After seven years of argument and paper shuffling, the bureaucrats in the glass towers that house the United States Centers for Disease Control have decided to follow the American Academy of Pediatrics in affirming that the benefits of circumcision outweigh the risk of complications. Although this was the headline conclusion of the AAP’s 2012 policy statement, it was an arbitrary assertion that did not follow from the evidence. Since the AAP was unable to quantify either the risks or the benefits of circumcision, it was logically impossible for them to reach such a conclusion. Even more seriously, as Brian Earp points out below, complications are only a small part of the story: for a non-therapeutic procedure involving the amputation of a significant body part it is not enough to assess the risk of complications (bleeding, infection etc); it is also necessary to factor in the value of that part and the harm of losing it. There is abundant evidence that men like having a foreskin, and thus that it removing it - especially if it is done without consent from an infant or child - is not quite the same thing as amputating a gangrened finger. The failure of both the AAP and the CDC to consider such a fundamental aspect of the circumcision decision means that their policies and guidelines are fatally flawed at their core and of little practical value. The CDC has made its draft guidelines available for public comment; as the early critiques published below suggest, it is likely to receive a lot of flak over the next few weeks. What is it with these Americans?
Comment by Brian Earp on the proposed guidelines concerning male circumcision
to be issued by the United States Centers for Disease Control
Several people have asked for my take on the provisional CDC guidelines announced today suggesting that the benefits of male circumcision outweigh the risks. What follows is a brief, preliminary comment, in which I highlight just a few of the key issues:
(1) The Centers for Disease Control (CDC) is largely following the American Academy of Pediatrics (AAP), whose statement I have already criticized here. Note that I have included some other professional critiques of the AAP documents in my post: the upshot is that the findings of the AAP were not taken seriously by the majority of its peer organizations in Europe, whose assessment of the AAP was that it exhibited cultural bias in favor of circumcision due to the status of circumcision as a routinized norm in this country. (Circumcision was absorbed into the medical establishment of the United States in the late 1800s in an effort to combat masturbation, among other dubious reasons, and then became preserved over time as a rationalized habit -- long past the time it was effectively abandoned by other developed nations). The CDC appears to be making the same mistakes, in part by misapplying the same - or similar - data to incommensurate epidemiological environments (i.e., by relying on studies carried out on adults in Sub-Saharan Africa to make recommendations concerning infant circumcision in the United States). It also falls flat in its (meager) ethical analysis in much the same way as the AAP did in 2012. For more on the AAP, the science of circumcision, and the attendant ethical issues, see my discussion here. See this recent paper well.
(2) The CDC is using the wrong formulation for assessing the prudence of circumcision, namely benefit vs. risk. Benefit vs. risk was designed for therapeutic procedures (sometimes referred to as "medically necessary" surgeries), where it must be shown that the benefits to the patient outweigh the risk of surgical complications. In the case of circumcision performed on healthy individuals who cannot—if they are minors—consent, however, the appropriate test is not benefit vs. risk, but rather benefit vs. harm. Here, “harm” includes not only the risk of surgical complications (an elusive figure, due to the poor quality of the existing data), but also the inherent harm of having a functional, erotogenic genital structure removed in the absence of either disease or deformity. In legal theory, at least, unnecessary surgeries that amputate healthy tissue are considered to be harmful per se. On this view, the loss of the tissue is in itself a harm, unless the tissue can be shown either to have no value or to serve no functions, neither of which can plausibly be demonstrated in this case. Since there is no disease present, and since any future diseases to which the tissue may one day fall prey can be avoided and/or treated through non-surgical means, an additional harm concerns the loss of choice, in light of alternative risk-management options, concerning an extremely personal part of one's anatomy.
The CDC glosses over all of this, however, and appeals (again) to an entirely inappropriate heuristic for non-therapeutic surgeries, according to which “surgical risk” is deemed to be the only morally-relevant cost to circumcision. (In its technical report, the CDC does point out that one advantage of adult circumcision, compared to infant circumcision, is that the former can be done autonomously, while the latter is always done without consent -- and may therefore lead to later resentment. This observation has not received much attention in the ongoing flurry of media coverage.)
