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The case for neonatal circumcision

Imagine if we could save lives from a dread and often fatal disease simply by performing a minor surgical procedure. People would hail this simple victory and rush to adopt it… Not exactly. The disease is HIV and the simple surgical procedure is circumcision and anti-circ activists oppose it under almost any circumstances.

In this month’s edition of the Archives of Pediatrics and Adolescent Medicine, Tobian, Gray and Quinn present a compelling case for neonatal circumcision. The paper is entitled Male Circumcision for the Prevention of Acquisition and Transmission of Sexually Transmitted Infections. The authors report:

The American Academy of Pediatrics (AAP) male circumcision policy states that while there are potential medical benefits of newborn male circumcision, the data are insufficient to recommend routine neonatal circumcision. Since 2005, however, 3 randomized trials have evaluated male circumcision for prevention of sexually transmitted infections. The trials found that circumcision decreases human immunodeficiency virus acquisition by 53% to 60%, herpes simplex virus type 2 acquisition by 28% to 34%, and human papillomavirus prevalence by 32% to 35% in men. Among female partners of circumcised men, bacterial vaginosis was reduced by 40%, and Trichomonas vaginalis infection was reduced by 48%. Genital ulcer disease was also reduced among males and their female partners. These findings are also supported by observational studies conducted in the United States. The AAP policy has a major impact on neonatal circumcision in the United States. This review evaluates the recent data that support revision of the AAP policy to fully reflect the evidence of long-term health benefits of male circumcision.

The AAP had long recommended male circumcision for prevention of urinary tract infections in young boys, but backed down in 1999, partly in response to pressure from anti-circumcision activists. According to circumcision.org:

Based on a review of medical and psychological literature and our own research and experience, we conclude that circumcision causes serious, generally unrecognized harm and is not advisable.


Anti-circ activists have employed inflammatory language to express their opinion. Circumcision is “mutilation” and parents who choose to circumcise their sons are “mutilators”. But the benefits of circumcision are real and clinically important. As Tobian, et al. explain:

The biological mechanisms whereby circumcision could reduce viral STIs may be due to anatomic and/or cellular factors. The foreskin is retracted over the shaft during intercourse and this exposes the preputial mucosa to vaginal and cervical fluids.61 It has been hypothesized that viral infections may enter the mucosa through microtears in the preputial mucosa. The moist subpreputial cavity may also provide a favorable environment for viral survival. The inner mucosa of the foreskin is lightly keratinized compared with the epithelium of the shaft, coronal sulcus, and glans, which may facilitate mucosal access of HIV, HSV-2, or HPV. The mucosa of the foreskin also contains a high density of dendritic (Langerhans) cells, macrophages, and CD4_ T cells, which are all targets of HIV …

Anti-circ activists are convinced that circumcision reduces sexual satisfaction. Until recently, it was difficult to study that claim because very few men were circumcised after becoming sexually active, making it almost impossible to determine the sensory effect of circumcision. But recent studies make it clear that sexual satisfaction is not affect by circumcision:

… [T]here were no reported differences in sexual satisfaction in the randomized study arms in either the Ugandan or Kenyan male circumcision trials or among men before and after they were circumcised. In addition, it has been hypothesized that behavioral disinhibition may counteract any protective effects of male circumcision. However, there was no consistent or substantial evidence of change in sexual behavior after circumcision in the Kenyan or Ugandan randomized controlled trials.

Tobian et al. call on the AAP to revise its policy to reflect the latest scientific evidence:

The World Health Organization/Joint United Nations Program on HIV/AIDS has concluded that “the research evidence that male circumcision is efficacious in reducing sexual transmission of HIV from women to men is compelling … and has been proven beyond reasonable doubt.” In 2007, the American Urological Association revised their policy to state that “circumcision should be presented as an option for health benefits.” However, the AAP, American College of Obstetricians and Gynecologists, and American Medical Association are likely to have the greatest influence on parental decisions and insurance coverage for neonatal circumcision in the United States. With the mounting evidence that male circumcision decreases viral STIs, genital ulcer disease, and penile inflammatory disorders in men, and bacterial vaginosis, T vaginalis infection, and genital ulcer disease in their female partners, it is time for the AAP policy to fully reflect these current data.

The AAP should heed the authors’ call.

Posted in: Science and Medicine

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653 thoughts on “The case for neonatal circumcision

  1. gimpyblog says:

    Shouldn’t males be entitled to informed consent when it comes to irreversible and non-essential surgical procedures that may affect quality of life in future? Especially so when some evidence suggests that those who undergo the procedure as adults report a loss in sexual satisfaction, despite your cherrypicked assertions otherwise.

    And why isn’t the permanent removal of a physical feature for no immediate medical benefit not mutilation and grossly immoral?

  2. PJ says:

    “The AAP had long recommended male circumcision for prevention of urinary tract infections in young boys, but backed down in 1999, partly in response to pressure from anti-circumcision activists”

    I’m not aware of any evidence that not being circumcised increases the risk of UTIs. Also, it would seem very odd to be advocating circumcision to avoid UTIs in boys when they are so very rare (any case of a UTI in a boy warrants further investigation of their renal tract, not the decision that it was due to the foreskin).

  3. cresur says:

    Neonatal circumcision saves lives the same way neonatal leg amputation does. “Hey, it might come in handy some day!”

    People can sarcasm-quote the word Mutilation when they’re talking about male circumcision as much as they want, it doesn’t change the fact that’s exactly what it is, both in the linguistic as in the medical sense.

    I’m sure if they tried to find “medical benefits” to female genital mutilation as hard as they do with male genital mutilation, they’d find plenty. (http://www.fgmnetwork.org/intro/mgmfgm.php)

    All the supposed benefits of this measure are related to sex, but newborns and infants are not supposed to be having sex. Once boys get old enough to start having sex, however, parents and doctors might be fully encouraged to include this discussion in their sex talks, presenting all the available information (http://www.youtube.com/watch?v=1vxeGQe_opU), so the boy can now make an informed and, most important, VOLUNTARY decision.

    Apparently “My body, my choice” only counts if you’re a woman.

  4. provaxmom says:

    “”The trials found that circumcision decreases human immunodeficiency virus acquisition by 53% to 60%, herpes simplex virus type 2 acquisition by 28% to 34%, and human papillomavirus prevalence by 32% to 35% in men.”"

    I don’t like the way those statistics are worded, especially when you look at the CDC website. There were only about 10,000 cases of HIV in this country in 2007, with just about 400,000 cumulative. Once you factor in race, income level, lifestyle and other factors–my boys are very low risk category. Decreasing that risk by another 50-60% sounds great on the surface, but they are already very low risk already.

    So for me, a yes, mutilating, permanent procedure that has all of it’s origins based in religion….I’m still more than 100% confident in my decision to not circ my boys. People flip their lids over female circumcision…why not for males?

  5. provaxmom says:

    I apologize–it’s o-dark-30 here and I didn’t finish my thought. To me, circ’ing boys to prevent STDs seems like a silly (for lack of a better word) reason to do it. We should be looking for other ways to prevent STDs.

  6. BelgianAtheist says:

    Since it is non-reversible it must be VERY effective for it to be forced on babies, it would have to be more effective than a vaccine (essentially there should be almost no circumcised men with HIV).

    I do not know anyone who is circumcised, here it is the norm to not circumcise and I have not heard of a difference in HIV infections with other countries where circumcision is the norm.

    And what is wrong with elective adult circumcision? If an adult wants to mutilate himself (piercings, scarring, circumcision, …) I have no qualms with that.

  7. cresur says:

    You can just grow a spine and deny my comment already. Keeping it “awaiting moderation” is not fooling me.

  8. Plonit says:

    Oooh, this should be fun.

    Disclaimer: I had both my sons circumcised for the usual cultural, ethnic, mumbo jumbo reasons. These are pretty much the only reasons that anyone in my country does infant circumcision. I felt happy in doing so, because I have no difficulty with circumcision per se, and I believe it should be the parents’ decision as to whether to circumcise their son – falling into the same category as the countless other irreversible decisions we make on behalf of our children.

    Having said that, I think Dr Amy’s argument around the AAP change of position deserves closer scrutiny.

    First, the AAP had “long recommended male circumcision for prevention of urinary tract infections in young boys.” But no mention of whether they were correct in doing so. What does science have to say on this subject? Given that presence of a foreskin is the physiological default, isn’t it for proponents of circumcision to properly demonstrate the benefits of its removal? Had the AAP done so, in their long history of recommending male circumcision? Surely the answers to these questions form part of any science-based discussion on routine infant circumcision.

