Circumcision of male infants and children as a public health measure in developed countries: A critical assessment of recent evidence

ABSTRACT

In December of 2014, an anonymous working group under the United States’ Centers for Disease Control and Prevention (CDC) issued a draft of the first-ever federal recommendations regarding male circumcision. In accordance with the American Academy of Pediatrics’ circumcision policy from 2012 – but in contrast to the more recent 2015 policy from the Canadian Paediatric Society as well as prior policies (still in force) from medical associations in Europe and Australasia – the CDC suggested that the benefits of the surgery outweigh the risks. In this article, we provide a brief scientific and conceptual analysis of the CDC’s assessment of benefit versus risk, and argue that it deserves a closer look. Although we set aside the burgeoning bioethical debate surrounding the moral permissibility of performing non-therapeutic circumcisions on healthy minors, we argue that, from a scientific and medical perspective, current evidence suggests that such circumcision is not an appropriate public health measure for developed countries such as the United States.

KEYWORDS:

• Male circumcision
• international public health
• health policy
• HIV prevention

Disclosure statement

Both authors have published articles and taken part in national and international debates concerning health-related, sexual, and ethical aspects of male and female circumcision. From a medical ethics perspective, they are generally sceptical about the advisability of performing non-therapeutic genital surgeries on minor children.

ORCID

Morten Frisch http://orcid.org/0000-0002-3864-8860

Brian D. Earp http://orcid.org/0000-0001-9691-2888

Notes

1. It is important to emphasise that this draft was made public, garnering much coverage in the popular media, prior to having been subjected to a formal peer review. In a notable turn of events, at least one medical professional who was invited by the CDC to perform such a review subsequently made his comments available online (van Howe, 2015). This freely accessible, 200+ page review is strongly critical of the CDC research and analysis, as are several other expert commentaries that were posted to the CDC website in response to a call for public feedback (e.g. Kupferschmid et al., 2015). Nevertheless, it is currently unclear whether, or when, the CDC intends to revise its recommendations in light of such critical feedback or else formalise them (or a modified version of them) as official policy.

2. It is widely acknowledged that removing the foreskin of the penis may confer certain health benefits, in much the same way that removing healthy tissue from any other part of the body could be expected to reduce the risk of medical problems affecting – or introduced via – that tissue (see e.g. Kluge, 1994). For example, routinely removing one testicle from every male child would almost certainly reduce the individual boy’s risk and the population-wide incidence of testicular cancer; but the costs, harms, and other disadvantages (sometimes misleadingly referred to as ‘risks’, see Darby, 2015) of prophylactic testicle removal would need to be factored into the equation, along with an array of moral considerations concerning autonomy, consent, and bodily integrity (not addressed in the present paper). In the case of male circumcision, then, the question is not whether certain health benefits may in fact ensue from the sheer surgical removal of the foreskin, but whether, in light of alternative, less invasive, means of achieving the same desired health outcomes, the benefits are sufficient to outweigh the costs, harms, and other disadvantages (i.e. ‘risks’), some of which may be subjective in nature and therefore difficult to quantify (see e.g. Adams & Moyer, 2015; Darby & Cox, 2009; Johnsdotter, 2013).

3. Moreover, as AAP task force member Freedman (2016) has additionally noted, in the United States, at least,

although parents may use the conflicting medical literature to buttress their own beliefs and desires, for the most part parents choose what they want for a wide variety of nonmedical reasons. There can be no doubt that religion, culture, aesthetic preference, familial identity, and personal experience all factor into their decision. (p. 1)

Consistent with this perspective, Freedman has stated in a separate interview:

I circumcised [my own son] myself on my parents’ kitchen table on the eighth day of his life. But I did it for religious, not medical reasons. I did it because I had 3,000 years of ancestors looking over my shoulder. (see http://www.thejewishweek.com/features/new-york-minute/fleshing-out-change-circumcision#zpW7AFLaLTQsqJMH.99)

Granting these considerations, a further question is raised, however, regarding who should get to decide about circumcision in light of such non-medical factors (about which there is no universal agreement about how to weigh them): the parents, as assumed by Dr Freedman (including in his own case), or the individual who must undergo the surgery and therefore live with its consequences, positive or negative, as judged in light of his own considered preferences and values (i.e. the child himself, when he reaches an age of competence)? As we have just seen, even purely ‘medical’ factors may be weighed differently in the minds of different individuals; how much more contentious might non-medical factors be?

