Brian Earp is unimpressed by the American Academy of Pediatrics ‘s (how do you make a possessive out of that, anyway?) revision of its policy on circumcision.
They now say that the probabilistic health benefits conferred by the procedure just slightly outweigh the known risks and harms. Not enough to come right out and positively recommend circumcision (as some media outlets are erroneously reporting), but just enough to suggest that whenever it is performed—for cultural or religious reasons, or sheer parental preference, as the case may be—it should be covered by government health insurance.
That turns out to be a very fine line to dance on. But fear not: the AAP policy committee comes equipped with tap shoes tightly-laced, and its self-appointed members have shown themselves to be hoofers of the nimblest kind. Their position statement is full of equivocations, hedging, and uncertainty; and the longer report upon which it is based is replete with non-sequiturs, self-contradiction, and blatant cherry-picking of essential evidence. Both documents shine as clear examples of a “lowest common denominator” mélange birthed by a divided committee, some of whose members must be well aware that United States is embarrassingly out of tune with world opinion on this issue.
Child health experts in Britain, Germany, Scandinavia, Australia, New Zealand, and Canada say there is no meaningful benefit and it shouldn’t be recommended. Seems fair. There is no meaningful benefit, so don’t snip off a bit of the penis. Err on the side of not snipping off, because no meaningful benefit.
In view of this empirical uncertainty on the medical question, it is problematic to assert, as the AAP does in its new report, that a person does not retain the right to decide whether he wishes to keep his own healthy foreskin–and preserve his genitals in their natural form–and that the right belongs instead to his parents.
Which is odd, because they have their own genitals. Why don’t they alter their own if they want to alter? Why is it always vicarious?
A more reasonable conclusion than the AAP’s, then, is that the person whose penis it is should be allowed to consider, for himself, the available evidence (in all its chaotic murkiness) when he is mentally competent to do so—and make a personal decision about what is, after all, a functional bit of his own sexual anatomy and one enjoyed without issue by the vast majority of the world’s males.
Ah but liberals. Choice. Secularism. Community. Just ask Giles Fraser.
I noticed that the AAP also wants the procedure to be covered by insurance. Perhaps their primary interest is the revenue stream.
Deacon Duncan pointed out that their reasoning is that they should perform circumcisions because it makes promiscuity safer when they get older.
If it weren’t for religion, this debate wouldn’t even exist.
Circumcision is an awful practice, and I’d say it should be outlawed. In fact, it probably would be, were it not for the religious roots of the practice.
I’ve altered my own, though not particularly drastically. I’m very happy with the results, and would recommend them to anyone seeking the same. And yet, somehow, I don’t want it to be forced onto people who cannot decide they would be happier with the same modifications. If only others could manage the same.
Wholething, Duncan’s use of the word “promiscuous” really irked me, and I alluded to that over there. If there is mutual consent, precautions are taken against STIs and unwanted pregnancy, and nobody is being cheated on, what’s the problem with having sex with multiple partners, either at once or sequentially?
Back when “Arrested Development” was on the air, it had an episode in which Lindsay Bluth Fünke (Portia di Rossi’s character) became involved in an anti-circumcision campaign with an organization called HOOP (“Hands Off Our Penises”).
My sentiments exactly.
Without commenting on the merits of the case one way or the other, this is problematic:
By the time a boy (or man, depending on how you draw the line) is mentally competent to make the decision, the risks and complication rate of the surgery are much, much higher than when it’s performed on an infant.
Assuming arguendo that circumcision does confer significant health benefits, vaccination becomes a reasonable analogy: you don’t allow a 1-year-old to refuse a pertussis shot because it hurts.
Two asides: I haven’t looked at the developing evidence in a while, but last I checked the health benefits were only shown to accrue to a particular population of African men who engaged in unprotected sex with many partners.
And, I have a friend whose family converted to Judaism when he was seven and they gave him the choice about whether or not to be circumcized, and he decided to do it. Which is not relevant except to say, kid’s got more balls than I’ll EVER have.
Good post. The recent flood of pro-circumcision headlines showing up in my news sources was/is sickening, saddening, and stupid.
