Circumcisions R US? Try again, AAP


Early Monday morning, the American Academy of Pediatrics put out an updated policy statement on circumcisions to replace the 1999 version. The new statement comes out mainly in favor of circumcision and says insurances should have to cover it.  I’m very disappointed, not only in the conclusion but in the way the authors reached it.

Previously, the 1999 statement said basically “we aren’t sure, there are reasons to circumcise and reasons not to—think about it and decide for yourself.”  Since then, the rate of newborn circumcisions in our country has declined gradually, to a little over half of newborn boys.  Some say this is a direct result of the AAP statement, leading to decreased coverage by insurers.  I suspect it is also because pediatricians and parents became more aware the evidence for cutting wasn’t powerful.

In other developed countries, circumcision is even less common.  I don’t think this is all based on finances but likely involves a more reasoned approach to the evidence plus a different ethic regarding the rights of children.  Even though the US did sign the UN Convention on the Rights of the Child, we never did ratify it.  We, of the developed countries, have one of the strongest tendencies to treat children as the chattel of their parents, rather than offering full protection of human rights from the state.

Without going into every detail of the policy statement, I’ll point out a few elements to give you the general flavor.  First, the authors say that based on new evidence, they can state “the health benefits of newborn male circumcision outweigh the risks.”  Further on, after a discussion of selected risks like surgical infection, bleeding, disfigurement and sexual function (but ignoring certain conflicting data on sexual satisfaction and pain), they acknowledge it proved impossible to quantify the risks!  They say “based on the data reviewed, it is difficult, if not impossible, to adequately assess the total impact of complications, because the data are scant and inconsistent regarding the severity of complications. ” And “financial costs of care, emotional tolls, or the need for future corrective surgery (with the attendant anesthetic risks, family stress, and expense) are unknown.”  And “the majority of severe or even catastrophic injuries are so infrequent as to be reported as case reports (and were therefore excluded from this literature review). These rare complications include glans or penile amputation, transmission of herpes simplex after mouth-to-penis contact by a mohel (Jewish ritual  circumcisers) after circumcision, methicillin resistant Staphylococcus aureus infection,  urethral cutaneous fistula, glans ischemia, and death.”

Now tell me, even without a statistical or medical background, how anyone can say benefits outweigh risks when said risks can’t be well described?  The authors probably know that, because in their shorter paper meant for lay persons to review, they admit “health benefits are not great enough to recommend routine circumcision for all male newborns.”

The authors divided up over 1000 medical papers between themselves to study, and they set some rules for which papers to consider.  One of their rules was to exclude any studies that failed to meet a certain level of evidence.  They used a common scale to describe level of evidence that goes from 1 to 8, with 1 being the best level of evidence and 8 being the poorest.  For this paper, they said they would not use any level of evidence worse than 4.

Unfortunately, their cornerstone of evidence favoring circumcision was a recent paper done by the CDC describing potential cost savings of newborn circumcision in the US, based on HIV data from studies in Africa.  There was no data on HIV prevention in the US by circumcision included in this study.  What’s the problem with that?  HIV transmission in the African studies was mostly heterosexual, and the disease happened in men who also had high rates of other STD’s that had caused skin breakdown and/or ulcers.  These other STD’s are not as common here.  Circumcision does not appear to reduce same-sex HIV transmission.  So while it might be true that the same protection from HIV in heterosexual males might happen in the US, we really still don’t know.  Medical history is littered with the bad results of reasoning that seemed good at the time.

Because we know reason in place of evidence often fails to hold up under scrutiny, studies that use extrapolated data or data collected for other purposes are labeled category 7 in quality of evidence. The only level poorer is “common sense.”  The crux of this new AAP statement is a paper with a level of evidence far lower than what the authors agreed to even look at, and they make no effort to point this out.  It should have never gotten past peer review.

How do we weigh risks and benefits in medicine, in general?  It can be harder than you’d think!  When the outcome involves death or permanent disability, it’s easier.  Otherwise, often we wind up looking at things so different they are like comparing vision to taste—which sense organ is your favorite?  Would you rather take this medicine that might make you live 3 more months or would you rather have 3 more weeks that will probably be less painful?  Would you rather wear a condom or do you place less value on your foreskin?   In those cases, it is most reasonable to explain the various outcomes to patients and let them make the call.

Sometimes policy recommendations are made on a cost-benefit basis, when the medical risks aren’t clear.  If there is an extreme cost difference, I won’t say that isn’t reasonable—but it should be made excruciatingly clear to individual patients when a given practice is based on cost, not risks and benefits.

When the science is in debate, I think it is ethical for parents to make the call as proxies for their children.  I don’t believe it is ethical, if the science says something is too risky, for parental religion or preference to overrule science. What is the situation with circumcisions?  I don’t know.  Personally, I think there should be an overwhelming evidence of benefit if you are going to permanently remove a body part.  I say I don’t know for certain, though, because for specific, individual children the risks could be overwhelming.  HIV can be overwhelming, even if it is now more treatable, and it might turn out that circumcision does reduce HIV even in our country.  Urinary tract infection, more common in uncircumcised male infants (as common as in girls), can be overwhelming or even deadly.  I have seen, with my own eyes, a newborn boy die of overwhelming kidney infection despite desperate and skilled resuscitation efforts (he was circumcised)—but only one, in 16 years of practice.  I don’t see evidence that the rates of these tragic events outweigh the occurrence of circumcision-related risks in the population as a whole, but for a specific child, I don’t have a crystal ball to know.  So I do think it may be acceptable for that child’s proxy, the parents, to decide.

