To circ or not to circ
Jennifer asked about the medical evidence for and against circumcision: “A family doctor friend said there is new evidence (based on studies in S. Africa and New Zealand) suggesting that circumcisions for boys can reduce chances for HIV by 50%, and that uncircumcised men had 3x the incidence of STDs between the ages of 18-25. He said there is also strong evidence that circumcising males lowers the risk for UTIs, genital ulcer disease, penile cancer and HPV. Has the medical community changed their minds recently on recommending circumcisions as a preventative measure based on recent (limited) evidence?”
The current recommendation of the American Academy of Pediatrics (AAP) is that there is not sufficient evidence to support routine circumcisions on all baby boys. They acknowledge that cultural and religious factors are important and should be considered when making recommendations to parents. In other words, while the AAP agrees that there are medical benefits to circumcision, these don’t clearly outweigh the risks of the procedure. In the opinion of the AAP, it’s not a slam-dunk to circumcise.
The AAP position statement on this was published in 1999, and re-affirmed in 2005. Since then, further solid evidence has accumulated supporting the benefits of circumcision. Recent studies have shown quite convincingly that circumcision protects against HIV and other sexually transmitted diseases, at least in the third world.
The risks of circumcision are small, but there are risks. There is some pain involved (though the surgeon should take steps to minimize this.) Circumcisions, rarely, can be really botched, requiring further surgery. There is also an active and I would say rather colorful internet-based community of men who feel that having been circumcised has caused them great grief as adults. Some of these men, apparently, are trying to “uncircumcise” themselves with some rather fiendish looking gadgetry (no, I’m not posting any links. Find them yourselves if you’re so interested.) Other overwrought advocates feel that circumcision mutilates the body, comparing the procedure to hellish Nazi experiments.
It’s clear to me that the vocal crowds at either far-end of this debate are entirely nuts. Yes, there are some medical benefits, at least from a public health point of view; but there are certainly less-invasive ways to reduce a man’s risk of disease transmission. Yes, there are risks of the procedure, but these risks really are small, and I’m having a hard time believing that circumcised men are really suffering because of their penis status. To me, it’s entirely reasonable to go either way, and almost all men will be happy with themselves with or without their little hoodie in place. There really are far more important things to worry about.
Based on my admittedly informal discussions at National AAP meetings, I don’t think there is a lot of enthusiasm for revisiting this issue or making a more bold proclamation about circumcisions. In my mind and I think the minds of many AAP members, the best recommendation for babies in the USA is to have their parents decide based on their own beliefs and the best known information. The pediatricians’ role should be to present an honest review of the risks and benefits of the circumcision, and not allow personal agendas to color their advice.
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The Pediatric Insider 
September 30, 2008 at 6:19 pm
With all due respect, I think the best recommendation for babies in the USA is to have their parents love, respect, and protect them until they are old enough to make this very personal decision for themselves. If just one male complained about his circumcision (and, in fact, there are countless thousands who have), that should be enough to make an ethical doctor think about his oath to “First, do no harm.” Ten out of ten babies oppose circumcision, shouldn’t we? We do not have the right cut normal body parts off our non-consenting minors to satisfy our own cosmetic whims. The time has come to look at the practice of circumcision through the human rights lens of the 21st century and, then, to “First, do no harm!”
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September 30, 2008 at 6:30 pm
I think it is far more important to consider what the man would want rather than argue over 3rd world studies about STDs. It isn’t the 1970s anymore. Young men think circumcision is stupid. Just frequent any forum that teens and 20-somethings inhabit. The remarks about circumcision are resoundingly negative. People are aware of the various studies and would much prefer to deal with the issues as they come up and practice safe sex rather than have their parents “deal” with the issue for them in a very personal, invasive manner.
The ethical issues AKA “The guy might not like being cut” is something that doctors, parents, and advice columnists seem to gloss over and ridicule. That needs to change.
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September 30, 2008 at 11:26 pm
I believe the Canadian medical ethicists, Dr. Margaret Somerville, perhaps said it best: “A common error made by those who want to justify infant male circumcision on the basis of medical benefits is that they believe that as long as some such benefits are present, circumcision can be justified as therapeutic, in the sense of preventive health care. This is not correct. A medical-benefits or “therapeutic” justification requires that:
1. Overall the medical benefits should outweigh the risks and harms of the procedure required to obtain them.
2. This procedure is the only reasonable way to obtain these benefits.
3. These benefits are necessary to the well-being of the child.
None of these conditions is fulfilled for routine infant male circumcision.”[1]
There is clearly no reasonable need to circumcise an infant or a child outside of some very specific medical requirements that would only apply individually. Any purported benefit, especially those involving STDs, are subjective and can only be properly weighted by the competent adult. For example, as a competent adult living in the first world, I know that early childhood circumcision has not been shown to have any substantial impact on STDs. And even if there was a small impact, or my living conditions were different, the benefit would still be subjective with a value to me of 0. Others may weigh the value differently but that is a decision only the adult can make for themselves not for their child.
