Notat om omskæring af drenge - Sundhedsstyrelsen

COMMENTARYIn this commentary, a different view ispresented by non–US-based physiciansand representatives of generalmedical associations and societiesfor pediatrics, pediatric surgery,and pediatric urology in NorthernEurope.CRITERIA FOR PREVENTIVEMEDICINEIt is commonly accepted that medicalprocedures always need to be justifiedbecause of their invasive nature andpossible damaging effects. Preventivemedical procedures need more andstricter justification than do therapeuticmedical procedures, as they areaimed at people who are generally freeof medical problems. Even strictercriteria apply for preventive medicalprocedures in children, who cannotweigh the evidence themselves andcannot legally consent to the procedure.4The most important criteria for thejustification of medical proceduresare necessity, cost-effectiveness, subsidiarity,proportionality, and consent.For preventive medical procedures,this means that the procedure musteffectively lead to the prevention ofa serious medical problem, that thereis no less intrusive means of reachingthe same goal, and that the risks ofthe procedure are proportional to theintended benefit. In addition, whenperformed in childhood, it needs to beclearly demonstrated that it is essentialtoperformtheprocedurebeforeanage at which the individual can makea decision about the procedure for himorherself.The AAP technical report points to 4health-related arguments in favor ofcircumcision: the reduced risks ofurinary tract infections (UTIs), penilecancer, some traditional sexually transmitteddiseases (STDs), and HIV infectionand AIDS.URINARY TRACT INFECTIONSAccording to the literature reviewed,∼1% of boys will develop a UTI withinthe first years of life. 2 There are norandomized controlled trials (RCTs)linking UTIs to circumcision status.The evidence for clinically significantprotection is weak, and with easyaccess to health care, deaths or longtermnegative medical consequencesof UTIs are rare. UTI incidence doesnotseemtobelowerintheUnitedStates, with high circumcision ratescompared with Europe with low circumcisionrates, and the AAP reportsuggests it will take ∼100 circumcisionstoprevent1caseofUTI.Usingreasonable European estimates citedin the AAP report for the frequency ofsurgical and postoperative complications(∼2%), for every 100 circumcisions,1 case of UTI may beprevented at the cost of 2 cases ofhemorrhage, infection, or, in rareinstances, more severe outcomes oreven death.Circumcision fails to meet the criteriato serve as a preventive measure forUTI, even though this is the only 1 ofthe AAP report’s 4 most favored argumentsthat has any relevance beforethe boy gets old enough to decide forhimself.PENILE CANCERPenile cancer is 1 of the rarest formsof cancer in the Western world (∼1case in 100 000 men per year), almostalways occurring at a later age. Whendiagnosed early, the disease generallyhas a good survival rate. Accordingto the AAP report, 2 between909 and 322 000 circumcisions areneeded to prevent 1 case of penilecancer. Penile cancer is linked to infectionwith human papillomaviruses, 5which can be prevented withouttissue loss through condom useand prophylactic vaccination. It isremarkable that incidence rates of penilecancer in the United States, where∼75% of the non-Jewish, non-Muslimmale population is circumcised, 1 aresimilar to rates in northern Europe,where #10% of the male populationis circumcised. 6As a preventive measure for penilecancer, circumcision also fails to meetthe criteria for preventive medicine: theevidence is not strong; the disease israre and has a good survival rate; thereare less intrusive ways of preventingthe disease; and there is no compellingreason to deny boys their legitimateright to make their own informed decisionwhen they are old enough todo so.TRADITIONAL STDsAccording to the AAP report, 2 there isevidence that circumcision providesprotection against 2 common viralSTDs: genital herpes and genital warts.However, the evidence in favor of thisclaim is based primarily on findings inRCTs conducted among adult men insub-Saharan Africa. For other STDs,such as syphilis, gonorrhea, and chlamydia,circumcision offers no convincingprotection. The authors of theAAP report forget to stress that responsibleuse of condoms, regardlessof circumcision status, will provideclose to 100% reduction in risk forany STD. In addition, STDs occur onlyafter sexual debut, which implies thatthe decision of whether to circumcisecan be postponed to an age whenboys are old enough to decide forthemselves.HIV AND AIDSFrom a public health perspective,what seems to be the AAP technicalreport’s most important argument isthat circumcision may reduce the burdenof heterosexually transmitted HIVPEDIATRICS Volume 131, Number 4, April 2013 797Downloaded from pediatrics.aappublications.org by guest on June 19, 2013