    Second, the AAP “backed down in 1999, partly in response to pressure from anti-circumcision activists”. I would like to see some evidence to support this statement. There may be a correlation between the rise of anti-circumcision activism, and change in AAP position, but can we conclude causation? What other factors may come into play here? Perhaps both ‘activists’ and paediatricians were both responding to a single-cause, for example lack of evidence to support the procedure – which may increase ‘activism’ insofar as many more people come to view their circumcisions as having been ‘unnecessary’ and may change the position of the AAP in an increasingly evidence-based medical context? Or perhaps the activism and AAP change of position are unrelated. Activism tapping into a culture that rewards victim status, while the AAP change of position may reflect a more conservative use of surgery in paediatrics generally (mirroring the decline in tonsilectomy, for example). The above narratives are, of course, entirely speculative. But no more speculative than the narrative presented in the opening post.

    While the research into the prophylactic effects of circumcision with regard to HIV is certainly interesting, for a population with low prevalence it doesn’t substantially change the terrain of the discussion about the benefits/risks of circumcision.

  9. Oedipa says:

    I usually back the doctors on SBM but I have to disagree this time. I cannot see the necessity for circumcision. Parents of uncircumcised boys have to teach them a bit more hygiene is all. The basis for most circumcision is religious and cultural, not medical.

  10. A visitor from outer space might be forgiven for concluding that the most important part of the human body is the foreskin. It is, after all, the only part of the body that has multiple organizations devoted to its preservation in the natural state. The visitor might get the impression that the choice of circumcision is a fateful choice with profound implications for the rest of life.

    Why does the issue of what other parents choose for their sons generate so much heat? The authors of the article are not proposing that circumcision be mandatory, merely that parents be informed of the benefits as well as the risks.

    Why do people attempt to derail the discussion by using inflammatory language like “mutilation”? If you don’t want to circ your sons, don’t do it, but why shouldn’t other parents make their own decisions?

  11. “If an adult wants to mutilate himself (piercings, scarring, circumcision, …) I have no qualms with that.”

    So you are equally opposed to piercing babies’ ears? By your definition, that’s mutilation, too?

  12. Dawn says:

    I didn’t have any male children so never had to make this decision. And, not being a male, I can’t speak from the sexual pleasure state. However, I have found that the glans of an uncirc’d male seems to be softer and more sensitive to touch during foreplay.

    I don’t have access to the full article so I don’t know if the studies looked only at the US, or at other countries. If they only looked at the US, I would prefer to see a study comparing STD levels in countries with high circ levels (i.e. the USA and Israel) to countries with very low circ levels (i.e. many of the European countries). Looking at the US, with its dismal record of sex education, use of contraceptives, and lack of health insurance only skews the results, in my mind. Compare the US to Belgium, The Netherlands (where prostitution is legal and controlled), or another European country.

  13. “People flip their lids over female circumcision…why not for males?”

    Because the male analogue of female “circumcision” is amputation of the penis. Why do anti-circ activists disingenuously equate male circumcision with clitoridectomy?

  14. “However, I have found that the glans of an uncirc’d male seems to be softer and more sensitive to touch during foreplay.”

    If that were the case, wouldn’t that be an argument FOR circumcision since prolonging intercourse seems to be an accepted goal for many men? There are certainly quite a few products out there that claim to let men “last longer” by decreasing sensitivity?

  15. gimpyblog says:

    Amy

    Why does the issue of what other parents choose for their sons generate so much heat? The authors of the article are not proposing that circumcision be mandatory, merely that parents be informed of the benefits as well as the risks.

    Could you deal with the ethical issues of why an irreversible medical procedure of no immediate benefit and of some risk should be carried out on a patient unable to give their consent?

  16. Oedipa says:

    “Because the male analogue of female “circumcision” is amputation of the penis.”

    You don’t need the clitoris in order to have intercourse.

  17. “a patient unable to give their consent?”

    Infants are unable to give consent to anything. They routinely undergo medical procedures with far more risks than circumcision based solely on parental consent. Why should circumcision be viewed differently?

  18. jebus19 says:

    Why do you gloss over the point of choice in the person being circumcised? What is wrong with actually waiting to perform circumcision in later life?

    In medical school now, our profs lecture us on patient and child autonomy. As MDs we need to as much as possible respect that. So what in this case necessitates performing this procedure when we’re doing without individual choice. Certainly, parent have some control over their children’s medical care but this doesn’t give them final say (i.e. parents of female children with severe mental retardation have wanted to have the reproductive organs removed to prevent menstruation as it creates a mess or there are issues with pregnancy from sexual abuse, they haven’t been allowed to do so). It would seem that many of the benefits are realized later in life. So why not wait? And again I don’t understand why don’t address that issue in your post, it’s a huge part of the debate.

  19. Dawn says:

    I don’t know, Amy. Maybe if the male was having problems with premature ejaculation, decreased sensitivity would help. But, again, since I’m not a male, I won’t make that call! :-)

    Can you clarify if the studies looked only at the US for the populations? Certainly, I am all for a procedure that is efficacious, but I want more information before I recommend it. And, were the populations matched for use of condoms, etc? As I said, I can’t get into the study so don’t know what they looked at.

  20. alison says:

    As someone with an intact husband and no sons this isn’t anything I’ve ever had to think about, but the idea of removing body parts just in case of future infection or disease seems a bit odd. Why stop at foreskins? Why not other non-essential bits of anatomy that might go wrong in future? Breasts, anybody? Where I live, lots more people die because of having breasts than because of having foreskins.

    BTW I disagree with having babies’ ears pierced …

  21. gimpyblog says:

    Amy

    Why should circumcision be viewed differently?

    Because its not medically necessary.

    PS as regards the ear piercings argument, in many countries it is illegal to pierce the ears of a child under the age at which the state considers them capable of giving consent.

  22. Plonit says:

    Because the male analogue of female “circumcision” is amputation of the penis. Why do anti-circ activists disingenuously equate male circumcision with clitoridectomy?

    +++++++++

    Actually, that is not completely accurate.

    There are many variations of female genital modification, as follows:

    Type Ia, removal of the clitoral hood only – this *is* analogous to male circumcision.

    Type Ib, removal of the clitoris and hood – as you say, analogous to penectomy.

    Type II – removal of clitoris and labia. The analogous structure to the labia is the scrotum, albeit that the contents are located elsewhere women.

    Type III – infibulation with excision – the equivalent would be sewing the remaining skin together after removal of the penis and scrotum.

    Type IV – “other” (pricking, piercing etc…), but which in a literal sense probably include genital piercings that are fairly widely-practised in the west.

    Efforts to eradicate the genital modification of girls typically do not differentiate between the types listed above (e.g. the Maputo protocol mandates signatories to prohibit all forms). One can see why from a legal perspective: if you allow Type Ia, then you can going to see a lot of intentionally ‘botched’ procedures to get around the law, especially given that Type Ia has always accounted for a small percentage of procedures amongst a much more damaging continuum. However, from a scientific standpoint, Type Ia in women is a exact analogue of the removal of the male foreskin, so it is worth asking ourselves (especially those of us who have circumcised our sons!) why we are content for this procedure (Type Ia) to be criminalised.

  23. caoimh says:

    “since prolonging intercourse seems to be an accepted goal for many men”

    I would say that the real goal is to ejaculate. How long it takes for this goal to be achieved depends on many circumstances.

    It is a poor argument for pro circ.

  24. Well, when the time comes I think I will be recommending to my son that he make use of condoms rather than editing is anatomy. The slant here seems to be (indirectly) endorsing riding bareback.

    Also, this post reads as pretty biased in favour of circ. Perhaps the author should work on her posts of persuasion coming off more impartial and less..well, smug.

    I don’t think the case is as self-evident as the author’s tone implies.

    Yours,
    CBB

  25. “Because its not medically necessary.”

    No one claimed it was necessary, merely that it is has medical benefits. In that, it is similar to many other medical decisions that we make for ourselves and our children every single day. It is not “necessary” to be vaccinated, but it is medically beneficial.

  26. David Gorski says:

    Imagine if we could save lives from a dread and often fatal disease simply by performing a minor surgical procedure. People would hail this simple victory and rush to adopt it… Not exactly.

    I think Harriet’s post on osteoporosis drugs is relevant here. What’s the number needed to treat to prevent one case of these diseases? This, I think, is just as important for a surgical procedure as it is for any drug.

    Also, FYI, Harriet has written about this before:

    http://www.sciencebasedmedicine.org/?p=269

    She mentioned that the NNT for sexually transmitted diseases is 72.

    Peter has written on this as well:

    http://www.sciencebasedmedicine.org/?p=431

  27. “There are many variations of female genital modification”

    And none have any medical benefit at all.

    Female genital mutilation is designed to mutilate. The purpose is to deprive women of sexual satisfaction in order to strengthen male power over women.

  28. “It is a poor argument for pro circ.”

    I wasn’t making that argument. I was pointing out that what anti-circ activists claim is a downside might just as easily be viewed as an advantage.