The AAP Committee on Bioethics report states, “Pediatric health care providers. . . have legal and ethical duties to their child patients to render competent medical care based on what the patient needs, not what someone else expresses. . . . The pediatrician’s responsibilities to his or her patient exist independent of parental desires or proxy consent.” (p. 315)[2]. With no specific benefit to the child that couldn’t be handled in less invasive, more reasonable ways, I wonder when pediatricians will take seriously their oaths to do no harm and their own statement on bioethics.
Finally, considering that a man can easily get circumcised if he want to and it is not really possible to reverse the damage, like the commenter Marilyn, I would love to know how many ‘colorful’ men it takes before their concerns are taken seriously. One? Ten? One-Hundred? One-Thousand? Ten-Thousand? or perhaps percentages would be easier, as long as no more than 5% of men complain there is no problem. And yes you should see what young men are saying about this, to be sure they aren’t necessarily all complaining but most realize how obsolete and pointless it is.
[1] Somerville, Margaret A. The Ethical Canary Science, Society and the Human Spirit, Viking/Penguin Canada, Toronto, hardcover, 344 pages (chapter 8, pp. 202-219).
[2] American Academy of Pediatrics Committee on Bioethics. “Informed Consent, Parental Permission, and Assent in Pediatric Practice.” Pediatrics 95 (1995): 31
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September 30, 2008 at 11:29 pm
Circumcision is like a cheap condom that breaks 40% of time.
For effective HIV protection you always must use a real condom, whether you are circumcision or not.
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October 1, 2008 at 5:24 am
There have been NO studies of circumcision and HIV in New Zealand. Two studies have looked at the effect on STDs, and the better one found NONE.
Very even-handed of you to to say they’re “entirely nuts” at both end of the spectrum. Having the most sensitive part of one’s penis cut off (see Sorrells, et al.) for no good reason could make anybody nuts. I don’t know what the excuse is of the people who want to cut parts off other people’s penises. THAT’s nuts.
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October 1, 2008 at 7:09 am
The author has revealed his insensitivity to the problem of non-therapeutic male circumcision in America by this statement: “To me, it’s entirely reasonable to go either way, and almost all men will be happy with themselves with or without their little hoodie in place.”
It seems clear that the anonymous author of this tract is a man, circumcised at birth, who has no experience with a normal body part and, consequently, no knowledge of the value of the foreskin.
The author does not understand that most, if not all, of the pro-circumcision medical literature is written by circumcised men, who have an acute need to justify, at least in their own minds, their personal loss of erogenous tissue in order to secure some mythical health advantage. Such literature makes false claims that the author has gullibly accepted, perhaps to satisfy his own emotional needs.
The author clearly has not recognized that non-therapeutic infant circumcision is an offence against the legal and human rights of the infant to bodily integrity, security of the person, and to personal autonomy in making decisions about the amputation of body parts.
The author has not recognized that the non-therapeutic amputation of healthy body parts from an infant is a hideous violation of medical ethics.
This author clearly would benefit by reading the 12 chapter evidence-based statement at:
http://www.doctorsopposingcircumcision.org/DOC/statement0.html
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October 1, 2008 at 8:49 am
Clearly, there is much passion from the anti-circ crowd. I’m happy to leave up any post that tries to make a point without any personal attacks or threats. Unfortunately, I’ve had to delete a few comments for crossing that line. If any of you who were deleted would like to re-post, leaving out the ad hominem attacks, be my guest.
One of the comments objected to my calling people at far-ends of the debate “nuts,” which, considering the subject, may have been a poor choice of words. Still, it’s ironic that this person thinks my comment applies to him.
I was also accused of being “anonymous,” which clearly I’m not.
One ethical point was made that children should be allowed to decide for themselves, but that doesn’t really wash. Parents have to decide many medical things for their kids, not just circumcision. Being a parent means making the best decisions for the long term health of a child, which sometimes might include something a child wouldn’t want done. Think about a finger-prick to check a lead level, or a vaccination. These hurt, but most parents agree to them because they’re in the best interests of the child, even if Junior would have said “no way.”
In the case of immunizations, I believe the choice is very clear: the benefits of vaccines far outweigh their risks, so I recommend them. For circumcision, the best decision is less clear: there are some medical benefits, but I am not convinced that these outweigh the risks, or that this procedure should be a routine part of neonatal care.
For more information:
http://www.mayoclinic.com/health/circumcision/PR00040
http://parenting.ivillage.com/newborn/ncare/0,,j8v1,00.html
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October 1, 2008 at 12:04 pm
With all due respect, permanent amputation of healthy, sexually sensitive tissue is not in the same category as a finger-stick or vaccination. It is a permanent bodily modification. Any decision to alter the appearance and functions of the penis belongs with the person who will have to live with the consequences for the rest of his life–not his mom and dad. If it’s “nuts” to care about human rights, I’m proudly insane!