(3) Let me make one last point by way of a thought experiment. Suppose it could be shown that removing the labia majora of infant girls reduced their risk of getting urinary tract infections (since there would be fewer folds of moist genital tissue in which bacteria could find a home), as well as cancers of the vulva (since there would be less tissue in which such cancers could develop). It's not implausible, and in fact in countries in which female genital cutting is culturally normative, it is easy to find “medical” support for these views: female circumcision is often thought to be “more hygienic” and well as more aesthetically pleasing: therefore, it is often said, it is in the best interests of the girl child to be circumcised so that she can attain these benefits. Remember, female circumcision falls on a spectrum, and some forms of it are less invasive than male circumcision, may not involve modification of the clitoris, and are sometimes done for reasons other than (attempted) control of sexuality. Nevertheless, it is actually illegal in Western countries to conduct the very research by which such "health benefits" could be discovered. Non-therapeutic, non-consensual surgeries carried out on the genitals of healthy girls—no matter how slight or under what material conditions—are defined as impermissible mutilations in Western law. This is because it is presumed that girls are entitled to grow up with their genitals intact, and to decide, at an age of understanding, whether they would like to undergo permanent alterations to their private parts, and if so, for what reasons, and what kind.
Whether a minor reduction in the risk of certain infections or diseases (whose prevalence is determined by socio-behavioral factors much more than anatomical-biological factors, and whose occurrence can typically be prevented and/or treated in much more conservatives ways) is worth the trade-off of losing one's labia (let’s say) -- or indeed one’s foreskin -- is a complex question, and one whose answer is likely to be highly subjective. Therefore, it should be up to the affected person to decide about permanent genital-modification surgeries at such a time as he or she can factor in his or her own preferences and values. Circumcision (of boys or girls) is not an effective health-promotion strategy, given less ethically problematic alternatives.
Brian D. Earp, University of Oxford, 2 December 2014
Brian D. Earp is a Research Fellow in Ethics at the University of Oxford. He holds degrees from Yale, Oxford, and Cambridge universities, including an M.Phil. degree in the history, philosophy, and sociology of science and medicine, focusing on male and female genital surgeries. Brian has served as a Guest Editor for the Journal of Medical Ethics, editing a special issue on the topic of childhood circumcision, and has published widely in the leading journals in his field.
Circumcision risks and harms outweigh benefits: Now published as Brian Earp. Do the benefits of male circumcision outweigh the risks? A critique of the proposed CDC guidelines. Frontiers in Pediatrics 3 (18), 21 February 2015
Intact America, an organization that opposes the forced genital cutting of babies and children, sharply criticizes the recent Centers for Disease Control (CDC) proposed guidelines for circumcision.
The CDC is calling for doctors to tell the parents of male infants, children and adolescents that circumcision has been found to reduce the transmission to men of HIV and other sexually transmitted infections (STIs). The guidelines were released on December 2, 2014, opening a public comment period that will end on January 16, 2015. “Beyond stating and restating its support for medically unnecessary circumcision, the Centers for Disease Control fails to provide any solid evidence to bolster the case for circumcision as a valid measure for disease prevention,” said Georganne Chapin, an attorney and executive director of Intact America. “The studies cited by the CDC purporting to show that circumcision reduces transmission of STIs were conducted in poor rural areas of sub-Saharan Africa over eight years ago. These studies have never been replicated elsewhere—let alone in the United States—and have no relevance to children or men in the developed world.”
“There have been no systematic studies conducted anywhere about the short-or long-term adverse consequences resulting from circumcision," says director Chapin. "Through thousands of personal stories from boys, men and their parents we know that circumcision causes myriad complications, some requiring surgical correction. Adult consequences include poor body image, painful sex, psychological problems, and erectile dysfunction. The CDC's continued persistence in recommending what they know to be an unnecessary surgery is questionable. It is happening in the face of increased public awareness about circumcision’s harms, declining U.S. circumcision rates, and the growing reluctance of states and insurers to pay for this medically unnecessary surgery.”
Intact America notes that the CDC’s proposed guidelines make no mention of the spontaneous and growing protests around the U.S. and Canada by men who are speaking out angrily about having been forced as children to undergo circumcision. “As a public health organization, the CDC should be calling for a study of the true risks and complications from circumcision that occur over the lifetime of boys and men,” says Chapin, “before it promotes its evidence-free claim that the benefits of newborn circumcision outweigh its harms.”