  29. BigHeathenMike says:

    “A visitor from outer space might be forgiven for concluding that the most important part of the human body is the foreskin.”

    While the reactionary and inflammatory language of the anti-circumcision side is justly identified, so should the condescending language seen here. No one is saying that the foreskin is the “most important” body part.

    With respect to the ear-piercing, it’s the same thing, in my personal opinion. I’m against doing anything surgical to my kid(s) that is attractive to me or beneficial in an elective way. When she’s old enough to ask, we’ll talk about it and then deal.

    It seems that with the statistics you (Amy) have stated, condoms are better in preventing the STIs and transmission, so they should be used. The exception would be places like Kenya and Uganda where there are wide-spread religious and cultural reasons to not use the most effective modality so to fight HIV, circumcision should be used.

    In locations like North America where there are no issues with condom use (apart from personal), the choice to circumcise boys should be the parents’ with the same, unchanged recommendation from the pediatric organizations, again, in my opinion.

  30. “Well, when the time comes I think I will be recommending to my son that he make use of condoms rather than editing is anatomy.”

    Great. And other people will make different decisions and different recommendations. The authors of the paper are arguing only that parents be informed of the very real medical benefits of circumcision. You might think those benefits are meaningless, or too small to lead to a decision to circ, but the benefits are real.

  31. “condoms are better in preventing the STIs and transmission, so they should be used.”

    Condoms should ALWAYS be used, but unfortunately are often not used. Circumcision provides another form of protection. It doesn’t render condoms unnecessary (particularly for prevention of unwanted pregnancy, obviously) but that doesn’t change the fact that circumcision independently lowers the risk of transmission of HIV and other STDs.

  32. provaxmom says:

    No one claimed it was necessary, merely that it is has medical benefits. In that, it is similar to many other medical decisions that we make for ourselves and our children every single day. It is not “necessary” to be vaccinated, but it is medically beneficial.

    Just as long as those benefits aren’t exaggerated, just like breastfeeding benefits are exaggerated at times. And unlike vax diseases, STDs are often contracted due to lifestyle choices (unprotected sex). My sons do not have the choice as to whether or not they sit next to an un-vax’d kid at school or at the playground. They do have the choices as to whether or not to have unprotected sex, or participate in IV drug use.

    I would also hate to see us reach a point in this society where a man doesn’t use a condom, thinking that he’s safe because he’s circ’d. Because although the benefit is there, it’s a very small benefit.

  33. provaxmom says:

    And fwiw, dictionary.com defines mutilate as:

    1. to injure, disfigure, or make imperfect by removing or irreparably damaging parts: Vandals mutilated the painting.
    2. to deprive (a person or animal) of a limb or other essential part.

    So while it is certainly a dramatic word, it’s not incorrect to use it.

    Also, this phrasing: “”The AAP had long recommended male circumcision for prevention of urinary tract infections in young boys, but backed down in 1999, partly in response to pressure from anti-circumcision activists. “”" makes those of us who don’t circ sound like the anti-vax crowd, when I really don’t think that is an accurate comparison.

  34. Plonit says:

    “There are many variations of female genital modification”

    And none have any medical benefit at all.

    Female genital mutilation is designed to mutilate. The purpose is to deprive women of sexual satisfaction in order to strengthen male power over women.

    +++++++++++++

    Actually, we don’t know that

    The possible medical benefits of those forms of female genital modification analogous to male circumcision have not been studied. Since the removal of the male prepuce has been found to have some medical benefits it is quite plausible that the exactly analogous procedure in women might also be found to have some benefits, if it were to be studied.

    Moreover, I would have had my sons circumcised even if there were not one shred of evidence that it was medically beneficial since I had it done for purely non-medical reasons. Jews (even cultural ones) are not going to stop circumcising their sons because this or that study shows a statistically significant decrease/increase of this or that – it is a non-medical decision.

    Your description of the purpose(s) of female circumcision massively oversimplifies. The proponents of FGM (many of them women) obviously do not regard it as a mutilation, but as something that enhances the status of women. Traditional discourse on male circumcision (e.g. Maimonides) also cite the reduction of sexual pleasure (this is seen as a ‘pro’, since this gives men control over their animal urges). (And if you want a laugh – see Scott Stein here http://whenfallsthecoliseum.com/2008/10/30/circumcision-jewish-conspiracy-theory/ )

    Anyway, if you are going to get into this, you do actually have to make the argument and not simply fall back on your cultural prejudices. Many parenting practices are sexist (including the inclusion of male children in the covenant without equivalent recognition of female children) but not criminal. What, specifically, is wrong with Type Ia FGM (removal of the female prepuce) such that it is reasonable to criminalise parents who wish to have this procedure performed?

  35. vexorian says:

    It has been a major disappointment to see this in sbm.
    * There are ‘claims’ that circumsition can somehow reduce the risk of infections the rates’ change seems extremely low however. Condoms are a magnitude more effective and do not involve such change to anatomy.
    * How exactly do you do correct trials for circumsition? This is exactly like trialing for acupuncture which has been taken care of by this site multiple times. I think the complaint is still valid in this case.
    * “anti-circ” people call it mutilation because it is exactly so. The prepuce is a very sensible sensory organ. The neonats do feel the pain. Besides that this organ is very important in the acquisition of pleasure during intercourse. At the end of the day, I’d rather use a condom…

    * This advice sounds exactly like the conservative groups’ advice for abstinence. Instead of recommending the most effective prevention – condoms- we lose time recommending things that , in theory, reduce the risks. But at least we know that abstinence is effective as long as you practice it. In the case of circ, the evidence is still way too blurry and the risk reduction is quite poor.

  36. Aaron says:

    I would also hate to see us reach a point in this society where a man doesn’t use a condom, thinking that he’s safe because he’s circ’d. Because although the benefit is there, it’s a very small benefit.

    Possible, but no more dangerous than America’s myriad other deficits of sex ed. Actually, it may provide some comfort that the study above considered this angle, and so far haven’t seen evidence of it, as quoted above:

    In addition, it has been hypothesized that behavioral disinhibition may counteract any protective effects of male circumcision. However, there was no consistent or substantial evidence of change in sexual behavior after circumcision in the Kenyan or Ugandan randomized controlled trials.

  37. windriven says:

    @Oedipa

    “You don’t need the clitoris in order to have intercourse.”

    No, only to enjoy it.

  38. Nick says:

    Why this phobia of foreskin ? It’s natural part of body.
    It’s ridiculous. Circumcision is painful and it’s disturbing. And female circumcision isn’t like removing the entire penis (it’s not even close).
    History shows circumcision is a cure in search of a disease. It was supposed to cure :

    1832 Nocturnal Emissions
    1845 Masturbation
    1855 Syphilis
    1865 Epilepsy
    1870 Proof that circumcision cures epilepsy
    1870 Spinal Paralysis
    1873 Bed Wetting
    1875 Curvature of the spine, Paralysis of the bladder, and clubfoot
    1879 Abdominal Neuralgia
    1881 Unspecified “eye problems” due to masturbation
    1886 Crossed Eyes
    1888 Circ as punishment for masturbating
    1890 Blindness, Deafness, Dumbness
    1894 Keeping blacks from raping whites
    1894 Urinary and Rectal Incontinence
    1900 Discourage Sexual Immorality
    1914 Tuberculosis
    1915 Clitoral Hood is the source of neuroses, female circumcision is recommended (Yes. This is the USA)
    1918 Female Circ will curb Masturbation
    1926 Penile Cancer
    1930 Claim of Epilepsy cure from a circumcision (notice the 65 year gap between claim and supposed proof?)
    1942 Prostate Cancer
    1949 Venereal Disease and Cancer of the Tongue
    1951 Male circumcision prevents Cervical Cancer
    1954 Cervical Cancer again
    1058 “the same reasons that apply for the circumcision of males are generally valid when considered for the female.” CF McDonald
    1959 Making Clitoris easier for husband to find
    1966 Masters & Johnson claim no difference in sensitivity between intact and severed penises. No proof given.
    1969 Nervousness, and of course masturbation (Still with the masturbation and we’re in Viet Nam by now)
    1971 Rectal Cancer & Bladder Cancer
    1973 Carcinoma

    1975 AAP declares circumcision has no medical indications, and does not recommend it
    1976 Benjamin Spock: “I strongly recommend leaving the foreskin alone. Parents should insist on convincing reasons for circumcision — and there are no convincing reasons that I know of.”

