced urinary tract infections and penile inflammatory disorders.

Second, approximately 50% of high school students report having sex prior to age 18 years. So delaying male circumcision until after 18 would deny these adolescents the potential benefits of circumcision during often the highest-risk period of sexual activity.

A third advantage is that the complication rate of male circumcision is substantially lower as a neonate than as an adult. So delaying the procedure would only add to surgical risk.

In that same JAMA editorial, you and Dr. Gray contend that if a vaccine were available that reduced HIV risk by 60%, genital herpes risk by 30%, and high-risk HPV risk by 35%, as male circumcision reportedly does, “it would be promoted as a game-changing public health intervention.” How do opponents who are health-care professionals argue this point with you?

Dr. Tobian: Some say these trials were performed in Africa, and they do not apply to the United States. However, despite decades of safe-sex education, sexually transmitted infections continue to have substantial morbidity and mortality in the United States. So there clearly is a problem in the United States.

Do you think you would have been as supportive of neonatal male circumcision before HIV, herpes, and HPV were on the public health radar?

Dr. Tobian: The short answer is no, I would not have been as supportive of male circumcision. The benefits of male circumcision have not been very clear up until the last five years. The first randomized trial was not published until 2005, and that showed a benefit for reducing HIV. Subsequently, just in the past few years, we've seen benefits for reducing genital herpes and human papillomavirus among the men, and then of course the female benefits that we discussed earlier: bacterial vaginosis, trichomoniasis, and human papillomavirus.

The data just were not available [before] that point.

What is the best argument you've heard from those who favor banning circumcision among males younger than age 18?

Dr. Tobian: The one concern about male circumcision is that there are medical risks to every procedure. So if there are no benefits to a procedure in medicine, you should not perform it. The complication rate of neonatal male circumcision is extremely low—about tenfold lower than even adult male circumcision. The risk of morbidity from a sexually transmitted infection is much higher and worse than the risk of [male circumcision] complications. So, the concern is the medical risk, but I think that if you weigh it against the benefits the answer is very clear in favor of male circumcision.

Are you concerned that a ban on neonatal male circumcision may be adopted, or do you think that is unlikely?

Dr. Tobian: During this past summer, I was quite concerned about a possible ban in California. However, since that time, the California legislature has acted to prevent these types of ballot initiatives.

My bigger concern is the lobbying efforts by the anti-circumcision activists who are continuing to lobby state legislatures to eliminate Medicaid insurance coverage. It is the reduced insurance coverage that is much more concerning.

Should urologists proactively recommend circumcision for their uncircumcised male patients, or should they just proactively point out the risks and benefits, or should they leave the topic unaddressed unless the patient specifically asks for information?

Dr. Tobian: Male circumcision as an adult is common in sub-Saharan Africa, primarily to reduce HIV. It is the World Health Organization's policy to promote male circumcision among adult men. However, the HIV epidemic is substantially different in the United States compared to sub-Saharan Africa.

If adult men are requesting circumcision in the United States, urologists should explain both the risks and benefits of the procedure. However, male circumcision is not 100% protective against HIV or other sexually transmitted infections.

Safe-sex education is also important.

But should this topic be addressed as part of the patient visit, whether the man asks or not?

Dr. Tobian: I think men should be aware of the risks and benefits. The risks of male circumcision are higher as an adult than as a neonate, and depending on the person's sexual activities, safe-sex education is important. So, I don't really like saying the urologists should go out of their way or they should not go out of their way.

So perhaps it's something to keep in mind if a patient comes in and falls into some high-risk group.

Dr. Tobian: Exactly.