Tuesday, April 6, 2010

Recommendations

Mothering magazine and Intact America (a non-profit advocacy group opposing circumcision) are calling for signatures on a petition to stop the Centers for Disease Control (CDC) recommending routine infant male circumcision.

Circumcision is not a big issue for me, though of course I'm aware that it's one of those parenting third rails, like breastfeeding and vaccination. I did a lot of reading about it before Ben was born, and the most I could muster was a mild bias against, based on a general principle of avoiding all non-crucial surgery. At the time, there was some not-extraordinarily-significant research supporting circumcision as plausibly prophylactic against certain STDs, and the combination of that, Andy's more-than-mild-but-not-very-strong bias for, and the extreme discomfort and embarrassment of a family friend who had to be circumcised for medical reasons in his 70s added up to a Yes. There's also in there somewhere, in a way I can't possibly justify, a weird little family-cultural / atheist-but-CYA adherence to the covenant. Or comfort in the tradition. Or notion of tribal belonging. Or something.

Anyway, like I said, it's not something I can work up a lot of strong feelings for or against, and it's one of those things, like whether you use a baby carrier or stroller, that I have a hard time understanding why some people are excited enough about to advocate publicly rather than simply decide for themselves. But I do feel strongly about this petition, strongly enough to have broken my own very sensible rule about not picking fights on Facebook.

Here's some of what Mothering says:
Based on flawed studies that ignore the risks and ethical concerns of infant circumcision, the CDC may recommend this unnecessary surgery for our baby boys. We know that safe sexual practices and abstinence – not circumcision – prevent sexually transmitted diseases. And we know that there is NO link between infant circumcision and better health.

We will be delivering our petitions to CDC headquarters in April with the hopes of convincing them to make the right decision.

Mothering doesn't specify which studies it considers flawed and what those flaws might be. Unlike the CDC, it doesn't cite references. The CDC's fact sheet on male circumcision contains a useful paragraph, helpfully titled "Risks Associated with Male Circumcision," which includes no fewer than eight cites to studies that explicitly did not ignore the risks of the procedure. Mothering doesn't state its ethical objections, but I'm guessing they have something to do with the fact that an infant can't consent. And that's not something to dismiss out of hand, but we make decisions for our children every day, and that kind of ethical hairsplitting simply can't weigh heavily against substantive evidence (should there prove to be any) that performing the procedure would be a significant benefit to public health.

Mothering knows some stuff. Again, they don't cite references for how they know circumcision doesn't prevent transmission of STDs or how they know "there is NO link between infant circumcision and better health." And this kind of arrogant ignorance professing knowledge just honks me off. Take the claim that there's NO link between infant circumcision and "better" (as if that's even a meaningful or specific term) health: the American Medical Association says in this report, "there is little doubt that the uncircumcised infant is at higher risk for urinary tract infection." Smaller risk of UTIs = "better health"! But that's hardly the point, is it? The question isn't whether circumcision has any health benefits whatsoever (the most cursory review of current research makes it clear that it does); the question is whether the benefits are significant, whether they outweigh the risks and justify the costs. The ability to make that kind of essential distinction is only one of the reasons we trust the CDC before Mothering magazine to advise us about public health issues.

Mothering claims to want to convince the CDC to make the right decision. But to convince someone of something, you need to present an argument -- ideally with some evidence to back it up. A petition is not an argument. It's political pressure. It's a more or less polite way of ganging up. And I think we should all think very carefully about whether applying political pressure to the CDC is something we'd want to put our names to, or something we seriously think a group like the CDC should allow itself to be persuaded by.

It would be one thing if the petition advocated further specific study, if it made specific criticisms of the evidence, if it provided, in other words, an evidence-based argument to which it could then legitimately claim the CDC wasn't giving enough credence. But that's not what the petition advocates. Here's the text of the introduction:

No medical society in the world recommends male circumcision – yet newborn male circumcision is the most common surgical procedure in the U.S. This painful and risky procedure deprives more than a million boys each year of healthy, functional tissue – without their consent – while increasing medical costs by an average of $678 per baby.