    1985 Urinary Tract Infection
    1986 AIDS
    1988 Group B Streptococcal Disease
    1989 AAP Reverses circumcision policy, and recommends it when Dr Edgar Schoen (known circumcisionist) presides over board.
    1991 Schoen tries and fails to get European countries to circumcise en masse
    1991 For sand in soldier’s foreskins (Desert Storm time)
    1997 Schoen once again tries and fails to chop off european dicks

    1996 JR Taylor finds that the average amount of removed foreskin is nearly half of penile skin.
    1997 Janice Lender discovers that circumcision without anesthesia is traumatic.
    1999 JR Taylor: foreskin “… a primary erogenous tissue necessary for normal sexual function.”

    1999 AAP after 40 years of research, reverses policy again..”potential medical benefits of newborn male circumcision… are not sufficient to recommend routine neonatal circumcision.” Hygiene “there is little evidence to affirm the association between circumcision status and optimum penile hygiene.” STDs “behavioral factors appear to be far more important than circumcision status.” Cancer “in a developed country such as the United States, penile cancer is a rare disease and the risk of penile cancer developing in an uncircumcised man, although increased compared with a circumcised man, is low.” UTIs “breastfeeding was shown to have a threefold protective effect on the incidence of UTI in a sample of uncircumcised infants. However, breastfeeding status has not been evaluated systematically in studies assessing UTI and circumcision status.” Ethics “is not essential to the child’s current well-being”

    2003 Edgar Schoen tries to pressure AAP to reverse it’s policy his way, claiming it prevents AIDS.

    2005 HIV rates are lower in females who have been FGM’d
    2007 The infamous Bailey/Auvert study … touting circumcision as a ‘vaccine’ that prevents HIV infection.

    2007 Langerhans Cells in the foreskin are found to to be a natural barrier to HIV
    2007 M Sorrels releases study that finds the foreskin the most sensitive art of the penis and the glans the least.

    Most authors of pro-circumcision studies claim that they have no vested interests in their work. However, when we examine who conducted these studies – their motives become evident. These studies are usually done by circumcised males who try to validate their own circumcision and legitimize the practice. Doctors who circumcise must protect their reputations and careers. Statements to the effect by the authors that they have no vested interest in conducting these studies are merely a facade to provide credibility to their research. It doesn’t take a great genius to see the obvious conflict of interest.

    I don’t think it’s up to parents to decide if a child is allowed (or not) to keep healthy and erogenous tissues. Infant circumcision should be banned unless there’s a solid medical reason and all other less invasive treatments have failed.

    Most parents are mislead into thinking circumcision is healthier. This isn’t true. Circumcision is medical fraud.

  39. windriven says:

    @provaxmom

    “1. to injure, disfigure, or make imperfect by removing or irreparably damaging parts: Vandals mutilated the painting.
    2. to deprive (a person or animal) of a limb or other essential part. ”

    Does removal of the foreskin:

    Injure? No, it offers some protection against disease.
    Disfigure? I suppose that is a matter of opinion.
    Make imperfect? Again, a matter of opinion
    Deprive of an essential part? Hardly.

    Mutilate is a word used in this context to inflame rather than to explain.

    That said, I fail to understand the rush to clip. If the literature demonstrated some huge, positive protection against a plague of dangerous adolescent UTIs then an argument could be mounted in favor of circumcision. But as I understand it the benefits, such as they are, accrue only to the sexually active and their partners.

    I for one would be more than disturbed to learn that a 6 year old son was having a hot affair. Circumcision pro and con could as easily be presented as part of sex education at an appropriate age and the choice made by the owner of the aforementioned foreskin.

  40. Pattoye says:

    I think this post shows a fairly clear lack of critical analysis from a cost/benefit perspective. That circumcision has some benefits is fairly clear. The benefits are not, by any measure, earth shattering. Since the benefits are marginal risk reduction, shouldn’t a real look at the risks be offered? I’m not saying specifically that the risks outweigh the benefits, but the fact that there are entirely omitted from this post is a glaring omission.

    This doesn’t even touch the ethical basis, in that the majority of the benefits of circumcision do not occur until after a male would be old enough to make this decision for themselves. There is little justification for the loss of autonomy by a parent making a decision for a child as a baby that could be left until they are old enough to at least have input in the decision. This is obviously not true with vaccines, so it is a specious analog to the autonomy issues raised.

  41. windriven says:

    There would seem to be some evolutionary advantage to the foreskin, though I can’t imagine what it might be. Does anyone know or care to speculate?

    Or perhaps it is simply vestigial?

  42. Plonit says:

    *If* there are clinically significant benefits (which has not been demonstrated) then the risks of the procedure may be reduced by it being performed in the neonatal period, rather than during adolescence.

  43. “the possible medical benefits of those forms of female genital modification analogous to male circumcision have not been studied.”

    And therefore you cannot make claims about their existence.

  44. windriven says:

    @Nick

    If you’re going to post putative facts complete with dates, how about citing a source so that those of us with a cynical bent can check for ourselves?

    Further, when you make statements like:

    “Circumcision is painful and it’s disturbing.” Disturbing? To whom and in what way?

    and more egregious still:

    “And female circumcision isn’t like removing the entire penis (it’s not even close).” Yes Nick, it is in most cases EXACTLY like removing the entire penis.

    and from bad to childish:

    “1997 Schoen once again tries and fails to chop off european dicks.” The use of gutter slang in a serous discussion is inappropriate.

    You mark yourself as someone disinclined to serious discourse.

  45. “Condoms are a magnitude more effective and do not involve such change to anatomy.”

    Why do you view it as an either-or choice? The benefits of condoms are only available when they are used. In contrast, the benefits of circumcision are always present.

    “How exactly do you do correct trials for circumsition?”

    You cannot correct RCTs, but RCTs are not the only studies that provide valuable and valid information.

    “This advice sounds exactly like the conservative groups’ advice for abstinence.”

    Actually, it is the anti-circ folks who sound most like the abstinence folks. Those advocating abstinence point out that it is 100% effective at preventing pregnancy and STDs. And the rest of us point out that 100% abstinence is not likely to happen in the real world.

    Similarly, anti-circ activists point out that condoms are effective in preventing transmission of STDs. However, 100% condom use is not likely to happen in the real world.

  46. Scott says:

    Amy,

    I can’t help but notice that you STILL haven’t responded to the repeatedly raised question, “why INFANT circumcision?” What is the rationale for circumcision of infants, as opposed to letting them make their own decision later in life?

    The fact that parents can make such decisions on behalf of an infant doesn’t necessarily mean that they should. There are clear and compelling benefits to waiting. Therefore there need to be clear and compelling benefits to NOT waiting in order for that to be a justifiable choice. You haven’t provided any.

  47. “I can’t help but notice that you STILL haven’t responded to the repeatedly raised question, “why INFANT circumcision?”

    This post is not about defending circumcision. It is an explanation of the current state of research on the reduction in transmission of HIV and other STDs by circumcision.

    If you don’t want to circumcise your sons, don’t do it. If you don’t think the benefits outweigh the risks, don’t do it. Just don’t claim that there are no medical benefits when there are real benefits.

  48. Plonit says:

    I did not make any claims about their existence. I merely observed that since the removal of the male prepuce has some medical benefits, it is plausible that the removal of the analogous structure in women may also have some (as yet unknown) medical benefits.

    Contrast with your own statement “And none have any medical benefit at all.” If you had said “And none have been shown to have any medical benefit” you would have been correct. It is also the case that, while we have copious evidence on the harm done by more extensive FGM, no research into the specific harms (and any possible benefits) of the removal of the prepuce only informed the decision to criminalise this procedure.

    So, I ask again, what, specifically, is wrong with Type Ia FGM (removal of the female prepuce) such that it is reasonable to criminalise parents who wish to have this procedure performed?

  49. joep says:

    Amy said: “It is not “necessary” to be vaccinated, but it is medically beneficial.”

    I would expect that Amy would understand that there is a chasm of difference between a vaccination and a circumcision. For one, a vaccination is typically the cheapest, most efficient, safest, and frequently the only way to gain a particular benefit. Circumcision almost never meets any of these criteria let alone most or all of them.

    I don’t, for example, know any other reasonable way to protect a child from measles other than a vaccination. On the other hand, as has alread been pointed out, there are far better ways to protect from STDs.

  50. Pattoye says:

    “This post is not about defending circumcision.”
    That is an odd claim to a post titled “The case for neonatal circumcision.”
    One of the expectations I’ve always had for this blog is that the views provided are balanced. When an issue is raised, it is covered in a reasonable perspective, discussing things like risk and practical and ethical implications. Many of the posts on here discussing vaccines cover the (albeit small) risks of vaccination. How can you make a balanced case when you say “Here are the benefits, now go form an opinion?”
    Please try to be a little more reasonable in your discourse. The ability to see shades of gray and deal with real world complexities is what separates us from the woo peddlers.

  51. Dawn says:

    Please – can anyone tell me the location(s) of the population studied and whether or not the population was controlled for condom use?

