Quinnipiac University College of Arts and Sciences

Neonatal Circumcision Debate

In Faculty, Research on January 31, 2013 at 4:22 pm

blog_neonatal

By Lauren Sardi, Assistant Professor of Sociology

Male circumcision (MC) is perhaps the most commonly performed medical procedure in the United States. Although rates of MC are declining, it is estimated that approximately one million infant boys are circumcised each year. Other than Israel, who circumcises their boys on the eighth day of their life for religious purposes, the United States has the highest rate of MC for non-religious purposes. (Please note that I do not study the religious reasons or implications of MC and view that as an entirely distinct and separate topic.) Considering the extremely high rates of non-religious MC in the United States, I decided to investigate the ways in which MC is practiced and maintained in hospital settings despite the fact medical professionals label it as a cosmetic procedure only.

Nearly six months ago, the American Academy of Pediatrics’ (AAP) Taskforce on Circumcision released a long-awaited revision to their previously neutral stance on male neonatal circumcision. With this new policy statement, the AAP has shifted their 1999 statement in which “the risks do not outweigh the benefits” to state currently that “…evaluation of current evidence indicates that the health benefits of newborn male circumcision outweigh the risks and that the procedure’s benefits justify access to this procedure for families who choose it.” (For the full report, please visit http://pediatrics.aappublications.org/content/early/2012/08/22/peds.2012-1989).

While the AAP contends that the statement is not “pro-circumcision,” many of its members state that the purpose of the change in language is to reverse legislation in a number of states in which MC is no longer covered by Medicaid. For example, the AAP Taskforce noted that “…although health benefits are not great enough to recommend routine circumcision for all male newborns, the benefits of circumcision are sufficient to justify access to this procedure for families choosing it and to warrant third-party payment for circumcision of male newborns [italics added for emphasis].”

Thus, the Taskforce on Circumcision hopes that all parents will have the ability to choose for themselves whether or not to have their boys circumcised, regardless of whether or not they can afford to pay for the procedure, which runs, on average, about $120 out-of-pocket if not covered by insurance in Connecticut. The logic behind this shift is also the result of “systematic evaluation of English-language peer-reviewed literature from 1995 through 2010 [that] indicates the preventative health benefits of elective circumcision of male newborns…” outweighs the risks of the procedure. The AAP Taskforce on Circumcision lists a number of benefits, including significant reductions in the risk of: 1) urinary tract infection in the first year of life; and 2) heterosexual acquisition of HIV/AIDS, other sexually transmitted infections, and diseases such as penile cancer. The Taskforce also notes that the procedure is “well tolerated” when using sterile conditions and “appropriate pain management.”

Perhaps unsurprisingly, this revised statement was not welcomed by a number of organizations which self-identify as “intactivist,” or who are against prophylactic and routine circumcision of male infants. (The word “intactivist” combines the words “intact,” or uncircumcised, with “activist.”) As someone who is studying a number of the groups who claim an intactivist social identity, I noted a number of professional responses to the revised AAP statement. Organizations including the National Organization of Circumcision Information Resource Centers (NOCIRC), Intact America, Doctors Opposing Circumcision, The Whole Network, and the Canadian Children’s Rights Group have all condemned the statement for a number of reasons, which are discussed below:

1) The AAP Taskforce on Circumcision does not mention any of the benefits of having foreskin, which is an important part of male anatomy and has a number of protective and sexual functions. The Taskforce also does not address the studies that demonstrate a positive correlation between circumcision status and rates of erectile dysfunction.

2) The Taskforce notes that “parents ultimately should decide whether circumcision is in the best interests of their male child.” However, proxy consent, which occurs when a parent or legally designated person makes medical decisions on behalf of someone who is not able to give consent on their own, does not apply to cosmetic procedures such as circumcision. Thus, intactivists argue that parents do not have the right to remove healthy tissue from a child who cannot make such decisions on his own and is a violation of the child’s basic human right to bodily integrity. It is important to note, as I’ve argued elsewhere (see references below) that there are a number of ways in which people define human rights. Intactivists conceptualize such rights as belonging to the individual, whereas some religious groups, for example, think of those rights as belonging to the group.

