AMERICAN FAMILY PHYSICIAN, Vol 54, No. 4, pages 1216-1217,
September 15, 1996.

Letters to the Editor

AAFP Fact Sheet on Neonatal Circumcision: A Need for Updating

TO THE EDITOR: Several recently published studies demonstrate the need for complete revision of the American Academy of Family Physicians "Fact Sheet for Physicians Regarding Neonatal Circumcision."[1] Any physician caring for infant boys should investigate other sources.

Recent retrospective studies[2] have estimated the neonatal circumcision complication rate to be more than five times higher than reported in the fact sheet. The complication rate is significantly higher than that reported for postneonatal circumcision.

The number of circumcised men developing penile cancer has been increasing. Of 110 cases of penile cancer, 41 (37 percent) were circumcised, with 22 (20 percent) having been circumcised in the newborn period.[3] Genital warts and smoking were the strongest predictors of penile cancer. Data from Denmark indicate that the incidence of penile cancer is lower in Denmark than in the United States. Approximately 1.6 percent of Danish men are circumcised. The incidence of penile cancer has been declining for the past 50 years in Denmark.[4]

The statement "Virtually all sexually transmitted diseases occur more frequently among uncircumcised men" may no longer be true. Recent studies have demonstrated that circumcised men are at increased risk of contracting gonorrhea, syphilis and genital warts.[5,6] Men are at equal risk for developing human papillomavirus lesions and herpesvirus infections regardless of circumcision status.[3,7] At least four studies have shown human immunodeficiency virus infection to occur more commonly in circumcised men.[8]

If linear regression analysis is applied to the relationship between circumcision rates and the prevalence of acquired immunodeficency syndrome in industrialized countries (using 1994 World Health Organization data) and weighted for population, a strongly positive correlation between circumcision and the prevalence of AIDS is found. While this does not prove that circumcision is a risk factor for AIDS, it is clear that the circumcision experiment in the United States did not prevent the spread of the infection.

It is now believed that neonates perceive stimuli to be more painful than older infants. The impact of a painful experience may have long-term ramifications. A recent study demonstrated that boys circumcised in the neonatal period cried longer and harder after their first set of immunizations.[9]

Finally, the American Academy of Pediatrics Committee on Bioethics recently cast doubt on whether a physician can ethically perform neonatal circumcisions.[10] Since a newborn is not competent, neither informed consent nor patient assent can be obtained. Likewise, parental permission is only accceptable in situations where medical intervention has a clear and immediate necessity, such as disease, trauma, or deformity. Routine circumcision does not satisfy these requirements. The committee suggests that in nonessential treatments, which could be deferred without substantial risk, the physician and family wait until the child's consent can be obtained. Without proper consent, the delineation between performance of neonatal circumcision and assault and battery becomes indistinct.[11]

Minoqua, Wisc.


  1. American Academy of Family Physicians Fact sheet for physicians regarding circumcision. Am Fam Physician 1995;52:523-6.
  2. O'Brien TR, Calle EE. Poole WK. Incidence of neonatal circumcision in Atlanta, 1985-86. South Med J 1995;89:411.
  3. Maden C, Sherman KJ, Beckman AM, Hislop TG, Teh CZ, Ashley RL, et al. History of circumcision, medical conditions, and sexual activity and risk of penile cancer. J Natl Cancer Inst 1993;85:19-24.
  4. Frisch M. Falling incidence of penile cancer in an uncircumcised population (Denmark 1943-90). BMJ 1993;311:1471.
  5. Donovan B, Basset I, Bodsworth NJ. Male circumcision and common sexual transmitted diseases in a developed nation setting. Genitourin Med 1994;70:317-20.
  6. Cook LS, Koutsky LA, Holmes KK. Clinical presentation of genital warts among circumcised and uncircumcised heterosexual men attending an urban STD clinic. Genitourin Med 1993;69:262-4.
  7. Aynaud O, Ionesco M, Barrasso R. Penile intraepithelial neoplasia. Specific clinical findings correlate with histologic and virologic findings. Cancer 1994;74:1762-7.
  8. Chao A, Bulterys M, Musanganire F, Habimana P, Nawrocki P, Taylor E, et al. Risk factors associated with prevalent HIV-1 infection among pregnant women in Rwanda. National University of Rwanda-Johns Hopkins University AIDS Research Team. Int J Epidemiol 1994;23:371-80.
  9. Taddio A, Goldbach M, Ipp M, Stevens B, Koren G. Effect of neonatal circumcision on pain responses during vaccination in boys. Lancet 1995;345:291-2.
  10. American Academy of Pediatrics Commitee on Bioethics. Informed consent, parental permission, and assent in pediatric practice. Pediatrics 1995;95:314-7.
  11. Bonner CA, Kinane MJ. Circumcision: the legal and constitutional issues. The Truth Seeker 1989; (July/August):51-84.

(File revised 17 June 2005)

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