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