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Vol. 44, No. 5

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The Flip-flop over Foreskin
Human Bodies
Elizabeth Reis, 08/28/2012

The Flip-flop over Foreskin

(Human Bodies) Permanent link

The American Academy of Pediatricians recently released a statement saying that the health benefits of circumcision outweighed the risks. This pronouncement contradicts the Academy’s earlier ruling, just thirteen years ago in 1999, which stated unequivocally that the health benefits of the procedure were slim. The 1999 statement reversed a previous one made in 1989 that said there were good medical reasons for it; but a few years earlier, in 1971, the Academy had officially concluded that it was not a medical necessity. Clearly, circumcision is one of those surgeries about which opinion shifts back and forth over the years.

Medical concerns have changed frequently. In the 1840s many worried about phimosis, a condition in which the foreskin does not retract completely. To read some of the medical journal articles from the period, one might think this problem was nearly epidemic. Circumcision became one of the cures widely touted by physicians for this particular disorder. They also recommended circumcision as a remedy for masturbation and nervous conditions later in the century; in fact, some even endorsed the surgery for women suffering the same maladies.

Unlike the nineteenth-century physicians who focused on individual ailments, today’s circumcision advocates turn to public health justifications. To be sure, even today there are some who argue for its benefits on an individual level: it might decrease the already low incidence of infant urinary tract infections and even rarer penile cancer in adults, but these studies are contested and are not so compelling to advocates as the possibility of stemming the rising numbers of HIV/AIDS infections, particularly in Africa. In each era, circumcision promoters have emphasized the particular health crisis most urgent at the time; syphilis during World War I, HIV/AIDS today.

Even if we agree that circumcision has some public health benefits, it is not the cure-all that we might imagine. The pediatricians’ report cited several studies done in Africa, where HIV is spread primarily among heterosexuals. This research found that it reduced transmission from infected women to men but had no effect on transmission between men. In addition, it ameliorated the spread of some sexually transmitted infections (HPV and herpes) but not gonorrhea, syphilis, or the most common STI, chlamydia. Is altering perfectly healthy bodies prophylactically really the best response, or might education campaigns about safe sex practices be more successful (and less invasive) for the prevention of all these diseases?

The public health crisis of HIV/AIDS should not be taken lightly, of course, but the endorsement of circumcision for newborns is a radical step, particularly when the surgery has its own complications; the New York Times noted that one in 500 infants suffer severe consequences (infection, excessive bleeding, and disfigurement of the penis), and some babies even die each year.

Anticircumcision proponents (known as intactivists) argue that it is unethical to make a decision that permanently alters another person’s body without that person’s informed consent. Babies cannot consent, obviously, and so intactivists deplore second party assent to unnecessary surgery. Though offering ethical arguments and critiques of procircumcision claims, those who question routine circumcision are too easily dismissed.

Pediatricians, like most other Americans, are accustomed to thinking of circumcision as natural, harmless, and beneficial. Indeed, popular perceptions of the surgery represent it as a mere “snip of skin.” So many men in this country have been circumcised as infants that the surgery can strike us as “normal,” and many (though not all) do not feel they have suffered from it. Paradigms are difficult to shift. But if we took a moment to put aside what we think we know, and to look carefully at the conflicting medical debates circumcision has inspired over the years, we might be persuaded to at least question the necessity and wisdom of the procedure, given its risks, its permanence, and the fact that its recipient might have chosen otherwise.

For some religious and cultural communities, of course, non-health reasons motivate circumcision. Jews and Muslims circumcise boys to fulfill religious covenants, and these rituals have recently come under scrutiny in Germany. Many there and in our own country as well are worried about pitting state power against religious freedom. By emphasizing parents’ rights to make informed decisions, the AAP statement speaks to those families for whom cultural or religious considerations might supersede all else. But most American families do not have these same concerns. Many parents are likely to simply ask their physicians what to do.

By affirming that medical benefits outweigh the risks, the AAP makes the health card difficult to trump. For those parents who rest their case on the most recent health claims, it would be worth keeping in mind that medical opinions have consistently flip-flopped over circumcision. The AAP’s decision is reversible. Is the parents’?

 

Elizabeth Reis, professor of women’s and gender studies at the University of Oregon, is the author of Bodies in Doubt: An American History of Intersex (Johns Hopkins University Press, 2009). This year (2012-2103) she is a visiting scholar in the History of Science Department at Harvard University.

Posted by Susan Gilbert at 08/28/2012 10:37:12 AM | 


Comments
The AAP policy is culturally biased and seriously flawed. It should be withdrawn.

(The policy itself is annotated at http/www.circumstitions.com/Docs/aap-12-anno.pdf to cite the faults that follow.)

