The case for circumcision has been dealt a final, fatal blow. Danish research showing that the vast majority of normal (uncircumcised) boys never experience any “foreskin problems”, and that only a tiny minority of boys with a problem require circumcision to fix it, has forced the American Academy of Pediatrics to admit that the case for routine (prophylactic) circumcision is empty and bankrupt. The key facts from the paper by Ida Sneppen and Jorgen Thorup, are as follows:
What this really means is that:
The paper also noted that meatal stenosis (narrowing of the urethral opening) is 3 times more common in circumcised boys.
This website pointed out some years ago that 93% of Aussie boys would never experience a foreskin problem, and thus that routine circumcision makes no medical sense at all. This latest, comprehensive Danish study confirms this assessment, and further shows that only a small minority of the unlucky few who do experience problems will require surgery. The case for precautionary circumcision in advance is now well and truly dead and buried.
Source: Ida Sneppen and Jorgen Thorup, Foreskin morbidity in uncircumcised males, Pediatrics 137 (5), May 2016. Advance access 6 April 2016
In response to this devastating avalanche of scientific evidence, the AAP has more or less conceded that its 2012 circumcision policy was not really concerned with the medical case for circumcision at all, but with cultural and religious issues. In an editorial accompanying the Sneppen/Thorup paper, Andrew Freedman, a member of the circumcision policy taskforce, makes the following amazing admissions:
Source: Andrew Freedman, The circumcision debate: Beyond benefits and risks. Pediatrics 137 (5), May 2016. Advance access 6 April 2016.
The obvious questions arising from Dr Freedman's admissions are:
1. If circumcision is not a medical procedure, is not recommended and is not necessary for health, and if it is primarily a religious, cultural or social ritual, how can the AAP justify its recommendation that it is legitimate for health insurance providers to fund it?
2. Given the above, plus the acknowledged non-medical significance of the penis in our culture, how can the AAP justify its assumption that it is the parents, rather than the owner of the penis, who are the appropriate parties to make the circumcision decision?
We must point out that it was Freedman who, when the AAP policy was under attack back in 2012, notoriously stated that he did not circumcise his own boys for medical reasons, but because he felt the weight of centuries of ancestors breathing down his neck. It is evidence of his continuing commitment to circumcision as a cultural/religious rite that he makes no mention of bioethical or human rights issues, such as the child’s right to an open future; nor does he acknowledge that the AAP’s risk/benefit calculation has been criticised as empirically false, conceptually misconceived and inadequate to the complexity of the “circumcision decision”. Despite the title of his editorial, Freedman has not gone far enough beyond “benefits and risks”.
The key point is that those who have sought to advocate or defend circumcision (whether for cultural or medical reasons) on the basis that the AAP had guaranteed the soundness of the health case in its favour now find that the cheque has bounced. The fact is that the AAP bank account is empty. The last remaining bastion of respectable circumcision advocacy has been the American Academy of Pediatrics; now that their fortress has been stormed by a devastating Viking raid, the case for circumcision is well and truly on its last legs.
One reason why the incidence of foreskin problems among Danish boys is so low is that Danish parents and doctors understand No I rule for managing the infant foreskin: leave it alone! Because circumcision never became established in Denmark, there was no loss of knowledge as to the nature of the foreskin and its natural development from infancy to puberty and adulthood. In anglophone countries, by contrast, the wide practice of routine circumcision led to a loss of medical knowledge about the foreskin and the growth of the myth that it should be retractable by age 3 at the latest, and even the harmful idea that it should be pulled back “for cleaning” as soon as possible, as the ignorant American obstetrician Alan Guttmacher wrote in 1941: “Present-day hygiene requires that the foreskin, the hoodlike fold of skin which covers the end of the penis (glans) be drawn back daily and the uncovered glans thoroughly washed.” ** This is wrong, wrong, wrong, and nothing more than a revival of a medical myth that developed in the late Victorian period. Its description of the foreskin is also wrong: the foreskin is not a bit of skin that covers the end of the penis, but rather a substantial and integral part of the penis.
In most cases the infant foreskin is self-cleaning and should never be retracted for “hygiene” or any other purpose. Such misguided ministrations are likely to be very painful for the boy and to cause tears and lacerations that may require surgery later. A common cause of foreskin problems in infancy and childhood are efforts to pull the foreskin back before it is ready. Boys whose foreskins are not retractable are often said to be experiencing phimosis, but in most cases the phimosis (inability to uncover the glans) is a natural developmental stage that will resolve itself as the boy matures. Genuine phimosis is usually associated with pathological conditions, such as lichen sclerosus (balanitis xerotica obliterans), but such cases are rare and usually respond to medical treatment.
** Alan Guttmacher, Should the baby be circumcised? Parents Magazine, September 1941, 26.
Advice on foreskin care and maintenance
OK, you may be thinking that even if very few uncircumcised boys experience a foreskin-related disability when young, but what about the other supposed health benefits of circumcision emphasised by the AAP and other advocates, such as reduced risk of sexually transmitted infections as an adult. We have sought to put that canard to rest as a piece of medical folklore on several occasions, but it persists. To show how wrong it is, here are comparative statistics for HIV, gonorrhoea and syphilis in (uncircumcised) Denmark compared with the (circumcised) United States:
HIV-AIDS
Denmark: 0.1-0.2% (2014, adults 15-49)
http://www.unaids.org/en/regionscountries/countries/denmark
United States: 0.4-0.9% (2012)
http://www.unaids.org/en/regionscountries/countries/unitedstatesofamerica/
Gonorrhoea
Denmark: 12.1 per 100,000 (2012)
http://ecdc.europa.eu/en/publications/Publications/sexually-transmited-infections-HIV-AIDS-blood-borne-annual-epi-report-2014.pdf
United States: 110.7 per 100,000 (2014)
http://www.cdc.gov/std/stats14/std-trends-508.pdf
Syphilis
Denmark: 6.1 per 100,000 (2012)
http://ecdc.europa.eu/en/publications/Publications/sexually-transmited-infections-HIV-AIDS-blood-borne-annual-epi-report-2014.pdf
United States: 6.3 per 100,000 (2014)
http://www.cdc.gov/std/stats14/std-trends-508.pdf
So the (circumcised) United States has 4 times the level of HIV, and 10 times the level of gonorrhoea as (uncircumcised) Denmark. This suggests that the foreskin is protective against, and circumcision increases the risk of, urinary tract infections such as urethritis and gonorrhoea, at least in adulthood – which is what Jonathan Hutchinson found in 1855, and Ferris et al in 2010.
Nor is prevention of cancer of the penis a valid reason for circumcision. Since the days of Jonathan Hutchinson, circumcision advocates have made much of the value of circumcision in preventing cancer of the penis (Morris et al, 2011). Whether or not it does so is less significant than the fact that penile cancer is a rare disease of older men – so rare that accurate statistics on incidence are difficult to find, and so rare that it is even less common than male breast cancer. The American Cancer Society (2016) estimates that 2600 cases of male breast cancer will be diagnosed in 2016 and that 440 men will die of it. The figures for cancer of the penis are 2030 cases and 340 deaths. If prophylactic removal of infant male breasts is not recommended as a breast cancer preventive, there is certainly no need for prophylactic removal of the foreskin as a penile cancer preventive.
What are the key statistics about breast cancer in men? The American Cancer Society estimates for breast cancer in men in the United States for 2016 are:
What are the key statistics about penile cancer? The American Cancer Society estimates for penile cancer in the United States for 2016 are: