In a wide-ranging commentary, Brian Earp replies to a proposal from two American gynecologists that Western societies should tolerate and doctors should perform “mild” forms of female genital cutting on girls. This is the same argument that was advanced by bioethicist Dena Davis over a decade ago and which was adopted, very briefly, as the official policy of the American Academy of Pediatrics in 2010. The argument then, as now, was that since circumcision of boys was tolerated, it was discriminatory not to permit less damaging versions of female genital cutting. If the religious rites of groups that practised circumcision of boys were respected, it was consistent to respect the cultural/religious rites of groups that circumcised girls. In reply it was pointed out that the argument could just as well work the other way: that if genital cutting of girls was rejected as an abhorrent denial of human rights, why should similar (and often more severe) surgery on the genitals of boys be tolerated?
While Davis, the AAP and the latest team argue that they are trying to even things up, other critics noticed that the situation would still be very unequal. Under their proposals, girls would still be protected from all but the most minimal and harmless scratch, while boys were still to have their entire foreskin cut off - no change, and not much equality there. It is hard to avoid the conclusion that the real aim of these proposals is not to “show respect” for cultures that practise female genital cutting, but to make it easier to defend circumcision of boys. Over the past decade or so an increasing number of bioethicists, human rights experts and independent thinkers have questioned the “quarantining” of female genital mutilation from male circumcision and argued that the two practices have much in common, socially, ethically and even physically. If cutting a girl’s genitals is a violation of her human rights, it is hard to see why cutting a boy’s genitals is not a violation of his human rights. Arora and Jacobs have already published uncompromising (though somewhat confused) defences of specifically male circumcision and clearly recognise this problem; it seems likely that their latest “modest proposal” on female circumcision is intended to make male circumcision less vulnerable to criticism as an instance of sexism and double standards, and to make it more difficult for those who oppose the practice on bioethical and human rights grounds. In other words, A&J’s real and underlying aim is not to promote female circumcision, but to defend and preserve circumcision of boys as a cultural and medical rite.
In his commentary on A&J’s latest efforts in the Journal of Medical Ethics, Brian Earp argues that all children have the same human rights and should have equal protection from non-therapeutic genital surgeries.
Abstract: Arora and Jacobs (2016) assume that liberal societies should tolerate non-therapeutic infant male circumcision, and argue that it follows from this that they should similarly tolerate — or even encourage — what the authors regard as ‘de minimis’ forms of female genital mutilation (as defined by the World Health Organization). In this commentary, I argue that many serious problems would be likely to follow from a policy of increased tolerance for female genital mutilation, and that it may therefore be time to consider a less tolerant attitude toward non-therapeutic infant male circumcision. Ultimately, I suggest that children of whatever sex or gender should be free from having healthy parts of their most intimate sexual organs either damaged or removed, before they can understand what is at stake in such an intervention and agree to it themselves.
Brian Earp. In defence of genital autonomy for children. Journal of Medical Ethics, online first, 20 January 2016.
A study in Melbourne has found a disturbingly high incidence of circumcision complications requiring emergency treatment. Over a period of 29 months 167 boys were brought to the Royal Children’s Hospital casualty department suffering from circumcision-related injuries. The principal problems were: bleeding (53.9%), pain (38.3%), swelling (37.1%), redness (25.7%), decreased urine output (13.8%), fever (7.2%) and infection (6%). In addition, 29.9% were brought in because parents were shocked at the ugly post-circumcision appearance of the boy’s penis. About half the circumcisions (54%) had been performed for religious/cultural reasons, 30% for so-called medical reasons, and the remainder for reasons unknown. There was some difference in the incidence of complications between hospital-performed operations (40%) and those performed in the community, presumably by GPs and “specialist” clinics (60%), but not enough to justify the common assumption that hospital-performed operations are completely safe. The mean age of the boys was 3 years, but the boys circumcised by community operators were much younger and had the highest incidence of complications.