  52. Plonit says:

    Given the intervening comments, my comment above would have been clearer had I begun

    “I did not make any claim that there are medical benefits for Type Ia FGM.”

  53. joep says:

    Amy said: ““the possible medical benefits of those forms of female genital modification analogous to male circumcision have not been studied.”

    And therefore you cannot make claims about their existence.”

    Actually, Stallings et. al. IAS 2005 did find that “circumcised” women in Tanzinia had a significantly lower risk of contracting HIV too. Couriously, they called this a “conundrum” and nobody cared to follow it up.

    @Scott

    I also see no compelling reason for ‘infant’. If there is a “benefit” to circumcision then present your case to the individual when they can make an informed choice. Particularly when you’re talking about benefits that have nothing to do with the infant or child’s health. That is the only ethical approach.

  54. Nick says:

    @windriven :

    If male circumcision wasn’t socially acceptable, common sense should tell you that removing a natural part of body isn’t the right thing to do. (especially without consent)
    It’s obvious that this procedure is unnatural. It’s a religious practice that became medicalized.
    The foreskin is supposed to be there, it’s not a birth defect and there’s nothing wrong with it. There are a ton of men (including myself) who are unhappy with a circumcised penis. I strongly feel it wasn’t up to my parents to make this decision. I have been restoring my foreskin for almost 2 years now and it enables me to get back a ton of sensitivity :

    http://www3.interscience.wiley.com/journal/118508429/abstract?CRETRY=1&SRETRY=0

    Also, where did you see that “in most cases”, female circumcision is like removing the entire penis ? Do you have any statistic ? And if removing the clitoral hood is banned because it violates basic human rights, can you tell why infant circumcision is still allowed ? Because the inner foreskin has far more nerve ending than the clitoral hood.

    Studies claiming male circumcision has health benefits are debatable at best. It is said that it reduces HIV by 55%. Why the USA has both the highest rates of circumcison and HIV among industrialized countries ? Why other countries like Sweden or Japon have both very low rate of HIV and circumcision ,

    If you want more information about history of circumcision in US, you can make your own research. It just takes a couple of minutes to realize it’s cure in search of a problem. You can start by reading that :
    http://www.historyofcircumcision.net/index.php?option=content&task=view&id=31

  55. Scott says:

    This post is not about defending circumcision. It is an explanation of the current state of research on the reduction in transmission of HIV and other STDs by circumcision.

    In light of:

    The AAP should heed the authors’ call.

    I don’t think you can duck the issue that way. The current policy as quoted by the paper:

    The American Academy of Pediatrics (AAP) male circumcision policy states that while there are potential medical benefits of newborn male circumcision, the data are insufficient to recommend routine neonatal circumcision.

    The change you are endorsing is apparently that the policy should state that the data are sufficient to recommend routine neonatal circumcision. But unless there are data showing that neonatal circumcision has specific benefits that circumcision later in life does not, then that is not true and the current policy remains accurate.

    The AMA recommending circumcision prior to becoming sexually active would be justifiable based on the data presented. But not the AAP recommending neonatal circumcision.

  56. JurijD says:

    there are two issues here

    a) the reviewed medical benefits/risks concerning male circumcision

    b) the question of whether it is sensible for medical institutions to advise parents to have it performed

    Concerning A:
    I think that research in recent years has shown that overall (especially in less developed countries) male circumcision does have tangible benefits when it comes to lowering the risks for STD. These effects are clinically relevant when one considers them in the context of unprotected sex. Of course, when one wears a condom these benefits disappear… as has been pointed out previously. Now while it is true that a condom “comes off” but circumcision is forever there is only a special subset of cases where circumcision would make a real benefit to lower the rates of say HIV infections:
    - it is certainly not in those who practice safe sex
    - it is also not in those who practice unsafe sex regularly with multiple partners (they will get infected perhaps only with somewhat of a temporal delay)
    - circumcision would probably help reduce infection rates in groups of people who “occassionally” (rarely) perhaps have unprotected intercourse.

    This is my personal opinion given what I know of infectious diseases. It would be nice if one could ascribe exact numbers to this and perhaps run a few simulations to see just what kind of an effect circumcision would have in certain countries.

    I suspect a generalized circumcision program say in some African country would lower infection rates quite a bit more than say in some European country.. since in the latter condom usage is mostly higher.

    Concerning B:
    This is more or less a value judgment and one needs to separate it from basic science so you do confuse the issues. In my own personal opinion the supposed benefits of circumcision are not nearly enough to warrant a recommendation for such an operation on infants in, say my region – Europe.

    If I were however practicing in Nigeria, I would have to reevaluate this stance based on what the local populus does, how high the rates of STDs are, how much condoms are used etc.

    If I were practicing in the US, I also would not recommend such a procedure because just like in Europe, simply educating on safe sex and promoting condom usage is far far more effective in my opinion.

    We would have to look at this procedure in terms of NNT (numner needed to treat) – that is how many people do we have to have circumcised to prevent say a certain number of STD infections. I have yet to see decent numbers on this topic. Any formal medical recommendation should be based on the comparison of this NNT against the % of possible circumcision related side effects.

  57. DevoutCatalyst says:

    For those who are hopping mad about their circumcision, foreskin restoration is there for you. Rejoice smegmates – let Google Image show you the way…

  58. Zoe237 says:

    I am in full agreement with provaxmom. You can’t look at reduction in the disease without also looking at the prevalence of the disease. It is misleading to say that there is a reduction of 60% (or whatever) without also looking at how often the disease occurs. Or Dr. Gorski’s NNTT.

    Thankfully, circ rates in Europe are well below 50% and the U.S. I believe are right around 50% and plummeting. And yet, there has been no increase in HIV that I’m aware of. There’s a big difference between STDs in Africa and here.

    Furthermore, the authors and Dr. Tuteur are advocating that ACOG, AMA, and AAP change their policies to RECOMMEND infant circumcision. This is not just a matter of presenting it to parents as an option- that is what is done now. And apparently it’s not good enough.

    This is just another example of Dr. Tuteur’s extremist, out dated, and unsupported by evidence views on current policies. I have to say that every single doctor who examined by sons (in the early 2000s) said some variation of “Good. It’s not necessary.” or “I’m glad to see you didn’t circumcise.” These were almost exclusively males.

    Please see Dr. Hall’s blog for a more reasoned exploration of the debate.

  59. Calli Arcale says:

    “This post is not about defending circumcision.”
    That is an odd claim to a post titled “The case for neonatal circumcision.”

    A pertinent point, especially in light of Amy’s reluctance to answer the question about “why *infant* circumcision”? Her title indicates that she is specifically talking about the circumcision of infants, which would suggest that the article would contain something of relevance as far as circumcising as young as possible.

    I had no sons, so luckily did not have to make this choice. My husband is in favor of infant circumcision.

    Interestingly, my grandfather is also in favor of infant circumcision. He is himself uncircumcised. I have never really felt comfortable asking him for his rationale; it’s an awkward topic to discuss with one’s elders. I am ambivalent about it myself; I would likely have formed a better opinion had ultrasounds not revealed the absence of relevant anatomy on my children. It was something of a relief not to have to think about it, to be honest.

    As far as female genital mutilation, numbers are not consistent so it is difficult to tell what the true rate of various procedures are, largely because it is primarily practiced in regions without consistent reporting and usually performed by non-medical personnel. It definitely has higher complication rates than male circumcision. (BTW, I think the term “circumcision” is odd for female genital mutilation, mostly because the word literally means cutting around the circumference, and that’s not really descriptive of the female procedure.)

    Both male and female procedures were originally designed to limit sexual desire, for a variety of reasons. Yes, they wanted to reduce *male* sexual desire as well, and a parent wanting to control his sons would want them circumcised if this would help in that effort. There are also factors of ethnic identity, not just in Judaism but in many groups. In some parts of Africa where various forms of genital modification are practiced, it is not done at infancy but rather at puberty as part of a coming-of-age ritual. To become a man or a woman, and ready for marriage.

    It is not surprising that there are some modest health benefits. But I still fail to see why it is better to do it as an infant rather than later in life. The one thing I am sure of is that it is absolutely abhorrent that until recently, it was common practice to do it without anesthesia or post-operative pain relief. Okay, I can kinda understand the religious aspects of that, but doctors should not be complicit in that. No, the baby won’t remember the pain ten years later. But the baby feels the pain *now*, and that ought to be significant. If the risks of pain relief and local anesthesia are too great in a newborn, maybe they should consider whether it’s really worth doing it right now anyway.

  60. Zoe237 says:

    Dr. Tuteur:

    “This post is not about defending circumcision.”

    Pattoye:

    “That is an odd claim to a post titled “The case for neonatal circumcision.”

    LOL! Seriously, this is like the fifth direct contradiction in two months between the blog posts and Dr. Tuteur’s comments. Really bizarre.

