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No scientific conclusion in debate over medical benefits/risks of circumcision

American families began adopting the practice in large numbers for non-religious reasons during the late 19th century, says science writer Jessica Wapner.

Today, about 75 percent of males aged 15 and older in the U.S. are circumcised for non-religious reasons, according to the World Health Organization.
REUTERS/Rick Wilking

Late last year, the U.S. Centers for Disease Control and Prevention issued new federal guidelines on male circumcision.

Although CDC officials did not advise parents to have their sons undergo the procedure (the agency acknowledged that the decision is a personal one for families, influenced by religious and cultural beliefs), they did say that the medical evidence suggests that circumcision confers more health benefits than risks.

This stance mirrors one taken two years earlier by the American Association of Pediatrics (AAP).

But, as science writer Jessica Wapner reports in a long and fascinating article in Mosaic, an online science magazine published by the Wellcome Trust, equally authoritative health organizations in other developed countries have looked at the same evidence and decided that the procedure is medically unnecessary.

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Indeed, “American parents are almost alone in the Western world in their desire to separate boys from their foreskins for reasons other than religion,” Wapner writes. “… In 2010, for instance, the Royal Dutch Medical Association reviewed the same studies the AAP looked at. Aside from preventing urinary tract infections, which can be treated with antibiotics, it concluded that the health benefits of circumcision are ‘questionable, weak, and likely to have little public health relevance in a Western context.’”

Today, about 75 percent of males aged 15 and older in the U.S. are circumcised for non-religious reasons, according to the World Health Organization. That compares with about 6 percent in Great Britain, 30 percent in Canada and 59 percent in Australia.  

Became popular in Victorian era

In her article, Wapner describes the “troubled” historic reasons for the U.S.’s high rate of circumcision.

“The best-known circumcision ritual, the Jewish ceremony of brit milah, is … thousands of years old,” she writes. “It survives to this day, as do others practiced by Muslims and some African tribes. But American attitudes to circumcision have a much more recent origin.”

As Wapner explains, American families began adopting the practice in large numbers for non-religious reasons during the late 19th century, mainly because of misguided beliefs among some physicians that it would cure several specific nerve-related ailments and reduce masturbation, which many in the medical community had declared was linked to epilepsy, mental illness and a host of other problems.

But even after such beliefs were discarded, circumcision remained popular in the United States, for it had by then become part of the medical dogma. A circumcised penis was seen as more “hygienic” and less prone to infections.

But does the current scientific literature continue to support that view? The answer to that question is not a simple yes or no, says Wapner. Here, for example, is her description of the uncertainly surrounding data on the risks of the procedure:

Immediate complications are usually easily treatable, and also relatively rare — the AAP report states that problems like bleeding and infection occur in up to 1 in 100 circumcisions. But the frequency of later problems is less well understood. Some studies find few; others conclude that as many as one in four patients suffer some kind of complication after the surgery and subsequent wound healing. The possible late problems are many. The remaining foreskin tissue can adhere to the penis. The opening of the urethra may narrow, making urination painful and preventing the bladder from fully emptying, which in turn can lead to problems. … Other late complications include a second surgery to correct an incomplete circumcision, a rotated penis, recurrent phimosis, and concealment of the penis by scar tissue, a condition commonly known as buried penis. …

“The true incidence of complications after newborn circumcision is unknown,” the AAP’s recent report states. But complications are risks. “They’re saying, ‘The benefits outweigh the risks but we don’t know what the risks are,’” says Brian Earp, research fellow at Oxford University’s Uehiro Centre for Practical Ethics. “This is basically an unscientific document.”

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‘No scientific conclusion’

Wapner says that after reading through all the studies, she realized “that the debate doesn’t have a scientific conclusion. It is impossible to get to the bottom of this issue because there is no bottom.”

There are good reasons that is so, she adds:

Even the premise behind this debate — that the usefulness of circumcision can be determined by weighing the risks and benefits — is questionable. A drug for a deadly disease has a lot of leeway in terms of side-effects. Cancer patients are willing to endure chemotherapy if it means they get to live, for example. But when the person is healthy and too young to weigh the risks and benefits themselves, the maths changes. “Your tolerance for risk should go way down because it’s done without consent and it’s done without the presence of disease,” says Earp.

These uncertainties undermine the case for circumcision. They don’t completely destroy it though. Even after the criticisms are factored in, circumcision does bring some benefits, such as reducing the risk of urinary tract infections in young boys. What the uncertainities do is raise questions about whether those benefits justify the procedure. And this is where an evidence-based approach breaks down. Because the procedure results in the loss of something whose value cannot be quantified: the foreskin. If you view the foreskin as disposable, circumcision might be worth it. For those who see the act as the removal of a valuable body part, the reverse is likely true.

Foreskin status affects opinions

Yet if you were to ask any physician or medical researcher about this topic (as I have from time to time), you usually get a very strong and opinionated answer.

Why that is so is, perhaps, the most interesting research that Wapner discusses in her article:

More than the medical data, it’s these unquantifiable feelings about the foreskin that shape doctors’ thinking about circumcision, or at least that of male doctors. Because when it comes to medical opinions on circumcision, the foreskin status of the opiner matters. A 2010 survey in the Journal of Men’s Health found that close to 70 per cent of circumcised male physicians supported the procedure. An almost identical fraction of uncircumcised physicians were opposed. The AAP Task Force behind the 2012 statement was made up mainly of men, all of whom were circumcised and from the US, where newborn circumcision is the norm. “Seen from the outside, cultural bias reflecting the normality of nontherapeutic male circumcision in the United States seems obvious,” wrote a group of European physicians in response to the AAP.

It’s also likely that most of these critics were not circumcised. “We never deny that we are from a non-circumcising culture,” said Morten Frisch, lead author of the response and an epidemiologist who studies sexual health at Statens Serum Institut in Denmark. “While we claim that the US view is culturally biased, the opposing view from the AAP was that it’s us who are culturally biased, and to an extent they are right.”

A difficult task for parents

“These cultural divisions make it nearly impossible to sort through the medical literature,” says Wapner.

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Indeed, even health professionals find it difficult. One epidemiologist whose professional focus is sexual health told Wapner that he “stay[s] out of the area. I want to have a life, I don’t want people bombing the front door.” 

Of course, parents with a newborn son can’t turn their back on the topic. They must make a decision for or against having their child circumcised.

Wapner’s thoughtful article is a good place for parents to start working their way through both sides of the arguments. You can read the article on the Mosaic website.