A study by Crosby et al of Black men in a southern United States city with an “extremely high” HIV prevalence, found that there was no difference in the incidence of HIV and other sexually transmitted infections between circumcised and uncircumcised partners. Curiously, the study also found that circumcised men were twice as likely not to wear a condom when taking the active role in intercourse. This is an interesting result, confirming earlier research that circumcised men are less likely to wear condoms, thus raising the possibility that they may be at greater risk of HIV infection. These points are discussed in a response letter by Morten Frisch, who notes that the study provided no evidence of circumcision having any protective effect against HIV in MM sex, and who draws attention to its side-finding - that circumcised men are far less likely to use condoms. As he points out, this is consistent with other evidence that circumcision dulls the sensitivity of the penis, leading to the frequent complaint from circumcised men that they can’t feel anything through the latex and often lose their erection. The key point is that since condoms (even if worn inconsistently) are the most effective means of HIV prevention, anything that discourages condom use raises the risk of HIV infection.
A recent study in Scotland concerns a group of 1000 children aged 0-16 years, consisting of 820 girls and 180 boys, who were referred to a centralized urinary tract infection unit in Western Scotland. UTIs are the only health problem for which there might conceivably be a tiny health benefit from early circumcision, but the study is of interest because it shows that UTIs are far more common in girls than in boys, and that circumcision is rarely necessary to correct cases of recurrent UTIs. The authors note that of the 180 boys referred for a first UTI, only 3 of them (1.7%) subsequently had to be circumcised due to recurrent UTIs. Since circumcision is rare in Scotland and “routine circumcision” practically unknown, it may be assumed that all (or nearly all) the boys were uncircumcised. This is suggested by the fact that the authors make no breakdown of the numbers by foreskin status.
The authors also present age-specific male-female ratios showing that girls are far more subject to UTIs in all age groups, even among children under 6 month of age (where the M:F ratio is 1:2). This is in contrast to some other studies finding that in this age group boys outnumber girls. Given the nature and size of the study (unselected, consecutive material, except for the likely underrepresentation of children with prenatal urinary tract problems identified by ultrasound), the results provide solid evidence that UTIs in early infancy are not a particular male problem that requires particular “male solutions”. The protocol used here seems to catch the vast majority of children in need of intervention, and shows that circumcision has no preventive place in that protocol, except among those very few boys who experience recurrent UTIs. In other words, rather than advocating routine circumcision for the prevention of UTI in boys (which, in any case, occur in only 0.5%-1% of boys), circumcision should be reserved as an option in those very few boys (only 1.7% according to this study) who experience recurrent UTIS. This means that no more than about 0.01%-0.02% (2% of 0.5%-1.0%) of boys should ever need to be circumcised for this reason.
Source: E. Broadis et al. ‘Targeted top down’ approach for the investigation of UTI: A 10-year follow-up study in a cohort of 1000 children. Journal of Pediatric Urology 2015 early view: http://dx.doi.org/10.1016/j.jpurol.2015.07.006
The death of a Canadian baby following a “routine” circumcision has exposed serious weaknesses in the mechanisms for child protection and medical regulation. The boy should not have been circumcised: his parents did not want it done, but were pressured by their family doctor, contrary to the policy of the Canadian Pediatric Society, which does not recommend circumcision. Investigating the death, the authorities focused on the subsequent actions of the staff at the hospital emergency department, rather than the doctor who performed the surgery. Despite the fact that this was an entirely unnecessary death, caused by an operation that should not have been performed, both parties were merely cautioned. This is the second death from circumcision bleeding reported in Canada in recent times. Unless the authorities take steps to provide effective protection for children, and impose meaningful penalties on medical personnel who cause them harm, it will not be the last.
People in Malawi, a small, inland country in south-central Africa, have reacted angrily to a United States aid package that must be spent on promotion of circumcision. The Americans insist that the money be spent on circumcision because it is supposed to reduce the risk of HIV infection, but Malawians say they would prefer it to be spent on economic development. They also point out that the there is no firm proof that circumcision does significantly reduce the risk of HIV, whatever the World Health Organisation may say. Statistics in Malawi show that the prevalence of HIV is actually higher among circumcised men, and that the incidence of HIV has increased in the very region where a circumcision program has been rolled out.