Fmr Senator,
That is another one of the exaggerations by the pro-circumcision groups. The best study on complication rates is this one: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2835667/
It says the median neonatal complication rate is 1.5% (range 0-16%) compared to a child complication rate of 6% (range 2-14%). However, the authors of the study point out how hard it is to measure these rates effectively as different studies used completely different definitions of complications, and there were numerous confounding factors, and none of the studies directly compared the rates across age groups, so you can’t really use them as direct comparisons.
According to the AAP’s own report, one of the key reasons to circumcise early is that “Newborn males who are not circumcised at birth are much less likely to elect circumcision in adolescence or early adulthood.” In other words, get ’em before they are able to consent.
Meanwhile, the reason we give infants vaccines is not because they are likely to refuse them when they are adults, but because they can contract these diseases in infancy and die or have major complications.
@ FSLC —
Yes, there are benefits to the circumcision-plus-STD-counseling package as compared to having access to neither. Which raises another question, of course…unless you’re to take the AAP approach and insist that STD counseling and an enforced period of celibacy couldn’t possibly have an impact on STD rates.
“Former Senator Larry Craig,” thanks for joining us. Can it be said you’re taking a wide stance on this issue?
I think Chris Lawson has adequately addressed your misconceptions, but I would like to ask you not to use “balls” as a synonym for “courage.” I don’t have balls and I am not lacking in courage.
Also, Ophelia, the apostrophe goes at the end, without an additional s. Thus:
But Ms. Daisy Cutter, it takes immense courage to walk around with such sensitive, fragile dangly bits dangling down there, such easy targets for athletic equipment, feet, knees, car doors, dogs, cats, bears, small deer, sharks, smartcars, broken rakes, and ninja-firehydrants.
#2, circumcision can’t be outlawed, that’s just silly! There are cases where it is medically necessary — just like any other form of amputation.
All you anti-circ people, allow me to ask the same question I do of anti-vaxers (and other conspiracists): what is the threshhold for you, of evidence that marks the point at which you would abandon your stance and advocate for neonatal circumcision (or at least not fight it)?
This is the question that delimits dogma from reason. So I want you to state, right now, for the record, what is the evidence you’d accept. I’ve seen how the anti-vaxers play it, and the threshhold for evidence for vaccine’s safety keeps moving, and they see conspiracy in every study affirming the safety of vaccines.
I’ve been watching this debate for the last few years, and for the record, I have no dog in this fight nor have I chosen a team. However, the the trend, as evidence is gathered and studies concluded, is clear: there are discernible health benefits to circumcision, and when performed on newborns, a vanishingly small risk. WHO, UNAIDS, and now AAP are all supporting this trend (even if the AAPs statement was full of equivocations meant not to inflame the intactivists).
So what are you: reasonable and evidence-based, or dogmatic?
“You can’t reason someone out of a position he didn’t reason himself into” (Unknown)
TGAP Dad, asserting that everyone who disagrees with you are dogmatic is not the best way to open discussion.
The evidence for vaccinations overwhelmingly show that it saves lives. The evidence for circumcision shows that it maybe lowers risks of maybe certain infection. Oh and is pretty.
Am I dogmatic?
Re infant male circumcision – the only rational basis I’ve ever heard for it is that it was originally a test for haemophilia (those who failed would be quietly exposed). Given that a haemophilia line is almost always started by a daughter of an older father, there would probably be a higher risk of this in a patriarchal polygynous tribe.
I have also heard it said that an uncut male produces a better experience for a female, all else being equal.
Exactly. I don’t want MY kid catching foreskin from some uncircumcised classmate just because that kid’s parents were irresponsible anti-circers.
I too am tired of people avoiding the evidence for the health benefits of circumcision, since those benefits were even widely known in the 19th century. Plus it helps them avoid the sin of masturbation.
@15 dalekitchens
By the sound of you, yes. You seem to have had trouble reading my comment, deliberately misinterpreting “mounting evidence” with “I’m right, and averyone else is dogmatic.”
Once again: I have no opinion on the debate. I am not part of an advocacy group, not awaiting the birth of a son, etc.
When I hear deliberately inflammatory language being used by the anti-circ crowd, like “amputation,” “hacking off part of the penis”, my opinion is that their minds are made up, and evidence will not sway them. However (like the anti-vaxers) they SAY that they want evidence, but that everything we bring them is inadequate/scant/tainted (by Pharma), etc.
