Back in 2008, I tried to look objectively at the scientific evidence for and against circumcision. I got a lot of flak from commenters who focused on the ethical issues rather than the scientific evidence. I concluded that the evidence showed small benefits and small risks, and I didn’t advocate either for or against the procedure. At the time, the American Academy of Pediatrics’ position was:
Existing scientific evidence demonstrates potential medical benefits of newborn male circumcision; however, these data are not sufficient to recommend routine neonatal circumcision. In circumstances in which there are potential benefits and risks, yet the procedure is not essential to the child’s current well-being, parents should determine what is in the best interest of the child.
On August 27, 2012, the American Academy of Pediatrics issued a revised Circumcision Policy Statement saying that the benefits outweigh the risks.
The revised policy is based on the findings of a multidisciplinary task force that did a systematic evaluation of the peer-reviewed literature from 1995 through 2010. The new statement has been endorsed by the American College of Obstetricians and Gynecologists. It says:
…preventive health beneﬁts of elective circumcision of male newborns outweigh the risks of the procedure. 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 … Parents ultimately should decide whether circumcision is in the best interests of their male child.
They cite evidence that circumcision reduces the risk of urinary infections in infancy and reduces the risk of HIV and other sexually transmitted infections in later life. They point out that complications are infrequent and far less likely in the newborn period than if circumcision is performed later in life. Evidence for other benefits and detailed information about risks are included in the Technical Report by the panel along with a discussion of the arguments and with further recommendations.
They report the scientific data. The decision to circumcise or not to circumcise is based on those data along with non-scientific considerations like religion, ethics, and cultural practices. It seems that most people are unable to discuss the risk/benefit data without getting all riled up about those other issues.
This confusion between scientific data and other issues is illustrated by a detailed 20 point critique of the AAP report that was published by an anti-circumcision group, the Circumcision Resource Center.
It’s worth looking at the 20 points in detail. I’ve commented on some of them in parentheses and left it to my readers to spot the logical fallacies in the rest:
- The underlying flawed assumption is that the way to evaluate circumcision is to perform medical studies. They say all that is needed is feelings and common sense.
- Committee members were biased because many of them were circumcised or had performed circumcisions.
- Other countries recommend against circumcision.
- Many of the cited studies have been challenged. (The challenges they cite are unconvincing or based on issues outside of the studies themselves.)
- The report doesn’t mention the word “condom.”
- The report says circumcision prevents penile cancer. (They try to refute this by citing cancer incidence in two countries with different rates of circumcision.)
- The decrease in UTIs is small and they can be treated with antibiotics.
- Preventive benefits are not actual health benefits.
- Is doesn’t mention the effects of circumcision pain. (The report advised adequate anesthesia).
- It doesn’t mention ethical objections or all circumcision risks. (False. It has a whole section about ethical issues, and it covers all reported risks.)
- It doesn’t mention physician coercion and unauthorized circumcisions.
- It makes an issue of penile hygiene.
- It doesn’t mention the functions of the foreskin. (Actually it does, and it provides evidence that foreskin removal doesn’t affect sexual pleasure or cause any significant loss of function.)
- It doesn’t examine the connection between circumcision and erectile dysfunction. (There’s no credible evidence of any connection.)
- It doesn’t mention psychological harm. (Because there’s no evidence in the literature.)
- It lacks balance, devoting more space to benefits than to harms. (Because there is more evidence of benefits than harms.)
- It calls for more research into potential benefits but doesn’t specifically call for more research into the harms.
- It ignores difficulties with informed consent.
- It shifts responsibility from physicians to parents.
- It ignores serious ethical questions. (same point as #10)
This critique is far less credible than the AAP statement. It gets some of its facts wrong, moves the goalposts, says studies are not the way to look at the problem but then cites studies… the whole thing amounts to anti-circumcision apologetics rather than a reasoned scientific critique.
- It refers to removing 12 square inches (77 square centimeters) of tissue. That’s an overestimate. According to this study the average area of the adult foreskin is more like 37 to 43 sq. cm.
- It says some infants don’t cry during circumcision “because they go into shock.” That’s ridiculous. They are clearly not in circulatory shock, and the idea that they are in some state of emotional shock is nothing more than a fanciful speculation. I would argue that it’s more likely to be because they aren’t experiencing pain. My own anecdotal observation: I’ve seen babies cry from being restrained but then calm down before anything else was done and not cry during the actual procedure, even when it was done without anesthesia. The cutting itself would not be expected to hurt, because the tissue that is cut has already been crushed and numbed by the application of hemostats and clamps.
- They say anesthetics are injected into the penis and don’t eliminate pain. That’s misleading. For the most effective anesthesia, the dorsal penile nerve block, two injections are given adjacent to the base of the penis, and they prevent pain from the circumcision, although the injections themselves are painful.
- They cite some poor quality cherry-picked studies.
- They engage in wild speculation:
the effect of circumcision on male distrust, anxiety, and anger toward women is unrecognized and unexamined. Do the psychological and sexual consequences of circumcision affect America’s uniquely high divorce rate? We do not know.
Conclusion: Science cannot decide nonscientific issues
The AAP policy is based on a fair evaluation of the scientific evidence for and against circumcision. Ethical, religious, legal, and cultural issues are outside the sphere of science, and the AAP rightfully leaves those issues for parents and society to decide.
This article was originally published in the Science-Based Medicine blog.