Recent publications by American bioethics experts and circumcision critics shows that the policy of quarantining discussion of female genital mutilation from male circumcision is no longer viable. In an important paper in the journal Medicolegal and Bioethics, Brian Earp argues that the moral and empirical (medical) basis for distinguishing between the two forms of surgery is unsustainable. As he writes in the abstract: “The non-therapeutic alteration of children’s genitals is typically discussed in two separate ethical discourses: one for girls, in which such alteration is conventionally referred to as “female genital mutilation” (or FGM), and one for boys, in which it is conventionally referred to as “male circumcision.” The former is typically regarded as objectionable or even barbaric; the latter, benign or beneficial. In this paper, however, I call into question the moral and empirical basis for such a distinction, and I argue that it is untenable. As an alternative, I propose an ethical framework for evaluating such alterations that is based upon considerations of bodily autonomy and informed consent, rather than sex or gender.” At the same time a paper by Laura Carpenter and Heather Kettrey in the Journal of Sex Research shows that media coverage of these issue is extremely biased, consistently warning against the harms of FGM while downplaying the harms and exaggerating the benefits of male circumcision.
Brian Earp. Female genital mutilation and male circumcision: toward an autonomy-based ethical framework. Medicolegal and Bioethics 2015;5 (3 October): 89-104.
Laura M. Carpenter & Heather Hensman Kettrey. (Im)perishable Pleasure, (In)destructible Desire: Sexual Themes in U.S. and English News Coverage of Male Circumcision and Female Genital Cutting. Journal of Sex Research 52 (8) 2015: 841-856.
See also Amy Wright Glenn, Circumcision: The case for extending legal protections to America’s boys. PhillyVoice, 26 September 2015.
In a statement released on 9 September the Canadian Pediatric Society confirmed its long-standing opposition to routine circumcision of male infants and boys. The new policy states clearly that the recommendation of the CPS is against circumcision because the benefits are small and outweighed by the risks. This outcome has surprised some observers, who were expecting the CPS to follow the American Academy of Pediatrics to conclude, while not recommending circumcision, that the benefits exceeded the risks, and that circumcision was a matter of “parental preference”. In rejecting this assessment as scientifically unsound, the new CPS policy aligns itself with those of the Royal Australasian College of Physicians and child health experts in Britain and all European countries. Their position leaves the Americans more isolated than ever as the only medical organisation in the world to think that there is anything worthwhile in routine circumcision. Scholars have criticised the risk/benefit calculus as inadequate for the “circumcision decision”, as it fails to consider the value of the foreskin and the likely future wishes of the boy, or to give adequate weight to bioethical and human rights principles. It is nonetheless significant that the CPS could recommend against circumcision after a narrow calculation of the strictly medical issues considered pretty much on their own. Once you add the functions of the foreskin and bioethical issues to the equation, the case against circumcision becomes overwhelming.
Many papers in medical journals claim to show that removal of the foreskin will significantly reduce the risk of some disease conditions, such as penile and cervical cancer, human papilloma virus (HPV), HIV-AIDS and urinary tract infections (UTIs). Most of these papers rely on elaborate statistical manipulation in order to reach this conclusion, but careful analysis shows that the statistical methods used are often inappropriate or wrong, and that the conclusions are invalid. Two recent papers by Dr Robert Van Howe, Professor of Pediatrics at Central Michigan University, show that most of the studies heavily relied upon and regularly cited by circumcision advocates as proof of the benefits of circumcision are seriously flawed and do not show the results claimed for them. One deals generally with the mathematics of statistical analysis, providing guidance on how to spot flaws in claims based on statistical manipulation, with particular reference to false claims that uncircumcised men and boys are at greater risk of penile cancer and UTIs. The other deals with the latest HPV scare and refutes current claims that anatomically normal (i.e. uncircumcised) men are more likely to harbour the virus and thereby infect women. The papers are available at Professor Van Howe’s Academia.edu page:
The death toll from circumcision during the annual circumcision season in South Africa now stands at 14, plus some 141 boys in hospital with horrific injuries, including loss of their entire penis from gangrene. The annual carnage affects boys from the Xhosa tribes, who are traditionally circumcised in “circumcision schools” during a bush retreat when they are in their mid- to late teens. While there has been mounting criticism of the death toll for many years, spokesmen for the Xhosa ethnic group describe the ritual as a necessary element of their cultural traditions, and efforts by the South African authorities to regulate the schools have been half-hearted. According to one recent report, circumcision is a lucrative business for the operators, bringing in around 1,500 rand (110 euros, $120) per foreskin. In June, South African police rescued 11 teenage boys from forced circumcision after their parents reported that they had been kidnapped in the street and taken away to be initiated.
