Once more unto the breach: the American Academy of Pediatrics and circumcision [Updated]

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.

Russell Saunders

Russell Saunders is the ridiculously flimsy pseudonym of a pediatrician in New England. He has a husband, three sons, daughter, cat and dog, though not in that order. He enjoys reading, running and cooking. He can be contacted at blindeddoc using his Gmail account. Twitter types can follow him @russellsaunder1.


  1. I predict this comment thread dies around the 350 mark. People LOVE to debate circumcision.

  2. If I practively remove my appendix I will have a much less chance of getting appendicictis later in life.

    If my wife removes her breasts, she will have much less of a chance of having breast cancer later in life.

    If my wife removes her uterus, she reduces her chance of having uterine cancer.

    If I remove my brain, I will believe I should mutililate penises as a medical recommended medical practices in the United States. Where the heck do we live anyway?

    • Your first three premises seem sound enough to me. The risk/benefit ratio may be unspecified, but at least the intervention and risk reductions stipulated are consistent and correct.

      Your last point is nonsense, but probably serves as an amuse bouche for the smorgasbord of lunacy I’ve just ordered up.

  3. I’ve written elsewhere, briefly, about being told once that I’m the type of person who repeatedly touches a hot stove, just to see if it’s hot, even when I ought to be certain that it already is. Apparently you are too. Good luck.

    • Well, it seemed craven to learn of this report and say nothing.

      Is it naive to note the spike in site traffic already but only one crazy comment?

    • When I’m at a restaurant and the server warns me, “be careful, the plate is hot,” I almost always try touching the plate just to make sure. Of course, I do so more carefully than I would if the server hadn’t warned me at all.

  4. MaleStrom:

    All the laws of Moses and all the knives of the Mohels cannot remove the foreskin from our homes, from our schools, our churches and our places of recreation and amusement.

  5. I suspect this debate will continue up until the day in which we can completely rebuild the body, to user specs, via nano-technology. In which case you can grow and lose your foreskin via a simple macro and a few day’s wait, and people can work out firsthand which works better for them.

    And then they can argue THAT on the internet, since the multiation/not mutilation debate will be resolved by simply bowing down to your tiny robot overlords and having them grow the sucker back.

    Although if I had THAT tech, I think I’d check out life on the female side (after solving a few health issues of my own). I’m far more curious as to what life’s like as the opposite gender than if my parents had made a different choice when I was an infant. But hey, different strokes, right?

    • Ever read John Varley’s Nine Worlds stories? If not, I’d especially recommend the collection The Persistence of Vision.

      • More of a Culture fan. 🙂 I’d immigrate in a heartbeat — but they’d probably not take me, horrible barbarian that I am. 🙂

        • I’ve (very belatedly) started to read Banks. The Wasp Factory was gripping, if horrifying, but I found the ending disappointing.

          • Wasp Factory’s the only thing I have read of his too. Which Culture book should I start with? Just start at the beginning?

          • Player of Games. It’s the most accessible, you don’t need to know anything else, and it’s fairly short and straightforward.

            His sci-fi is a bit different than his fiction, although I like both.

            After Player of Games — Consider Phlebas then Use of Weapons.

            There’s a trio — Excession, Inversion, and Look to Windward that should be read next. Not necessarily in that order (though I prefer it and that’s the published version). Those three form a view of the Culture from ‘outside’, so to speak — with Inversion never actually mentioning the Culture — Excession deals with something as ‘above’ the Culture as they would be above us, Inversions deals with a primative society the Culture is meddling in, and Look to Windward shows Culture contemporary society.

          • Go with use of weapons for his Sci Fi, and Complicity for his mainstream fiction.

          • The first three books he published, Consider Phlebas, Use of Weapons, and Player of Games, are all pretty much independent of each other. Use of Weapons is the best Culture novel, in my opinion. But Player of Games is also good and considerably more accessible.

            Many people who like the rest of the series dislike Consider Phlebas, so I wouldn’t recommend starting there, even though it was the first published.

            After the first three, publication order is as good a choice as any; they aren’t strongly ordered, but there are occasional references to previous books.

  6. I can’t fully explain it, but I kind of met this report with suspicion. Like, it had more to do with trying to keep insurance/Medicaid from dropping it than it did with having a change of heart (to the extent that it was such) on the subject of circs. That you sign off on it (more or less) gives me a more positive view of it, though.

    • I sign off on it only insofar as it seems to present a plausible argument for a medical benefit. It doesn’t really contain anything to change my answer to the question as a whole, however.

        • Since it’s a question of risk reduction, I would imagine that kind of evidence would be nigh unto impossible to gather. You’d essentially be trying to prove a negative, eg. baby X wouldn’t have gotten that UTI had he been circumcised.

