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Problems such as infection, improper healing, bleeding and unsatisfactory cosmetic results may not emerge for days or weeks after the surgery.Dave Sidaway/The Canadian Press

For a procedure that's been around for thousands of years, there sure is a lot of debate about circumcision.

To many, it's a deeply ingrained rite. Some see it as a way to prevent potential health problems. And to others it's an unnecessary, invasive procedure that can pose very real risks. Highly anticipated national guidelines on circumcision are expected soon from Canada's top association of pediatricians. Some doctors suspect it may reverse its earlier position and follow the lead of the American Academy of Pediatrics by supporting, for the first time, the health benefits of circumcision. In that case, the debate over circumcision in Canada will only just be getting started.

If the Canadian Paediatric Society endorses the health benefits of circumcision, it would be a disservice. Important information about risks and the fact that health benefits are relatively small would likely get lost in translation, and we could expect to see a surge in the number of parents choosing to have their newborn sons circumcised.

The background

Circumcision, or the surgical removal of the foreskin from the penis, has been practised for thousands of years and continues to be performed today, particularly on individuals of the Jewish and Muslim faiths. Others grapple with the question of whether to circumcise their male infants as a protective health measure.

New studies only seem to muddy the waters. This month, researchers from the University of Montreal made headlines when they suggested that circumcision may help prevent prostate cancer. The actual findings, published in BJU International, were not statistically significant, however, and there is no evidence to back the claim. A paper published this month in Mayo Clinic Proceedings compares circumcision to vaccination and argues it should be widely recommended – but considering that the paper's author is a vocal pro-circumcision advocate, it's hardly an unbiased source of information.

According to the World Health Organization, about 30 per cent of males age 15 and older around the world are circumcised. The rate in Canada was even higher until provinces stopped funding circumcision in the early 1990s, leading to a drop that put us in line with the rest of the world.

A growing divide

Few national medical organizations support circumcision of newborns that isn't required for medical reasons. In fact, the United States became somewhat of an outlier in 2012 when it came out with guidelines that stated the health benefits of circumcision outweigh the risks. Circumcision rates in European countries are low and opposition to circumcision from medical circles seems to be growing. The Council of Europe, a major human-rights organization, called last year for a ban on non-medical circumcisions. Earlier this year, medical associations in Sweden and Denmark also recommended a ban on non-medical circumcisions. (Some religious groups have taken issue with that view.) A consortium of international doctors published a paper last year in the journal Pediatrics that criticized the AAP's view on circumcision, accusing the U.S. group of having a "cultural bias" toward the procedure (a significant number of the world's population of circumcised individuals live in the U.S.).

Risks versus benefits

Studies have demonstrated that circumcisions may lead to a reduction in urinary-tract infections in young boys. But UTIs aren't that common in that age group. The AAP points out that it would take about 100 circumcisions to prevent a single UTI in boys. Infections can be readily treated with medication.

Circumcisions are also cited by the WHO as an effective way to reduce the spread of HIV and sexually transmitted infections, such as gonorrhea and genital herpes. While studies conducted in sub-Saharan Africa have shown that transmission rates are reduced when males are circumcised, the same patterns haven't been replicated in Western populations. Some experts suggest it would be better to focus efforts here on proven prevention methods, such as the use of condoms.

Similarly, circumcision is promoted as a way to prevent transmission of human papillomavirus which causes certain diseases, such as genital warts and cervical cancer in women. But now vaccination against HPV is increasingly common and is a much less invasive preventive tool. Rates of penile cancer may also be reduced in males who are circumcised. But the rates and risks are small – the Canadian Cancer Society said 139 men were diagnosed with the disease in Canada in 2007, the most recent year for which data are available. Many cases of penile cancer are linked to HPV, which could be prevented through condom use and vaccination.

Given this, is a permanent, invasive surgery really the best way to tackle those health problems? The 2013 Pediatrics paper summed it up this way: "The cardinal medical question should not be whether circumcision can prevent disease, but how disease can best be prevented."

And what about the risks? While studies have shown circumcision is generally safe and rarely dangerous, some physicians argue that doesn't tell the full story. Most of the medical literature looks at individuals only immediately after circumcision, despite the fact that many problems – including infection, improper healing, bleeding and unsatisfactory cosmetic results – may not emerge for days or weeks after the fact.

Dr. Jorge DeMaria, a pediatric urologist at McMaster Children's Hospital in Hamilton, said he and a colleague treat at least 10 patients a month for complications or unsatisfactory results. Dr. Martin Koyle, head of urology at Toronto's Hospital for Sick Children, said the hospital sees two to three "significant complications" every week. He recently treated a child who couldn't urinate because his penis became trapped under the scrotum post-surgery.

Bottom line

There will likely never be consensus on circumcision. But the decision on whether to get one should be guided by evidence. Instead of coming down on one side of the debate, the Canadian Paediatric Society could help parents more by offering guidance that clearly spells out the potential advantages and risks of circumcision, without bias or omission.

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