Controversy surrounding the African circumcision programs has been reignited by a special issue of the journal Global Public Health, which subjects the current policies of UNAIDS and WHO to a searching critique. What makes this special issue of Global Public Health remarkable is that it represents the first sustained critique of the “circumcision solution” to the African HIV crisis from a major international journal at the heart of the public health policy community. Up until this time, critics of the circumcision programs have mostly been marginal and isolated figures whose views have been ridiculed by the biomedical experts and ignored by the media. This time it is different, and the circumcision lobby has reacted with some annoyance – not merely at the specific criticisms raised, but at the very idea that there was anything controversial about the “circumcision solution”. As far as they are concerned, the issue was settled by the three clinical trials and a subsequent “consultation” in Montreux, and they are furious at the suggestion that there is anything left to debate: the only issues they want to discuss are the most efficient circumcision instruments and the best ways to persuade men to submit. With articles by leading public health experts, historians, anthropologists and sociologists, this issue Global Public Health has reopened the debate.
A conference in Germany heard experts from eleven countries in Europe and the Americas defend the right of all children to bodily integrity. During the conference, one basic principle became clear: since bioethical and human rights standards are universal, the right to genital autonomy cannot be differentiated by the age, gender, religion or culture of the person concerned. Highlights of the conference included Shemuel Garber explaining the interdependence of cultural, religious and medical justifications for male circumcision from the perspective of an American Jew. He particularly rejected the accusation of anti-Semitism that is frequently made against circumcision critics, and and stressed that Jewish people are prominently represented in the genital autonomy movement, especially in the United States. Turkish author Kaan Göktaş argued that circumcision is not required by Islam. Circumcision is not mentioned in the Koran, and there is no proof that the early followers of the prophet underwent circumcision. Moreover, in light of the fact that there are Sura in which body modifications are called sinful, he believes that the sayings about circumcision were not added until later. On the question of medical benefits, Dr. Michel Garenne (Institut Pasteur, France) pointed out that there is good demographic and epidemiological evidence that circumcision has little effect on the incidence of HIV infection transmission. HIV prevalence does not differ significantly between populations which practise circumcision and those which do not. On the legal side, Professor Michael Thomson (University of Leeds, UK) spoke on the recent ruling by a senior British judge that male circumcision was more harmful than mild forms of female genital mutilation.
Speakers at the conference, “Genital Autonomy: Myths and Multiple Standards”, came from from Germany, Austria, Switzerland, Denmark, France, Great Britain, Finland, Turkey, the USA, Canada and Iran. It was held in Frankfurt, Germany on 8-9 May, the third anniversary of the ruling by the Cologne court of appeal that non-therapeutic circumcision of boys was unlawful.
In two recent papers, psychology professor Dr Greg Boyle considers the physical and mental harms of non-therapeutic circumcision. After reviewing the extensive literature in medical and scientific journals, he finds that not only are the risks and complications of the surgery greater than commonly believed, but also that the harms of foreskin loss itself (i.e. without complications) are far more extensive than most people think. These are very harms of circumcision that are completely ignored by circumcision advocates and bureaucratic policy makers (such as the US Centers for Disease Control), who talk narrowly about “risks vs benefits” and ignore the usefulness of the foreskin (contrary to what the Jewish philosopher Maimonides stated) and regard the removal of a healthy foreskin as no different from the removal of a diseased appendix. Professor Boyle particularly rejects recent claims by Morris and Krieger that circumcision “makes no difference” to sexual function as implausible and contradicted by the evidence, and notes that other experts have found serious flaws in their analysis.
See also, Robert Darby. Risks, benefits, complications and harms: Neglected factors in the current debate on non-therapeutic circumcision. Kennedy Institute of Ethics Journal 15 (1), March 2015.