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October 1, 2008 at 3:28 pm
Dr. Roy,
Reviewing your blog I find your viewpoints to be generally within the mainstream of American medicine, and this topic is no exception. It is the case, however, that at certain points in time, the mainstream gets it wrong. I believe this is one such case. Indeed, the current circumcision policies in the United States are our of step with medical communities around the world. That should be a strong indicator that we need to undertake a serious re-evaluation.
Consider your recognition that the medical evidence is insufficient to recommend circumcision. With any other surgery, unproven efficacy would not cause physicians to just leave it up to parents when the child is perfectly normal and healthy. Why should circumcision be different?
You may be aware that it is as or more sensitive that any other part of the penis, thus contributing significantly to sensory perception (Sorrells). But why did you omit this from your discussion?
On the ethical point that males should be allowed to decide for themselves, you commented “Parents have to decide many medical things for their kids, not just circumcision.” That begs the question. When a decision needs to be made, parents need to make it. But the question here is, why should circumcision be seen a choice for parents at all, when there is no medical need, no significant health benefit, and it removes a normal part of a child’s body?
I really hope you’ll come around on this, and consider joining DOC. Take a look at their comprehensive Genital Integrity Policy Statement. In fact, one of DOC’s members, George Hill, posted a comment here.
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October 1, 2008 at 7:38 pm
Dr Roy:
Although it seems I’ve been beaten to the punch I’ll add that I too find your analogy unconvincing. Setting aside the fact that a vaccination or a finger-prick test is far less invasive than a circumcision, your examples actually quite easily fall within the bounds of medically therapeutic.
A vaccination against Measles or Polio, for example, is the most reasonable least invasive way that I am aware of to protect a child from those diseases (without making him or her live in a hermetically sealed bubble). And since, for the most part, a child can contract these diseases, and many other diseases we vaccinate for, at any age, through no action of their own other then simply circulating in public, it is a benefit that can be construed to be necessary to the well-being of the child. The only thing that even comes close to meeting this definition is a purported protection from UTI. However, even that fails since UTIs can be easily treated with a round of antibiotics, same as girls, and recurrent UTIs are usually the result of a congenital anomaly of the urinary tract and not necessarily related to the foreskin.
Although they don’t circumcise routinely in Britain, the British Medical Association produced a reasonably good piece of guidance for doctors concerning this issue where the BMA states:
“Unnecessarily invasive procedures should not be used where alternative, less invasive techniques, are equally efficient and available. It is important that doctors keep up to date and ensure that any decisions to undertake an invasive procedure are based on the best available evidence. Therefore, to circumcise for therapeutic reasons where medical research has shown other techniques to be at least as effective and less invasive would be unethical and inappropriate.” [1]
Perhaps it is the fact that they don’t have as much invested in the procedure that allows them to produce statements that put circumcision into the proper ethical context.
[1] Medical Ethics Commitee, British Medical Association, 4 April 2003, Revised 15 June 2006
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October 1, 2008 at 8:24 pm
“One of the comments objected to my calling people at far-ends of the debate “nuts,” which, considering the subject, may have been a poor choice of words. Still, it’s ironic that this person thinks my comment applies to him.”
It’s not ironic, it follows logically because I am at one of the far ends of the debate (but only because nobody actually holds the positions theoretically possible beyond mine, such as that babies with real health problems of their foreskins should not be circumcised (I would grant that they should), or that consenting informed adults should not be circumcised if they want (I would grant that they should). (And in passing, the law in many jurisdictions including mine is that consenting informed adult women may not have any genital tissue cut off, except for pressing medical need, even if they want.)
Therefore it is inescapable that you have said I am “entirely nuts”. My position is that normal healthy tissue should not be cut from the genitals of any baby of any sex (lacking pressing medical need) – exactly as we treat the rest of a baby’s body. If that is “entirely nuts” so be it. I do not object.
As to the other end of the spectrum, a recent paper uses the term “mandatory circumcision” 30 times without defining it, but the term seems to suggest that the decision should be taken even from the parents. See http://www.circumstitions.com/Ethics.html#mandatory .
But already I have fallen into the same trap you have, of treating this as a debate between two symetrically opposed views, like the scales of Libra or Justice. We advocate leaving babies alone, doing nothing whatsoever. They advocate holding them down and cutting parts off their genitals, changing their sexual bodies for life. They are completely different kinds of position to hold.
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October 1, 2008 at 9:29 pm
Dr Roy- keep up the good work. Excellent site, and good info. The more these people post, the more you’ve made your point.