3) HIV/AIDS, other sexually transmitted infections, and penile cancer prevention is not a sufficient reason for circumcising an infant who is not sexually active. Condoms are more effective at preventing the spread of HIV/AIDS and other STIs, and furthermore, the AAP still recommends condoms be used during all sexual activity, even if individuals are circumcised. Circumcision studies performed in sub-Saharan Africa demonstrated that although circumcision slightly lowered HIV transmission rates from women to men, circumcised men were actually more likely to spread HIV to their female partners. Disease prevention through circumcision also doesn’t hold up through simple measures of external validity; for example, the United States has one of the highest rates of circumcision in the world as well as one of the highest rates of HIV/AIDS. Europe, which has some of the lowest rates of male circumcision, has some of the lowest rates of HIV/AIDS and other STIs. Penile cancer among all countries is extremely rare, and some researchers suggest that it is actually linked to handling/smoking cigarettes rather than circumcision status. (For a greater discussion of the above points, please see http://goodmenproject.com/ethics-values/the-aap-report-on-circumcision-bad-science-bad-ethics-bad-medicine/).

To summarize, there is actually no conclusive evidence that male neonatal circumcision offers any of the benefits the AAP Taskforce suggests. The majority of people who are in positions of authority to make statements regarding the bodies of our baby boys also do not have the experience of having (male) foreskin or know its proper functions. Furthermore, studies suggest that uncircumcised infant males have the same rates of UTI transmission as do their female counterparts, and yet, girls are protected from circumcision by a federal law enacted in 1996 which bans any type of female genital cutting (FGC) in the United States. Thus, a medical professional who removes the foreskin of a boy need only have signed consent from his parents; one who removes foreskin from a girl will face fines and prison time. Also, in my analysis of the same studies the AAP Taskforce cites, there is simply no evidence at all to suggest that circumcision provides the same or better protection against infection and/or disease than do condoms. While a new study suggests that a decline in male circumcision rates would (hypothetically, not actually) cost our country approximately four billion dollars in disease treatment, these numbers do not empirically hold up when compared to other countries or when compared historically within our own country. (See coverage of this study as discussed on ABCNews here: http://abcnews.go.com/blogs/health/2012/08/21/cutting-out-circumcision-could-cost-billions-study/)

Finally, in my field research in hospital settings of both the informed consent process and circumcisions, along with in-depth interviews of dozens of medical professionals who work in pediatrics, obstetrics, and in labor and delivery departments, it is impossible to ensure that babies do not feel pain during the procedure. Medical professionals have admitted repeatedly that anesthesia is not always used, and if utilized (in the form of a topical numbing cream or a penile nerve block—a painful injection into the penile nerve) doctors often do not wait long enough for the block to take effect. As a result, babies can suffer from shock or even have heart attacks. If the crushing/clamping mechanism is not utilized properly, babies can also die of blood loss or sepsis. While we as parents want to make sure we are making the most informed decisions regarding our children’s health, it is important to deconstruct and question some of the claims of those medical organizations who should have all of our best interests in mind.

For further reading:

Boyle, Gregory J., and George Hill. 2011. “Sub-Saharan African Randomised Clinical Trials into Male Circumcision and HIV Transmission: Methodological, Ethical and Legal Concerns.” Journal of Law and Medicine 19(2): 316-334. Available: http://xa.yimg.com/kq/groups/23477339/1441224426/name/JLM_boyle_hill.pdf

Green, Lawrence W., John W. Travis, Ryan G. McAllister, Kent W. Peterson, Astrik N. Vardanyan, and Amber Craig. 2010. “Male Circumcision and HIV Prevention Insufficient Evidence and Neglected External Validity.” American Journal of Preventative Medicine 39(5): 479-482.

Sardi, Lauren M. 2011. “The Male Neonatal Circumcision Debate: Social Movements, Sexual Citizenship, and Human Rights.” Societies Without Borders 6(3): 304-329. Available: http://societieswithoutborders.files.wordpress.com/2011/12/ross2011final.pdf

  1. Nice job Lauren. This is going to be a useful piece for teaching purposes, as well as hopefully provoke interesting discussion.