A couple of years ago, I was explaining this to a group of residents and students while in process of teaching them to do a circumcision on a baby whose parents requested it.  I said my gut feeling was that the evidence was going to weigh more against circumcision than for it, and that we would eventually regard it with as much horror as most of the world does female genital mutilation.  But I said we were probably not yet in the position to know enough to outlaw it or refuse to do it at parental request.  I am very comfortable with refusing to do something to a patient for medical reasons, but not at all comfortable with refusing for personal reasons.

Right afterwards, we got in the elevator, and a little girl of about 4 looked up at me with solemn eyes as she asked, “Why did you cut that baby’s pee-pee?”  I was struck dumb—it was as if I’d dropped into a movie like the Sixth Sense.  The procedure room is closed, so I knew she couldn’t have seen us.  Her mother laughed and told us the girl’s brother had his circumcision that morning.  The memory of that question still unnerves me, and I am quite relieved that I personally no longer have to do the procedure, now that a “circumcision team” has formed at my hospital and I’m not on it.  I guess that is a cop-out.  I still am not sure how to answer the little girl’s question.

Whatever you think about the science and ethics of circumcision and medical decision making, I would think most of us could agree that the AAP policy statement, by dismissing risks it can’t quantify and using a level of evidence it claims not to, has serious flaws.  I am embarrassed for a paper like that to be issued from my professional society.  It should be revised and made honest. 

22 Comments

Filed under Children's Issues, evidence based medicine, healthcare

22 responses to “Circumcisions R US? Try again, AAP

  1. tom brindley

    Your comments are well reasoned and should be considered seriously by all medical journals and societies

  2. You mention condoms. The AAP doesn’t.
    You’ve made some good new points, that will soon be in the annotated version of the policy at tinyurl.com/aapanno It gives citations for these objections:
    The policy fails to consider the structure or functions of the foreskin, a normal healthy body part, only the cutting of it off. It does not, for example, cite Taylor’s groundbreaking 1996 paper, The prepuce: Specialized mucosa of the penis and its loss to circumcision. The erogenous value of the foreskin has been known for millennia, even to its enemies. Recent denial of that value is confined to those who have no experience of it.
    It bases its conclusions about sexuality on two physiological studies that did not consider the foreskin, and on surveys of African adult volunteers for circumcision in the context of HIV prevention.
    It treats normal intact penile features as pathological; late separation of the prepuce from the glans can take as long as 17 years but the AAP says it should separate within two months; and it associates “preputial wetness” with disease when it is normal, just like oral wetness.
    It is filled with confirmation bias – finding the results the authors want.
    It claims benefits of circumcising outweigh the risks without ever numerically comparing them.
    It exaggerates benefits and minimizes risks and harm: For example -
    It cites a study showing that “circumcision ablates [removes] the most sensitive part of the penis” and ignores that finding.
    It admits the African HIV findings may not be applicable to the USA, but goes ahead and applies them.
    It cites a study suggesting circumcising men increases the HIV risk to women, and ignores that finding.
    It cites a study showing that a narrow foreskin (phimosis), not a normal one, is the issue in penile cancer, and ignores that finding.
    It dismisses major complications and death from circumcision because it did not find any statistical studies of them.
    It discusses the action of the Mogen circumcision clamp without mentioning that the clamp has caused too much of several boys’ penises to be cut off; lawsuits have driven the company out of business.
    It repeats the common claim that it is safer to circumcise babies than adults, but offers no evidence for that claim.
    Its discussion of the ethical question of removing genital tissue from a non-consenting person versus leaving it for him to decide assigns no value to his autonomy or his human right to bodily integrity.
    It compares the costs of doing it early vs late, but not with the benefits of not doing it at all.
    Its ethical consultant, Dr Douglas Diekema, has said elsewhere that circumcision is not necessary and has a risk of harm, and that a parental wish is not sufficient to justify doing any surgery, and it ignores that.

    The AAP’s policy seems bent, not on considering the healthy intact penis at all, but on restoring insurance and public funding to circumcision in order to find a new market among the poor.

    The AAP should withdraw its circumcision policy the way it withdrew its female genital cutting policy after a storm of outrage two years ago, when it recommended a token ritual nick to baby girls, much LESS extensive than neonatal male genital cutting.(Dr Diekema headed that committee and has never recanted from that policy.) If that was unacceptable, how can this be acceptable?

  3. Karen Glennon

    If you cannot answer why to a 4 year old, I think you know that what you did to that boy was wrong. I applaud you for having the courage to look at this issue and to speak honestly. I, also, foresee that we will come to a time when we look back in horror that the medical community ever adopted and perpetuated this atrocity upon generations of American men. I only wish that I could live long enough to see it. I can say, circumcision ended in my family with my children. They are mere little ones but they know that this is done to babies because I am active in educating about the structure, the histology, and the function of the male foreskin – for the man and his partner. They overhear carefuly constructed conversation designed to shield them from the worst of the facts but still they understand and they ask “Why do they cut babies?” and I answer “Because they think it is cleaner and because they can make money doing it”. Children see through this and they know it is wrong. Lucky for my children, I always knew it was wrong too. (I’ve also had the pleasure of intimacy with a whole man and the difference is stark and more pleasureable, in my experience.)
    Thank you for speaking out.

    • I did not circumcise my son either, 22 years ago– I had him prior to clinical training, so knew really nothing about it except that I wasn’t about to have him cut right after getting here unless there was some incredibly necessary reason. His doctor was fine with that. I have tried strenuously to talk families out of it, often successfully, by emphasizing the risks and telling them I personally think it should not be done, but I disagree that I could have the certainty of wrongness enough to outright refuse, given that there are competing but different risks and benefits making it impossible to compare them. I don’t want to be like docs who refuse to do abortions because of their personal (not medical) opinions.