The American Academy of Pediatrics released a statement in 2012 promoting the benefits of infant circumcision and calling for insurers and state Medicaid programs to pay for the surgery, performed in the U.S. often without anesthesia. This report is at sharp odds with the ethical and medical stance taken by physicians here and in Europe concerning the removal of healthy sexual tissue from children who cannot consent. In early 2013 in the journal Pediatrics, a large group of physicians, medical organizations, and ethicists from European, Scandinavian, and Commonwealth countries issued a strongly-worded statement, calling American medicine’s support for infant circumcision “culturally biased,” and “different from [the conclusions] reached by physicians in other parts of the Western world, including Europe, Canada and Australia." In October 2014, Britain’s National Health Service affirmed its previous position stating that, “most healthcare professionals now agree that the risks associated with routine circumcision, such as infection and excessive bleeding, outweigh any potential benefits.”
Source: Intact America website
The human rights organization Attorneys for the Rights of the Child (ARC) is preparing a response to the Centers for Disease Control and Prevention (CDC) regarding its release on December 2, 2014 of a draft of proposed circumcision guidelines.
J. Steven Svoboda, ARC’s Executive Director, commented today, “Sadly, the CDC has chosen to ignore the medical evidence to try to justify an outmoded and painful cultural—not medical—practice. In these days of constantly mounting medical costs and ever scarcer resources, we simply cannot afford to continue supporting and performing a harmful and antiquated procedure.” Regarding the CDC’s claim that circumcision’s benefits outweigh the risks, Svoboda commented, “The CDC omitted the functions of the amputated tissue. If the CDC advocates for cutting off a body part, shouldn’t we know what that body part does?” Svoboda commented, “If circumcision is as desirable as the CDC suggests, why are European countries moving towards banning it, why are their males healthier than Americans, and why does the CDC not come out and recommend it?” By the CDC’s own admission, Americans are increasingly choosing to leave their sons intact, as circumcision rates have plunged in recent years.
Svoboda added, “A recent study by Bossio et al in the Journal of Sexual Medicine, concluded that the literature favoring circumcision contains considerable gaps, lacks rigor and is largely not applicable to North America.” Studies of HIV in adult males in Africa suffer from methodological and statistical errors and even if valid, given vast differences in health conditions and modes of transmission, the results can hardly be applied to justify infant male circumcision in the United States. “Doctors cannot ethically remove tissue from babies without consent, based on speculation about their possible sexual behavior decades later,” Svoboda added.
“Male circumcision,” Svoboda said, “violates a child’s right to bodily integrity, not to mention numerous civil and criminal statutes.” Malpractice awards are mounting up; a list of seventy such cases were released by ARC, the largest amounts to 22.8 million dollars (Antonio Willis v. Northside Hospital Atlanta, March 1991)
Last Tuesday, the Centers for Disease Control and Prevention (CDC) released its proposed guidelines on male circumcision for public comment. The new federal guidelines would recommend male circumcision as a healthy choice that doctors should offer for parents to make for their sons and for teenagers and adults to consider. The CDC background report claims that circumcision has been shown to prevent HIV, HPV and other infections. The new CDC report mimics the 2012 American Academy of Pediatrics Circumcision Policy Statement which drew widespread criticism for its claim that circumcision benefits outweigh the risks.
IntactNews asked the CDC for comment about the risks for an average American male in acquiring HIV. “It’s hard to establish one, single figure for risk of HIV acquisition by a heterosexual male,” the CDC responded in an email to IntactNews today, saying the risks are not well documented. One study estimates the chance of an American male acquiring HIV through a single unprotected sex act with a known HIV+ female partner is less than 0.04%. That adds up to a 6% risk per year, with an estimated total of 620 new HIV infections per year for white, heterosexual males with known HIV+ or high-risk female partners. What these numbers show is that the average American man has a comparably low risk of getting HIV through unprotected sex. In fact, the number of average American men getting infected with HIV per year is so low that the CDC does not have data on this demographic.