A majority of Americans now believe that non-therapeutic circumcision of male infants should not be routine. A survey conduced by earlier this year by the YouGov opinion group found that 53 per cent of Americans thought that circumcision should not be routine and only 47 per cent that it should be. Not surprisingly, the result was heavily influenced by age: in the 18-29 age group, only 33 per cent thought it should be routine, and 43 per cent in the 30-44 age group. The strongest support for routine circumcision was in the 65-plus age group, at 63 per cent. We can be confident that if the 0-18 age group had been included in the survey the opposition to circumcision would have been much stronger: after all, what what the average baby say if he had been asked and was capable of understanding and replying?
Source: Young Americans less supportive of circumcision. YouGov Life, 3 February 2015.
In related news, Morten Frisch explains to an American audience why, contrary to the opinion of the American Academy of Pediatrics and the Centers for Disease Control, the benefits of circumcision do not outweigh the risks, and argues that it is time for U.S. parents to reconsider the acceptability of infant male circumcision: Morten Frisch. Time for U.S. parents to reconsider the acceptability of infant male circumcision. Huffington Post, 9 April 2015.
Also, a survey of reader comments in the Atlantic Magazine show that Americans are now recognising the parallels between female genital mutilation and male circumcision and agree that that there are more similarities than differences between them.
Latest figures from health monitoring agencies show that the United States has a far higher incidence of sexually transmitted infections (STI) and HIV-AIDS than Europe. While the prevalence of Chlamydia, Gonorrhoea and Syphilis has declined steadily in Europe since 1980, in the United States the incidence syphilis has increased and the the incidence of chlamydia has soared. The incidence of gonorrhoea has declined during the same period, but is still far higher than in Europe: around 100 cases per 100,000 persons, compared with about 5 in Europe. Most alarming is the far higher incidence of HIV in the United States, particularly in some of the states: Washington DC reports an incidence of 179.56 per 100,000 - very similar to the epidemic levels found in sub-Saharan Africa. The researchers, from On-Line Doctors, comment that the district’s own health officials have called its HIV rates “higher than rates in West African nations” and pointed out that “the District’s massive rates of HIV and AIDS are linked to delays in treatment after diagnosis, a lack of testing, and misconceptions about susceptibility to HIV/AIDS.”
These figures are very bad news for circumcision advocates and makes nonsense of the Center for Disease Control’s claim that more circumcision is needed so as to reduce the incidence of STIs and HIV. The fact is that the countries of Europe, where circumcision is extremely rare, have far lower rates of all STIs and HIV than the United States, where the vast majority of the sexually active adult male population are circumcised. Also revealing is the lower incidence of HIV in in the western states of the USA, where circumcision rates are the lowest in the country: on these figures you would have to conclude that circumcision increased the risk of HIV transmission. The DC health officials did not specify what they meant by “misconceptions about susceptibility to HIV/AIDS”: could they be referring to the illusion, so assiduously fostered by circumcision advocates, that circumcision gives a male immunity to HIV?
Source: Americans are more likely to have an STD than Europeans. Daily Mail, 12 March 2015.
We have previously drawn attention to other reports of poor health and well-being outcomes in the United States, including rates of child mortality that put on a par with the Third World. Clearly, there is no connection between a high rate of circumcision and improved health; on the contrary, if the experience of the United States is any guide, circumcision seems to make the situation worse.
Australian child health experts have given (yet another!) decisive thumbs down to non-therapeutic circumcision of male infants and boys. An article in Australia’s leading child health journal makes clear that the key issue in “the circumcision decision” is the best interests of the child (not the desires or misconceptions of his parents). The article – by David Forbes, chair of the task force that prepared the 2010 circumcision policy statement issued by the Royal Australasian College of Physicians – discusses both medical and ethical aspects of circumcision, observes that it is “more damaging to tissue” than mild (though still illegal) forms of female genital cutting, and suggests that the proposals of both the Tasmania Law Reform Institute and the Royal Dutch Medical Association (KNMG) deserve further discussion. The TLRI recommended much stricter regulation of circumcision, including restrictions on the advertising of circumcision services by profit-oriented entrepreneurs and so-called “specialists”, while the KNMG called on doctors to defend the interests of the boy by actively working against the practice.