      To a certain extent, unless something is 100% medically wrong (like administering death penalty drugs), there are reasons it is safer for patients to have doctors work within a professional medical ethic, as opposed to a purely personal one. That’s why I was so hoping for the AAP to go a different direction. It is easier than you’d think for docs to go off the rails in their own direction with practice, when they start ignoring what their colleagues say! I’ve seen that happen, and the patients suffer.

      To say it is all over the hygiene/ money aspects discounts the real struggles many of us face making these types of decisions. I am salaried and am not affected money-wise by whether I do or don’t do it, other than I guess that if I refused to do something that was legal and for which I had training/ hospital privileges I’d possibly have lost my job, and my patients, mainly poor, would have an even harder time finding care. So I can’t say there would have been no personal consequences, in all fairness– I try not to take that stuff into account when making decisions but it’s hard to know what all is happening inside our own brains… It might be that I am just rationalizing and am an unethical person, but I really hope that isn’t the case.

      At any rate, I am incredibly glad I will not be put in that position anymore. I hated doing them with a passion. I hope the AAP will back down from this paper, so that my colleagues will also have more freedom to choose.

  4. concerned cynic

    The post describes a quality grading of extant studies that surely was a very convenient and disguised way of eliminating studies that were inconsistent with the conclusions the Task Force wanted to reach, namely making it impossible for third parties to refuse to pay for routine infant circumcision in American hospitals.

    In my experience, American doctors detest being told “you can’t do procedure X because it conflict with human rights or cultural practices” They detest even more being told that “if you prescribe drug X or procedure Y, the patient’s insurance won’t cover it.”
    The reason why Europe and Japan do not circumcise is because the operation strikes them as sexually bizarre and damaging, and as addressing no problems that can’t be addressed much more satisfactorily by fidelity and condoms.

    By leaving the decision to parents, the AAP is trying to be all things to all families, and reveals that it does not truly believe that circumcised is healthier. By firmly arguing that health insurance and Medicaid (the biggest single insurer of childbirth in the American economy) should reimburse RIC, they are serving the desires and interests of American doctors, who detest being constrained by insurance reimbursement practices. The AAP’s real goal is to circumcise the underclass at taxpayer expense, believing that that class is too poor, too careless and too lecherous to be trusted to use condoms. American medicine silently admits that the white middle class will eventually be conquered by intactivism. Which doesn’t matter, because middle class intactivist parents seldom raise boys who are hopeless horndogs and manwhores.

    The link is to an article that dismantles the credibility of the African clinical trials claiming that circumcised men are less likely to contract AIDS from infected women:
    http://www.salem-news.com/fms/pdf/2011-12_JLM-Boyle-Hill.pdf

    Irresponsible behaviour, not foreskin, cause STIs. Having foreskin causes very few infections that cannot be treated with Neosporin and the like. If one takes the studies cited by the AAP at face value (and I do not), circumcision is an odds changer. The only game changers are condoms and fidelity. Pushing odds changers will discourage people from adopting the game changers. Look up “risk compensation” in Wikipedia.

    The fundamental problem with the AAP’s report is that it did not look closely at Europe and Japan, which enjoy a sophisticated medical profession, ready access to condoms, a high standard of living, enlightened sexual attitudes — and do not circumcise routinely. STI rates are a good deal lower in intact Europe & Japan than they are in that Empire of the Bald Johnson, the US of A.

    The AAP is also deaf and blind to the possibility that the nervous system of the foreskin and frenulum, and the mobility of both, enhance foreplay and sexual acts. And to the possibility that this enhancement confers benefits on women as well as men. The AAP’s report admits that nothing is known about possible long term adverse effects of infant circumcision on PE and ED in adult men, especially after age 40 or 50. Hence the costs of routine circumcision are not known, and hence the AAP has no business saying that the benefits exceed the costs. The desire to circumcise is grounded in serious ignorance of how Nature intended sex and foreplay to work.

    • All superb comments. These two are especially compelling.

      “If one takes the studies cited by the AAP at face value (and I do not), circumcision is an odds changer. The only game changers are condoms and fidelity. Pushing odds changers will discourage people from adopting the game changers.”

      The AAP’s report admits that nothing is known about possible long term adverse effects of infant circumcision on PE and ED in adult men, especially after age 40 or 50. Hence the costs of routine circumcision are not known, and hence the AAP has no business saying that the benefits exceed the costs.

      Indeed. They are playing fast and loose with the facts and ignore what they should not. The AAP is seriously and willfully ignorant.

  5. Can you explain this comment to me?

    “…. I am very comfortable with refusing to do something to a patient for medical reasons, but not at all comfortable with refusing for personal reasons.”

    And although I am thrilled that you have admitted so many things in this post and that you followed your heart with your own child, I still find it unethical that you still teeter on the fence of benefits with regard to genital cutting on infants.

    The four year old had an understanding of genital cutting on infants that many people (including doctors) miss completely……and that is that cutting off a normal healthy part of a baby is wrong! No other part of an infant is expendable…… why is a penis different? Surgical procedures should always have an immediate medical benefit to the patient….not theorized ones for the future. No one can know if that infant would be at risk for any of the so called risks 20+ years down the road or in the case of penile cancer…..60 – 80 years down the road! If people think critically about this procedure and tune into the emotions of an infant…..they would not condone it for a second. A baby owns it’s own body….not the parents….and he deserves genital integrity, regardless of what doctors say or what parents think.