As one legal expert comments, “It is ludicrous and scientifically unsound to recommend the removal of a normal body part from all males to reduce the incidence of sexually transmitted diseases that can be prevented by ABC—practicing abstinence, being faithful and using condoms,” says David Llewellyn, an Atlanta-based attorney whose practice focuses on botched and wrongful circumcisions. “The idea that doctors should counsel teenage boys to get circumcised rather than teaching them ABC is equally absurd.
“Furthermore, the CDC recommendations completely ignore the known functions of the foreskin, how circumcision changes the penis, and the hidden but well recognized common injuries that happen every day as a direct result of neonatal circumcision. In my practice, I see the devastating results of circumcision every day. In particular, the high rate of the narrowing of the urinary opening (meatal stenosis) which occurs to tens of thousands of circumcised boys every year. This is not sufficiently addressed by the CDC, even though it is a well-known complication of circumcision. The CDC needs to be paying more than lip service to the devastating effects of these injuries. ”
Pediatric urologist warns on high incidence of circumcision complications and other harm
“It is regrettable that the CDC has chosen to position itself on the wrong side of scientific evidence with its endorsement of circumcision for male newborns and heterosexual adult males,” says Dr. Alexandre T. Rotta, Chief of Pediatric Critical Care at University Hospitals in Cleveland, Ohio. “By cherry-picking data that, at best, have marginal relevance (if any) in parts of Africa with high heterosexual HIV transmission, the CDC recommendation is empty, counterintuitive, and irrelevant to the health of the very Americans it aims to protect. As a pediatrician, I am deeply troubled by this form of government-endorsed mutilation of children, fragile human beings who will forever be robbed of the right to make an informed decision on such a deeply personal matter carrying irreversible consequences. This is an egregious violation of personal autonomy and medical ethics.”
Source: Experts denounce CDC’s “blind promotion” of circumcision in proposed guidelines, Intact News, 4 December 2014
Further critical comment at the Canadian Children's Health and Human Rights Partnership
In compiling its proposed recommendations, the CDC has ignored the considerable and reputable literature from the fields of medicine, medical ethics, law, and human rights that calls into question the legitimacy of foreskin removal (circumcision) as a health care measure.
Recommendation 1 acknowledges that routine circumcision in the United States, though performed “medically,” is primarily a religious, social, cultural and cosmetic procedure. As such, and in the absence of a diagnosable pathology, the circumcision of infants and children, and the circumcision of any individual in the absence of truly informed consent by physicians who understand the normal male genitalia and the function and benefits of the foreskin, is unethical. The CDC fails to mention that numerous medical organizations, legislatures, physicians and ethicists from European and Commonwealth countries with sophisticated medical systems and lower rates of sexually transmitted infections (STIs), including HIV, have criticized the American medical establishment for its cultural bias toward circumcision, for exaggerating the procedure’s benefits, and for ignoring and understating its risks and harms. The CDC also fails to acknowledge that even the merest pin prick of a minor girl’s genitals – whether motivated by religion, culture or aesthetic preference – violates federal laws against “female genital mutilation.” The United States Constitution guarantees equal treatment of females and males, and thus the circumcision of non-consenting male minors combined with the protection of female minors constitutes illegal discrimination. It also may constitute establishment of a religion in violation of the United States Constitution.
Recommendation 2 states that all sexually active adolescent and adult males need to use “other” (i.e., other than circumcision) “proven HIV and STI risk-reduction strategies.” The question must then be asked: Why perform surgery at all, especially considering that no benefit whatsoever is obtained for the (circumcised) male’s sexual partners?
Recommendation 3 fails to mention that there has been no systematic longitudinal study of the long-term harms and complications from neonatal circumcision – many of which doctors are not taught to recognize and some of which do not appear until later in life. Nor do the recommendations acknowledge that unnecessary surgery in itself causes harm. As a California Appeals Court has stated, “Even if a surgery is executed flawlessly, if the surgery were unnecessary, the surgery in and of itself constitutes harm. (Tortorella v. Castro, 140 Cal. App.4th 1, 43 Cal. Rptr.3d 853, Cal.App. 2 Dist. (2006))
Recommendation 4 fails to mention:
The AAP’s 2012 technical report on circumcision has been roundly criticized for reasons also applicable to the CDC recommendations: cultural bias, cherry-picking of evidence, repeatedly stating that benefits of circumcision outweigh its risks without providing evidence of the harms, and omitting information about the functions of the foreskin. In sum, the CDC exaggerates the benefits of circumcision, minimizes its risks, utterly ignores the function and benefits of the foreskin, and blithely disregards critical ethical and legal questions regarding the rights of all children to enjoy their normal, natural sex organs.