The Centers for Disease Control (CDC) is developing public health recommendations for the U.S. on male circumcision that could ignore the serious risks of this non-therapeutic surgery. As the foremost expert on public health in our country, the CDC has a responsibility to share the truth about infant circumcision.

We need just a few more signatures to help us reach our 25,000 goal before the end of March. Sign our petition to the CDC below and demand a truthful statement on the risks and harms of newborn male circumcision.

So, if the CDC's recommendations don't ignore the risks of the procedure and do present a truthful assessment of said risks, but conclude that the benefits outweigh the risks, Intact America will support the recommendations?

Here's the text of the petition itself:
As the foremost expert on public health in our country, the Centers for Disease Control (CDC) has a responsibility to share the truth about public health issues that can affect millions of Americans.

Newborn male circumcision is the most common surgical procedure in the U.S. - yet this painful and unnecessary surgery carries serious risks, including hemorrhage, infection, surgical mishap, and death.
The role of circumcision in preventing sexually transmitted diseases (STDs) and other health claims has been investigated by public health researchers and remains highly debatable. Only safe sexual practices, such as the use of condoms and abstinence, can prevent STDs, including HIV/AIDS. Circumcision cannot be responsibly recommended as a way of preventing disease.
If the CDC chooses to promote newborn male circumcision, it is supporting a procedure called "non-therapeutic" by the American Medical Association - in favor of inconclusive and highly debatable research.

I ask that the CDC not recommend circumcision as a means of preventing HIV/AIDS and formally recognize the risks and harms of the procedure and the right of every child to bodily integrity.
Though Intact America makes no wild claims about what they know about circumcision, they throw the word "debatable" around as if it means "worthless." But they fail to mention what standard of proof they would find conclusive, and indeed fail to cite a single reference, most notably for their claims of the associated risks. They demand that the CDC admit the truth, implying of course that the CDC has failed to do so or is likely to fail to do so, but there is no evidence presented that suggests any kind of obfuscation or dishonesty.

What I can't understand is, if they accept that the CDC is the foremost expert on public health in the US, that the CDC has a duty to present the truth to the American people, and that there is debatable evidence about whether routine circumcision is beneficial to the public health, why on earth they can't just get the hell out of the way and let the CDC examine the evidence and make its conclusions?

The evidence is debatable, so for pity's sake, let's debate it! Let's hear it, all of it, including what the CDC -- the acknowledged experts -- think we should do. Let's open our minds to the possibility that while there might not have been significant evidence to support recommending routine circumcision five years ago, or last year, perhaps there is now. And if there isn't this year, perhaps there will be five years from now. Let's keep asking the questions whose answers might save or improve lives, and let's listen to the people who can speak about those questions with informed intelligence before we start arguing with them. Let's not dig so deep into the trenches we make of our personal decisions that we can't occasionally climb out and take a look at what a new day's sun might have revealed.

8 comments:

Mark Lyndon said...

These are the current positions of other English-speaking medical bodies:

Canadian Paediatric Society
"Recommendation: Circumcision of newborns should not be routinely performed."

http://www.caringforkids.cps.ca/pregnancy&babies/circumcision.htm
"Circumcision is a 'non-therapeutic' procedure, which means it is not medically necessary."
"After reviewing the scientific evidence for and against circumcision, the CPS does not recommend routine circumcision for newborn boys. Many paediatricians no longer perform circumcisions.


RACP Policy Statement on Circumcision
"After extensive review of the literature, the Paediatrics & Child Health Division of the Royal Australasian College of Physicians has concluded that there is no medical reason for routine newborn male circumcision."
(almost all the men responsible for this statement will be circumcised themselves, as the male circumcision rate in Australia in 1950 was about 90%. "Routine" circumcision is now *banned* in public hospitals in Australia in all states except one.)

British Medical Association: The law and ethics of male circumcision - guidance for doctors
"to circumcise for therapeutic reasons where medical research has shown other techniques to be at least as effective and less invasive would be unethical and inappropriate."

The only thing that's changed recently is the promotion of circumcision to fight HIV in Africa.

