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.
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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.