  61. jonny_eh says:

    I can’t believe all the fallacies I’ve counted reading these comments. I expect more from this audience.

    So far (that I’ve noticed):
    -False dichotomy (condom vs circumcision)
    -Appeal to nature (It’s unnatural to remove the foreskin)
    -Appeal to emotion (Calling it mutilation)
    -False equivocation (Comparing it to removing a leg or female circumcision)
    -Appeals to anecdotes

    I suspect that many skeptics are not thinking very rationally on this issue due to its association with religion.

    This is a debate worth having, but please try to use valid arguments and avoid inflammatory rhetoric. It really reads like people are taking this issue personally.

  62. vexorian says:

    Thank you for also adding argument from fallacy to the list.

    If condoms are a lot more effective against STDs, specifically AIDS than circumcision. How is it worth doing it? Also, how is it not mutilation? This article is of pseudo-scientific nature first appealing to using AIDS as a scare (which is not too effective as condoms are a lot more effective than that) and at the end trying to appeal to authority and also indures on false equivocation itself by trying to put people who oppose to circumcision in an equal level to anti vaccine nuts. It seriously harms SBM’s reputation.

    How can these studies be believable at all? You cannot make double blind tests with circumcision. I also think that exposing humans to having intercourse with people that have infections or AIDS would not be humane. All the studies seem to do is measure infection rates between circumcised people and non-circumcised people which would not really be scientific at all.

    What we have here is an article that advices a surgical procedure that removes a part of the body that increases the sensory experience of intercourse stating that there are dubious trials that demonstrate doing this can mildly reduce the rates. While there is already a solution for STDs and AIDS that is a lot more effective and without permanent effects.

    You are right though that the only reason humans have started doing it is related to religious beliefs and also some conservative groups that would think it would stop masturbation. It is the only way such great idea would come to pass and we wouldn’t have these ‘studies’ if it weren’t for such irrational reasons. It is fairy science all over again.

  63. “That is an odd claim to a post titled “The case for neonatal circumcision.”

    That’s the subtitle of the scientific paper.

  64. Nick says:

    “False dichotomy (condom vs circumcision)”

    Condoms are cheaper and much more effective than circumcision. Not to mention these African studies are flawed in many ways. Please note than infants and children aren’t sexually active so that doesn’t justify neonatal circumcision. HIV is another poor excuse to justify a barbaric procedure (please read my post about history of circumcision).

    “Appeal to nature (It’s unnatural to remove the foreskin)”
    I don’t see any problem with that. Foreskin is nautral part of body and is supposed to be there.

    “Appeal to emotion (Calling it mutilation)”
    I don’t have any problems with emotions, we aren’t robots, are we ? Have you ever watched a video of infant circumcision ?
    Also appeal to emotion has been also used in this article : “Imagine if we could save lives from a dread and often fatal disease simply by performing a minor surgical procedure.”
    This seems exaggerated, if not completly incorrect.
    And circumcision is mutilation.

    “False equivocation (Comparing it to removing a leg or female circumcision)”
    Please reread the different posts. There are many types of female circumcision. Some types are equivalent or less invasive than male circumcision. But all types of female circumcision are banned because they all violate bodily integrity and cause harm. So why male circumcision isn’t banned yet ?

  65. David Gorski says:

    This post is not about defending circumcision.

    You could have fooled me. That’s certainly how it came across to me when I read it. Indeed, the wag in me can’t resist asking: If your post isn’t a defense of infant circumcision, why entitle it “The Case for Neonatal Circumcision” even if it is the title of the paper you’re discussing and especially given that there was no discussion of a risk-benefit ratio? I don’t deny that circumcision likely has benefits, but given the aforementioned NNT, are they worth the risks (even relatively small ones) and the need to do 72 circumcisions to prevent one case of STI?

    Now, it’s entirely valid to present the case for circumcision in a single post, but isn’t presenting the case for circumcision in essence defending it, particularly given the glowing first sentence about stamping out disease, the dismissive references to the “anti-circ” crowd, and your final sentence, in which you state bluntly that the AAP should heed the authors’ call,” presumably to change its position statement stating that the evidence doesn’t justify recommending routine circumcision of neonates to parents? What is that if not defending neonatal circumcision, at least implicitly? Why deny that that’s what you were doing? There’s nothing wrong with taking a position, as long as it’s clear what your position is and you back it up with evidence.

  66. Pattoye says:

    ““That is an odd claim to a post titled “The case for neonatal circumcision.”

    That’s the subtitle of the scientific paper.”

    That’s dodging the original claim that your post is not in defense of circumcision.

    You open with a sentence that all but endorses circumcusion as a minor surgical procedure that can save lives from a dread and often fatal disease. That certainly sounds like a defense of circumcision to me.

    You close with the sentence “The AAP should heed the authors’ call” to update its circumcision recommendations to more strongly support circumcision.

    I’d say your position is clear. There is nothing wrong with having a clear position. Unless, of course, you then try to say that it isn’t your position at all. I’m baffled as to why you would even make that argument.

  67. vexorian says:

    Please note than infants and children aren’t sexually active so that doesn’t justify neonatal circumcision.

    I am “anti-circ” as that seems to be the derrogatory term of choice today. However, I think that if these claims were true (and I don’t agree the studies mentioned are doing science right) then it would be an argument for neonatal circumsition since in theory, adult circumcision is a much more complicated and risky procedure.

    “HIV is another poor excuse to justify a barbaric procedure ”
    It is the single poorest excuse since circumcised males still need to use a condom to protect themselves against AIDS. However, as barbaric as it is it is not necessary to appeal to that fact to show that circumcision is definitely not necessary.

    “I don’t have a problem with emotions”
    Well the thing is that they aren’t a scientific argument. So appealing to emotions does not really help to justify the argument.

  68. vexorian says:

    Why do you view it as an either-or choice?

    I don’t . I do see that even if the “studies” named were reliable the small rate decrease will require me to still use a condom even if I was circumside.

    The benefits of condoms are only available when they are used. In contrast, the benefits of circumcision are always present.

    Unfortunately , the studies have failed to demonstrate beyond doubt that these benefits exist at all. They did demonstrate that even if they did exist I would still need to use a condom when circumcised.

    It sounds unnecessary. I also think that maybe there are chances an uncircumcised guy did not receive the important teaching that he needs to clean it up. There are no studies that ensure that we are comparing circumcised males and uncircumcised males that practice hygiene…

  69. joep says:

    JurijD said: “I think that research in recent years has shown that overall (especially in less developed countries) ”

    And indeed this is what the recommendation from the WHO and UNAIDS has indicated, that circumcision should be considered as a potential intervention for HIV where there is high prevalence and the epidemic is not focused in a particular population. This would exclude most countries including the US and those in Europe.

    One must also consider the ethics of such an intervention, something which Amy in her many posts on this subject consistently ignores.

  70. JurijD says:

    On the “condom-circumcision” false dichotomy issue

    A number of commenters and Amy herself have asserted that bringing condoms into this debate somehow constitutes a case of the false dichotomy fallacy. I do not believe this is the case for how most people formulated the argument (myself included) and here is why:

    saying just “circumcision is not warranted as we have condoms that offer more protection” could be considered a false dichotomy as one could argue that performing circumcision alongside wearing a condom is perfectly possible but this ignores all the baggage that comes with both of these two options.

    Circumcision is not just an added procedure with no risks to it. As performed usually (religiously) it does cause pain and suffering to infants and while this could be prevented by having the procedure performed only in hospitals under anesthesia there are other risks that are common to all operative procedures: risks of infections, scarring, genital mutilation etc. On top of that I am not convinced that the available literature can give a decent enough guarantee that removing the foreskin does not lessen sexual pleasure in men. It does seem to lean in that direction but we have to set the bar much higher if we plan on cutting away a perfectly functioning part of the male anatomy in the hope of some future benefits.

    There is really no false dichotomy here. One cannot just casually perform circumcision with the rationale that it lowers STD risks while claiming that those who point out that we have a more effective way of doing that with no operative risks attached, are making a false dichotomy fallacy.

    We DO have an excellent way of preventing STDs – condoms. They do not require us to impose operative risks on children and then also do not require us to possibly risk diminishing their future sexual pleasure to gain what is only a partial decrease of STD infection risk. If this were not the case the circumcision option would be far more appealing.

    It can be logically argued then that in light of this non-invasive option, circumcision is simply not justified for the benefits attributed to it and in light of the fact that it is not risk-free.

    It would however be greatly beneficial to have hard numbers here: NNT for circumcision related STD risk reduction (in say western countries), % circumcision related adverse effects, and the prevalence of condom usage.

    If such data was available and it pointed strongly towards circumcisions lowering the risk of STDs while having only an insignificant number of adverse effects in the whole NNT population IN western countries then a case could be made for a general recommendation to have males circumcised.