The trend is clear: growing evidence is showing benefit from neonatal circumcision, and there are virtually no long-term harms (although infants are tender for a few days afterwards). Meanwhile AIDS is burning through the continent of Africa like a brushfire, and Catholics are fanning those flames. Circumcision isn’t the answer, but accumulating evidence shows that it helps.
You can either follow the evidence as it now stands, or continue to employ the tactic of the anti-vaxers and deny it. One marks you as dogmatic. One marks you as evidence-based. You decide.
TGAPDad @ #14
So, as a Canadian am I being dogmatic or rational when I accept the position of child health experts in my country who tell me that there is no meaningful benefit to circumcision? I’m sure that you’re not suggesting that only the AAPs’ opinion on circumcision is the rational opinion and that all other child health experts are dogmatic anti-circs.
Circumcision is unnecessary. The penis is capable of normal function without the procedure. The “benefits” such as they’ve been identified are not worth intervention. A child has bodily integrity and that integrity should be respected by its parents.
Here’s a better analogy than your vaccination offering- what if removing your son’s pinky finger at the second joint increased his chances of long-term happiness. For the sake of argument let’s say there are some studies that suggest it might and some studies that fail to support the position. Do you remove the finger at the 2nd joint? The studies that support the removal say it makes no difference if the removal is performed in infancy or adulthood, except that infants seem less traumatized by the procedure than adult men. Men who have had the finger removed do report some loss of dexterity but, on the whole, function normally even if they’re stumpy on one hand. Do you let your son choose or do you lop off his finger at the 2nd joint?
Some people would choose the amputation option. I’m not one of those people. Does it make me dogmatic that I believe that my child’s bodily autonomy trumps some potential benefit that can be achieved through other, non-intrusive measures?
dalekitchens @ #15
I have to disagree re. the pretty comment. I think a circumcised penis looks fucking weird. While I wouldn’t use the word “pretty” to describe a penis in general terms, I certainly would never claim to have an aesthetic preference of circcumcised over non-circumcised.
TGAP Dad, perhaps I should have been more clear.
“So what are you: reasonable and evidence-based, or dogmatic?” It was not a deliberate misinterpretation. If I did indeed interpret you incorrectly it was an honest mistake. I reject the claim that circumcision is good for an infant based on lack of good and consistent evidence. Not dogma. Your assertion seems to be that either I accept the evidence that you accept or else I’m dogmatic. I don’t and I’m not.
Also, the comparison to vaccination is a false equivalency. One is based on science and the other is based on ancient belief systems.
Mounting evidence? Seriously?
One study that suggests a possible, slight effect is mounting evidence?
I’m no scientist, but I’m pretty sure that’s now how science is done.
The evidence tells me how to stop the spread of AIDS in Africe – condom use, affordable treatment, an improvement in the status of women, education, acknowledgement that AIDS is a disease spread through bodily fluids and not a conspiracy of the West to re-colonize, research into cures/better treatments, etc. Those are the things AIDS groups in Africa need to be concentrating on; not the neonatal circumcision of infants.
Also, I fail to see how the AIDS epidemic in Africa relates to circumcision rates in North America or Northern Europe.
‘Medical evidence’ in favor of infant circumcision seems to be produced ONLY in the US, where routine circumcision became an entrenched institution for entirely non-medical reasons.
One could guarantee a dramatic reduction in breast cancer by performing ‘hygenic’ mastectomies on pre-adolescent girls. Here is an example where the ‘benefits’ would be real, and easily calculated. Does anyone think such an argument would be considered for even a moment?
In the US, potential anti-circ sentiments are choked off because most adults are too close to the matter. Mutilated men can’t handle the outrage and many parents have allowed their sons to be cut before they have thought about the issue.
One leading anti-circ activist began her activism after witnessing the procedure for the first time. A nurse, she began showing parents a film of the operation before they chose whether to do it. She was fired after her patients circumcision rate dropped to zero. What makes her story more tragic, and heroic, was that her own sons had both been subject to ‘routine’ cutting years earlier.
