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

REUTERS/Rick Wilking
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.

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.

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.”

‘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.

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.

Comments (12)

  1. Submitted by Adam Miller on 03/03/2015 - 11:24 am.

    This article is deeply irresponsible

    The scientific content is in the first paragraph: “CDC… say[s] that the medical evidence suggests that circumcision confers more health benefits than risks.”

    But one writer disagrees, so we get an entire article premised on the assertion that no conclusion can be reached? How does that make any sense?

    • Submitted by Mark Lyndon on 03/03/2015 - 11:56 am.

      It’s not just one writer disagreeing though. This is what some other national medical organizations say:

      Canadian Paediatric Society
      “Recommendation: Circumcision of newborns should not be routinely performed.”
      “Circumcision is a ‘non-therapeutic’ procedure, which means it is not medically necessary.”
      “After reviewing the scientific evidence for and against circumcision, the CPS does not recommend routine circumcision for newborn boys. Many paediatricians no longer perform circumcisions.”

      Royal Australasian College of Physicians
      “After reviewing the currently available evidence, the RACP believes that the frequency of diseases modifiable by circumcision, the level of protection offered by circumcision and the complication rates of circumcision do not warrant routine infant circumcision in Australia and New Zealand.”
      (almost all the men responsible for this statement will be circumcised themselves, as the male circumcision rate in Australia in 1950 was about 90%. “Routine” circumcision is now *banned* in public hospitals in Australia.)

      British Medical Association
      “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.”

      The Royal Dutch Medical Association
      “The official viewpoint of KNMG and other related medical/scientific organisations is that non-therapeutic circumcision of male minors is a violation of children’s rights to autonomy and physical integrity.”

      “[30 September 2013] – At a meeting today in Oslo, the children’s ombudspersons from the five Nordic countries (Sweden, Norway, Finland, Denmark, and Iceland), and the children’s spokesperson from Greenland, in addition to representatives of associations of Nordic paediatricians and pediatric surgeons, have agreed to work with their respective national governments to achieve a ban on non-therapeutic circumcision of underage boys.”

      German Pediatric Association
      “Therefore it is not understandable that circumcision of boys should be allowed but that of girls prohibited worldwide. Male circumcision is basically comparable with FGM types Ia and Ib that the Schafi Islamic school of law supports”

      “The other claimed health benefits, including protection against HIV/AIDS, genital herpes, genital warts, and penile cancer, are questionable, weak, and likely to have little public health relevance in a Western context, and they do not represent compelling reasons for surgery before boys are old enough to decide for themselves.”
      (Written in direct response to the AAP’s position statement on male circumcision, and signed by 38 senior physicians, about half of them presidents or chairs of national paediatric or urological organisations).

      • Submitted by Adam Miller on 03/03/2015 - 02:19 pm.

        There is way too much cultural baggage around this issue

        To start looking up foreign health authority document and reach any conclusions. I don’t know what the dynamics are in any of those countries. Why should I trust them over the CDC?

    • Submitted by Roland Day on 03/04/2015 - 12:12 pm.

      Comments on CDC statement

      The CDC statement has received more than 3,000 comments. Nearly 100percent of the comments were highly critical of the CDC’s paper.

      The problem seems to be that the authors of the CDC paper were circumcised doctors. Men who were circumcised as infants have involuntarily lost a body part, the possession of which is essential to their good emotional health.

      Circumcised men have an acute need to assert that they have lost nothing due to surgical amputation of an essential part of their penis. They do all sorts of mental gymnastics to “prove” this to themselves.

      When such circumcised men become medical doctors, they write tend write articles in praise of circumcision. Other non-circumcised, foreskinned doctors know their claims are absurd and write other articles in opposition. The medical literature regarding male circumcision is a swamp of conflicting claims about male circumcision of which little sense can be made by the casual observer.

      Moreover, certain medical specialities, such as pediatrics and obstetrics made huge amount of money from doing circumcisions, so their trade associations (such as AAP and ACOG) publish statements to promote and defend the practice. These statements are riddled with conflict of interest and cannot be believed.