    The question of whether one is justified in performing this operation on infants is another matter entirely.

    But currently I tend to err on the side of caution and not promote an operative procedure with questionable benefits in a real-life European scenario and real adverse effects – in the complete absence of hard data on the issue.

  71. Nick says:

    “adult circumcision is a much more complicated and risky procedure.”

    Where did you see than it’s much more complicated and risky for an adult ? Do you have some studies to support that position ?
    I would think it’s the opposite. During infancy, the foreskin is fused to the glans whereas for an adult, the foreskin is already retracted making the amputation more easier. Also the foreskin is bigger, the procedure can be performed with greater precision, it can be a loose/tight etc… cut whereas for an infant the result is more random. ALso adults are under genral anesthesia, they don’t feel anything during the procedure. So it’s more uncomfortable than painful.

  72. Nick says:

    “adult circumcision is a much more complicated and risky procedure.”

    Where did you see than it’s much more complicated and risky for an adult ? Do you have some studies to support that position ?
    I would think it’s the opposite. During infancy, the foreskin is fused to the glans whereas for an adult, the foreskin is already retracted making the amputation easier. Also the foreskin is bigger, the procedure can be performed with greater precision, it can be a loose/tight etc… cut whereas for an infant the result is more random. ALso adults are under genral anesthesia, they don’t feel anything during the procedure. So it’s more uncomfortable than painful.

  73. steveisgood says:

    Regarding a commenter who pointed out the potential for decreased sexual sensitivity in men, Dr. Teuter responded,

    If that were the case, wouldn’t that be an argument FOR circumcision since prolonging intercourse seems to be an accepted goal for many men? There are certainly quite a few products out there that claim to let men “last longer” by decreasing sensitivity?

    I have to ask by what authority does anyone have that can claim a) how much sensitivity is ideal b) why “lasting longer” is necessarily desirable for all men, c) whose business is it that men should have decreased sensitivity anyway? Some men last too long, and cannot climax because of too little sensitivity. I worry that a forced procedure would contribute to that problem even more.

    In contrast, another commenter brought up the (barbaric) practice of female genital mutilation, to which Dr. Teuter (rightly) responded,

    Female genital mutilation is designed to mutilate. The purpose is to deprive women of sexual satisfaction in order to strengthen male power over women.

    I admit to some cognitive dissonance here, and I’m hoping Dr. Teuter could clear this up. Why is decreasing sexual sensation in men okay but not okay in women? I understand that part of it is a level of degree (in women it’s intended as total removal of sexual sensation), but that doesn’t appear to be the argument, which is about having sexual sensation in general.

    It seems to border on hypocritical and I’d like this apparent conflict cleared up please. Thanks.

  74. provaxmom says:

    johnnyeh wrote:

    “So far (that I’ve noticed):
    -Appeal to nature (It’s unnatural to remove the foreskin)”

    But it is unnatural. Please give me another socially and medically accepted example of where we surgically remove body parts without serious justification.

    Why don’t we just start removing gall bladders, appendices and spleens, and routinely do double mastectomies? Then we would have zero appendicitis, spleen and gall bladder disease, and we could effectively reduce breast cancer to zero. After all, we know that we can live without them, right?

  75. edgar says:

    “How can these studies be believable at all? You cannot make double blind tests with circumcision. ”

    There are many instances where double blinding cannot occur. Still studies must be done and taken on their merits. It is a limitation sure, but studies shouldn’t be dismissed because of it.

    I think the scientifically supported position should be to recommend AGAINST routine newborn circumcision, and discuss it as an option to adults.

  76. carrie says:

    You need to watch out for the way comparisons are made between adult and infant circumcision. I remember one study I read on the WHO AIDS page said that adults had more complications but then I looked at the criteria and the adults figures included “pain” while the infants did not!

    Also, many infant complication numbers do not include things like metal stenosis or webbed penis.

  77. carrie says:

    sorry that should read “meatal stenosis”

  78. Nick says:

    “I remember one study I read on the WHO AIDS page said that adults had more complications but then I looked at the criteria and the adults figures included “pain” while the infants did not!”

    For a long time doctors used to think infants didn’t feel pain. No, we know it’s untrue. In fact, they may be far more sensitive to pain. There are a decent number of studies showing infant have long term consequences for the future adult :

    http://www.sciencedaily.com/releases/1999/08/990816065623.htm

    http://www.circumcision.org/response.htm

    “Also, many infant complication numbers do not include things like metal stenosis or webbed penis.”

    Of course they do.

  79. Brett Charles says:

    Amy I see you are an Ob/Gyn.

    You do seem to be clutching at straws looking for the benefit.

    A reduction in infection rates of 10-15% is not significant enough to allow any scientist to claim a benefit in face of the risks and potential complications. After all you are talking about clinical amputation.

    Furthermore, to make the claim that there may be a benefit because men might last longer is nothing short of scandalous from a medical professional.

    On the balance of probabilities, it is far more likely that surgical amputation upon the penis is equally or even more likely to create dysfunction.

    But given your profession, I see where you’re coming from in this.

    Given some people’s stridency on the right to circumcise, I can only see a few justifications:

    1) cognitive dissonance – i.e. they have participated in performing it, or themselves have suffered it, and must make the case to themselves that there is nothing wrong with taking knives to any young boy’s penises;

    2) religious indoctrination;

    3) castration fantasies.

    The argument that the child has no right to their body integrity is completely unsupportable. The parent simply does not have a right to circumcise their child, male or female. They should not bind the feet of their child.

    We could save a lot of lives if we mandatorily circumcised breasts, and indeed nobody would get HIV at all if you just lopped the entire thing off!

    However it is fundamentally a crime against the rights of a child to do body modifications upon them without their consent.

    You aren’t saving anyone, you are merely justifying the act of circumcision and violations of the rights of the child post-fact.

  80. Some may see it as quite unfortunate that the scientific evidence is not in line with politically correct thinking on the subject of circumcision, but that doesn’t change the scientific evidence.

    Would anyone like to discuss the actual evidence? An argument can be constructed that the benefits in a low risk population do not justify the World Health Organization recommendation for circumcision, but I haven’t seen that argument. Instead there is a lot of opinion on why other people should not circumcise their sons.

    Forget the false (and in my judgment misogynistic) attempts to equate FMG and male circumcision. Forget the naturalistic fallacy that the existence of the foreskin means that it must be “good.” Let’s talk about the evidence of whether circumcision decreases the transmission of HIV and other STDs and how that may translate into fewer deaths, less disease, less female infertility, and decreased cervical cancer.

  81. tommyhj says:

    This debate is getting heated because of the lack of proper facts.

    1: Raw risk/benefit ratio. How many circumcisions have complications and how often does it result in protections from STI that couldn’t becured with simple antibiotics?

    2: Ethics. Does a (possible) medical benefit warrant an ethically questionable practice? Is it OK to steal from the rich if it’s for the poor, or is it still stealing? Would you kill your wife if it could save your child? 5 children? 100 children? Is it OK to clean up our genome by sterilising the genetically sick? It’s a question of utilitarism, and to answer it we need to quantify harm done by circumcising (both physical, psychic, to autonomy, human rights etc) and benefit acquired, and discuss it WITHOUT religious and cultural bias. This is the tough one…

    3: Quality of the studies that support circumcisions. How long was the follow-up? Were they based on self-reporting of sexual activity in religious individuals? Difference in condom-use before/after? Bias of the authors? This is the most interresting thing, and it is what I’d come to expect being answered in a SBM entry. I strongly suspect that the studies are questionable at best, but I’d like to see someone smarter than me point it out. If the science isn’t good, then there is no question that the medicalization of circumcision was fueled by religious and cultural bias and should be treated as such (eg. with disdain)

    There is a huge amount of bias from both sides. Pro side won’t admit that it would be the same as performing prophylactic neonatal appendectomy, and con side won’t admit that there may be a benefit that would warrant routine circumcision of boys in countries, where it’s the only preventative measure other than abstinence that the church (and therefore state) will allow.

    Still, there is no medical reason to do it while they are infants, other than the fact that it would be cheaper, and infants don’t remember pain anyway (Or do they? Studies anyone?)…

    Imagine if noone in the world ever thought about cutting off the foreskin – would we begin doing it with the kind of evidence at hand now? That’s how most Europeans feel about this.

  82. “This debate is getting heated because of the lack of proper facts.”

    Yes, and I’m waiting for the anti-circ folks to present some numbers, as opposed to personal opinions.

  83. steveisgood says:

    Dr Teuter, I wasn’t equating male and female circumcision (though others certainly were), I was merely asking why you think that decreasing sexual sensation in men is okay (just so that they can supposedly “last longer”) but not okay in women (of course a clitorectomy is barbaric….I don’t think anyone was suggesting that the two are equal procedures). Cognitive Dissonance: I haz it.