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October 2, 2008 at 11:30 am
Ditto to what Avery said, Dr. Roy. Although I have 3 boys and went against my religion NOT to circumcize any of them, I would not fault anyone for making a different decision. Most people who make the decision to circumcise, I have found, do so for either religious reasons or because they want their son to “look like” the father or like “all the other boys in the locker room.” Since the OFFICIAL medical community does not take a strong position one way or the other, these are entirely legitimate reasons. It’s a shame that there are people out there who try to use strong arm tactics and guilt to affect this very personal, sometimes difficult, decision that new parents have to make. Interesting that I don’t see any pro-circ people on here on the attack, feeling the need to defend/propound their position. Hmmm……
But hey, Dr. Roy, on the bright side, your blog is getting noticed!! 😉
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October 4, 2008 at 8:15 pm
I may sound really misinformed but here it goes. First of all my only son is circumcised and I do not regret this decision. I realize I am going pretty much against the grain but I am all for circumcision. Now saying that, I read on your original entry that “Circumcisions, rarely, can be really botched, requiring further surgery.”. When my first child, my son, was born, my regular OB circumcised him. I wasn’t given a choice of who did it(well at least to my knowledge)- I was just asked if wanted him to be circumcised. Is it common procedure to have OB’s perform this procedure? Are OB qualified to do this procedure? I am asking this question because our next baby is due in the near future(we dont know the sex,yet). If our child is a boy we will have him circumcised but I don’t know who is “supposed” to do the circumcision. Do pediatricians ever do circumcisions? Sorry to ask so many questions but I will admit I never thought about this until I read your blog. Thank you for any information you can give us overly- concerned parents. ****As a side note I am also going to ask this question in your blog suggestions but please respond anywhere you fell necessary. Thank you again!!!!****
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October 4, 2008 at 8:21 pm
Nancy, physicians from several fields can be qualified to do circs, and can do it well: OBs, pediatricians, urologists, surgeons, family practitioners, and others. Who does it depends on the traditions of your community. Where I practice, the OBs do all of the circumcisions. I am personally not qualified to perform them; knowing I was going to practice in Georgia, I never had appropriate training.
What’s most important isn’t what specialty the physician is from, but how many that person has done. You want the person doing the procedure to be someone who has done hundreds of them. If you’re uncomfortable, ask about the OBs experience with this procedure.
Best of luck with your second child!
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October 11, 2008 at 3:13 am
Nancy: “my only son is circumcised and I do not regret this decision. ” The question is, will HE regret your decision? If you’d decided to leave his penis alone and he regretted that, he could have it done when he wanted. You should bear this in mind before cutting any parts off your next child.
Allison: “because they want their son to “look like” the father”. What with size and hair, sons will not look like their fathers however you cut them. And you wouldn’t apply this rule if the father had had any other part cut off his body. (See http://www.circumstitions.com/Images/looklike.gif ) Why this one?
” or like “all the other boys in the locker room.””. With the circumcision rate now close to 50% he’s guaranteed to look like some of the others, and unlike some. (And I’m told they don’t make kids undress in lockerrooms any more.)
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October 23, 2008 at 5:34 pm
The American Academy of Pediatrics says it is legitimate to circumcise a boy for cultural or religious reasons.
Dr. Roy, what other medically unnecessary surgery is it legitimate for a doctor to perform on a child for cultural or religious reasons?
What other normal, healthy part of a child’s body is it legitimate for a doctor to amputate for cultural or religious reasons?
If the answer to these two questions is none, then how can your profession justify allowing non-therapeutic circumcision to remain a unique exception to the normal standard of pediatric care?
The fact that Jewish and Muslims parents believe that male circumcision is a religious requirement is not a sufficiently good reason for American doctors to tolerate the practice of non-therapeutic circumcision of healthy non-Muslim and non-Jewish boys.
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October 23, 2008 at 6:00 pm
“The fact that Jewish and Muslims parents believe that male circumcision is a religious requirement is not a sufficiently good reason for American doctors to tolerate the practice of non-therapeutic circumcision of healthy non-Muslim and non-Jewish boys.”
RH, are you saying that we should only tolerate circumcision for Jewish or Muslim families? What about mixed families? Or families who are largely secular, but have a religious cultural heritage? How will we judge who has a legitimate right to circumcise?
The impression I have gotten from the links provided by the anti-circumcision community is that in general they don’t condone this procedure for any children, regardless of religion.
In any case, from my point of view as a physician I view this as a matter to be decided based on risks and benefits. I’ve already posted the details several times above: there are modest benefits of circumcision, and there are risks as well. The exact degrees of both the benefits and risks are debatable. The anti-circumcision posters above feel quite passionately that the benefits are overstated and that the risks have been minimized. There are plenty of links above for more information from these groups and from other organizations.
Unless anyone has anything new to say, I’m going to close this thread to further posts. I appreciate everyone’s comments.
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