The 2010 Royal Australasian College of Physicians' policy statement ‘Circumcision of infant males’ is not evidence based

Abstract

Infant male circumcision (MC) is an important issue guided by Royal Australasian College of Physicians (RACP) policy. Here we analytically review the RACP's 2010 policy statement ‘Circumcision of infant males’. Comprehensive evaluation in the context of published research was used. We find that the Statement is not a fair and balanced representation of the literature on MC. It ignores, downplays, obfuscates or misrepresents the considerable evidence attesting to the strong protection MC affords against childhood urinary tract infections, sexually transmitted infections (human immunodeficiency virus, human papilloma virus, herpes simplex virus type 2, trichomonas and genital ulcer disease), thrush, inferior penile hygiene, phimosis, balanoposthitis and penile cancer, and in women protection against human papilloma virus, herpes simplex virus type 2, bacterial vaginosis and cervical cancer. The Statement exaggerates the complication rate. Assertions that ‘the foreskin has a functional role’ and ‘is a primary sensory part of the penis’ are not supported by research, including randomised controlled trials. Instead of citing these and meta‐analyses, the Statement selectively cites poor quality studies. Its claim, without support from a literature‐based risk‐benefit analysis, that the currently available evidence does ‘not warrant routine infant circumcision in Australia and New Zealand’ is misleading. The Statement fails to explain that performing MC in the neonatal period using local anaesthesia maximises benefits, safety, convenience and cost savings. Because the RACP's policy statement is not a fair and balanced representation of the current literature, it should not be used to guide policy. In the interests of public health and individual well‐being, an extensive, comprehensive, balanced review of the scientific literature and a risk‐benefit analysis should be conducted to formulate policy.

Recommendation by a law body to ban infant male circumcision has serious worldwide implications for pediatric practice and human rights

“…Similar to the AAP policy, the 2010 policy of the RACP, despite its weaknesses [2], nevertheless states “ It is reasonable for parents to weigh the benefits and risks of circumcision and to make the decision whether or not to circumcise their sons . When parents request a circumcision for their child the medical attendant is obliged to provide accurate unbiased and up to date information on the risks and benefits of the procedure .…”

“…With the exception of the upper classes, it then declined in the United Kingdom after the 1940s when the National Health Service withdrew coverage for it, and in Australia began to decline in the 1970s because of a sudden change in pediatric policy that has continued to lack accordance with the ever-growing medical evidence [2]. In contrast infant male circumcision has remained popular amongst Americans of Anglo-Celtic heritage [1], which is also the predominant ethnic group in Australia.…”

“…The new AAP policy moves beyond its neutral policy in 1999 and it accords with another evidence-based policy assessment in Australia in 2012 that went further by calculating the risk-benefit (100:1 in favour) and finding that over their lifetime up to half of uncircumcised males were at risk of a medical condition caused by the foreskin [6]. These new pediatric policies are, however, at odds with statements by the British Medical Association [7], the Royal Dutch Medical Association [8], and the Royal Australasian College of Physicians (RACP) [9] advising against infant circumcision, and that, unlike the more recent ones, did not involve a scholarly literature-based review of the scientific evidence [2]. A claim in the RACP statement that it was evidence-based is untrue since, unlike the AAP policy statement, the authors of the RACP statement did not explain how they selected the literature used as the basis for their conclusions.…”

“…Some poor quality observational studies, which did not support male circumcision, were cited while rigorous research, including randomized controlled trials and meta-analyses, supporting the practice were not cited. For these reasons, the RACP report should not be considered fair and balanced and should not guide policy [2]. New policies have been foreshadowed by the Centers for Disease Control and Prevention [10] and by the Canadian Paediatrics Association [11].…”

Should Male Circumcision be Advocated for Genital Cancer Prevention?

“…This policy was based on the infant circumcision policy of the Royal Australasian College of Physicians (2010) that ignored much of the compelling evidence concerning the medical benefits of male circumcision (Morris et al, 2012a). The American Academy of Pediatrics (2012) new policy statement and technical report concludes that the health benefits of male circumcision outweigh the risks.…”