  6. Ok, I will do my best to explain. Sorry that this is long. Medical ethics can get very complicated, and there seem to still be several areas open to debate from what I can tell. When I wrote this post, I anticipated questions like yours might come up– I could have stuck to the discrepancies in the AAP statement to avoid them, but that seemed dishonest and unfair to me. So I guess I opened myself up to whatever accusations can be made, and I will have to take my lumps.

    First, to address the personal vs medical reasons– I should have made clear that medical reasons include ALL the patient’s (not the doctor’s and not the parent’s, IMO) personal opinions and values. When we don’t know the patient’s personal opinions, such as when a person is nonverbal or unconscious, if we don’t have something like a Living Will, you probably know it gets really hard. The default position, when there isn’t a good way to figure that out, is basically the “first do no harm”, but that also includes prevention of future harm, not only immediate harm, if the future harm is potentially great.

    I can’t agree with your statement that procedures should ALWAYS have an immediate benefit– and you’d have to define “immediate”. I bet you don’t completely agree with that statement either, if I gave you a hypothetical extreme example. Let’s say researchers find a new gene that is easy to pick up by newborn screen, and if a baby has this gene there is 100% chance the baby will get bone cancer and die by age 16, unless the left foot is amputated. I’m making it ridiculously straightforward– not much in medicine is ever like that. Let’s go even further and say the foot must be amputated before age 1. Would you still say the surgery is unethical, because the benefit isn’t immediate?

    What if the death wouldn’t happen until 24 (but the surgery still had to be done by age 1)? 45? 60? Then you have to decide at what point you think the person gets enough years of life that he/she would be prefer to live a shorter life with both feet. Who is able to really make a choice like that, for another person? None of us– each individual may have very different takes. But in that hypothetical, we have to make a decision– not amputating is a decision too– so we would use all sorts of approximations.

    Now say the decision doesn’t have to be made until 16, but that the surgery has a 75% risk of death at 16 compared to only a 1% risk at age 1. How would you decide, for that 1 year old?

    Obviously, circumcision isn’t even close to having numbers like that! I am just saying that making decisions for babies is nowhere near as clearcut as you want to believe. The medical evidence changes constantly, and new diseases come up. If we develop a new illness 5 years from now that only kills uncircumcised men, even though that is incredibly unlikely, I would think the pendulum would legitimately swing towards circumcision. If the illness becomes curable, it would swing (I’d hope) away from it. These decisions are always a moving target.

    To use a less extreme situation, many parents where I live decide to pierce the earlobes of their baby girls. Many doctors do it for them– I will not. A medical reason given is that there is a lower risk of keloids in babies than in teens, but since there is zero adverse medical consequence I know of for NOT piercing the ears (the teens can use clip-ons if they don’t want to risk keloids), I think I’m on very safe ground to say no. I have no idea on earth what that girl will want her ears to look like when she is 16. What if there was a significant consequence to not piercing– let’s say there was a high risk of suicide in girls who got keloids from teen ear piercing? I’d have to rethink.

    Using one’s personal opinion, vs the medical one that attempts to account for the patient’s opinion, is wrong to me. As an example, many states are trying to pass “conscience” legislation that would make it legal for doctors to refuse to prescribe birth control to women, just because they don’t think it is right themselves. I believe that if those doctors can’t work within the professional ethic, they should choose another career.

    You might be interested to know that this weekend, I mentioned my blog to a some young adults to see what they’d think– almost to a person, both male and female, they were aghast that a doctor might refuse to circumcise a male infant! One of them said, “if you’d been my doctor and you had refused to do it, I would be really angry at you right now.” That completely startled me. The one male who felt differently was, as you might guess, uncircumcised. Obviously, if none of them had been circumcised and it was not done here, they’d all have likely been opposed to circumcision. The ones who are circumcised (and the women who’d only had sex with circumcised men) are unable to compare options they haven’t experienced, so I guess their reactions are understandable.

    I don’t think the penile cancer is at all a good argument for circumcision– it is just too rare. I’m not sure you are correct to use age (60 to 80) because you are putting your personal value judgement on years of life vs foreskin– we have to try not to do age discrimination.

    The HIV question needs to be addressed, not in terms of cost, but in terms of risk here, in the US. Without good data, we can’t know. If it turns out that the risk is substantially increased without circumcision. we should take that into account. Yes, as other responders point out, sex education and condoms could work even better. Every day, I preach condoms to my teen patients, but I only get to see them for checkups once a year. We have to do better as a society to change how we approach sex and sex education. But, knowing that the environment here is repressive and difficult for teens, and that they can’t change this themselves, we are back to needing to take HIV into account IF it is a risk.

    Otherwise, I can imagine myself facing a 15 year old uncircumcised boy with HIV who might say to me, “You KNEW I had a higher risk, you KNEW my parents and school would make it hard for me to understand the importance of condoms, you KNEW adolescents are impulsive, and you refused to circumcise me– how could you do that?” Pitting that question against the 4 year old’s question– I do not know what I would say. Perhaps it is easy for you, but not for me.

    I think, given the lack of good evidence, the AAP should lean away from recommending circumcision at this time. As with all medical issues, they should re-address the question periodically upon getting new information and as the epidemiological environment changes.

    • joe

      Pippa, I am not sure I agree with how you’ve framed the ethical discussion I have to read more and think about what you’ve said when I have more time, probably later tonight. Personally, with the information currently available, I feel it’s at best unethical and I support the efforts in European countries and Australia to curtail the practice. I don’t believe my parents should have had any say in that matter unless there is some overwhelming, to use your words powerful, reason.

      What are your feelings regarding the UTI assertions?

      How much of an HIV risk must exist for it to be ethical to consider? Even if we assume that the risk reduction is the same in the heterosexual population, using their figures, this only changes my lifetime risk by about 0.3%, a figure which I think is inflated but even still would not motivate me to make that decision for myself. Especially considering that there are better ways for me to manage that risk. Out of curiosity, how would the conversation go with a 15 year old whose circumcision was severely botched?

      • Parents have a say in many matters of huge impact to children, and there are many of them we allow here that I disagree with. I think exposing children to secondhand smoke in the home is child abuse and should result in removal from the home, but good luck for me getting DHR to go with that one! A lot of what we allow probably is because we don’t have resources to do otherwise. What parents feed their children, how they talk to them, the examples they set– all these things can have far broader impact on a child’s life than anything medical.

        I do think, though, that when there are medical risks and benefits which are competing and hard to compare directly, what we are trying to do is figure out what the child would want in the future (as an adult) to have been done. We are bad enough at even doing that for ourselves, from what I’ve read– our predictions of what present action would create the most personal happiness in the future are quite often wrong. So to take that on for another person is incredibly hard. Not acting is just as much a thing as acting– parents deciding not to circumcise (when it is commonly done where they live) is also a decision. It seems to me that the ethical tradition here rests partly on the assumption that a child’s parents may be most likely to have his/her deepest well-being, now and in the future, at heart and so the proxy has passed to them. The problem of course is that the parents are not always able or willing to take that responsibility so seriously.

        If you think many significant decisions should be removed from parent control and the state should intervene much more powerfully as a proxy for children, I am sort of with you, but it would depend on the fitness of that state as well, right? We’d have to have a government much more responsive to the ethical beliefs of its citizens, and less so to the demands of big money. You are probably not going to find a perfect proxy decision-maker for a child. As a non-theist Christian (subject for another day), I don’t believe there is any such thing as “natural right”, built into our DNA or given to us by a supernatural God– no standard basis of ethics we will all agree on perfectly. But I believe we have gradually evolved an understanding of what rights we ought to extend to one another, in order to have what we perceive to be decent, humane lives. It seems likely that we will need to improve in that direction much more if we are to survive as a species or if the planet will make it.

        The UTI issue is tricky, and I have a little trouble making sense of it. It doesn’t seem to be dependent on hygiene in babies. But the incidence would simply equal the incidence in girls. Makes me want to say “so what? Why do you need to do better than a girl?” As a single risk factor, in absence of any others, that doesn’t seem enough. Seems like it would be different if uncircumcised boys had a significantly higher risk of UTI, and death from kidney infection (or later kidney failure from scars) than girls.

        However, it also seems like it would be malpractice not to tell a person (or that person’s proxy) that the risk is different for circumcised and uncircumcised boys. Because if they didn’t decide to circumcise him, he got a UTI and died, and they realized his risk might have been decreased by even 1 in 1000, he was 100% that one baby — my not sharing that information would have been great hubris and they would be justified in blaming me. What if the boy was born with only one kidney– would that change things? What if he was born with vesico-ureteral reflux (where the urine flows backwards from the bladder into the kidney) putting him at higher risk of kidney infection if he got a bladder infection?

        You ask how much of an HIV risk would be enough to create a factor in the decision– I don’t know! That is part of what I’m trying to say– so much is arbitrary. And it isn’t only a matter of quantifying each outcome– you also have to somehow add up the risks on one hand and the benefits on the other. We’d wind up with a bunch of risk factors on different issues and then would be trying to compare those with the benefits of having a normal foreskin, followed by trying to predict what a baby would have wanted us to have done once he was grown. How do you add up things that are so different– is there some sort of factor you’d use if an outcome is only inconvenient, like needing antibiotics, causes pain (and maybe a pain scale), causes death? I see that some people on this comment threat think that’s a no-brainer, but I don’t, even though I do think with our present evidence, refraining from doing circumcisions probably makes more sense. I can at least say that for the AAP to make a recommendation supporting benefits over risks is irresponsible, when we haven’t even quantified or considered all the aspects.

        I should also say that the general public probably does not realize how hampered physicians are in our decisions by our lack of access to reliable data. This isn’t just in circumcision studies but in general. So much doesn’t get published, especially studies that don’t find what the journals or corporate sponsors are interested in, and we never get to see it. Far too much of what does get published is inferior– bad data, bad statistics, etc. I am not by any means a statistician, so unless the journals insist on proper peer review and good practices, I’m a bit at their mercy. I can look at what disputing letters/ articles say, but then basically I have to decide who to trust.

        Because of that, part of my leaning away from circumcision is based on the knowledge that the other developed countries don’t do them routinely anymore– I put a good bit of credibility on that, but it isn’t based on any specific evidence. As a decision help, that sort of practice can go wrong (not until recently did France veer away from doing psychotherapy for autism, instead of behavioral therapy, for example), so it can’t be the only thing I look at.

        How would my conversation go with a 15 year old with a botched circumcision? I never botched one, so it wouldn’t have been mine. My gosh, I was completely OCD about getting them exactly right. I’m not saying that in a self-aggrandizing way– everyone makes mistakes and we are all human, but I’ve not ever made that particular mistake. If I had, I’d have to throw myself at the 15 year old’s feet and beg for mercy. I once miscalculated a med dose, and for some reason it hit me suddenly the next week on vacation, out of the blue, that I’d used the wrong strength. It wasn’t dangerous with that particular medicine, but the very idea of getting a dose wrong was horrific to me. I ran up the sand in a panic, called my office to fix it, and spent the rest of the week worrying about what if it had been a different medicine and the child had been hurt. Even thinking about that makes me want to hyperventilate and it was 10 years ago! So, for sure, something like that would put me over the edge. How could it not? All these things are reasons a policy about something like circumcision needs to be a shared endeavor– not just one proxy for the child but many voices.