How many people who would call Child Protective Services if they saw a baby girl with pierced ears, have compartmentalised circumcision out of their moral view?
Mr TGAP –
The second para belies the first. Your own tendentious language betrays the fact that you do have an opinion on the debate, which is that people who oppose non-medically-necessary circumcision are a “crowd” and that they’re like anti-vaxxers, also that there is robust evidence that circumcision is beneficial, that “the anti-circ crowd” ignores it, and that you yourself belong to the opposite crowd, which brings evidence to the irrational “anti-circ crowd.”
I would like to see infant circumcision be stigmatized. An infant has so little voice. Even if parents were allowed to decide for their sons at the age of seven or ten or fourteen, it would be fascinating to see how parents explain to the kid what they wanted to do and why. They’d have to see their kid’s “oh, hell, no way” face. I would hope that many parents would realize the significance of what they are doing and change their minds.
“There are cases where it is medically necessary — just like any other form of amputation.”
Yes I’ve considered it myself as an adult for medical reasons.
And I support morphological freedom. So if adults want to do that particular body modification I don’t believe they should be prevented from doing so.
It’s simple: Provide evidence that it provides a measurable health improvement of the neonatal and early childhood life (and I don’t mean the silly hygiene argument). If it provides no benefit at that age, then it can and should be done later as needed.
Doing body modification to someone who can’t object for reasons not medically necessary, regardless of if that is FGM, circumcision, or pierced ears is wrong.
“Yes I’ve considered it myself as an adult for medical reasons.”
My son had to have it done when he was 3, because of chronic infections. His uncle did too. I had it done as a baby because of Phimosis, but I understand there are superior treatments for that now.
@21 sambarge
I think our analogy is flawed in terms of its long-term impact. A finger has bones, for one thing, and even the last segment of a pinky has some useful functions. In terms of impact and risk, I would place circumcision on par with ear piercing, except for the fact that age seems to make no difference in risk of complications for the piercing.
As for the Europeans and Aussies, who the hell knows why they recommend against. Possibly because, without a decades-long history of the procedu, they know this might be a hard sell to their populations, or perhaps they would like to see more substantial data before issuing a recommendation. I also can’t explain why otherwise-rational europeans have fetishes for their many “healing” spas with their mineral baths. Or why Koreans have such a widespread belief in “fan death.”
@22 dale
The bulk of anti-vaxers are primarily obsessed with mercury. This is not an ancient belief system. The ancient Egyptians did not invent thimerosal. And my comparison was to their tactics and unbending nature.
@23 Jafafa
Are you under the impression that this is the only study, and that the AAP stands alone in this recommendation?
@29 ckitching
When done after early infancy, circumcision has a higher risk of complication, and longer recovery period. The benefits are retained into adulthood regardless of when it’s done.
@26 Ophelia
I don’t believe there was any identification with any group, intentional or not. And I really don’t have skin in this game. I do need some means of collectively identifying this dedicated group of people who
– Use intentionally inflammatory language in describing circumcision
– Deny or minimize evidence that contradicts their adopted positions
– Use shrillness and repetition as means of confronting anyone who attempts to enter the other side of the debate
That is why I thought the use of “anti-circ” was applicable. “Intactivist” is too awkward to say, and Besides, implies activism, which I was not my intent.
Can we just stop that shit?
IMO it’s extremely irresponsible to propagate that stuff because even if the most optimistic of the data were true it wouldn’t make fucking around with no condoms safe.
Sure, slower infection rates lower the number of cases, but only if your control group is not using any precautions.
If your uncut control group is using condoms that also avoid unintended pregnancies, I have a very good idea who is going to have lower infection rates (hint: look at western Europe vs. USA: better sex ed, lower circumcision, lower infection rates)
And yes, i can already hear the guys telling the women that they don’t need to wear a condom because hey, they’re circumcised.
The funny thing about the AAP statement is the claim that the benefits slightly outweigh the risks. Now, since the risks are always handwaved away, like it’s hardly any, really, safest thing on earth, not to be mentioned, according to their own logic that must be true for the benefits as well, if they’re almost about equal.
Brad:
You have reminded me of Dan Savage.