Along with the recent paper by Na, Tanny and Hutson, this “viewpoint” represents a decisive rejection of the American view of circumcision (as embodied in the policies of the American Academy of Pediatrics and the Centers for Disease Control), and implies a return to the Australian policy of the 1970s and 80s, when child health authorities saw it as part of their duty to actively discourage medically unnecessary circumcision. Such an attitude is very good news for baby boys.
Source: David Forbes. Circumcision and the best interests of the child. Journal of Pediatrics and Child Health 51 (March 2015): 263-265.
A GOLD Coast surgeon was barred from performing circumcisions after he undertook the procedures without wearing gloves and had his dog at his practice during consultations. Dr Rodney Michael Tracey went to a tribunal to apply for a stay on the conditions placed on his medical registration in February last year, but was unsuccessful. One of the conditions imposed by the Medical Board of Australia was that he complete an approved education course in infection control. He was not allowed to perform circumcisions until approved by the board, the Queensland Civil and Administrative Tribunal said in a recently-published decision.
The conditions were put in place because a board committee believed Dr Tracey’s practise of medicine was below the accepted standard of a medical practitioner. The action was taken as a result of notifications to the Health Quality and Complaints Commission about Dr Tracey’s performance of circumcisions. The board said there were factual matters that could not legitimately be disputed by Dr Tracey, including that he did not wear gloves while performing Plastibell circumcision procedures. The board told the tribunal Dr Tracey’s dog was present at his practice during the course of consultations. The tribunal refused the application for a stay of the board’s decision.
Source: Kay Dibden. Doctor took his dog to surgery with him and did not wear gloves while circumcising patients Courier Mail, 8 February 2015.
Checking Dr Tracey’s registration at the Medical Board of Australia, we find that he graduated from University of Sydney (MB, BS - the basic medical degree) in 1957 - nearly half a century ago. If he was around 25 at the time, he must now be in his early or mid-80s; is it really appropriate for somebody at such an advanced age to be performing delicate operations on the penises of baby boys?
The full transcript of the Tribunal’s decision can be downloaded from the Supreme Court Library website
Circumcision is not appropriate for 21st Century Aussie boys. A definitive article in Australia’s leading child health journal confirms the judgement of Australian paediatricians since 1971 that boys should not be routinely circumcised as a health precaution. In a rebuff to the American Academy of Pediatrics (and by extension the Centers for Disease Control, which repeats its errors) the article endorses the conclusion of the circumcision policy statement issued by the Royal Australasian College of Physicians in 2010, namely, that there is no medical warrant for routine circumcision in the Australian and New Zealand context. As the authors conclude, “There is insufficient scientific evidence to support routine newborn circumcision in Australia …. From medical point of view, the ‘price’ is still too high.”
Circumcision is “one of the most painful procedures a baby can undergo”, and no fully effective anaesthetic method has yet been devised. This is the disturbing conclusion of a paper in the Italian Journal of Pediatrics, which examines the various circumcision and anaesthetic techniques in use and finds none of them satisfactory. The authors note that although “relief of human suffering is one of the most important goals for health care providers”, there have been only half-hearted efforts to eliminate the pain of circumcision, partly because the operation originated as a cultural ritual in which endurance of intense pain was part of the rationale. “Unfortunately, even during clinical trials, babies still undergo circumcision without analgesia, and the continuous production of studies for a better analgesia is the sign that a gold standard has not yet been found”, they write. The authors found that the Mogen clamp was less painful than both the Gomco clamp and the Plastibell, though seem to be unaware that the Mogen caused such a high incidence of additional injuries that a series of lawsuits drove the company out of business. It is increasingly common these days for boys to be given a local anaesthetic with a needle, but if the evidence of many Youtube videos is to be believed, the needle is itself extremely painful and often causes bleeding. EMLA cream, much vaunted by Australian circumcision salesmen, is neither effective nor recommended for use on young babies. As the authors of the present study conclude, “more research is required to find a better analgesic approach, in order to make circumcision a totally painless procedure without stress or discomfort. Present methods do not yet guarantee a total analgesia during this procedure.”
Source: Bellieni CV et al. Analgesia for infants’ circumcision. Italian Journal of Pediatrics 2013 39:38.
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?
