Health and Science News for Parents
Aug
30

To cut or not to cut… the AAP weighs in on circumcision

written by Tara Haelle

So you’ve likely heard by now that the American Academy of Pediatrics issued their updated policy statement on circumcision, the first since 1999. I’ve been sitting on the statement and the task force technical report for a week now, and even though I’ve written a news summary for dailyRx…  I have many mixed feelings.

I am grateful that their statement was issued with the sensitivity and caution needed for such a controversial practice and decision. Some of the headlines have been frustrating, implying that the AAP said “Circumcision is better.” Um, no. That’s not what they said. They said that the “preventive health benefits of elective circumcision of male newborns outweigh the risks of the procedure.” (To be fair, most headlines basically ran with “benefits trump risks” or some variation thereof.)

"You wanna do WHAT?!" Photo courtesy of Justyna Furmanczyk at sxc.hu.

In other words, if you choose to do this procedure, the benefits you will gain are greater than the risks involved in the procedure. This is very different from saying “It’s better to be circumcised.” In fact, their policy explicitly points out that they do not officially “recommend” the procedure routinely: “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.” (That last part just means yes, insurance companies, you should pay for it.)

An analogy: A child with obstructive sleep apnea can have a tonsillectomy/adenoidectomy (called an adenotonsillectomy) to remove their tonsils and adenoids for treatment. The tonsils and adenoids (lumps of issue behind the nose) generally cause the blockage that interferes with a child’s breathing while asleep, so removing them can usually cure the sleep apnea (in 75 to 100 percent of the cases).

There are risks to adenotonsillectomy, namely infection and excessive bleeding. There are risks to sleep apnea, including obesity, heart disease, diabetes, depression and death. For a child with obstructive sleep apnea, the benefits generally outweigh the risks of the procedure. A parent can still elect not to give their child the surgery.

Is it better for the child with sleep apnea to have the surgery? Probably. But perhaps not. It depends on the situation and the child. Is it better for a child without obstructive sleep apnea to have the surgery? Of course not. Why take any risk when there’s no benefit?

Now consider the two primary benefits conferred by circumcision: lower risk of urinary tract infections during the first year and reduced risk of HIV and a several other sexually transmitted infections during heterosexual sex. The risks of circumcision are most commonly bleeding, infection or the wrong amount of tissue snipped off, and this happens in about 1 of every 500 newborn boys (0.2 percent). Other studies found the rates higher, up to 2 to 3 percent, but these complications were still just minor bleeding. They even offered a comparison of a similar surgery as the one I discussed above: complications involving severe bleeding from tonsillectomies occur about 1.9 percent of the time in kids age 4 and under.

For parents with wild imaginations about horror stories, fear not: “The majority of severe or even catastrophic injuries are so infrequent as to be reported as case reports (and were therefore excluded from this literature review). These rare complications include glans or penile amputation, transmission of herpes simplex after mouth-to-penis contact by a mohel (Jewish ritual circumcisers) after circumcision, methicillin-resistant Staphylococcus aureus infection, urethral cutaneous fistula, glans ischemia and death.” Basically, yea, there’s a bunch of really bad stuff that can happen, but it’s really, really, really, really rare. Probably rarer than being struck by lightning. Twice. But that happens too.

So, the risks are pretty low. How beneficial are the benefits? Here’s a condensed run-down from the AAP’s technical report:

— Circumcision reduces the odds of contracting HIV during male-female sex by 40 to 60 percent… in Africa. When the CDC calculated that figure with the rate of contracting HIV by heterosexual sex in the U.S., they came up with a 15.7 percent reduction here. It’s something, but nowhere near as good as a condom. Plus, if your kids turns out to be gay, there’s not much evidence that circumcision helps him avoid contracting HIV. (And on the other side of the coin, circumcision can make it a little easier for women to contract HIV from a man, per one study cited in the AAP review.)

— Circumcised men are about 30 to 40 percent less likely to get any type of human papillomavirus (HPV), including both the relatively harmless strains and the ones that can lead to cervical cancer or raise your risk of cancer of the mouth, throat, penis and anus. Now, the CDC has recommended that boys get the HPV vaccine, but the vaccines available do not cover all the strains. Gardasil takes care of four of them, including the two responsible for about 70 percent of cervical cancer (HPV-16 and HPV-18) and the two responsible for 90 percent of genital warts. Cervarix only takes care of HPV-16 and HPV-18. So, circumcision would offer some protection against getting the HPV strains that the vaccines don’t cover, most of which — but not all — are not linked to cancer or warts.

— There’s some evidence that circumcision reduces risk of herpes (HSV-2) by about 28 to 34 percent, based on two studies in Africa.

— Evidence for protection against syphilis is weak. There’s no evidence that circumcision decreases the risk of contracting gonorrhea or chlamydia.

—There’s good evidence that uncircumcised boys get more urinary tract infections that circumcised boys, in part because bacteria can hang out in that moist area under the hood. The AAP estimates that 7 to 14 of every 1,000 uncircumcised boys will get a UTI before their first birthday, compared to 1 to 2 out of 1,000 circumcised boys. With such a low rate overall, in either population, the AAP notes that “the benefits of male circumcision are, therefore, likely to be greater in boys at higher risk of UTI, such as male infants with underlying anatomic defects such as reflux or recurrent UTIs.” (These are mostly the boys that get UTIs anyway.)