      The reader needs to know the culture of origin and the circumcision status of the author of any medical article about circumcision in order to get some sense about the value of the article.

  2. Submitted by Adam Cornish on 03/03/2015 - 12:28 pm.

    the US versus the world

    There are only a handful of countries who routinely practice non-religious circumcision… the US, South Korea, the Philippines.
    The difference between the US and the others, is that the others don’t pretend it is for medical reasons. America does pretend.
    The European doctors tell Americans all the time that they are biased, and that the evidence does not support their conclusion. The Americans don’t bother to adjust their opinion. Another group (first the AAP, and then the CDC) released their opinion that the benefits outweigh the risks, based on flimsy evidence.
    There are many countries who used to practice routine circumcision, but now no longer do. They include the UK, Canada, Australia, and New Zealand.
    If there was a medical benefit, it hasn’t shown up in their statistics. There has been no spike in penile diseases. Canada eliminated circumcision, by ceasing to pay for it. This has been done in about 16 US states. It works. Circumcision rates have plummeted, where it is no longer paid for.
    I take issue with the WHO saying that “about 75 percent of males aged 15 and older in the U.S. are circumcised for non-religious reasons”. This can’t possibly be true. The rate hasn’t been published in years, and when it was, it was down to between 58.3% and 32.5%, depending on which person you believe in the CDC.
    There is no other routine surgery which removes healthy tissue.
    If circumcision protected against HIV, why have nearly a million mostly circumcised American men died of AIDS?
    If we were discussing removing half the skin from a female’s genitals, there would be an outcry. Why does conditioning make this appear like it is not problematic for males?

  3. Submitted by Andrew Bush on 03/03/2015 - 02:02 pm.

    Isn’t it peculiar that a woman can keep herself clean, and disease free, with a washcloth, but a man requires surgery.

  4. Submitted by Hans Jørgen Lassen on 03/03/2015 - 04:47 pm.

    What’s the hurry?

    Susan Perry sees no way around the problem. Parents “must make a decision for or against having their child circumcised”.

    Nope, parents are not forced to make a decision. The decision can very well be postponed and it is never too late. It can wait till the boy has grown to be a man – and is able to make his own decision on this matter.

    It does not work the other way around, however. Once the foreskin has been destroyed, the decision cannot be undone. Then it is too late.

    So leave the decision to the boys/the men. There is no hurry.

    Their penis, their choice.

  5. Submitted by Michael Glass on 03/03/2015 - 07:14 pm.

    Tough restrictions are needed.

    There is great gulf between those who regard circumcision as an abuse of human rights and those who regard it as a religious obligation. However, there are things that can be done to reduce the harm done by unqualified or incompetent operators, and to discourage dangerous traditional practices.

    The most obvious change is to prohibit unqualified people from circumcising others. Unqualified people who attempt to circumcise others should be prosecuted for assault. If a man is circumcised against his will, it should be treated as a sexual assault.

    The second change is that no one should be circumcised without an independent doctor certifying in writing that there are no contraindications such as prematurity or a bleeding disorder. Those who circumcise anyone without this certificate should be prosecuted for malpractice.

    The third change is to ensure that no child may be circumcised without the written consent of both parents. If the parents do not agree, then it is up to the owner of the foreskin to decide what to do with it when he reaches adulthood.

    The fourth change is to ensure that qualified but incompetent operators are weeded out fast. If a circumciser is responsible for one botched job, he or she should have to pay for any remedial actions and either be retrained or be banned from performing any more circumcisions. If the operator is responsible for more than two botched circumcisions, he or she should be automatically banned for life from performing circumcisions.

    Dangerous traditional practices, such as metzitzah b ‘peh or tribal circumcisions must be discouraged by public education and warnings to parents in baby books.

    Around the world, men have been forcibly stripped to determine their circumcision status and/or have been forcibly circumcised. Such strip searches are indecent acts, and forced circumcisions must be regarded as sexual assaults. Perpetrators should be treated as sex offenders and prosecuted accordingly.