In Europe, almost no-one circumcises unless they're Muslim or Jewish, and they have significantly lower rates of almost all STI's including HIV.

Even in Africa, there are six countries where men are *more* likely to be HIV+ if they've been circumcised: Cameroon, Ghana, Lesotho, Malawi, Rwanda, and Swaziland. Eg in Malawi, the HIV rate is 13.2% among circumcised men, but only 9.5% among intact men. In Rwanda, the HIV rate is 3.5% among circumcised men, but only 2.1% among intact men. If circumcision really worked against AIDS, this just wouldn't happen. We now have people calling circumcision a "vaccine" or "invisible condom", and viewing circumcision as an alternative to condoms. . The South African National Communication Survey on HIV/AIDS, 2009 found that 15% of adults across age groups "believe that circumcised men do not need to use condoms".

The one study into male-to-female transmission showed a 54% higher rate in the group where the men had been circumcised btw.

ABC (Abstinence, Being faithful, Condoms) is the way forward. Promoting genital surgery will cost lives, not save them.

Remember that circumcision won't make any difference unless someone is having unsafe sex with an HIV+ partner.

Female circumcision seems to protect against HIV too btw, but we wouldn't investigate cutting off women's labia or prepuces, and then start promoting that. Different rules seem to apply to the male prepuce though - it's the only part of the body where healthy living tissue is routinely removed.

Neither you nor the CDC seem to have considered the possibility that foreskin might have a value. It is in fact the most sensitive part of the penis - it's not just there to protect the glans. Even on a circumcised man, the glans isn't the most sensitive part of the penis (it's usually the scar line, or the frenulum if that wasn't removed).

I'd like to write waaay more, but time is short. References available on request.

Jake said...

Brilliant!

Having blogged about Intact America's campaign previously, I was pleased to read your analysis of this petition. It was the model of clear thinking.

susan said...

I have let my subscription to Mothering magazine drop b/c I finally got weary of the not-well-sourced arguments about various medical issues (including vaccines). In many ways, my parenting values are in tune with much of what Mothering promotes, but I've finally been turned off by the smug certainty of their scientific writing. Your analysis here is spot-on.

Hugh7 said...

Here is a comprehensive review of the claims that circumcision prevents HIV. Since that was published, a study in Uganda (Wawer et al., Lancet 374:9685, 229-237) has shown (it was stopped early "for futility") that circumcision does not protect women from infection by men (and women are at greater risk already). Since 50% more of the women with circumcised partners became HIV+, circumcision may even increase the risk, but stopping early prevented that from reaching statistical significance.

And now a study has just come out (Bassler et al., JAMA. 2010;303(12):1180-1187) showing that stopping a trial early makes it more likely to seem to show a benefit, even if there is none. All three of the African trials on which the claims for circumcision are based were stopped early. This is especially so where events are few (less than 500). The total number of events (men becoming HIV+) in the three trials was 201 (65, 69 and 67).

Yes, "parents make many decisions for their children" - but there is no other decision like this one - to cut a normal, healthy, functional, non-renewing part of the anatomy off, absent any medical indication except being male. Why the anomaly? The most nearly corresponding part of the female anatomy is specifically protected by Federal and many state laws, with no exemption for religion or culture, and sometimes not even the adult woman's informed consent. Why the double standard?

Your acknowledgement of your own irrational aspect is only the tip of the iceberg. For millenia, circumcision has been promoted through fear, fear of breaking the Covenant, then fear of this or that disease - always the most fearsome of its day (so it was inevitable that AIDS would join the long line) - and fear of failing to conform.

Intact America and Mothering are sending a petition, not a scientific paper. Many of the signatories add first person statements about how much they hate having been circumcised. Before you say "get a life", ask whose body is it? Whose rights? And sometimes, whose life?

Hugh7 said...