  2. I think there are two major missing pieces in this otherwise comprehensive review. The first is an in depth view of informed consent. Parents regularly give proxy consent for indicated, life-saving procedures for their children. However, male infant circumcision is not indicated; the tissue being removed is healthy and normal. As such, it is an elective surgery. In most, if not all, states parents cannot give proxy consent, no matter how well informed, for elective surgery. We would be appalled if parents requested breast reduction or augmentation surgery on a newborn girl. In fact it is illegal to perform the most minor non-indicated procedure upon a girl’s genitals; even a pinprick. Male circumcision is certainly more severe than that. This leaves us with an inescapable conclusion, non-indicated genital surgery upon any minor must be delayed until such time that they both request it, and are competent to give informed consent.

    The second point concerns solicitation. Hospitals, nurses, and doctors are soliciting an unnecessary surgery when the initiate a conversation about circumcision, inquire about it, handout circumcision information, or ask the parents to sign a consent form. Repeated requests, which are common, could be considered coercion. Soliciting an unnecessary surgery is illegal in most states, and unethical everywhere in the world.

    • Fair critique. I have written about those exact issues elsewhere, and am happy to send you my dissertation. My concern, for the purposes of this entry, was to provide an overview of such issues, and I appreciate your additions above. Thank you. Please also note that original typos have since been fixed.

  3. Wonderful job summarizing the main problems with the AAP statement. Curious about the “Canadian Children’s Rights Group” you mention as I was only aware of one Canadian organization that issued a formal response – the Children’s Health & Human Rights Partnership

    Their Co-Director Dr. Christopher Guest also had a letter published in the AAP’s journal “Pediatrics” regarding their statement, available here: http://pediatrics.aappublications.org/content/130/3/585/reply#pediatrics_el_54495

  4. Great entry.

    I specially appreciate you pointing out that “the AAP Taskforce on Circumcision does not mention any of the benefits of having foreskin”. This is the main health fallacy. By ignoring the value of the foreskin they simply present it as a health liability.

    One point to note is that while you state that ” the AAP still recommends condoms be used during all sexual activity”, the Technical Report on Circumcision does not mention condoms at all and does not mention any alternative ways of preventing the conditions that circumcision is supposed to reduce the risk.

    • I agree, I could not find any comment on the use of condoms in the 2012 report and yet in the previous report AAP clearly stated in the last sentence under the section titled

      CIRCUMCISION STATUS AND STD INCLUDING HUMAN IMMUNODEFICIENCY VIRUS (HIV):

      “However, behavioral factors appear to be far more important risk factors in the acquisition of HIV infection than circumcision status.”

      http://pediatrics.aappublications.org/content/103/3/686.full

      The omission of this statement in the latest report in my estimation is a reckless and unethical. It gives a false sense of adequacy of circumcision to prevent HIV transfer.

    • I completely agree with you. Regarding condom usage, you bring up an excellent point that it is NOT mentioned in the Technical Report. However, other documents (along with interviews of various pediatricians) all note that condoms should still be used during all sexual activity. One would think that condom usage really should be discussed in the report.

  5. Nice article, nice references. I am an academic social scientist who has followed the RIC controversy since reading Wallerstein (1980) 30 years ago.
    While I like Boyle and Hill (2011), please be warned that the Lord Voldemort of RIC advocacy, Brian Morris of the Faculty of Medicine at the University of Sydney, published an article in the same journal (Journal of Law and Medicine) claiming to refute Boyle and Hill. Morris’s coauthors were a laundry list of American and British RIC advocates (Tobian, Halperin, Bailey, Waskett, etc.)

    • Yes, warning heeded. I have read Morris’ refutation, but as you noted above, their claims are logically unsound. Thank you again for bringing this issue to my attention.

  6. Thank you for breaking down this debate into a concise and readable piece, well done. One of the glaring points I thought was missing, however, was that in the AAP technical report there were numerous references to not having enough data on the risks that they claim are outweighed by the benefits of circumcision. Considering what a pivotal statement they’ve made about the risks, it seems necessary to back up that point with solid data, which they have not even attempted to do. Sadly, one would have to read the technical report to ascertain that detail.