” I would place circumcision on par with ear piercing, except for the fact that age seems to make no difference in risk of complications for the piercing. ”
For real? Pierced ears heal if you don’t actively maintain them by wearing jewelry. Amputated foreskins are gone forever. It is a permanent change that affects sexual functioning. You might as well make the same claim about FGM.
I’m seriously stunned that anyone would think that surgical alternations to human genitalia are somehow comparable to cosmetic piercings. WTH!
TGAP Dad: “As for the Europeans and Aussies, who the hell knows why they recommend against.”
That’s easy, in the UK, Aussie, and NZ the practice of circumcision used to be fairly widespread, and then at some point they said to themselves what the hell are we doing this for? They were spending rather a lot of money for an procedure that was unnecessary and held some risks such as bleeding, infection etc and any so-called benefits were (and still are) theoretical, in the future and might not apply to the infant. That’s one of the benefits of having a public and universal health system – they tend to fund what has clear benefits and is cost effective as intervention, rather than what the patient or insurance company is prepared to pay for. There isn’t and has never been a ban though, if deemed medically necessary circumcision will be done and parents could if really motivated find a doctor to do it outside of the health system.
With alleged benefits for example, UTI’s are rare in boys full stop, they are treatable with antibiotics and 30-50% are due to urinary tract abnormalities meaning even if you do circumcision, it’s likely to be of no benefit in a reasonable proportion of cases. Same with HIV, and funny enough all those countries mention have low circumcision and lower HIV infection rates than circumcised US. The benefit, even in Africa is small and nebulous let alone when you are trying to transpose those circumstances to other countries where heterosexual transmission is not the primary way infections occur.
Simple, it’s an unnecessary procedure, same as if they still did routine tonsillectomies, or decided to do routine prophylactic appendectomies. With the tonsils, or with the appendix there is a possible future risk of problems, but similar to routine circumcision of a healthy neonate, the risks can only be counted where the procedure is intentionally done for no clinical reason. That makes them pretty significant and would be a hard sell here. Circumcision can always be done where and when there is a clear benefit to the child, such as if they develop phimosis or if they have hypospadias, where the foreskin can be used to repair the defect.
As regards doing circumcision later, I’ve seen the claim it’s easier and have less complications, but I wouldn’t be so sure about that. The foreskin is adherent in infancy and must be forced away to circumcision for a starter, that means more trauma to tissues. Also, when done later in life, the child has had a chance to grow a bit, and can have proper anaesthetic and pain relief. Any complications would be a bit easier to handle.
Therefore, while they’ve taken note of the data re HIV, they’ve stopped well short of recommending routine circumcision of unconsenting babies. It’s unethical where no reason exists to do the procedure in the first place.
In the comments at practicalethics, anonymous supports the AAP:
They’re talking about HIV. *sigh*
Jeezis – really? People think circumcision is like a vaccination against HIV??!
Supposedly the area between the foreskin and the penis head gives HIV somewhere to be before it invades the body, so circumcision removes this hiding place.
I’ve said it before and I’ll say it again – earlobes serve no purpose, and you know how hard it is to get kids to wash behind their ears, so…
… snip ’em off while they’re young enough to not feel it.
The screaming is just a reflex action.
Ophelia:
Those who support that belief may use a Cochrane summary as support:
Bugger, I feel like a right drongo now, because I don’t know what’s wrong with my simple explanation:
No proven benefits of surgery for infants or children. Therefore no need to recommend unnecessary surgery for infants or children.
But I guess we simple folk in the old world and antipodes need simple answers, and the sophisticated thinkers of the Americas have much cleverer brains and answers.
The problems with the HIV trials are several
1) The newly circumcised men (this is important: adult men, not babies were circumcised) actually couldn’t have sex for the healing period, which already explains lower rates
2) The circumcised men received additional counselling
3) Even if the effects hold true (and mind, they were nowhere in the same ballparkt as we usually have with vaccines), they only hold true for men. Women, who always have a higher risk of STIs anyway don’t benefit from lower infection rates.
Sure, if their husbands don’t catch HIV in the first place it also benefits the wives, but they get zero protection if their partner is infected.
Believing in lower risks leads to higher risk behaviour, which you can see in lower condom usage rates in the west after AIDS lost a lot of its horror.