Pediatricians Group May Ease Its Opposition to Circumcision

The nation’s largest pediatricians group is in the final stages of revising its policy on circumcision, apparently signaling a change in attitude in which the procedure may re-emerge as a front-line childhood health practice.

The expected policy change on the procedure--whose medical appropriateness has been officially questioned for 16 years--has been prompted most significantly by a growing body of evidence focusing on urinary tract infections in boys. But evidence of a link between non-circumcision and AIDS is also involved.

Even after new data linking circumcision to AIDS prevention was reported at an international AIDS conference last week, doctors on the American Academy of Pediatrics circumcision task force said the group believes that the data remains indirect and that the relationship is likely to remain unresolved.

Far stronger, these experts say, are studies showing a link between non-circumcision of boys and dangerous urinary tract infections, including some with life-threatening complications. And circumcision may also confer some protection against a variety of sexually transmitted diseases, including gonorrhea and perhaps herpes, though one doctor characterized such evidence as “strongly circumstantial.”

The new policy statement has been eagerly awaited by physicians, health organizations and health policy officials since the review was ordered in January by the American Academy of Pediatrics. It reportedly abandons pediatricians’ current position that there is no absolute medical need for routine circumcision, doctors involved in the panel’s deliberations say. Circumcision is the surgical removal of the foreskin from the penis.

Draft language of the new position, reviewed for The Times by a physician familiar with the report, characterizes circumcision as “a highly personal matter for parents.”

Medical Evidence in Conflict

It concludes that existing medical evidence conflicts on the issues of protection against venereal diseases and cancer of the penis but acknowledges the strong new evidence on urinary tract infection.

In the final analysis, however, the statement concludes, the decision whether to circumcise a baby is almost entirely a cultural--as opposed to a medical--issue.

The American Urological Assn. also has formed a circumcision study group, which is expected to produce a final report within a few weeks. Earlier this year, the California Medical Assn.’s policy-making body voted overwhelmingly to endorse a resolution calling circumcision “an effective public health measure.”

Circumcision fell from favor in the early ‘70s because critics contended it had no medical benefit and needlessly caused babies pain. AIDS entered the current deliberations largely because Mountain View, Calif., urologist Dr. Aaron Fink proposed the thesis in a letter to the editor of the New England Journal of Medicine in 1986.

AIDS Link ‘Mostly Theory’

But the pediatricians committee chairman, Dr. Edgar Schoen of the Kaiser Foundation Hospital in Oakland, said in a telephone interview that despite two reports presented at the AIDS conference, “there isn’t very much good data” on AIDS and circumcision.

“AIDS has been mentioned but it’s been mostly theory,” said Dr. Ronald Poland of Children’s Hospital in Detroit and another member of the panel. Schoen said the final draft of the proposal will be sent to the academy’s board within a month. The academy said a new official statement could come late this summer or in the fall.

The pediatrics academy’s existing position paper was adopted in 1971 and reaffirmed in 1975. While it rejects the existence of an absolute indication for circumcision, it urges doctors to provide a wide range of information on circumcision so parents can make their own decisions.

A spokesman for the American Academy of Obstetricians and Gynecologists, which adopted a similar position statement in 1977, said the group was watching the deliberations closely and would probably reevaluate its position if the pediatricians act.

Media Missed Balance

Meanwhile, Dr. Frank Hinman, a UC San Francisco urologist and a member of the panel, said news media ignored what he said is a balanced view of circumcision in the existing statement, focusing instead on the single phrase that declares it to be without an “absolute” medical indication.

While the majority of male babies are still circumcised in the United States, the rate has been dropping in recent years as anti-circumcision forces have argued that circumcision is medically unnecessary, cruelly painful to a baby and possibly prone to complications.

A separate debate has focused on whether babies undergoing circumcision should be anesthetized. A key element in the re-emergence of circumcision has been work by Dr. Thomas Wiswell of Walter Reed Army Hospital in Washington. In studies of 200,000 boys born to Army families, Wiswell has found uncircumcised boys have urinary tract infections 10 times more often than those who are circumcised.

In two studies awaiting publication in medical journals, Wiswell said in a telephone interview, he and other investigators have found that one uncircumcised boy in 100 developed a serious urinary tract infection.

Dire Consequences Reported

The infections frequently moved into the bloodstream, and a study of 81 boys who had complications showed there were two deaths, three babies who contracted meningitis and one boy who went into kidney failure.

“This is very bothersome to us,” Wiswell said. “The numbers of infections was less than 1%, but a third of them had complications.” The findings, Wiswell said, have been responsible for a major change in his own thinking. He said circumcision complications occur in only about one in 1,000 boys and are generally minor.

The committee chairman said that while the panel had been aware of one of two AIDS-related studies reported on in Stockholm last week, members were unaware of research by Dr. King Holmes, of Seattle, who also described a relationship between circumcision and AIDS. Schoen said he expects to contact Holmes to ask to review his data.

The circumcision studies presented by Holmes and Dr. William Cameron, of the University of Manitoba, at the AIDS conference focused on research led by Dr. Frank Plummer. The research showed that, among 292 men who patronized prostitutes in Nairobi, Kenya, 20% of those who were uncircumcised became infected with the AIDS virus but only 3% of circumcised men did. More than 85% of the prostitutes were infected.

Another study focused on a group in Miami, with similar results. Schoen said Cameron’s data had been consulted by the circumcision panel during its study.

Schoen said the new statement will include an extensive bibliography of the medical literature on circumcision so physicians and parents can review the studies involved.