  7. This is one of those issues where we now have some data and sensible people can make these decisions for themselves and their children. The data doesn’t seem to point one way or the other. Won’t stop some people from screeching and flinging poop like so many terrified vervet monkeys when a leopard comes by.

    Meanwhile, gonorrhea has become resistant to pretty much every known antibiotic. HIV continues its dreadful march across the landscapes of the world. Would that the same folks who raise such a fuss about circumcision were as exercised about STDs.

    • Nothing frustrates the committed more than data that is ambiguous.

      “This data doesn’t support our position!”

      “But it must, our position is correct!”

      “Well, if we ignore that data (and hey, that guy is probably in the pocket of Big Pharma), and we ignore this data (and hey, that gal is trying to retroactively justify her decision to mutilate her *own children*) and… well, now, you’re right! The data *does* support our position!”

    • Also, malaria continues to kill people and countermeasures, despite being relatively easy and inexpensive, and are insufficiently deployed. And speaking of drug resistance, take a look at tuberculosis and staph aureus.

      Would that people people who raise such a fuss about STDs get as exercised about non-sexually transmitted infectious diseases. Because, obviously, words on the internet are a precious resource that should only be allocated to the most pressing public health risks.

  8. You came to much of the same conclusions regarding the HIV studies in Africa I did – I find it difficult to extrapolate a benefit for snipping when the differences in the ‘cultural’ and ‘sexual’ norm have such an influence.

    Personally, I never cared if there was a ‘hoodie’ or not. It was *ahem* performance that mattered to me.

    Husband 1.0 was snipped. Husband 2.0 wasn’t. Husband 2.0 also came with an upgrade operating system and a better set of hardware, but that’s beside the point.

    Where I am now, it’s not the norm to be cut, although that didn’t really factor into our decision. Obviously, Hubby 2.0 was against it (since he enjoys having his foreskin) and I could understand his reluctance to consider altering our son.

    For me, it came down to a simple decision – if I were a male, would I want to make that decision for myself? YES! So, our son isn’t snipped – and if he decides when he’s a teenager that he doesn’t want a turtleneck, we can get it fixed then. If I do it now, I’ve taken that choice away from him.

  9. Even though I am largely secular, I still maintain a strong ethnic and cultural Jewish identity. And I maintain that Judaism is equally an ethnicity and culture as much as a religion despite the protests of my hardcore Dawkinite friends. All of whom are not Jewish and don’t seem very interested in learning about Jewish history especially in terms of anti-Semitism.

    I have a Jewish body and am proud of it. No tattoos, no piercings, and am circumcised. My lack of a foreskin has done nothing to me psychologically or reduced my capacity for sexual pleasure.

    I have a hard time buying the moans of people who claim that being circumcised before they were a month old was a highly traumatic event.

    I also think that there is a civil liberty towards non-assimilation. I have a lot of secular and atheist friends who grew up practicing or nominally Christian. Even though they are not religious now, they still love Christimas because “secular Christmas” is awesome. It seems like every year, I have the same circular debate about why I don’t want to celebrate Christmas* (putting up a tree and lights) because it is not my holiday. I really don’t understand why it is so hard for these people to comprehend my feelings that putting up a Christmas tree would go against my background and identity. These are smart and educated people.

    Last summer, there was an attempt to place a ballot referendum banning circumcision in San Francisco city limits. It took absolutely zero time for the proponents to slip into gross anti-Semitic attacks by publishing a comic called Foreskin man featuring a blonde hair blue eyed hero and grubby, ugly, and dirty Hasiddic rabbis as the bad guys. Luckily, polls showed that an overwhelming majority of San Franciscans were against the ban because ti violated the religious liberty of Jews and Muslims. A judge eventually blocked the proposal because it was not a proper municipal issue but an issue for state law.

    This is all to say that if I have sons, they will probably be circumcised.

    • This is very much a side point, and I don’t tend to go into much detail about my own religious beliefs and affiliations, but I identify as Jewish along ethnic and cultural lines, even though it is not my religion.

      • I suppose it is my religion as well even though I am very Reform and usually just go to services on High Holidays. I also celebrate Passover. Though if I have kids, I intend for them to be bar or bat mitzvahed.

        I am certainly not kosher and never have been. Perhaps people will see my stance on this is strange. I know many Jewish people in their 20s and 30s with tattoos who practice and identify as Jewish but this has always struck me as dishonest. They often justify their tattoos by saying it is a “reclaiming” from the Nazis. My question is “How can you reclaim something that never belonged to you in the first place?”

        I think I would find it more intellectually honest and acceptable if these fellow Jews said that they no longer found that prohibition against tattoos to be relevant.

    • I was engaged to marry a nice Jewish boy from Long Island….

