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How medical opinions on circumcision have shifted over the years

REUTERS/Rick Wilking
U.S. circumcision rates are still much, much higher than those in many other developed countries.

Few medical topics generate as much debate — often quite heated — as newborn male circumcision. Earlier this month, the American Academy of Pediatrics (AAP) announced that it was reversing its position on circumcision, arguing that new research suggested the health benefits of the surgical procedure slightly outweigh the risks and thus “justify access to this procedure for families who choose it.”

This announcement wasn’t, however, a recommendation that all parents have their baby boys circumcised. As one of the physicians who authored the new policy told the New York Times, “We’re not pushing everybody to circumcise their babies. This is not really pro-circumcision. It falls in the middle. It’s pro-choice, for lack of a better word. Really, what we’re saying is, ‘This ought to be a choice that’s available to parents.’ ”

The AAP’s new position statement may stop efforts to ban circumcision, such as the one that failed in San Francisco in 2011. But it’s not clear if the statement will halt the recent decline of circumcisions in the United States. From 1999 to 2008, the percentage of American newborn boys who were circumcised fell from 63.5 percent in 1999 to 56.9 in 2008, according to the National Center for Health Statistics.

U.S. circumcision rates are still much, much higher than those in many other developed countries, particularly those in Europe, where the rates are generally under 20 percent, according to the World Health Organization. In France, for example, 14 percent of men have been circumcised. In some European countries, circumcision prevalence is extremely low: 1.8 percent in Spain, for example, and less than 1 percent in Finland.

Shifting opinions

On issues like this, it’s often enlightening to trace the history of the medical community’s former attitudes and positions, particularly the reasonings behind those earlier positions. So I read with interest a recent guest posting about circumcision on the Hastings Center‘s bioethics forum by Elizabeth Reis, an associate professor of women’s and gender studies at the University of Oregon.

The AAP “pronouncement contradicts the Academy’s earlier ruling just 13 years ago in 1999, which stated unequivocally that the health benefits of the procedure were slim,” she writes. “The 1999 statement reversed a previous one made in 1989 that said there were good medical reasons for it; but a few years earlier in 1971, the Academy had officially concluded that it was not a medical necessity. Clearly, circumcision is one of those surgeries about which opinion shifts back and forth over the years.”

Reis then offers this additional history:

Medical concerns have changed frequently. In the 1840s many worried about phimosis, a condition in which the foreskin does not retract completely. To read some of the medical journal articles from the period, one might think this problem was nearly epidemic. Circumcision became one of the cures widely touted by physicians for this particular disorder. They also recommended circumcision as a remedy for masturbation and nervous conditions later in the century; in fact, some even endorsed the surgery for women suffering the same maladies.

Unlike the nineteenth-century physicians who focused on individual ailments, today’s circumcision advocates turn to public health justifications. To be sure, even today there are some who argue for its benefits on an individual level: it might decrease the already low incidence of infant urinary tract infections and even rarer penile cancer in adults, but these studies are contested and are not so compelling to advocates as the possibility of stemming the rising numbers of HIV/AIDS infections, particularly in Africa. In each era, circumcision promoters have emphasized the particular health crisis most urgent at the time; syphilis during World War I, HIV/AIDS today.

Even if we agree that circumcision has some public health benefits, it is not the cure-all that we might imagine. The pediatricians’ report cited several studies done in Africa, where HIV is spread primarily among heterosexuals. This research found that it reduced transmission from infected women to men but had no effect on transmission between men. In addition, it ameliorated the spread of some sexually transmitted infections (HPV and herpes) but not gonorrhea, syphilis, or the most common STI, chlamydia. Is altering perfectly healthy bodies prophylactically really the best response, or might education campaigns about safe sex practices be more successful (and less invasive) for the prevention of all these diseases?

The public health crisis of HIV/AIDS should not be taken lightly, of course, but the endorsement of circumcision for newborns is a radical step, particularly when the surgery has its own complications; the New York Times noted that one in 500 infants suffer severe consequences (infection, excessive bleeding, and disfigurement of the penis), and some babies even die each year.

You can read Reis’ entire commentary on the Hastings Center website. You can download and read the AAP statement on circumcision on its website.

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Comments (3)

  1. Submitted by Roland Day on 09/01/2012 - 08:10 am.

    AAP circumcision statement is all about money

    I would be remiss if I did not point out the conflict of interest inherent when the people who profit from doing circumcision also give advice about its alleged value. In this case, the conflict is especially obvious. The three medical specialities who profit the most from doing medically-unnecessary, non-therapeutic circumcisions were all represented on the task force that prepared this travesty of a medical statement. Lesley Atwood, MD, represented the family physicians (AAFP) and Sabrina Craigo, MD, represented the obstetricians (ACOG). The AAP took the lead and appointed Stephen Wegner, MD, JD, who represented the Committee on Health Care Financing.

    There is great interest on the part of these trade associations in getting third party financing for circumcision. They are quite upset because taxpayer-funded Medicaid operations in 18 states (including Minnesota) no longer waste public money on paying doctors to perform unnecessary non-therapeutic circumcisions.

    The medical information is absurdly bad. It provide zero information regarding the nature and physiological function of the foreskin, which is the human body part amputated by circumcision.

    The medical literature was cherry-picked to provide information only favorable to circumcision. Many African sources were used which may not be relevant to the United States.

    The medical ethics were horrible and used a reference that discussed the treatment of dying children and is completely inapplicable to heathy children. There was no mention of the right of the child to his bodily integrity. This statement is a sham to promote more money for doctors. The public should reject it.

  2. Submitted by Gail Garvey on 09/03/2012 - 01:30 am.

    A boys eye view.

    My son at age 5 asked about the difference between himself (intact) and other boys (circumsicized) at daycare. When I explained circumcision to him he sighed and said “I don’t think it is very nice to cut pieces off of babies” My pediatrician at the time said the only reason for circumsicion was “fulfillment of the covenant”. I had heard that insurance companies were no longer paying for this so it is no surprise that someone decided that it was now advised..

  3. Submitted by Phil Dech on 09/04/2012 - 09:23 am.

    It’s interesting how the rationale changes

    over the years. My understanding has been that problems with balanitis, or an infection under the foreskin, among GI’s during WWII was at least partially responsible for the spike in circumcisions in the late 40’s and 50’s, which then perpetuated.

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