Nicholas C. DiDonato
In a time when medical knowledge seems to grow exponentially, suspicion of ancient medical practices seems to grow at nearly the same pace. If an ancient medical practice has religious meaning, then skepticism skyrockets. Many consider male circumcision an obsolete, if not barbaric, practice. Yet, its medical efficacy remains an empirical question, regardless of people’s gut reactions. The American Academy of Pediatrics (AAP) has updated their position on circumcision, concluding that it reduces the risk of urinary tract infections, sexually transmitted diseases, and penile cancer.
In 1971, the AAP conducted research on male circumcision, concluding “…that there was no absolute medical indication for routine circumcision.” With no obvious medical benefits and potential medical risks (as with all surgery), this conclusion implicitly sided against the practice of circumcision. Later in 1999, the AAP reviewed evidence that male circumcision could reduce instances of urinary tract infections (UTIs) and sexually transmitted diseases (STDs) but found the evidence inconclusive. Still, they slightly modified their 1971 position by stating “that newborn male circumcision has potential medical benefits and advantages as well as disadvantages and risks.”
Fast-forward to the present, and the AAP has become convinced that newborn male circumcision does indeed reduce the risk of UTIs and STDs (including HIV) as well as penile cancer. They reached this consensus by conducting a massive literature review on the topic of circumcision and health. They assembled a task force to investigate the issue, a task force which included their own members with expertise in the subject, as well as experts from the American Academy of Family Physicians, the American College of Obstetricians and Gynecologists, and the Centers for Disease Control and Prevention.
This task force evaluated 1,388 peer-reviewed abstracts using the American Heart Association’s criteria to ensure that only sound research factored into the study. These criteria resulted in the elimination of 374 articles.
With the wheat separated from the chaff, the task force concluded that the “Specific benefits from male circumcision were identified for the prevention of urinary tract infections, acquisition of HIV, transmission of some sexually transmitted infections, and penile cancer. Male circumcision does not appear to adversely affect penile sexual function/sensitivity or sexual satisfaction.” After citing various studies supporting these claims, the task force offered plausible mechanical explanations for why exactly circumcision yields these benefits.
First, circumcision reduces the risk of UTIs probably because of the greater ease with which bacteria can colonize the environment inside the foreskin. No foreskin means less chance of bacteria colonies. Most UTIs occur during the first year of life, and so the AAP specifies that circumcision most benefits newborns. The risks associated with treating a UTI (possibly involving surgery) outweigh the risks of circumcision (which the AAP found to be infrequent and minimal – especially for newborns – when performed by a professional).Second, circumcision reduces the risk of many STDs (e.g., HIV) likely because the foreskin easily tears (microscopically) and so provides an easy pathway for STDs. Furthermore, the foreskin contains a high concentration of cells that HIV targets, which also facilitates an HIV infection. Finally, the secretions of the foreskin increase the chances of a male transmitting HIV to his partner. With circumcision, these vulnerabilities disappear.
Lastly, circumcision reduces the risk of penile cancer because phimosis significantly increases the chances of penile cancer. As the AAP explains: “Phimosis is a condition in which the foreskin cannot be fully retracted from the penis.” Obviously, no foreskin means no phimosis and thus a decreased chance of penile cancer.
The benefits of circumcision seem to have no real drawbacks other than the initial surgery. The task force found no evidence that “circumcision adversely affects penile sexual function or sensitivity, or sexual satisfaction, regardless of how these factors are defined.” In fact, they found studies from Uganda and Kenya indicating that men who were circumcised as adults reported greater sexual satisfaction in a two-year follow-up study. Of course, the task force did not endorse this view given the subjective nature of such self-assessments.
In fact, the task force did not outright endorse circumcision. While they believe that “Evaluation of current evidence indicates that the health benefits of newborn male circumcision outweigh the risks and that the procedure’s benefits justify access to this procedure for families who choose it,” they temper this statement with another: “Although health benefits are not great enough to recommend routine circumcision for all male newborns, the benefits of circumcision are sufficient to justify access to this procedure for families choosing it and to warrant third-party payment for circumcision of male newborns.”
In other words, the AAP wants (a) health care providers to cover the costs of circumcision and (b) parents to know the scientifically based pros and cons of the procedure. Since infants cannot provide legal consent for their health care until the age of 18 (in the US), parents must decide in the best interests of their child. Given the emotional gravity for some in a situation like this, one might describe the AAP’s position as pro-choice.
For more, see “Male Circumcision: Task Force on Circumcision” in the Journal of the American Academy of Pediatrics.