      • joe

        “Parents have a say in many matters of huge impact to children, and there are many of them we allow here that I disagree with. ”

        I don’t disagree with you on the fact that parents have a say in many matters of huge impact but I feel (as a guy) that non-theraputic circumcision falls far outside the scope of what is reasonable. To be honest, I have the same feeling about non-theraputic circumcision as you have about second hand smoke.

        “I do think, though, that when there are medical risks and benefits which are competing and hard to compare directly, what we are trying to do is figure out what the child would want in the future (as an adult) to have been done.”

        I would say that someone would want the choices made for them which least limits their future options, that is making the choice that is least restrictive of the person’s freedom of action. If one decides to non-theraputically circumcise a child, they limit his choices in the future. In 1995 the AAP committee on bioethics in their 1995 report, Informed Consent, Parental Permission, and Assent in Pediatric Practice noted that: “Such providers have legal and ethical duties to their child patients to render competent medical care based on what the patient needs, not what someone else expresses. Although impasses regarding the interests of minors and the expressed wishes of their parents or gardens are rare, the pediatrician’s responsibilities to his or her patients exist independent of parental desires or proxy consent.” I have to double check but I don’t believe they cited it.

        The British Medical Association discussed this in, The Law and Ethics of Male Circumcision – Guidance for Doctors, the AAP statement cited part of this document but they did so selectively, ignoring what I would consider the primary point of the document. “Unnecessarily invasive procedures should not be used where alternative, less invasive techniques, are equally efficient and available. It is important that doctors keep up to date and ensure that any decisions to undertake an invasive procedure are based on the best available evidence. Therefore, 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.” I don’t honestly see how circumcision can be squared ethically.

        “Not acting is just as much a thing as acting– parents deciding not to circumcise (when it is commonly done where they live) is also a decision. ”

        I disagree with this statement insofar as I don’t see circumcision as any more of a choice then say asking you to remove my child’s earlobes.

        “If you think many significant decisions should be removed from parent control and the state should intervene much more powerfully as a proxy for children, I am sort of with you, but it would depend on the fitness of that state as well, right? ”

        No, I wouldn’t go this far. I think we have a good handle (mostly) for what we permit and what we don’t’. Circumcision is anomalous.

        “What if the boy was born with only one kidney– would that change things? What if he was born with vesico-ureteral reflux (where the urine flows backwards from the bladder into the kidney) putting him at higher risk of kidney infection if he got a bladder infection?”

        I would say that being born with some anomaly of the urinary tract puts you into a category of potential therapeutic need, it’s quite a different situation.

        “You ask how much of an HIV risk would be enough to create a factor in the decision– I don’t know!”

        I would hope someone would because it’s my feeling that they based their recommendation on only this question. As a practical matter, little else has changed. The information regarding UTI risk reduction is largely unchanged other STIs are nearly always treatable (as are UTIs) and the arguments for penile or cervical cancer are largely deprecated based on the availability of an HPV vaccine. If that is the case, that the HIV information largely informed this outcome, I would be even more disappointed with their process than I am now, which would be pretty difficult.

        “followed by trying to predict what a baby would have wanted us to have done once he was grown.”

        I am not sure it’s that difficult, most intact men don’t ever choose circumcision, that says a lot.

        “I can at least say that for the AAP to make a recommendation supporting benefits over risks is irresponsible, when we haven’t even quantified or considered all the aspects.” I’d say that is an understatement. In addition to not quantifying the risks, they don’t provide proper information on care for intact boys and they fail to consider the value and functions of an intact body. Personally, I feel that North American doctors go in to these things with their scales tared against normal penises.

        ” So much doesn’t get published, especially studies that don’t find what the journals or corporate sponsors are interested in, and we never get to see it.”

        This statement is profound. I wish more people realized that this is a significant problem. And it’s hard to prove because, well you don’t have the data that was never published.

        “Because of that, part of my leaning away from circumcision is based on the knowledge that the other developed countries don’t do them routinely anymore– I put a good bit of credibility on that, but it isn’t based on any specific evidence.”

        I think this is a bit of an understatement. Most Western countries never routinely performed them, Anglican countries are an exception. Are you aware that there are, and have been, movements to criminalize male circumcision in several countries in Europe? The support from their medical communities only wavers at concern for the practice going underground.

        “How would my conversation go with a 15 year old with a botched circumcision? I never botched one, so it wouldn’t have been mine. My gosh, I was completely OCD about getting them exactly right. ”

        I don’t think a circumcision can every be done right. If I was that 15 year old child though, it’s something I could never forgive. The first thing that would come to my mind is what was the condition or need that made the attempt, and its failure, necessary. I don’t’ see the answer in the AAPs statement.

      • I understand what you are saying. I wonder if what has made it difficult for us (pediatricians) as far as knowing what the person’s preference would be is that the fathers of these babies, who were circumcised as infants, often (but somewhat less often now) want their sons to have the same thing? Which would say that they are now glad it was done to them to the point they are sure their sons will feel the same way. The hardest people for me to persuade were the fathers– mothers were more likely to be talked out of it, in my very unstatistical experience. Women (and circumcised men) who are pediatricians, having not been in the other situation, have been stuck in a position where we are relying on people who have had that experience telling us what a person would likely want. We’ve been more stuck in that because the generation of fathers now deciding is more often circumcised, but the more we are able to hear from uncircumcised men that they would be horrified to have had that done to them, the more sense it would make to stop doing them. The circumcised men can be forgiven, to me, for thinking it is fine, because how would they have any basis for comparison? At any rate, you can be sure that if we’d been confronted from the beginning with circumcised men who are angry about it (I know, they exist substantially, but I’ve never had a father in my practice say it), pediatricians would not have been on board with all this.