4. It appears that such expansion of coverage would be of direct financial benefit to several CAA board members, including the organisation’s inaugural president, Dr C. Terry Russell (Russell Medical Center, ‘Trusted Australian Circumcision Since 1993’, http://www.circumcision.net.au), along with board members Dr Mojtaba Athari (Melbourne Vasectomy & Circumcision, http://www.mvandc.com.au/circumcision/), Dr Luke Bukallil (who has performed ‘over 2000’ circumcisions, http://drluke.biz/Circumcision/circumcision.htm), Dr Mohamed Hajoona (Victoria Circumcision Clinic, http://www.vcc.net.au), Dr Colin C.M. Moore (The Australian Center for Cosmetic and Penile Surgery, http://www.drcolinmoore.com), and Dr Anthony Dilley (who ‘conducts up to 40 circumcisions per week’, http://www.dailytelegraph.com.au/news/nsw/unkindest-cut-of-all-back-in-favour/story-e6freuzi-1225991948585). The group’s political petition to ‘restore elective male circumcision to public hospitals … increase the Medicare rebate [and] ensure [that] Medicare applies to prophylactic circumcision not just circumcision for medical problems’ can be found here: http://chn.ge/1otJ9Bv. A similar petition posted separately by Brian Morris is available here: https://www.change.org/p/nsw-ministry-of-health-restore-elective-male-circumcision-to-public-hospitals.

5. Please note that the reply to Jenkins by Morris et al. (2014b) suffers from many of the same problems that Jenkins pointed out in his critique of their original paper. For example, most of the references in the reply are to other contested papers by Morris and colleagues (with no mention of published criticisms of those papers), creating what others have described as a ‘rabbit hole’ of selective self-citation (Svoboda & van Howe, 2013).

6. Alexandre T. Rotta, M.D., FCCM, is the Linsalata Family Chair in Pediatric Critical Care and Emergency Medicine, and Chief, Division of Pediatric Critical Care, Rainbow Babies & Children’s Hospital (University Hospitals of Cleveland); as well as Professor, Department of Pediatrics, Case Western Reserve University School of Medicine. Dr Rotta describes some of the difficulties in linking circumcision-related complications with the circumcision surgery itself due to coding issues in an interview that is available online at the following link: https://www.youtube.com/watch?v=x_BohYj-VMw.

7. Further, indirect support for this view comes from a recent review paper by Springer (2014) concerning complications associated with surgery for hypospadias, another penile surgery that is often carried out in infancy or early childhood. As summarised by Carmack, Notini, and Earp (in press), on the issue of underreporting, Springer ‘identified numerous barriers to complete reporting of surgical, functional, cosmetic, and quality-of-life outcomes’ associated with the surgery, including

numerous techniques in use; most publications reflecting single-center and single-surgeon retrospective case series with limited follow-up periods and small numbers of patients undergoing follow-up; transition of care from pediatric to adult specialists, thus limiting follow-up into the period when sexual activity is likely to occur; assessment of cosmetic outcomes by surgeons who may be biased to approve of their own ‘work’ … and difficulty assessing sexual function and behavior in young adults. (p. 6)

Many of these ‘barriers to complete reporting’ of adverse outcomes are likely to apply to circumcision as well, although the matter has not been adequately studied to date. This lack of direct and comprehensive research into the issue calls for still further caution in interpreting available estimates of circumcision-related complications.

8. Indeed, the CDC working group mistakenly listed the El Bcheraoui et al. (2014) paper twice – as references 158 and 164 – in its background report (CDC, 2014b), and as one of only 15 highlighted references in the shorter recommendation document (CDC, 2014a).

Additional information

Funding

The authors report no financial or personal relationships with other people or organisations that could inappropriately influence their work.