Notat om omskæring af drenge - Sundhedsstyrelsen

infections in the United States. 2 ThreeRCTs in Kenya, Uganda, and SouthAfrica suggest that circumcision inadulthood may lead to a noticeablereduction in risk of heterosexual HIVacquisition in areas with extremelyhigh HIV prevalence. 7–9 Specifically, theAfrican RCTs seemed to show thatadult male circumcision halves heterosexualmen’s (but not women’s)risk of HIV infection in the firstfew years after the operation from2.49% to 1.18% in high-endemic areaswhere viral transmission occurs mainlythrough heterosexual intercourse. Thisevidence, however, is contradicted byother studies, which show no relationshipbetween HIV infection rates andcircumcision status. 10However, there is no evidence that circumcision,whether in infancy, childhood,or adulthood, is effective inpreventing heterosexual transmissionin countries where HIV prevalence ismuch lower and routes of transmissionare different, such as Europeand the United States. Sexually transmittedHIV infections in the West occurpredominantly among men who havesexwithmen,andthereisnoevidencethat circumcision offers any protectionagainst HIV acquisition in thisgroup. 11,12The African findings are also not in linewith the fact that the United Statescombines a high prevalence of STDsand HIV infections with a high percentageof routine circumcisions. Thesituation in most European countriesis precisely the reverse: low circumcisionratescombinedwithlowHIVandSTD rates. Therefore, other factorsseem to play a more important role inthe spread of HIV than circumcisionstatus. This finding also suggeststhat there are alternative, less intrusive,and more effective ways ofpreventing HIV than circumcision,such as consistent use of condoms,safe-sex programs, easy access toantiretroviral drugs, and clean needleprograms.As with traditional STDs, sexual transmissionof HIV occurs only in sexuallyactive individuals. Consequently, froman HIV prevention perspective, if atall effective in a Western context, circumcisioncan wait until boys are oldenough to engage in sexual relationships.Boys can decide for themselves,therefore, whether they wantto get circumcised to obtain, at best,partial protection against HIV or ratherremain genitally intact and adoptsafe-sex practices that are far moreeffective.As with the other possible benefits,circumcision for HIV protection inWestern countries fails to meet thecriteria for preventive medicine: thereis no strong evidence for effectivenessand other, more effective, and less intrusivemeans are available. There isalso no compelling reason why theprocedure should be performed longbefore sexual debut; sexually transmittedHIV infection is not a relevantthreat to children.COMPLICATIONSAs mentioned in the AAP report, 2 theprecise risk and extent of complicationsof circumcision are unknown. It isclear, however, that infections, hemorrhages,meatal strictures, and otherproblems do occur. Incidental deathsand (partial) amputations of the penishave also been reported, but exactfigures are not available. Althoughsome studies suggest that circumcisioncan lead to psychological, painrelated,and sexual problems later inlife, 13–15 population-based prospectivestudies of long-term psychological,sexual, and urological effects of circumcisionare lacking.It seems that the authors of the AAPreport consider the foreskin to bea part of the male body that has nomeaningful function in sexuality. However,the foreskin is a richly innervatedstructure that protects the glans andplays an important role in the mechanicalfunction of the penis duringsexual acts. 16–20 Recent studies, severalof which were not included in theAAP report (although they were publishedwithin the inclusion period of1995–2010), suggest that circumcisiondesensitizes the penis 21,22 and maylead to sexual problems in circumcisedmen and their partners. 23–29 In light ofthese uncertainties, physicians shouldheed the precautionary principle andnot recommend circumcision for preventivereasons.CONCLUSIONSThe AAP’s extensive report 2 was basedon the scrutiny of a large number ofcomplex scientific articles. Therefore,while striving for objectivity, the conclusionsdrawn by the 8 task forcemembers reflect what these individualphysicians perceived as trustworthyevidence. Cultural bias reflecting thenormality of nontherapeutic male circumcisionin the United States seemsobvious. The conclusions of the AAPTechnical Report and Policy Statementare far from those reached by physiciansin most other Western countries.As mentioned, only 1 of the aforementionedarguments has some theoreticalrelevance in relation to infant malecircumcision; namely, the questionableargument of UTI prevention in infantboys. The other claimed health benefitsare also questionable, weak, and likelyto have little public health relevance ina Western context, and they do notrepresent compelling reasons for surgerybefore boys are old enough todecide for themselves. Circumcisionfails to meet the commonly acceptedcriteria for the justification of preventivemedical procedures in children.798 FRISCH et alDownloaded from pediatrics.aappublications.org by guest on June 19, 2013