  7. Wow…..this is excellent….I want to use it for educational purposes, how do i get a link to it?

  8. The serious problems with the AAP’s new circumcision statement are enumerated below.

    http://www.doctorsopposingcircumcision.org/pdf/2012-11-26_Commentary.pdf

    http://www.drmomma.org/2012/08/aap-circumcision-policy-statement.html

    http://intactamerica.wordpress.com/2012/08/31/my-letter-to-the-american-academy-of-pediatrics/

    The risks from infant circumcision can be serious and tragic. Below are too many sad cases
    of botched circumcisions and circumcision deaths, which the AAP statement minimizes. Circumcision harms children, and the men that they become.

    http://www.glorialemay.com/blog/?p=581

  9. Thank you for speaking out publicly. It is refreshing to have other voices comment on this topic. The AAP task force clearly has a pro-circumcision agenda, but failed to follow the basic tenets of evidence-based medicine as would be expected for a scientific document. They are an embarrassment and will go down in history as failing to protect a child’s right to bodily integrity and personal autonomy, which is a violation of the AAP’s own policies. The European medical community has denounced the AAP policy on circumcision soundly.

  10. Thank you! An excellent essay filled with logical thought and facts. This intactivist loves it!

  11. Excellent outline of the issues. This gives a clear overview of the important questions that should have been answered by the AAP, but were not. The arguments given by the AAP about the medical aspects of infant circumcision are spurious, but entertaining. More importantly they are there to draw attention away from the basic questions (primarily ethical) that you raise. If the medical reasons were valid (which a complete reading of the medical literature would quickly reveal that they are not) then the AAP would have recommended it. Instead they waffle and leave the decision up to parents who do not have the training to expertly evaluate the medical literature and do not have the right to violate the right of their infant to bodily integrity and security of person. Anything to get the physicians off the hook.

    So to avoid answering the basic questions, they give the wrong answers to the secondary, less important, questions.

    It will be interesting to see if the AAP’s failure to evaluate the ethics and science of infant circumcision in a complete and unbiased fashion will lead to liability issues for the organization. While they failed to formally recommend circumcision, some may rely on the report, which can easily be demonstrated to be inaccurate and biased, in choosing circumcision for their their child. If the child dies from the circumcision, how liable is the AAP?

  12. It needs to be pointed out that while the AAP does indeed state over and over again that “the benefits outweigh the risks” of circumcision, it stops short of a recommendation.

    The deceitful language needs to be analyzed. This is from their latest statement:

    “Although health benefits are not great enough to recommend routine circumcision for all male newborns, the benefits of circumcision are sufficient to justify access to this procedure for families choosing it and to warrant third-party payment for circumcision of male newborns.”

    So while the latest AAP statement repeats the “benefits outweigh the risks” mantra several times, the AAP still maintains, as it did in their last statement, that the same “benefits” are “not great enough to recommend” infant circumcision.

    It needs to be asked, if the so-called “benefits” weren’t enough for what has been up until now, a well-respected health organization, to recommend circumcision, why would lay parents, most of whom are incapable of discerning medical literature, be expected to weigh the same exact evidence, and reach a favorable conclusion?

    It is medically fraudulent that parents are being allowed to make a “choice” that is inconsistent with the conclusions of entire organizations of medical professionals, that doctors pretend that they can comply with such a “choice,” and that public coffers are expected to reimburse them.

    • Excellent comment. I would have written “parsing the” where you wrote “discerning.”

      The Holy Grail of American medicine is for doctors to be able to recommend treatment or procedure on supposed medical grounds, with insurance covering the cost, without question. Doctors hate it when insurers decide that they will not cover a procedure or drug. They feel that this intrudes on their professional autonomy and prerogatives.

      Most American doctors silently accept that the preferred look for a boy’s penis is evolving away from the bald norm of 30-50 years ago. With the exception of a few people like Aaron Tobian, American doctors are not willing to go to the mat and insist that all foreskins be removed. But they apparently do not accept that evolving reimbursement practices are facilitating that evolution.

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