The Circumcision Debate

Should males be circumcised? This is clearly an issue about which many people feel strongly, for a host of social, religious and personal reasons, but there are a number of facts related to the issue that clearly came under consideration in the American Academy of Pediatrics  guidelines just released related to circumcision of male infants and published in Pediatrics.  The guidelines basically state that the benefits of the procedure outweigh the risks and access to circumcision should be available to parents of male infants.  Rick and I wholeheartedly agree in this week's PodMed.

These guidelines were last updated in the late 1990s, and since then, several studies have provided compelling evidence for the health benefits of the procedure.  Interestingly, much of this evidence comes from studies in Africa, prospective studies investigating whether males who were circumcised acquired HIV infection more readily than their uncircumcised peers.  The answer was resounding, and showed clearly that uncircumcised males became infected much more frequently.  Historical data and studies have already shown that other STIs are also more likely in men who remain uncircumcised, as are UTIs and penile cancer.

These facts fly in the face of perceptions that since many infectious diseases may seem under control in the US, circumcising male infants isn't as important domestically.  Thus an increasing number of parents have chosen not to circumcise their male infants in the last decade or so.  Hopefully the new guidelines will help reverse this trend.

The Academy does acknowledge that circumcision needs to be performed by a well-trained provider who also employs adequate pain relief and sterile technique.  Such a provider need not be a physician but can be another medical or religious professional who is proficient in the procedure.  Specific methods that don't provide adequate analgesia include infant positioning or sucrose pacifiers, and the guidelines specifically name penile nerve blocks as effective and caution about the use of analgesic creams in preterm infants as a potential source of irritation.

Parents also must be educated about circumcision, and the paper cites the rather sobering statistic that only about 4% of parents report having discussed circumcision with their clinician before pregnancy.  The speculation is that information about the procedure is gleaned from family and friends rather than clinicians or education. A suggestion is made that circumcision should be a topic in childbirth education classes so parents have factual information.

Rick emphasizes in the podcast that these guidelines apply to infant male circumcision, the least problematic time in a male's life in which to undergo the procedure.  The guidelines do mention that some parents are reluctant to make this choice for their male children, preferring to defer such a decision until the individual is old enough to choose for himself, yet the likelihood that an older male will do so, especially once he's become sexually active, is remote.  I would also say that at this year's International AIDS conference in Washington, DC, a very courageous African man was extolling the virtues of adult circumcision and revealing his own personal journey with it, but men such as him are rare indeed.  Seems like one place where parents need to step up to the plate.

Other topics this week include a CDC recommendation that all persons born between 1945 and 1965 undergo a one time screening for hepatitis C, the effect of midlife exercise on chronic disease in later life in Archives of Internal Medicine, and marijuana use in adolescence in the Proceedings of the National Academy of Sciences (PNAS). Until next week, y'all live well.

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Comments

Christopher Sewell November 13, 2012 at 12:10 am

Elizabeth,

I don't have the time to reply at length right now, but since no one has commented on your article yet I wish to point out some significant facts.

The AAP is the only medical institution, worldwide, which now positively supports male circumcision, child or adult. It has 'shot itself in the foot' and the deafening silence from august medical bodies across the world should speak for itself.

The African 'studies' which were global news some few years ago have been proven seriously flawed. But the USA, with its entrenched culture of circumcision, funded the failed African experiment heavily - and hence has an axe to grind in its defence.

Only American historical data suggests circumcision as a means to prevent STDs and UTIs. Yet STD infection, per capita, in the USA is far greater than any non-circumcising first-world nation; this in a country peopled with circumcised adult males in its millions. The UTI issue is a total nonsense. Again it's based on an almost ancient American survey many years ago when there were inadequate 'samples' of intact penises to provide a scientific comparison. Yet the fallacy is still trotted out today among pro-circumcision advocates. In the UK boys are allowed to keep their foreskins with next to no UTIs from birth to old age.

Rick has a matter to consider earnestly, like it or not. The notion that infant male circumcision is "the least problematic time in a male's life in which to undergo the procedure" is a tragic example of American duplicity. Ignore 'he won't remember it' (another worn-out excuse for the infant procedure). A newborn baby boy's metabolism cannot accept a nerve-block injection to the strength of anything like that of an adult male who will nothing - absolutely nothing as his foreskin is incised and removed. Post-operative pain? An adult know why he must accept it, and more to the point, he CAN.

I was circumcised as a mature adult in 2002, for reasons following abuse as a boy. It's irrelevant to this discussion, but it explains why I have spent a thousand and more hours ever since on the intenet promoting genital integrity.

I could answer much more from your article, Elizabeth. Please keep in mind your perspective on male circumcision as woman who can never fully understand male genital issues any more than I can a female.

Do consider why evolution has not rid the penis of its foreskin.

Both male and female, our coccyx is now the remnant of our tail bone. Nature evolves as it must, following its basic premise for survival. Did nature make a mistake with foreskins?

Christopher

Reply

Elizabeth Tracey November 13, 2012 at 11:33 am

Dear Christopher-

Thank you so much for your lengthy and thoughtful comment. There are some points you bring out I must disagree with, especially the studies conducted in Africa regarding HIV transmission in circumcised versus uncircumsized males. I'm not sure what vested interest group you make reference to would support and skew research such as this; since there are no drugs or devices in the mix a profit motive isn't operative.Having attended the HIV meeting this year in Washington, DC, I was privileged to hear a presentation by an adult African male who was advocating for the procedure among adult men in his country as a means to reduce the burden of HIV infection, so clearly some adult men are willing to make this choice, and your point is well taken that none of us can appreciate the level of pain an infant male might feel, especially women. That's unfortunately the type of prospective, peer-reviewed and double-blinded study it's impossible to do!

With regard to nature conserving a foreskin, that's what I often call a 'God question.' I don't know the ecological impact of ticks but sure wish they weren't around! No doubt they occupy some place I can't fully grasp in the great scheme of things and that may be true of foreskins as well. Again, many thanks for your comments.

Reply

Christopher Sewell October 2, 2013 at 11:53 pm

Elizabeth, a very late response to your welcome reply. It was so long ago I lost the link until I recently Googled my name coupled with 'circumcision' - and one of the results brought up this website.
I would be glad to talk more about your 'God question', but could we discuss it via personal email? I am daily involved with two family-orientated websites, both American - and both take much of my free time discussing boy and adult male circumcision.
Christopher

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