    These six provisions will not stop circumcisions for medical, social or religious reasons. However, they might help to reduce the abuses.

    • Submitted by Paul Mason on 03/04/2015 - 05:16 am.

      Religion vs Human Rights

      There is NO gulf between the human rights of a baby and the religious obligations of a parent. The parent’s human rights to freedom of belief do not extend to freedom to do whatever they believe is obligated to another person. Think 9/11. No parent has the right to cut bits off their baby. Every baby has the right to decide whether they are going to adopt religion X or religion Y. Simple. Wait till the boy is old enough to decide for himself.

  6. Submitted by Roland Day on 03/04/2015 - 12:24 pm.

    Circumcision in Canada

    Minnesota is bordered on the north by the nation of Canada.

    It might be useful to compare the situation of male circumcision in Canada to situation of male circumcision of the United States.

    The practice of medically-unnecessary, non-therapeutic child male circumcision has been declining for decades in Canada. Although many older Canadian males were circumcised decades ago, most boys are not circumcised.

    The French-speaking people generally do not favor circumcision.

    Male circumcision is offensive to the culture of Inuit, First Nations, and Métis populations.

    The medically-unnecessary circumcision of male children is an apparent violations of the child’s legal rights under the Charter of Rights and Freedoms.

    The Canadian Paediatric Society (CPS) has favored genital integrity (non-circumcision) for children since 1975. The CPS says circumcision should not be routinely performed (meaning that circumcision should only be performed when needed to treat existing disease).

    The thirteen health insurance plans stopped paying for non-therapeutic circumcision a decade or more ago.

    When boys in Canada are circumcised, it is usually because the father is circumcised, not because of medical need. The number of circumcised fathers is gradually declining, so the incidence of circumcision of boys is also declining.

    A survey of mothers carried out nearly a decade ago found that about 31 percent of boys were circumcised (and 69 percent were not circumcised).

    Since the practice is in a long-term decline, it is likely that the rate of circumcision is even lower today. Foreskinned boys are in the majority in every province and territory.

    The rate varied from province to province but in all provinces and territories, non-circumcised foreskinned boys were in the majority. Newfoundland boys are almost never circumcised.

    http://www.cps.ca/en/documents/position/circumcision

    http://chhrp.org

    http://www.courtchallenge.com/refs/yr99p-e.html

  7. Submitted by Ron Low on 03/04/2015 - 03:04 pm.

    The science is VERY clear – HIS body, HIS decision

    The main point the AAP mentions that would justify rushing to cut an infant instead of letting him decide as an informed adult is that circumcion is trickier or more expensive as patients get older. This is NONSENSE and they know, as they fail to cite any evidence for this assertion.

    The SAME cheap risky haphazard method we tolerate for infants (PlastiBell) is now available cheaper for adults (PrepEx), but it’s EASIER to do to an adult whose skin is no longer fused to the glans.

    The CDC should never have relied on the biased AAP (a trade association for the ones doing the cutting) in their draft policy.

  8. Submitted by Jay Davis on 01/28/2016 - 11:37 am.

    Too late as this subject runs hot and cold..

    But, its worth noting if you know anything about medical studies, then you know its called very soft science that can be manipulated.
    Indeed, many drugs are said effective, but usually 50 percent could be sugar pills and give same effects.

    If in fact the pro circumcision fanatics who secured grants to do HIV/AIDs studies had done proper science and had objectivity, neither of which they had, the results would have been much different.
    The hidden truth, Obama’s CDC chief is Jewish, the majority of AAP panel were circumcised men, three in fact Jews and all volunteered for their pro circumcision interpretation of so called trustworthy data. But, even if it were some what true, would not condoms and safe sex be a better choice.

    No, of course not, because they all had a hidden pro circumcision agenda in their pants. 80 percent of circumcised men from infancy favor circumcision and actually have no experience with a normal penis. Also recognize doctors only see men who have issues not the billions who do not. How objective could such a group be?

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