It fails to consider the structure or functions of the foreskin, a normal healthy body part, only the cutting of it off. It does not, for example, cite Taylor's groundbreaking 1996 paper, The prepuce: Specialized mucosa of the penis and its loss to circumcision. The erogenous value of the foreskin has been known for millennia, even to its enemies. Recent denial of that value is confined to those who have no experience of it.
It bases its conclusions about sexuality on two physiological studies that did not consider the foreskin, and on surveys of African adult volunteers for circumcision in the context of HIV prevention.
It treats normal intact penile features as pathological; late separation of the prepuce from the glans can take as long as 17 years but the AAP says it should separate within two months; and it associates "preputial wetness" with disease when it is normal, just like oral wetness.
It is filled with confirmation bias - finding the results the authors want.
It claims benefits of circumcising outweigh the risks without ever numerically comparing them.
It exaggerates benefits and minimizes risks and harm: For example -
It cites a study showing that "circumcision ablates [removes] the most sensitive part of the penis" and ignores that finding.
It admits the African HIV findings may not be applicable to the USA, but goes ahead and applies them.
It cites a study suggesting circumcising men increases the HIV risk to women, and ignores that finding.
It cites a study showing that a narrow foreskin (phimosis), not a normal one, is the issue in penile cancer, and ignores that finding.
It dismisses major complications and death from circumcision because it did not find any statistical studies of them.
It discusses the action of the Mogen circumcision clamp without mentioning that the clamp has caused too much of several boys' penises to be cut off; lawsuits have driven the company out of business.
It repeats the common claim that it is safer to circumcise babies than adults, but offers no evidence for that claim.
Its discussion of the ethical question of removing genital tissue from a non-consenting person versus leaving it for him to decide assigns no value to his autonomy or his human right to bodily integrity.
It compares the costs of doing it early vs late, but not with the benefits of not doing it at all.
Its ethical consultant, Dr Douglas Diekema, has said elsewhere that circumcision is not necessary and has a risk of harm, and that a parental wish is not sufficient to justify doing any surgery, and it ignores that.

The AAP should withdraw its circumcision policy the way it withdrew its female genital cutting policy after a storm of outrage two years ago, when it recommended a token ritual nick to baby girls, much LESS extensive than neonatal male genital cutting. If that was unacceptable, how can this be acceptable? (Dr Diekema headed that committee and has never recanted from that policy.)

The AAP's policy seems bent, not on considering the healthy intact penis at all, but on restoring insurance and public funding to circumcision in order to find a new market among the poor.

It does a disservice to the growing number of boy babies being left intact, and their parents - and an even greater disservice to the boys who will be circumcised as a result of its advocacy, and to the men they become.
Posted by: hughcirc@gmail.com ( Email | Visit ) at 9/1/2012 7:39 PM


Professor Reis makes many valuable comments on the inadequacies of the new AAP statement, particularly her observation that the AAP has been flip-flopping about circumcision since 1971 - or as I would prefer to say, tossing and turning. In 1971 there was no indication for circumcision of infants; in 1989 there were “good medical reasons” for it; by 1999 those reasons had disappeared; and in 2012 they are back again. Such shifts in opinion can hardly be the result of accumulating medical evidence - which remains as contradictory, contested and uncertain as it ever was - much less of changes in human anatomy. They are simply the result of the shifting balance of power on the policy committee: one year the anti-circumcision group has the edge; next year the pro-cutters get the majority. It’s really no way to reach decisions that have such an important bearing on the future health and happiness of millions of boys

Professor Reis concludes with a very important point: while the decisions of the AAP are reversible, those of parents influenced by their policy are not. What she means is that policies can be changed, but once a boy’s foreskin is taken away it cannot be restored. In making medical decisions for children, parents must therefore remember the open future principle and take care not to do things that they cannot undo. Childhood is a passing phase; circumcision is for ever. Given the AAP’s history of indecision, it is a certainty that in a few years time they will dump this policy and issue a new one stating that the risks and harms of circumcision outweigh the benefits. What compensation will the AAP then offer to all those boys who have been deprived of their foreskins as a result of parents believing and acting on what it said in 2012? Given the American tendency to litigation, the AAP may well find itself facing some pretty hefty lawsuits. (But then, a committee unaware that the makers of one of the circumcision devices that it discusses - the Mogen clamp - has been driven out of business by successful damages claims is perhaps too out of touch with reality to be aware of such issues.)
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Our analysis of the AAP 2012 Circumcision Policy Statement finds that it is an entirely self-serving attempt to get more money for medical doctors. Why else would they appoint Stephen Wegner, MD, JD, an expert in health care financing, to the task force?

The AAP had the support of the American College of Obstetricians and Gynecologists, whose members also receive hefty fees for doing medically-unnecessary, non-therapeutic circumcisions.

The self-contradictory statement twists good medical practice and medical ethics into pretzels to make it seems as though non-therapeutic circumcision of children is good, ethical medical practice.

We recommend that the American public completely reject this self-serving attempt to get more money at the expense of the health and well-being of American boys. Our commentary on the AAP statement is located at:

http://www.doctorsopposingcircumcision.org/pdf/2013-04-24_Commentary.pdf

George Hill
Vice-President for Bioethics and Medical Science
Doctors Opposing Circumcision
2442 NW Market Street, Suite 42
Seattle, Washington 98107-4137
Posted by: iconbuster@bellsouth.net ( Email | Visit ) at 12/12/2013 12:57 PM


Our analysis of the AAP 2012 Circumcision Policy Statement finds that it is an entirely self-serving attempt to get more money for medical doctors. Why else would they appoint Stephen Wegner, MD, JD, an expert in health care financing, to the task force?

The AAP had the support of the American College of Obstetricians and Gynecologists, whose members also receive hefty fees for doing medically-unnecessary, non-therapeutic circumcisions.

The self-contradictory statement twists good medical practice and medical ethics into pretzels to make it seems as though non-therapeutic circumcision of children is good, ethical medical practice.

We recommend that the American public completely reject this self-serving attempt to get more money at the expense of the health and well-being of American boys. Our commentary on the AAP statement is located at:

http://www.doctorsopposingcircumcision.org/pdf/2013-04-24_Commentary.pdf

George Hill
Vice-President for Bioethics and Medical Science
Doctors Opposing Circumcision
2442 NW Market Street, Suite 42
Seattle, Washington 98107-4137
Posted by: iconbuster@bellsouth.net ( Email | Visit ) at 12/12/2013 12:59 PM


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