It's not enough to say circumcision "reduces the risk" of this or that disease without some figures. When a disease is very rare and circumcision makes it rarer, you can get a huge figure for the difference with very little actual benefit. "Circumcision reduces UTIs tenfold" Wowee! But since it's from 1% to 0.1% (by circumcision advocates' own figures) that's 991 circumcisions in every 1000 wasted (1 on a boy who will get UTI anyway, and 990 on boys who weren't ever going to get them). Likewise penile cancer, one of the rarest of cancers (rarer than male breast cancer), and many studies find no significant difference in STDs.

Leah said...

Thank you for the fact based arguments.

I am the mother of two girls. However, as a Jew, it wouldn't have been a question for me whether or not to circumcise. It is beyond medical for our family, though I feel that the impartial scientific articles do rule that circumcision is not harmful to our children. Choosing it for our families does not make us old irrational barbarians or bad parents.

Circumcision is something I would have chosen for my son. He would have left my arms into his grandfather's, where the procedure would have been performed by a urologist trained as a mohel. He would then be returned to my arms. He would have nursed and fallen asleep. If his healing ran its course with the vast majority of babies who are circumcised, a statistic even higher for those circumcised by a mohel, he would have been fully healed in a few days time.

@Mark, you site rulings that do not recommend routine circumcision. However, they do not say that the risks are statistically significant enough to discourage it.

The comparison of female to male circumcision is inaccurate and inflammatory. The male equivalent of female 'circumcision' is the removal of the foreskin and the entirety of the glans, the tissue at the head of the penis. Additionally, the opening to the vaginal canal is often stitched shut during female 'circumcision.' There is no male equivalent.

Bottom line: There are strong feelings on all sides of an issue. Bravo to Holly for a reasoned argument that transcends emotions.

Mark Lyndon said...

There probably aren't statistically significant risks to cutting a child's earlobes off, but that wouldn't make it acceptable. In fact, it's not legal to cut healthy living tissue off children at all, with one exception - the male prepuce.

The risks of male circumcision include amputation and death btw. Those are both very rare but do happen - isn't that enough to stop people doing it?

I regard it as inaccurate and inflammatory to suggest that female and male circumcision are fundamentally different. You're talking about the worst cases of female circumcision, but some forms of female circumcision do less damage than the usual form of male circumcision. Sometimes there's just an incision with nothing actually removed. One form just removes the clitoral hood (the female foreskin), so it's the exact equivalent of cutting off a boy's foreskin.

(male circumcision can be pretty bad too btw - 79 deaths last year in just one province of South Africa)

Why is it illegal even to make a symbolic pin-prick on a girl's genitals, but not to cut part of a boy's pen1s off? Many Muslims consider it their religious right to cut parts off their daughters, but it was still made illegal.

Doesn't everyone have the right not to have parts of their genitals cut off unless there's an urgent medical reason?

Not all Jewish people believe in circumcision. Brit Shalom is an alternative naming ceremony to celebrate the birth of baby boys to Jewish families. These sites are all run by Jewish people opposed to circumcision:

http://www.jewishcircumcision.org/
http://www.jewsagainstcircumcision.org/
http://www.circumcision.org/

FredR said...

Holly, First to help you understand the function of the male and female prepuce, a brief history of its developemental stages.
In the womb we all start out feminine because of our original X chromosomes. Then when the evolved Y chromosomes functions kick in the Womb's parts close up and the labias and clitoral hood, now called foreskin end up at the tip of the clitoris now called the glans , the nerves in the G spot get elongated into the Gee string. Part of the lower Labias major now enclose the testicals. As a woman you know that these parts of the prepuce cause sexual arrousal when played with same function as in men. Withholding these functions is dishonest, subversive when persueding people to cut them off.
Second, In infant male and females, as well as the elderly, UTI's are caused from unclean diapers, not from having a prepuce. Claiming that UTI's are caused from having a prepuce is dishonest, in denial to parental irresponcibility. Othet UTI's resulting as STD's, originated from having sex with animals. Claiming that the prepuce allows STD infections, is again to hide the truth to how exactly these infection showed up in humans.
Thirdly, Sexual trauma to anyone distroyes neurological function to the affected areas and adjacent brain parts and chemistry. Sexual violence to anyone is known to cause PTSD's, even concenting adults.