      Er… excuse me, “Lawn Guyland”

      But we had discussions about kids/faith and whatnot (as smart couples do before agreeing to tie the knot). If I had to label myself with a ‘starting faith’ (kind of like a starting class in D&D) …well, I was raised in the Catholic church, but I got better.

      Our holidays were easy – we celebrated both. (I’ll never like the taste of Manischewitz wine, ever)

      But despite no longer identifying myself as religious, I still celebrate Christmas (or Yuletide, if you want), etc. I do it because I like the ‘Holiday Spirit’ – where people try to be nicer to each other, and smile more often (unless you’re buying Christmas gifts, then it’s every man (or woman) for themselves). For me, it’s more about the connection with my friends and family than any religious meaning for me. To see people I haven’t seen or spoken to in years, etc.

      If your friends nag at you about putting up a tree. Get an evergreen branch and call it your Chanukah Bush. That’s what my ex in Lawn Guyland did.

      • Hannuakah has a Menorah and other traditions of its own.

        It does not need to borrow from Christianity for the sake of conformity.

          • Hey, borrowing from other traditions is what made those traditions Christian in the first place. Most of “Christmas” is imported pagan rituals.

            Steal ’em for Judaism, I say. Everybody should steal ritualistic silliness from each other.

    • I forgot about my asterisk.

      I do enjoy Christmas Day but largely because as a non-celebrant, it is a completely free and quiet day. Possibly one of the few days during the year that I have absolutely no responsibilities. The other being New Year’s Day.

      • It’s not like there are no Jewish traditions for Christmas day. Go out for Chinese food and then see a movie.

        • This Christmas I went to see A Dangerous Method.

          There must be extra Jew points for seeing a movie about Freud (and directed by David Cronenberg) on Christmas Day.

  10. That’s a good point about the Africa studies. They’re the part of this post that interests me the most, because I wrote a paper on the different HIV prevention and treatment methods in the developing world (particularly Africa) last year and was very surprised to find that basically the only prevention method that had a clear statistically significant success rate in reducing transmission of HIV – besides use of antiretrovirals to reduce viral load – was male circumcision. I was also amazed that a significant number of adult men will actually choose to undergo it for this reason, even if they had no religious reasons, since my understanding was that adult circumcision is debilitatingly painful. I suppose anaesthetics deal with that these days.

  11. Comments along the line of “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” feel dismissive of a larger argument for control of bodily integrity. The implication that if there’s no statistical difference, there’s little benefit to allowing people to make their own decisions about their bodies. My intuition is that most people would be hostile to a parent choosing the pierce the ears of their infant.

    • My intuition is that most people would be hostile to a parent choosing the pierce the ears of their infant.

      You would, I guess, be appalled at how very many of my infant patients have pierced ears.

      • MIL 1.0 nagged at me to pierce my daughter’s ears when she was 6 months old. I refused.

        When my daughter was 12 she said she wanted to get them pierced, and we went and did it.

        Now she has 2 piercings in both earlobes, an additional one in the upper curve, one in her nose and one in her navel and a tattoo on her foot. She’s also 21.

        I gave her some very simple rules when she was 12. She could get her ears pierced. When she was 16 she could get her navel done. When she was 18 + she could pierce anything else she wanted, and if it was below the neck, I didn’t want to know about it.

        Regarding her tattoo – I told her that she could draw up a design when she turned 18, and she could give it to me to hold on to. On her 19th birthday, if she still liked the design, I’d pay to get it done. If she didn’t, then she had to come up with a new one, and we’d repeat the wait.

        She could appreciate the thought behind the rules, and had no issue with them.

        • I’d draw a distinction between a parent granting permission for something that a child wants versus making a decision for the child without getting input from the child. I would guess you fall into the first category; your daughter wanted her ears pierced, and you (once you thought she was ready to make the decision) gave permission. Obviously, that’s not the case for infants.

          Although, apparently, not everyone shares my scruples about infant ear piercings, either.

      • A while ago, there was an op-ed in the NY Times about a pediatrician who relocated to Miami from somewhere in the Northeast. Probably NY. She was writing about how many Hispanic parents wanted her to pierce the ears of their newborn daughters.

        She refused for a while but eventually relented and justified it by stating that she would rather do it and now the piercing will be sterile and clean over having someone less-reputable do this.

        • Harm reduction is a rationale I can understand, but that’s not usually the rationale given in terms of doctors doing male circumcision (in contrast to “ritual nick” female circumcision, which the American Academy of Pediatrics has, if I recall correctly, suggested be made available in order to reduce more harmful versions of female genital mutilation).