Circumcision risks and harms outweigh benefits
Yet another hard-hitting critique of the American Centers for Disease Control draft circumcision guidelines finds its conclusions unsupported by the evidence and its recommendations invalid: Brian Earp. Do the benefits of male circumcision outweigh the risks? A critique of the proposed CDC guidelines. Fronters in Pediatrics 3 (18), 21 February 2015
A study of men attending sexually transmitted disease clinics in the United States has found that circumcised men are significantly less likely to use condoms and have double the incidence of sexually transmitted infections. This is the first published study of condom use that compares circumcised with normal men and reaches a conclusion strongly at variance with popular perceptions, and which refutes the claims of circumcision advocates that circumcised men are less susceptible to STIs and find it easier to use condoms. On the contrary, as the authors of the study point out in their discussion: “The investigation is important because it sheds light on a previously unexplored area of inquiry: whether intact men have greater issues with condom use than circumcised men. While intuitively appealing, the suppositions that intact men may have poorer perceptions and behaviours regarding condom use were not supported by the present findings. Indeed, these findings suggest quite the opposite in that intact men were less likely to report UVS and less likely to report infrequent condom use compared with their circumcised counterparts. These two observations are quite consistent with the descriptive finding that showed a greater than two-fold past history of STIs for circumcised men compared with intact men.”
The researchers added that “intact men were more likely to have complete confidence in their ability to use condoms than circumcised men. This observation suggests that intact men may, for some reason, have gained information or skills associated with condom use that their circumcised counterparts lacked.”
Although the authors state theirs is the first study of differences in condom use between circumcised and normal men, there is an earlier Australian study which found that circumcised men had greater difficulty using condoms, and specifically that condoms were more likely to slip off if the wearer was circumcised. This is the same as finding that uncircumcised men found it easier to use condoms. (Juliet Richters, Basil Donovan and John Gerofi, Why do condoms break or slip off in use? An exploratory study. International Journal of STD and AIDS 6 (1), Jan-Feb 1995: 11-18.
Source: Crosby R1, Charnigo RJ. A comparison of condom use perceptions and behaviours between circumcised and intact men attending sexually transmitted disease clinics in the United States. International Journal of STD and AIDS 2013; 24:175–178. doi: 10.1177/0956462412472444
In a landmark judgement, a senior British judge has stated that male circumcision constitutes “significant harm” and is more damaging than mild forms of female genital mutilation. Delivering his judgement in a case involving allegations of female genital mutilation, the President of the British Family Court, Sir James Munby, said that the case inevitably brought up the question of male circumcision and its very different status in British law. The judge observed that “circumcision involved the removal of a significant amount of tissue, created an obvious alteration to the appearance of the genitals, and leaves a more or less prominent scar around the circumference of the penis.” Accordingly, it can readily be seen that while severe forms of FGM are more invasive than male circumcision, mild forms (such as Type IV in the WHO classification), “are on any view, much less invasive than male circumcision.” Sir James further observed that there were more similarities than differences between circumcision and FGM, the most important being that the former was sanctioned by some religions and was thought by some to confer certain health benefits. Despite these similarities, both law and custom treated circumcision and FGM very differently: the former tolerated, unregulated and even advocated, the latter legally prohibited. This judgement represents a major development in anglophone legal thinking and echoes the decision of the Cologne appeal court in 2012 that non-therapeutic circumcision of minors constituted bodily harm and was a violation of the child’s right to physical integrity. The case is sure to renew the debate on whether NTC of boys should be regulated and restricted, as argued by the Tasmania Law Reform Commission.
Although the United States is still the last bastion of routine (infant) circumcision, more Americans are turning against circumcision and opting to leave their sons’ foreskins alone. If the overwhelmingly negative response to the Centers for Disease Control (pro-circumcision) draft guidelines were not enough evidence for this trend, recent articles in Psychology Today show that intelligent Americans recognise that the claims for circumcision having medical benefits are spurious, and that the harms are very real. In one article, Darcia Narvaez, a professor of psychology at Notre Dame University, criticises the CDC for engaging in a “conspiracy” to foist circumcision onto baby boys and even teenagers who have so far escaped. She points out that the CDC’s argument - that circumcision is necessary as a preventive of HIV - is irrational because the United States does not have a generalised HIV epidemic as in Africa, and that the risk of any adult acquiring it through heterosexual intercourse (the only situation where circumcision might lessen the risk) is so small as to be incalculable.