Even the mainstream United States media, usually avid in their promotion of circumcision have been forced to recognise that Americans are now “telling Uncle Sam to leave the foreskin alone”
Cheryl Wetzstein, Americians push back against CDC recommendation on circumcision, Washington Times, 9 December 2014
Victoria Colliver, Federal circumcision guidelines meet with opposition, San Francisco Chronicle, 10 December 2014
See also the analysis at Circwatch, showing how the media have misrepresented the content of the guidelines.
Unscholarly, selective and biased are a few of the more complimentary terms applied by paediatrician Robert Van Howe to the draft guidelines on male circumcision issued for public comment by the United States Centers for Disease Control in December 2014. Appointed as an official peer reviewer for the guidelines, Dr Van Howe, Professor of Paediatrics at Michigan Central University, did not muck about. In a 200-page review, with over 1300 references, he subjected every statement in the CDC’s draft to a withering critique and found nearly all its facts to be wrong, its claims dubious, its conclusions invalid, and its recommendations dangerous. The most striking features of the document were the glaring gaps in its research, the lack of logic in its arguments, and its irresponsible resort to scare tactics, particularly its attempt to use fear of AIDS in sub-Saharan Africa as a means of driving Americans to embrace circumcision. As Professor Van Howe asks, if the CDC guidelines are meant to assist Americans, how come it is so obsessed with Africa?
More specifically, Van Howe identifies seven major flaws in the CDC’s report. (1) It lacks scientific rigour. (2) It is thin on details. (3) It disregards much of the medical evidence. (4) It ignores the anatomy, physiology and functions of the foreskin. (5) It is out of step with world opinion on non-therapeutic circumcision. (6) Despite massive consultation, the document is not significantly different from the draft issued in 2007 – eight years ago. (7) It urges health providers to supply the public with misleading, irrelevant and out of date information.
The introductory paragraphs of Professor Van Howe’s peer review are given below. The full document may be seen at his Academia.edu page.
A CDC-requested, Evidence-based Critique of the Centers for Disease Control and Prevention
2014 Draft on Male Circumcision: How Ideology and Selective Science
Lead to Superficial, Culturally-biased Recommendations by the CDC
Several things are remarkable about this draft.
First, is the obvious lack of scientific and scholarly rigor that went into preparing this draft. While it is stated that the writers of the draft performed a search of the medical literature, the evidence (in the form of the draft itself) indicates that their search was far from complete. Instead of collecting and analyzing data, they relied on review articles to do the work for them. One review article was published in 1983 — a bit dated to say the least. In some sections, the draft relied on opinion pieces as their sources of information. In areas where review articles were not available, the information provided was far from complete. For example, in reviewing the medical literature on the impact of male circumcision in North America, which is a major thrust of the draft, only two of the eight available studies are mentioned. Similarly, no serious attempt was made to review the harms, risks, complications, or pain associated with circumcision. The draft has only 255 references, some of which are redundant, which are only a small sampling of the material available in the literature. A PUBMED search using the search word “circumcision” on January 12, 2015 identified 6338 publications.
The draft also ignores basic epidemiological principles. It fails to apply the standards that are needed to identify when an intervention should be applied. Throughout the draft, it is assumed that circumcision will be successful as a primary prevention for HIV, when the data clearly demonstrate that it is ineffective as primary prevention. Even its role as a secondary preventive measure has only been evaluated in one study in the United States, which included a very small, limited population. For this very small population, modeling by the CDC has estimated that circumcision’s impact on infection risk is nearly inconsequential. Policy should be based on more than one small subset of patients from a single study when several other studies fail to support this conclusion. It is clear that both the investigators of the randomized clinical trials and the CDC draft authors do not understand the epidemiological difference between efficacy (a positive finding in a research setting) and effectiveness (positive results in the real world).