  84. JurijD says:

    “Let’s talk about the evidence of whether circumcision decreases the transmission of HIV and other STDs and how that may translate into fewer deaths, less disease, less female infertility, and decreased cervical cancer.”

    what exactly is your evidence that in a western country with a low prevalence of STDs and high condom usage a general circumcision would lead to reduced deaths and less disease ?

    What is the NNT for circumcision in say the US (or Europe) to prevent a single HIV infection ?

    What are all the possible adverse side effect applied to that NNT ?

    What is your data that circumcising infants specifically and not say young adults is needed?

    I’ve never seen data like that, if I do perhaps I’ll change my position that circumcision is not justified in countries with low STD rates and good sexual education (high condom usage).

  85. carrie says:

    I understand that some complication rate studies do look at meatal stenosis but others do not, which is why I simply said you have to be careful about the comparison and make sure you look at what is included in the numbers.

  86. windriven says:

    @Johnny_eh

    I’m with you, buddy. This debate has gone off into the weeds where emotion and partisanship prevail.

    @DevoutCatalyst

    “Rejoice smegmates – let Google Image show you the way…”

    I’ll forward my dry cleaning bill to you but a few papers on my desk have been damaged beyond reclaim. ;-)

  87. Plonit says:

    The other issue worth raising is the difference between efficacy as measured in clinical trials, and real-world effectiveness. The risk of transmitting a blood borne infection is present in any surgical procedure, and lots of precautions are taken in light of this fact.

    Now translate that not to the context of a well-funded clinical trial, but to the real world of countries with very restricted access to trained health care professionals and disposable/sterile equipment.

  88. Nick says:

    “Forget the false (and in my judgment misogynistic) attempts to equate FMG and male circumcision.”

    It was already said that there are MANY types of FGM. Some of them are the same and even less invasive than male circumcision. But all forms of FGM are banned.

    “Forget the naturalistic fallacy that the existence of the foreskin means that it must be “good.” ”

    Why is it fallacy ? It seems logic (like 2+2=4, the basics of science) that if you are born with, it is there for a reason and shouldn’t be removed. Why do you want to forget that ? Why not studying the role of foreskin instead of always finding a new excuse to remove it ?

    Do you know the history of circumcision in US ? Why this phobia of foreskin ?

    Let’s look at the backgrounds of the doctors who are conducting these studies. How many are long-standing circumcision advocates who have failed to make an association between circumcision and other diseases? How many are Jewish?

    Are these people REALLY interested in “HIV reduction,” or are they interested in circumcision evangelization?

    I think it’s about time we outlawed all of these circumcision “studies.” They’re not looking for a solution to a problem, they’re looking for problems to legitimize their pre-determined “solution.”

  89. Nick says:

    “This debate is getting heated because of the lack of proper facts.”

    Even if these pseudo scientific studies claiming circumcision prevent HIV by 55% were true, that still doesn’t justify neonatal circumcision. However, I’ve nothing against adult circumcision with consent if someone thniks it will protect him from AIDS.

  90. BigHeathenMike says:

    My main point here is to question why Dr. Tuteur suggested (and still holds to it) that the AAP change its position with respect to neonatal circumcision when the situation with respect to education and disease prevalance contrasted with certain African countries is obviously different.

    Making pre-sexually-active circumcision routine in high HIV-rate/low condom use countries makes sense, but in North America it does not and the AAP’s position statement refects this.

    Please clarify the need to change the policy in light of this, if you would.

  91. Plonit says:

    Would anyone like to discuss the actual evidence?

    ++++++++++++

    Yes, and that’s what I’ve asked from right at the top of this comment thread.

    “First, the AAP had “long recommended male circumcision for prevention of urinary tract infections in young boys.” But no mention of whether they were correct in doing so. What does science have to say on this subject?

    Second, the AAP “backed down in 1999, partly in response to pressure from anti-circumcision activists”. I would like to see some evidence to support this statement.”

    Any chance of a response?

  92. Sid Offit says:

    Only a doctor could advise someone to a amputate part of their child’s body to decrease the risk HIV – of a disease for which that child will never be at risk. Amazing!

  93. steveisgood says:

    @Sid Offit

    Only a doctor could advise someone to a amputate part of their child’s body to decrease the risk HIV – of a disease for which that child will never be at risk. Amazing!

    Only a doctor? I can think of a few more professions which advocate it…..some with the precise surgical tools of a Rabbi’s teeth!

  94. joep says:

    Actually, the WHO states that circumcision as it pertains to HIV is a targeted intervention. From the French National Council on AIDS:

    http://www.cns.sante.fr/IMG/pdf/2007-05-24_rap_en_politique_internationale.pdf

    “The same measures are not applicable to the Northern countries. The recommendations of the WHO state that this strategy is aimed
    at countries with high prevalence, and not at countries with low prevalence or in countries where it relates specifically to one part of the population such as in France or the United States.”

    This seems a reasonable application of the information I am still waiting to hear though how Amy can believe that such a recommendation would be useful in a country where the prevalence is low and the vast majority of transmission occurs in a population where circumcision has not shown to provided much (if any) benefit.

  95. moderation says:

    I agree with others who are posting that this subject was presented without enough reference to the research which might go against circumcision.

    However, there is a point I would like to see some of the vociferous opponents to circucision posting here who seem to view this in absolutist terms as human rights issue, address. Most specifically: how do you view the use of routine circumcision in a country where the HIV prevalence rate is more than 25%, anti-virals are expensive and in short supply and culturally, condom use is viewed as taboo and has failed to take hold despite years of effort? There are currently four such countries and many more follow closely behind at 15+%prevalence rates. With rates this high and the lack of condom use, circumcision appears to be a way to save live. There are people who give their lives for the greater good and the the science proves out, I would have no problem with my child giving up his foreskin for the greater good.

    And there are significantly less risks/negatives for neonatal vs adult circumcision – if you are going to circumsize. These risks include: increased risk of bleeding, the need to often use general anesthesia and its inherent risk and not to mention cost differences.

    The bottom line is that parents should get to recieve ALL the information about potential risks and benefits of a given procedure and then make an informed decision.

  96. Sid Offit says:

    I remember your post on the eugenics / “natural” birth connection.

    You should use the same vigor to pursue the anti-sex / Victorian mindset behind circumcision.

  97. Zoe237 says:

    “Any chance of a response?”

    Wouldn’t hold your breath.

    Ironically, there was no “science” in the original post. Dr. Tuteur posted a review of previous studies- author opinion. Were these studies conducted in the U.S (no)? Were they even conducted in a first world country or continent? Were the RCTs double blinded (no)? How many subjects were there (I don’t know)? What is the absolute vs relative risk (very low absolute)? What is the NNTT (fairly high)? What are the risks of the procedure (varied)? Should they be done on neonates or adults? How on earth are these not scientific objections?

    Dr. Tuteur, did you even read the studies, or did you just post a review (not even a meta-analysis) as confirmation bias? Because, sorry, the review from the Archives was solely author opinion.

    Now, I agree that there’s a lot of heated rhetoric from both sides.

    But YOU are the one who made the claim that the AAP should revise it’s recco. Well, darn well PROVE it. ;-)

  98. joep says:

    I should also add that Amy’s assertion that certain posters are ‘anti-circumcision’ is a bit misleading. I am not certain but I don’t think I saw anyone post that adults shouldn’t be allowed to get themselves circumcised for any or no reason.

    You could say that there are posters who are against infant circumcision where there is no clinical need or immediate benefit to the infant or child. That would be accurate. This is in fact the position of many other professional medical organizations

    The British Medical Association for examples notes:
    http://www.bma.org.uk/ethics/consent_and_capacity/malecircumcision2006.jsp

    “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. ”

    And this seems to be a reasonable stance, one American’s should adopt.

  99. Nick says:

    “Let’s talk about the evidence of whether circumcision decreases the transmission of HIV and other STDs and how that may translate into fewer deaths, less disease, less female infertility, and decreased cervical cancer.”

    We could talk about something far more interesting :

    It becomes increasingly clear, as more and more studies are done, that the same group of U.S. researchers keep looking for newer ways, and more and more excuses, to promote
    circumcision. If it weren’t so serious, it would almost be comical.

    These individuals seem to have a fixation with promoting and performing circumcisions. Perhaps the next study should be of these researchers’ brains, to discover why they have
    such an unhealthy fascination with cutting off healthy foreskins from others. It almost borders on pathological! (Or, could it be just their way to get more research dollars?)
    Perhaps the next study should be a mental health assessment of these researchers, conducted by unbiased psychiatrists and psychologists. Hopefully there’s a treatment for
    their disorder.

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