  12. I’m not a medical professional, so I don’t feel equipped to evaluate the medical evidence.

    But for myself, the issue has always come down to bodily integrity, and a rather horrific anecdotal case that I became personally familiar with. Barring medical necessity, I would view involuntary circumcision as a violation of my son’s bodily integrity. I’m perplexed by the often-expressed desire to have the son’s penis resemble the father’s/fathers’. And while I recognize that the statistical odds of a horrific accident being repeated in regards to a prospective son, I will not put him through even that minute risk for something that I perceive as intrinsically unnecessary.

    • I consider that a perfectly reasonable perspective, Nat. Frankly, there is nothing in this report that I find sufficiently compelling such that, were you to solicit my professional opinion, I would try to change your mind.

    • I suspect everyone would agree with you on that.

      Isn’t that your job as parent to an infant? To, among other things, make such decisions for him or her?

      I’m not aware of any vast pro-circumcision lobby (there might be, it’s not a topic I’ve ever had a burning interest in) — it seems mostly cultural, the good/bad seems to be a wash medically so doctors just shrug and say “Whatever floats your boat” and since it’s done as an infant, the parents make the call.

      I realize it used to be pretty much the routine — now days, isn’t it basically an option parents of boys are offered?

      I was in my mid-twenties before I realized some people got very, very, very upset about the whole affair.

        • I’m sadly much older than mid-twenties. 🙂 I only dabble around the edges of these conversations, more interested in the meta aspects — why people are upset, and how they feel, and how they communicate, and who tends to think what — than the actual circumcision choice.

          We, as a species, do a lot of weird things that seem normal to us. Male circumcision seems a relatively harmless variant of that, and on the decline as it is.

          As I said, I’m waiting for nano-technology. 🙂 I’ll start my body mods when I can control them on the molecular level. And I suspect some people will get very upset by that. (My wife, for starters! She’s very against me tinkering with me own biology. Thankfully, the argument is entirely theoretical. For now. 🙂 )

      • some people got very, very, very upset about the whole affair.

        Especially Rush fans.

      • People opposed to male circumcision can get very upset about the fact that it’s treated as not a big issue, just an issue of taste for the parents. I don’t think anyone was surprised that people got very, very upset about the AAP’s statement about the ritual nick in females, even though the AAP endorsed it only as a harm reduction measure (in contrast to this statement) and even though it’s still a case of parents making a decision for an infant with no showing of harm either way.

  13. If I practively remove my appendix I will have a much less chance of getting appendicictis later in life.

    If my wife removes her breasts, she will have much less of a chance of having breast cancer later in life.

    If my wife removes her uterus, she reduces her chance of having uterine cancer.

    However all I need to do is remove some skin from my penis and I reduce my chance of getting penile cancer. Isn’t that grand? No loss of the appendage but I still get protection.(Particularly since I’d hate to risk needing to have my penis removed by getting penile cancer. I know it is unlikely anyway but that would be a rather devastating short straw. I’d feel less of a man without it.) Of course if it is done as a young infant then I also get protection against UTIs and there are all those other benefits but I won’t go into them since you are skeptical.

    “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.”

    To the contrary. HPV has been a hot topic of research. Circumcision confers better long term protection than Gardisil at a much lower cost if taken care of in infancy.

    • The risk of penile cancer is incredibly low. As the report itself points out, the cancer risk is essentially limited to boys with phimosis, and the circumcision benefit comes from alleviating phimosis. For non-phimotic boys, the cancer-prevention benefit is basically nil.

      I have conceded the UTI prevention benefit. Whether it is sufficient to recommend the procedure is a different story.

      Regarding your last point, Gardasil has only been recommended for administration to boys in the past few years. How is it possible to have reliable comparative data when the cohort that has received the vaccine is still relatively young and small?

  14. At least a day and a half of the post being up, and fewer than 60 comments so far, nearly all of them from LoOG regulars, and an even-keeled, even interesting discussion.

    I feel robbed. Where’s the CrayZee?

      • There was a post about the same thing on Volokh. Maybe it drew all the crazies.

        Last I checked, there was a comment suggesting that the health benefit and Obamacare allowed the government to force people to circumcise their children.

        • It’s strange how much of the crazy in politics could be removed if you told people: “Any explanation involving the opposite party having, being led by, or influenced by actual mustache-twirling villians must be discoutned”.

          Greed, fine. Idealogy, fine. Stupidity, fine. All the sins and virtues of mankind, fine.

          But outright starting with “villian tying helpless girls to railway tracks”? No.

          Obama (or Bush, or Cheney, or Clinton, or Romney) might be wrong. They might be mistaken. They might lack appropriate understanding of the issue, or not give a crap about things you consider important. They can be greedy, they can be venal, they can be ordinary fallible humans, they can even have hidden agendas.

          But they are not comic book villians.

          • Very true. Except for Cheney. He’s Mr. Potter from “It’s a Wonderful Life”.

  15. Has Sully ever written about whether Trig Palin is circumcised?

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