        I know there are studies saying uncircumcised men would not want it done now, but I haven’t seen one looking at whether they would be angry if it had been done to them as infants. That might be a good study for someone to do, to convince doctors of this issue. And maybe also ask circumcised men if they are angry, although as I said, many of them appear not to be– but seeing even a minority but significant percentage who are angry would be important.

        Yes, I am aware of the move to criminalize circumcision and the recent court decision in Europe. I think you misunderstood my meaning– I was saying that my putting weight on other practices is important but limited because it is still possible everyone else could have decided wrong. Like the thing my mom used to say about “you wouldn’t jump off the cliff just because everyone else is doing it, would you?” I live in Alabama, where most people will vote for Romney, and most of the rest will vote for Obama, while I cast my vote for Stein. So the majority opinion isn’t always right, but I pay more attention to it when it comes from Europe than from the US, which seems sad.

        Your idea of using the most future options as a deciding point is interesting but not as simple as you are making it. There are examples from other procedures in medicine that tell me that. For instance, some babies are born with something called a “nevus sebaceous” on their scalps, which is benign at birth but can develop cancer in it later. Previously, because the risk was thought to be very high, the standard treatment was to remove them early on. Now the incidence appears to be lower, so it is more reasonable to leave them alone but watch them very closely. If they were really likely to become cancerous, removing them would limit the person’s choice to keep them (that might sound weird, but I once had a kid who didn’t want to get rid of a wart on his knee– he liked it, so we left it alone), but it might increase his choice to not have cancer. So IF circumcision prevented very serious outcomes to a point most people thought was significant enough to worry about (no matter what level of risk you pick, it is always going to be somewhat arbitrary), then you are deciding between limiting the future choice to remain uncircumcised or limiting the future choice to be healthy. You also would limit their future option to have had it done as an infant, since they can’t go back in time. So the option idea doesn’t completely settle it. I know there is controversy over whether the procedure is really riskier as an adult, but my understanding is that most urologists use general anesthesia, which is possibly not healthy for your brain. Children that have general anesthesia can be shown to have learning problems later, a scary thing, but infants have them done under local.

        Nothing I said goes against the doc being responsible for opposing the parental proxy when appropriate– I do that in large or small ways on a regular basis. I was saying that in the context of a situation where the risks/ benefits are unclear to us.

        I appreciate very much your input and the other commenters. When I respond, I’m not trying to talk you out of anything but just to try and help you see that there are serious thinking processes going on in the medical community about the whole thing at the grassroots level. We are not taking it lightly, and we are not all about money, at least not most of us. We do not want to hurt our patients. We are trying hard to get this right. And we really need our professional organization to be more helpful here.

      • joe

        “The hardest people for me to persuade were the fathers– mothers were more likely to be talked out of it, in my very unstatistical experience. Women (and circumcised men) who are pediatricians, having not been in the other situation, have been stuck in a position where we are relying on people who have had that experience telling us what a person would likely want.”

        I think this matter is the most compelling. It is why I don’t put much faith in the ability for a North American physicians group to evaluate the data objectively. Or for North American researchers to write about their results objectively. I find that they’ve tended to downplay the risks while inflating or up selling the potential benefits.

        “The circumcised men can be forgiven, to me, for thinking it is fine, because how would they have any basis for comparison? At any rate, you can be sure that if we’d been confronted from the beginning with circumcised men who are angry about it (I know, they exist substantially, but I’ve never had a father in my practice say it), pediatricians would not have been on board with all this.”

        I don’t think this would have been a likely possibility since circumcision took a firm hold in the US before it was common to really question doctor’s advice. And once you have a situation where everyone is circumcised, how is anyone to know they weren’t simply born that way? You might have not learned about it until you were having a child. We are less provincial now and it is possible, long before you’re in that position, to learn that not only is secular circumcision very rare outside North America, they never did it anyway, there is no epidemic of foreskin problems (hygiene, STD, HIV, ect.), and more than that (especially recently) there have been moves to criminalize it (not just in Germany but also Denmark, the Netherlands, Sweden, Finland, Norway, ect.).

        “So the majority opinion isn’t always right, but I pay more attention to it when it comes from Europe than from the US, which seems sad.”

        A good policy, I don’t think you can make a rational decision on this if you’re in a culture that circumcises. This is why FGM is difficult to eradicate.

        “Your idea of using the most future options as a deciding point is interesting but not as simple as you are making it. There are examples from other procedures in medicine that tell me that.”

        I appreciate your example but I don’t think it fits. In the situation you present, where cancer is very likely, removal is the appropriate option since a cancer diagnosis kind of limits your options in a more profound way. If you follow what I am saying. I haven’t seen any information about circumcision that leads me to believe that the decision fits into that category. Some might posit (and I think the AAP acted on this) that the HIV potential meets that burden but I would disagree since the risk in the general population is low, making the potential benefit low. Further, your risk relies more on your individual behavior than whether you have a foreskin. It’s telling that the Europeans, where circumcision is rare, has HIV prevalences lower than we do. We should really be looking at them to see whats working.

        “You also would limit their future option to have had it done as an infant, since they can’t go back in time. So the option idea doesn’t completely settle it. I know there is controversy over whether the procedure is really riskier as an adult, but my understanding is that most urologists use general anesthesia, which is possibly not healthy for your brain. Children that have general anesthesia can be shown to have learning problems later, a scary thing, but infants have them done under local.”

        This is not something that I believe in (the idea of going back in time because you missed that opportunity). I am also shaky on the argument that it’s riskier for adults. I see no reason this can’t be done on older children and adults with a local. They are surely not using general in those African countries where they are pushing it. If they’re doing it like that in Africa, surely we can do it just easily.