So, those are definitely some benefits to circumcision, especially if your little guy will have sex one day (which, presumably, you want him to do at some point in the far off, I-don’t-want-to-think-about-it future). It’s also fair to say that good sex education and condom use would make those benefits almost moot (not the UTIs, which are pretty low risk, and not all HPV strains, which sometimes infect even with condom use).

In any case, these two benefits, a lower risk for UTIs and some STIs, then become the risks of not being circumcised. The former is — usually — not very serious. There are some very serious urinary tract infections, and untreated ones can damage the kidneys. And they’re certainly not fun. They aren’t, however, usually life or death situations. HIV (somewhat still) is. Of course, boys are still at a pretty high risk for getting HIV if they sleep with someone who has it and don’t use a condom, circumcised or not. But every bit of protection helps, right?

Unless it requires lopping off part of a little boy’s penis. There. I said it. Because that’s what many parents are simply uneasy about, regardless of the health benefits, which are great or marginal, depending on your perspective. And that’s why the AAP stopped short of recommending circumcision as a routine procedure.

They did include in their review several studies related to sexual satisfaction and sensitivity, one of the complaints that “intactivists” bring up. The AAP summarizes it pretty nicely: “The literature review does not support the belief that male circumcision adversely affects penile sexual function or sensitivity, or sexual satisfaction, regardless of how these factors are defined.”

But it’s not possible to take into consideration, in scientific, mathematical terms, the primary complaint of those who oppose circumcision, which is that the man these little boys become may have wanted that little flap over the tip. And this is one of those gray areas that give parents pause. Once you cut that hood, you can’t put it back. How many circumcised men regret what their parents did? Well, probably not vast numbers, or circumcision rates would have plummeted.

Rates have, in fact, decreased, from somewhere around three-quarters of all boys in the 1960s to around 55 to 59 percent in 2010. (Here’s a nifty map to see where your states’ rates are.) But they haven’t plummeted.

So, this is where we end up. There are some decent benefits. There are very few and mostly minor risks to the procedure. And there’s big, giant, gray unknown area of “what if’s” and “could have been’s” for the boys who get snipped. It’s disingenuous to compare the practice to female circumcision, as some do, since neither its intent nor its effect is to influence sexual satisfaction. But whether it’s the right thing to do…? The AAP says it’s up to mom and dad. (Which, in many households, like mine, probably means mostly dad.)

“Parents ultimately should decide whether circumcision is in the best interests of their male child,” they wrote. “They will need to weigh medical information in the context of their own religious, ethical, and cultural beliefs and practices. The medical benefits alone may not outweigh these other considerations for individual families.”

What are those other considerations? Well, whether you want your little guy to have a foreskin. Or, whether you don’t know if he does or doesn’t want it and figure he should decide that in 18 years. Maybe daddy’s not circumcised and you both want him to look like daddy. (I know many people who circumcised for this reason alone.)

About the only certain thing that can be said about circumcision, based on the AAP’s policy statement and research and what we know about opposition to the practice, is that this controversy will be with us for years to come.

2 Responses to “To cut or not to cut… the AAP weighs in on circumcision”

  1. I find the “sleep apnea” compassion disingenuous, we don’t remove all children’s tonsils because it will help some people in the future. We remove tonsils after the problem has been identified. One is a solution the other is “preventive”.

    Also for the percentage improvement, what are they raw numbers, “2 in 100,000” to “1 in 100,000” is a 50% improvement, but a small real change. When only talked about as 50% is seems wonderful.

    Possibly the saddest point “to look like dad”. To avoid awkward questions form children or avoid questioning your parent’s actions and avoiding question the act itself.

    The female topic, is mechanically the same to me.

  2. Tara Haelle

    Hi Simeon, thanks for commenting as well over here on the original article. I appreciate your comments, and one thing I didn’t mention in my other comment or in this article is that my son is uncircumcised, so we probably have similar views on the practice personally.

    However, I try to remain open to thinking about what the science means for others who feel circumcision is important to them. I’ll repost here what I responded on the DoubleX blog:

    Yes, using relative risk is not terribly helpful. In this case, I used it for two reasons – one, I have not looked up every study that the Pediatrics committee looked up, and they provided numbers that they crunched in their meta-analyses. Short of gathering all those studies and doing that number crunching myself across the studies, I can’t provide the specifics, but at least the relative risk provides a general idea. I don’t think the relative risk numbers are terribly convincing anyway (one of the things I tried to convey) because a condom is so much more effective with STDs. For the one risk that’s not preventable by a condom – UTIs – I did provide the raw numbers instead of relative risk.

    The sleep apnea comparison is intended to show what it means, scientifically, to say benefits do or don’t outweigh risks, not to compare a tonsillectomy to circumcision. I included it because of headlines which erroneously interpreted the study as saying that “circumcision is better.” As I point out, the “risks” of not circumcising are simply the higher risks of UTIs and STDs. Those may not be convincing enough for many people to circumcise.

    Whether it’s sad that someone wants to “look” like their father is one I don’t pass judgment on. There are plenty of identity and self-esteem issues to consider here, and it’s not my place to judge those. However, there is a significant mechanical difference between male and female circumcision. Female circumcision removes the physical ability for a woman to achieve an orgasm by the clitoris. Even aside from the differences of intention (female circ does not prevent any health ailments and can cause infection, so prevention of sexual satisfaction is its only purpose), male circumcision does not prevent a man from enjoyment of sex, achieving orgasm or ejaculation.

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