Source: Darcia Narvaez, Protect (all) your boys from early trauma
In a further article, Professor Navaez stresses the psychological damage of circumcision, pointing out that in addition to the physical damage, the pain of infant circumcision affects the brain; the fact of being circumcised can cause distress, resentment, anger and depression in adult men; older children are likely to experience operations on their private parts as traumatic invasions of their identity and suffer other forms of psychological harm. There is good evidence emerging that many boys circumcised as children or adolescents suffer post-traumatic stress disorder. Finally, she warns that by encouraging circumcision, advocates are teaching men to despise and be ashamed of their bodies: “If the CDC guidance is followed, medical providers will be communicating a psychologically damaging message to boys with intact genitals—that their penises are somehow “bad” or inferior. The negative effects of such communications have been studied with regard to intersex children and have been found to be frightening, shaming, and embarrassing to the child. This is a particularly cruel message to send to adolescents, many of whom are already experiencing concerns regarding body image.”
Source: Darcia Narvaez, Circumcision’s psychological damage
Guidelines issued by European authorities for the management of various inflammations of the penis stress that topical medical treatment (ointments, creams etc) are usually effective, and that circumcision is very rarely indicated. There is no need to be afraid of these big words: balanitis describes inflammation of the glans penis; posthitis is inflammation of the prepuce. In practice both areas are often affected and the term balano-posthitis is then used. It is a collection of disparate conditions with similar clinical presentation and varying aetiologies affecting a particular anatomical site. The guidelines describe ten separate conditions usually referred to broadly as balano-posthitis and the management regimes most appropriate for each. The only mention of circumcision is in persistent cases of a rare condition called lichen sclerosus (balanitis xerotica obliterans) that do not respond to topical medical treatment. Balanitis is not an indication for therapeutic circumcision, let alone for precautionary circumcision in advance.
Source: S.K. Edwards et al, 2013 European guidelines for the management of balanoposthitis. International Journal of STD and AIDS 25 (9), August 2014: 615-626. Full text available free on-line.
Research in Denmark suggests that circumcision may increase the risk of boys developing autism - a neuro-developmental condition characterised by impaired social interaction, reduced communication and restricted behaviour. The study found that circumcision raised the overall chances of an autism spectrum disorder before the age of 10 by 46 per cent, but that if circumcision took place before the age of five it doubled the risk. The leader of the study, Morten Frisch, a professor at the Statens Serum Institut, Copenhagen, said: “Our investigation was prompted by the combination of recent animal findings linking a single painful injury to lifelong deficits in stress response ... and a study showing a strong, positive correlation between a country's neonatal male circumcision rate and its prevalence of ASD in boys. Today it is considered unacceptable practice to circumcise boys without proper pain relief. But none of the most common interventions used to reduce circumcision pain completely eliminates it, and some boys will endure strongly painful circumcisions.” Professor Frisch stresses that the study is preliminary and suggestive rather than definitive and concludes that more research is needed, especially in countries where circumcision in infancy is common. “Given the widespread practice of circumcision in infancy and childhood in some regions, our findings should prompt other researchers to examine the possibility that circumcision trauma in infancy or early childhood might carry an increased risk of serious neuro-developmental and psychological consequences.”
This study was widely reported in Europe and Britain (e.g., the Daily Mail, which devoted as much space to criticising the study as to reporting it), but it has been largely ignored by the Australian media. This is in contrast to studies which claim to find an association between “lack of circumcision” and this or that disease: these are always reported without any criticism from authorities who disagree, and lapped up eagerly by Australian media. CIA makes no comment on the validity of the study, except to say that it is suggestive and agree that “more research is needed”. There are plenty of good reasons not to circumcise, and no good reasons to do it, without the need to bring up rare complications. The most serious harm of circumcision is simply the loss of the foreskin - a harm suffered by all circumcised boys.
Source: Morten Frisch and Jacob Simonsen. Ritual circumcision and risk of autism spectrum disorder in 0- to 9-year-old boys: National cohort study in Denmark. Journal of the Royal Society of Medicine, advance access, January 2015: DOI: 10.1177/0141076814565942
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