        “I appreciate very much your input and the other commenters….
        We do not want to hurt our patients. We are trying hard to get this right. And we really need our professional organization to be more helpful here.”

        It’s no problem, I comment because I want people to know that not everyone finds this acceptable, that argument can be rationally made, and it’s a very broad opinion (globally). In fact, it’s something that I would like to see disposed of, except where there is therapeutic need. And the professional organizations haven’t been very helpful at all. There are demonstrable mistakes in their statement, they leave out or minimize important information, and if it isn’t clear, I find their ethics section to be abdominal.

        There is a good blog, maintained by a friend of mine, that make compelling arguments against circumcision, I invite you to peruse it at your leisure. http://www.chooseintact.com

      • “I don’t think you can make a rational decision on this if you’re in a culture that circumcises.”

        Wow. You know, that is most likely true, and it is probably why all this has been so frustrating and hard to figure out! It feels like slogging through mud. I had a personally startling recent experience changing political parties from Democrat to Green. I thought I was being objective about things, and that the Republicans were the ones who ignored facts. All of the sudden, I can “see” this crazy blinder situation going on for both sides that I was oblivious to before. I’ve read that our “rational” thinking really evolved more as a persuasive tool than anything else, but the illusion of rationality as a way of correctly interpreting reality is powerful.

        It may be a good thing that this paper has such blatant errors, calling attention to the whole issue again. Maybe when parents and doctors see that there are severe flaws in the paper, they will also question the practice more consciously. I appreciate your dialogue.

  7. Pippa, thanks for posting about this issue. I commented on this elsewhere but can’t find my comments to copy over here so, briefly, when I reviewed the studies on which the updated policy referenced, I found them in terms of scientific inquiry limited and weak. If there had been a mega-study done of all the research in this area, I don’t believe the same conclusions would have been made. Besides, when I read the policy itself on the AAP website, I didn’t see anything extremely conclusive. I agree that it would be great if they continued the same policy (the science hasn’t given us enough evidence to know) but the fact that they posted a policy and someone who promotes mutualation of little boys decides to pull out a statement or two and use it to justify their side, does not help the situation. Thanks for the medical viewpoint added in your blog.

  8. To be fair, it’s not a totally spurious explanation in itself, it just doesn’t match up with the historical trends regarding circumcision. Given the historical importance of circumcision as an in-group marker among Jews, it’s not beyond imagining that an anti-Semitic culture may develop an exaggerated objection to it, it’s just not something that happened in Europe.

  9. They brand men like a herd of cows. “Neonatal post-traumatic stress disorder” — the recurrent American nightmare for boys. American men are such wimps to let their sons be subjected to this absurd surgery. If it were women tied down & cut, the Feminists would be howling all over the world. The male genitals are a cheap commodity. There is no argument too absurd for the circumcisers. They insult the appearance of the intact penis, claim that circumcision heals everything from body warts to HIV, and draw an illogical distinction between female & male genitals. Circumcision is the mark of a slave, not a free man.

    Top Ten Tortures Less Painful Than Circumcision

    10. Get waterboarded.
    9. Pull out your fingernails.
    8. Eat a pile of steaming bear crap.
    7. Skin yourself alive.
    6. Fall into a vat of molten iron.
    5. Get run over by a train.
    4. Go through a sausage grinder.
    3. Saw off your legs.
    2. Poke out your eyes.
    1. Go To Hell

    ~Dick-Scalper

  10. Hello, I find your article really interesting and your comment exchange with Joe very enlightening.

    At some point you mentioned: “At any rate, you can be sure that if we’d been confronted from the beginning with circumcised men who are angry about it (I know, they exist substantially, but I’ve never had a father in my practice say it), pediatricians would not have been on board with all this.”. I feel that the American medical community refuses to see the number of men who are angry or feel damaged from their circumcision, and our attempt at reversing the damage.

    Are you familiar with non-surgical foreskin restoration? There are documented thousands of men doing it right now, in spite of being a lengthy, tedious process (takes between 2 to 8 years). It’s a process of tissue expansion and most of us are upset that we can’t reverse the damage to the nerve endings, the frenar band or the frenulum, but at least recovering the moving skin and protection of the glans, added to the psychological effect of not having to look at a scar, seems to be a good reason to do it.

    I often point people to this section of a forum: http://foreskin-restoration.net/forum/forumdisplay.php?f=61 so they can see the deep feelings and emotions running in men who wish they had not been circumcised.

  11. Wafa

    Pippa: I work a lot with statistics on a daily basis. I would suggest you post close attention to the patterns of the recent surge in HIV infection in the US. It has spiked among 2 groups- gays & African Americans. The later group is disproportionately affected by cuts in Medicaid, & in many states, Medicaid stopped paying for circumcision after the 1999 report. I think you are correct to pinpoint insurer behavior as the underlying motivation for the report, but please do not dismiss cost concerns so readily, especially for groups that particularly need it.
    I admit I am biased on the subject- I belong to a religion that has practiced it for centuries with no real evidence of harm. I see nothing wrong with leaving the decision to the parents.

    • I would be hesitant to draw any causal conclusions from the data you mention for 2 reasons– first, men affected by any change after 1999 would just now be turning 15, and the increase in African Americans you refer to started surging in 2006 when that group was 7 years old and not in the age group showing the increase. Also you would need to demonstrate that the increase was significantly more concentrated in uncircumcised young teens. Finally even an association is not cause/ effect automatically, even if there were one. Many false tracks have been followed in medical history due to over-interpreting associations– the harm is not just side effect from a non-causal intervention but failure to search for real causes.

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