It was with a sinking feeling that I heard the news this morning — the American Academy of Pediatrics has issued a new policy statement regarding circumcision of newborn males. I don’t normally greet news of revised policy statements by my professional organization with dismay. However, considering the utter brouhaha that ensued hereabouts when my co-blogger offered a tentative, measured, qualified moral justification for circumcision, it’s really a topic I’d rather not touch with a ten-foot clown pole.
However, mama didn’t raise no coward. So here we go.
First of all, it’s important to note what the policy does and does not actually say. What it does say is that the health benefits of male circumcision outweigh the risks of the procedure, and that it should be available to parents who choose it for their children and covered by insurance. It does not go so far as to recommend it routinely for all infants. Among the benefits listed are reduced risk of urinary tract infection (UTI) as infants, and decreased risk of sexually-transmitted infections (STIs) later in life. Viewed in aggregate, these benefits are seen to outweigh the low risk of complications when appropriately performed by trained medical personnel.
The full report is available here [PDF]. I have some qualms with it, but in general consider it to be a good document, and a useful piece of information to share with parents when they ask about circumcision before the delivery of male children.
Considering the maelstrom I might be stepping into with this, it’s hard to know where to begin. I will start with the benefit I find most compelling, perhaps because it is the one I have seen often enough myself. The evidence does seem to support a decreased risk of UTI in circumcised male infants, and for my own part I have seen far more UTIs in uncircumcised boys. Per the report:
By using these rates and the increased risks suggested from the literature, it is estimated that 7 to 14 of 1000 uncircumcised male infants will develop a UTI during the first year of life, compared with 1 to 2 infants among 1000 circumcised male infants.
While the absolute risk in either case is low, the benefit does appear significant enough to be worth considering. That being said, alone it is not enough for me to advise parents who ask that I think the procedure is worth doing.
The objection that seems to be raised with greatest frequency is that circumcision diminishes sexual function and satisfaction. The study seems to have taken that concern into account:
The literature review does not support the belief that male circumcision adversely affects penile sexual function or sensitivity, or sexual satisfaction, regardless of how these factors are defined.
It goes on to reference several studies that, if anything, seem to indicate greater sexual pleasure following circumcision than before. I am skeptical, however, that anti-circumcision partisans will consider any of this compelling. Anyhow, it says what it says and cites what it cites, and I’m going to leave it at that.
However, I have a major qualm with this report, pertaining to its finding of a risk reduction in HIV transmission rates following circumcision. While the report does reference several studies that have demonstrated a reduced risk of HIV transmission to heterosexual men who have been circumcised, unless I am reading the report wrong I see none that come from outside of Africa. Generalizing findings from a very specific population with particular risk factors to a totally different population is extremely problematic to me. Sexual habits and cultural norms are very different there, and there are at least some sexual practices that are common in Africa that may increase risk of HIV transmission and are essentially unknown in the United States. Given that no studies are referenced that come from the developed world, I cannot look at this report and consider the possible HIV risk-reduction compelling for my patient population.
Other STI risk reductions are similarly shaky. Much of their herpes data come from Africa, with the remainder too equivocal to carry much weight. There may be some risk reduction regarding STIs that are fleetingly rare in the US, but for the much for common illnesses gonorrhea and chlamydia there is no benefit. There appear to be better data regarding risk of transmitting human papillomavirus (HPV), the virus that causes genital warts and increases the risk of cervical cancer in women. Several of the cited studies do come from the United States and Western Europe, though I must admit I haven’t taken the time to review each in detail. It appears there may be some benefit in reducing HPV transmission risk, though to what degree this benefit may be obviated by widespread vaccination against HPV remains to be seen.
My take-away from all of this is that the report is a flawed but reasonable document. It gives me something to discuss with interested parents, and does present justification for the procedure to be offered and reimbursed by insurers. However, for my part the report does not contain sufficient evidence for me to recommend circumcision for parents who would be otherwise uninterested in having it for their children.
A note about comments: Before I hit “Publish,” I’d like to make a few things plain. After Rose wrote her piece about circumcision, it became very clear in the subsequent comments that people feel very passionately about this subject. Fine. However, it also became clear that our blog had become yet one more venue in an ongoing clash of online personae who had fought the same battles over and over and over again, and who knew each other well. If you have an opinion or insight to share, please feel free to do so. But if you’re only here to toss brickbats at an old adversary, why not spare us all? In any case, I expect a modicum of civility. Comments that do not meet my own subjective definition of same will be deleted, and I make no apologies for choosing to take an active role in keeping my comment section from devolving into a frothing mess.
Update: Andrew Sullivan has responded to the report in his usual even-keeled, cool-headed way:
The main advantage of permanently mutilating the infant penis is that studies claim to have shown that the subsequent scar tissue helps prevent HIV-infection from woman to man in heterosexual sex. This is a major issue in Africa, but is far less common in the US.
The Times also estimates that around 117 infant boys die in mutilation procedures in the US per year. So mercifully, the report is not as clear-cut as Rosenberg wants it to be. It doesn’t mandate routine circumcision as has happened in the past – instead placing it clearly as an elective procedure to be decided by the parents. That would still mean millions of human beings involuntarily mutilated in ways that dull their sexual sensitivity for a small gain in not getting HIV from a woman – proven only in Africa under radically different circumstances.
So far the comments have been almost entirely sane, probably because I express a tepidly anti-circumcision bent in the post above. Perhaps I will call down holy hell for quibbling with Sully’s usual bombast. But:
1) Boys who are circumcised do not develop collagenous scar tissue. They heal with regular skin.
2) I’ve already dealt with the HIV issue, but Sullivan completely elides all the other purported benefits of circumcision. He is not giving the full report due consideration.
3) If the report is to be believed (and he does nothing to call the underlying scientific validity into question), then there is no dulled sexual sensitivity following circumcision.