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Pokarowski et al., 2022. Examining Clinical Practice Guidelines for Male Circumcision: A Systematic Review and Critical Appraisal Using AGREE II. The Journal of Pediatrics
There are not many issues in men’s health that are more controversial than the circumcision of baby boys. When the American Academy of Pediatrics released its Circumcision Policy Statement in 2012, stating that “the health benefits of circumcision outweigh the risk”, they were met by widespread disagreement and accusations of cultural bias.
The AAP policy statement did not go so far as to recommend routine circumcision of all newborn males, making it consistent with the 2010 statement by the Royal College of Australasian Physicians that guides current practice in Australia. This permissive position sits at one end of the range of recommendations and guidelines about infant male circumcision. At the other are government policies that make non-therapeutic male infant circumcision unlawful (in South Africa and parts of Scandinavia).
The range of recommendations about infant male circumcision reflects variations in cultural, religious and health practices that date back hundreds of years. For a topic so mired in controversy, it is unsurprising that different attempts at objective reviews of evidence reach different conclusions. For example, a PhD thesis on the subject is used to support both pro- and anti-circumcision arguments. Such bias is common because “the data don’t interpret themselves”.
Methods to gauge the quality of evidence are useful for assessing interpretations of data. Systematic reviews are regarded as more rigorous and reliable than ‘narrative’ reviews, in much the same way meta-analyses trump individual studies. Clinical guidelines can be similarly assessed. Thus, the AGREE (Appraisal of Guidelines, Research and Evaluation) collaboration’s AGREE II methodology has recently been used to examine clinical practice guidelines for male circumcision.
AGREE II ranks six different domains of guideline quality: (1) scope and purpose; (2) stakeholder involvement; (3) rigour of development; (4) clarity of presentation; (5) applicability; and (6) editorial independence. Scores ranging from one (strongly disagree) to seven (strongly agree) are given by independent assessors for 23 statements to arrive at the six domain scores, and an ‘overall’ score (from one to seven) is also given. (A short version of the methodology, the AGREE Global Rating Scale Instrument, is available for evaluating the quality and reporting of practice guidelines in settings where time and resources are limited).
Thirteen individual clinical practice guidelines for male circumcision were ranked using AGREE II, by a general paediatrician, a paediatric general surgeon, a paediatric urologist and a general urologist. The guideline documents from the Canadian Urological Society, US Centre for Disease Control and Prevention, and the American Academy of Paediatrics were judged the three of highest quality.
For helping parents to decide whether circumcision is right for their male child, the key recommendations of the three top-ranked clinical guidelines are:
- Health providers should provide facts about risks and benefits to health in an unbiased manner
- Parents or guardians should make decisions about circumcision on behalf of their male children after considering health risks and benefits in combination with religious beliefs, cultural practices and personal preferences
- Parents should make their decision about male circumcision prior to conception or early in pregnancy.
When it comes to the provision of facts about the risks and benefits of infant male circumcision, at least some of what we believe will be out of date. Many guidelines list protection against HPV infection as a benefit of circumcision but contemporary widespread vaccination against the virus — resulting from Australia’s National Immunisation Program — diminishes this benefit. Protection against HIV in a country with low prevalence and access to Pre-Exposure Prophylaxis (PREP) makes this advantage of circumcision less valuable than in places with high prevalence and less protection against infection.
Protection against penile cancer appears to be mediated by phimosis, poor hygiene, inflammation, and HPV infection — all things that can be treated, if not avoided, by adequate care.
The health information provided to parents considering circumcision for their infant sons might not actually be very influential, at least for some families. A survey of 60 parents in the US suggests cultural factors contribute more than health considerations when deciding about male infant circumcision. However, this might make the accuracy of health information about male infant circumcision more critical, if parents are to be properly informed before providing consent. Unfortunately, there is more disagreement in the academic literature about the risks and benefits of male infant circumcision, than there is information about what parents want, and need, to help them make their decisions.
In the efforts to provide robust evidence from rigorous scientific studies in clinical guidelines, some sources of information are discounted or entirely ignored, which risks a lack of consideration of legitimate issues. The existence of a group of men who feel damaged by their circumcisions is undeniable. This is a real risk of the procedure, with a profound impact. We should not lose sight of the fact that “individuals can either perceive their circumcision status as a blessing or a curse depending on the values and preferences of the different communities or social environments where they belong”. Rather than ignore these men or dismiss their concerns we should try to understand the reasons for their distress and find ways to help them deal with it.
Whether boys and men are circumcised or not, they all should be provided with the health care necessary to help them look after themselves.
 Blank et al., 2012. Circumcision Policy Statement. Pediatrics
 Frisch et al., 2013. Cultural Bias in the AAP’s 2012 Technical Report and Policy Statement on Male Circumcision. Pediatrics
 RACP, 2010. Circumcision of infant males
 Raveenthiran, 2018. The evolutionary saga of circumcision from a religious perspective. Journal of Pediatric Surgery
 Morris et al., 2019. Critical evaluation of arguments opposing male circumcision: A systematic review. Journal of Evidence-Based Medicine
 Hammond & Carmack, 2017. Long-term adverse outcomes from neonatal circumcision reported in a survey of 1,008 men: an overview of health and human rights implications. The International Journal of Human Rights
 May, 2021. Bias in science: natural and social. Synthese
 Brouwers et al., 2010. AGREE II: advancing guideline development, reporting and evaluation in health care. Canadian Medical Association Journal
 Pokarowski et al., 2022. Examining clinical practice guidelines for male circumcision: a systematic review and critical appraisal using AGREE II. The Journal of Pediatrics
 Thomas et al., 2021. Penile cancer. Nature Reviews Disease Primers
 Sardi & Livingston, 2015. Parental Decision Making in Male Circumcision. MCN: The American Journal of Maternal/Child Nursing
 Jenkins, 2014. Bias and Male Circumcision. Mayo Clinic Proceedings
 Morris et al., 2014. In reply—Bias and Male Circumcision. Mayo Clinic Proceedings