The draft fails to adequately scrutinize the validity of the few studies it identified. It assumed the randomized clinical trials could not harbor any bias (the draft actually states this!) and did not question the methodology of these studies, although their methodology has been questioned extensively. Instead of accepting the study results at face value, the expectation of scholarly rigor would demand that these studies be carefully scrutinized, and a determination made as to whether the studies generated valid results and/or if the criticisms raised about these studies were convincing. The writers of the draft made no effort to question or analyze these studies.
If a student were to submit these drafts for consideration as a senior undergraduate or master’s thesis, they would fail based on their lack of scholarship. It appears the CDC was only going through the motions in preparing this draft. If the CDC had performed an adequate search of the medical literature and applied the expected level of scholarly rigor, their conclusions and recommendations would have been different. Perhaps that was the point. Perhaps the hope was, by releasing the draft with a selective bibliography, no one would recognize the lack of scholarly effort or call the CDC out on doing a subpar job. It worked for the American Academy of Pediatrics, and they seemed to get away with it. The difference is that CDC documents are open for public comment because it is a government agency. One would think that, after all of the embarrassment the CDC has endured in the recent past, they would want to put their best foot forward by publishing a rigorous, balanced, evidence-based assessment of male circumcision. That obviously did not happen.
Second, is the lack of attention to detail. Many of the citations given have the authors and journals incorrectly listed. Several of the citations require updating, while several of the citations were redundant. There are several misspellings in the manuscript. This indicates the CDC did not expend sufficient effort putting forth this piece of work, which is consistent with its lack of scholarly rigor.
Third, is the wanton disregard for the medical evidence. It is clear throughout that the writers of the CDC draft believe absolutely in the presumption that infant male circumcision can reduce HIV and sexually transmitted infections beyond a shadow of a doubt. As a consequence, the draft goes about finding evidence to support their presumption and primarily presents evidence supportive of this presumption, despite evidence to the contrary. The quality of the evidence supporting the presumption is never questioned. Any evidence that does not support their presumption is either ignored, criticized, or dismissed. As a consequence, the draft is laughably biased and reflects the expectation bias of its writers.
Fourth, is the lack of a thorough discussion of the foreskin and its anatomy, histology, physiology, and function. It is standard procedure for review articles of this type to review these topics to provide a basic science foundation. How can the CDC discuss the biological plausibility of sexually transmitted infections without a knowledge of the basic anatomy, histology, physiology, and function? This information must be included since health care providers must understand what is lost by removing the normal foreskin/prepuce. How else can they explain the impact of its removal to patients? This information is also an essential element of the disclosure given during the informed consent process.
Fifth, is how out of step the CDC is with the rest of the world. National medical organizations and human rights groups throughout the world, including the Council of Europe, are, in increasing numbers, denouncing infant circumcision as being medically unnecessary and a blatant human rights violation. At this point in time, the CDC and the American Academy of Pediatrics are the last stronghold in the defense of infant circumcision. Remarkably, the draft fails to mention all the medical organizations outside of the United States who have weighed in with an opposing opinion on male circumcision. Is there some source of special knowledge the CDC has in its possession that allowed them to reach conclusions that are diametrically opposed to every other national medical organization (other than the American Academy of Pediatrics)? If it exists, why is it missing from the draft? Please provide enlightenment. If the CDC has a clue, they could at least share it.
Sixth, it took over seven years for the CDC to produce a substandard, scientifically unacceptable product, nearly identical in content to what was presented at the 2007 consultation.
Finally, the most remarkable thing is that the CDC is recommending clinicians and health care providers relay information that is counterfactual, incomplete, and biased to medical decision makers. In essence, they are deliberately encouraging health care providers to misinform their patients and thus commit medical malpractice.
The CDC needs to throw out this draft and start again from scratch, this time without a preconceived conclusion in mind. They need to review the entire medical literature, thoroughly scrutinize the studies in the literature, and properly apply basic epidemiological principles. When they have done so, they need to consult with experts from around the world to make sure their findings are not culturally biased. They also need to focus on the United States, not Africa.
Source: Robert Van Howe, MD, MS, FAAP. A CDC-requested, Evidence-based Critique of the Centers for Disease Control and Prevention 2014 Draft on Male Circumcision: How Ideology and Selective Science Lead to Superficial, Culturally-biased Recommendations by the CDC. January 2015.
[ Back to Top ]