Pediatrics
May 2016
The Circumcision Debate: Beyond Benefits and Risks
by Andrew L. Freedman and M.D. Faap
In 2007, following a flurry of reports describing a benefit of
circumcision in the fight against HIV, the American Academy of
Pediatrics reconvened the task force on circumcision to update its
policy statement of 1999.[1] Rather than simply incorporating this new
information, the committee chose to start from scratch and rereview the
medical literature. The task force’s work culminated in a policy
statement published in 2012, the centerpiece of which was the statement
that “the health benefits of newborn male circumcision outweigh the
risks.”[2] This formulation of the debate, “benefits versus risks”
rather than “medical necessity,”
[or
"benefits and harms", or "functions of the foreskin" or "ethics"]
resulted in wide-ranging ramifications.
To many, especially in the lay press, this was interpreted as moving
the needle from a neutral stance, as the 1999 guidelines were viewed,
to being pro circumcision. It was vigorously criticized by
anticircumcision activists, as well as many, primarily European,
physicians and medical societies. Difficulties with this approach
included
the lack of a universally
accepted metric to accurately measure or balance the risks and benefits.
[In fact, the AAP
made no effort to balance them at all] In
particular, there was insufficient information about the actual
incidence and burden of nonacute
[or
acute] complications
[or
death].[3] In this
issue, Sneppen and Thorup[4] use meticulous epidemiologic technique to
assess the likelihood of needing a circumcision in a society in which
the cultural norm is to preserve the prepuce.
[And they find that likelihood to be less than
one in 200]
Work such as this, along with the subsequent avalanche of reports
evaluating the risks and benefits
[What
"avalanche" apart from a flurry of advocacy articles by wild-eyed Brian Morris?],
has helped to inform and animate the
dialogue among physicians with a stake in the circumcision debate. But
has this really helped to inform the public? Or are we just arguing
among ourselves?
What is often lost in the reporting on the American Academy of
Pediatrics guidelines was the second half of the benefits/risk
sentence, “the procedure’s benefits justify access to this procedure
for families who choose it, ” and later “
health
benefits are not great enough to recommend routine circumcision.”
[This line was missing from most
summaries.] What was the task force really
saying?
To understand the recommendations, one has to acknowledge that when
parents decide on circumcision, the health issues are only one small
piece of the puzzle. In much of the world, newborn circumcision is not
primarily a medical decision.
[In
most of the world it is not a decision at all.]
Most circumcisions are done due to religious and cultural tradition. In
the West, although parents may use the conflicting medical literature
to buttress their own beliefs and desires, for the most part parents
choose what they want for a wide variety of nonmedical reasons.
There can be no doubt that religion, culture, aesthetic preference,
familial identity, and personal experience all factor into their
decision. Few parents when really questioned are doing it solely to
lower the risk of urinary tract infections or ulcerative sexually
transmitted infections. Given the role of the phallus in our culture,
it is not illegitimate to consider these realms of a person’s life in
making this nontherapeutic, only partially medical decision.
[The owner of a phallus, unlike a
mere penis, is an adult man. He is the only one
with any right to make this nontherapeutic, only
partially medical decision.]
The task force was sensitive to the fact that as physicians, although
we claim authority in the medical realm, we have no standing to judge
on these other elements.
The ethical standard used was “the best interest of the child,” and in
this setting the well-informed parent was felt to be the best proxy to
pass this judgment.
[But
there is no need for a judgement, and hence no need for a proxy.]
Protecting this option was not an idle concern
[Who said this
option has to be protected, or that paediatricians have any role in
protecting it?] at a
time when there are
serious efforts in both the United States and Europe to ban the
procedure outright.
[No,
only to agre-restrict it until the owner is of
an age to decide for himself whether he wants less penis. ]
...
In circumcision, what we have is a messy immeasurable choice that we
leave to parents to process and decide for themselves rather than
dictate to them.
[False
dichotomy. The real choice is between leaving the baby alone and
anyone being allowed to cut healthy parts off her or him or
them.] This may seem odd in a society
in which circumcision
is rarely sought, but makes perfect sense in the multicultural world in
which many of us live.
[The
elephant in the room here is the ethics of performing unnecessary,
nontherapeutic, only partially medical reductive genital surgery on a
non-consenting person.]
To the medical community, your efforts to improve our ability to
accurately educate parents are needed.
[Physician,
educate thyself. Learn about the complex structure and many functions
of the foreskin before you claim any right to educate others about it.]
But we have to accept that there likely will never be a knockout punch
that will end the debate.
...
To the anticircumcision activists, I would suggest that rather than
directing an angry focus on the negative and the courts, your efforts
would be better spent to educate and promote the prepuce positively
[which is why we call ourselves
"intactivists"] , to
win in the court of public opinion, and to change the culture, so as to
make having a foreskin be the “popular thing to do.”
{He still doesn't get it. Having a
foreskin is not something you do, because it is "popular". A foreskin
is something you have
as of right because you were born with it, unless someone steals it from you.]
I know it sounds naïve, but my challenge to all of us is to imagine a
day we can peacefully live in a world in which not all penises have to
look the same.
['Why can't
we just get along?' They don't have to look the same, but how they look
should be up to their owners, nobody else. And it's
not all about looks.]
REFERENCES
1. American Academy of Pediatrics. Circumcision Policy
Statement. Task Force on Circumcision. Pediatrics. 1999;103(3);686-693.
Reaffirmation published on 116(3);796
2. American Academy of Pediatrics Task Force on Circumcision.
Circumcision policy statement. Pediatrics. 2012;130(3):585–586
3. Blank S, Brady M, Buerk E, et al; American Academy of
Pediatrics Task Force on Circumcision. Male circumcision. Pediatrics.
2012;130(3).
Available at: www. pediatrics. org/ cgi/content/ full/ 130/ 3/ e756
4. Sneppen I, Thorup J. Foreskin morbidity in uncircumcised males.
Pediatrics. 2016;137(5):e20154340
-----
POTENTIAL CONFLICT OF INTEREST: The author has indicated he has no
potential confl icts of interest to disclose.
[Except
being paid to cut babies' genitals, and cutting his own son on his
parents' kitchen table, contrary to all surgical protocols.]
To cite: Freedman AL and FAAP M. The Circumcision Debate: Beyond Benefi
ts and Risks. Pediatrics. 2016;137(5):e20160594
