EDITORIAL www.nature.com/clinicalpractice/uro Neonatal circumcision: the controversy rages on Suzanne J Farley In this issue, the second of a pair of pro/con “Very few complications against the potential benefits of Viewpoints addressing the clinical utility of adult men [in the procedure is so fraught that the decision circumcising male infants is published. Robert is often based solely on personal belief—both Van Howe, a Clinical Professor of Pediatrics, developed of the child’s parents and, indirectly, of their rebuts the points raised by Paul Austin in the countries] medical advisors. January issue of the journal. Van Howe asserts choose to be If parents elect to have their son circumcised, that “as a public health measure, newborn circumcised.” who should pay? In 16 US states, Medicaid circumcision in the US has failed to show a no longer covers the cost (estimated to be Given the benefit in protecting against cervical cancer, $250–300) of nonessential neonatal circum- penile cancer, STIs, and HIV.” By contrast, it is available data, cision. Circumcision rates are markedly lower Austin’s view that “an abundance of data and would you? in these regions (Leibowitz AA et al. [2009] emerging evidence supports the public health Am J Public Health 99: 138–145). If a clinical benefits associated with circumcision.” benefit of ‘preventive’ circumcision is proved The divergence in the opinions of these two in the future, this fiscal discrimination will have authors is indicative of widespread confusion potentially compromised the health of men among practitioners about how best to advise whose parents could not afford to have them parents who are considering circumcision circumcised as children, as well as increasing for their sons. Guidance from the American the cost to the state of managing conditions Academy of Pediatrics is of little practical that might have been prevented. value to clinicians negotiating the minefield of The most compelling evidence for the preven- personal beliefs, cultural influences and con- tive value of circumcision is that drawn from flicting data that affect the circumcision deci- three randomized controlled trials conducted sion. The most recent AAP policy statement, recently in Africa. On the basis of these studies, published in 1999, concluded that “there are the WHO and the UN have recommended that potential benefits and risks, [but] insufficient circumcision be incorporated into HIV preven- data to recommend routine neonatal circum- tion programs. As Austin points out, “in the cision.” The upshot is that parents should future this could be a public health benefit that determine what is in the ‘best interests’ of can be transferred to the US and other indus- their child. trialized countries” (Austin PF [2009] Nat Clin Can two people truly determine what is in the Pract Urol 6: 16–17). ‘best interests’ of another? How can the future The African studies enrolled adults; it is opinions of a newborn be predicted, even by problematic, therefore, to extrapolate the the child’s parents? Does ‘best interests’ in this results to neonates. Promotion of noninvasive context, therefore, essentially boil down to the HIV prevention practices (e.g. condom use) preferences of the parents? has been more successful in controlling the Of course, these questions can be asked of SJ Farley is Deputy spread of infection in developed nations, consent for any pediatric procedure. Circum- Editor of Nature and could negate any benefit of pre-emptive cision cannot, however, be considered a Clinical Practice circumcision. Furthermore—and perhaps most ‘treatment’ in the same way as, for example, Urology. importantly—the men who participated in the surgical correction of a life-threatening injury. African trials were able to consent to the proce- Indeed, the AAP concludes that “[circum- Competing interests dure themselves. As Van Howe points out on The author declared no cision] is usually not essential to the child’s competing interests. pages 74–75 “very few adult men [in developed well being.” In the absence of irrefutable, high- countries] choose to be circumcised.” Given www.nature.com/clinicalpractice quality data, weighing the immediate risk of doi:10.1038/ncpuro1300 the available data, would you? FEBRUARY 2009 VOL 6 NO 2 NATURE CLINICAL PRACTICE UROLOGY 59.