In the land of instant information and where everyone has a blog (like me – ha!) it can be hard to know where to turn for reliable, trustworthy information. This fact is especially true for any hot-button or emotional topic, like circumcision. If you google the word, you get hundreds of thousands of hits, with tones varying across the whole spectrum from dry academic research to heated parental debate to the frankly weird. From my perspective, even the results that seem to be trustworthy can be tricky, because, as with everything involving statistics and medical research, numbers can be read many different ways, and research can be spun. The two key lines of distinction that need to be drawn in reading research and making decisions are first, the difference between relative and absolute risk, and second, the difference between causation and correlation. I’ll come back to this point below. I am rather reinventing the wheel here – all the links I posted last time contain this information. The absolute best thing to read is by an Oxford University ethicist named Brian Earp.
One response to my previous post on circumcision raised the current stance of the American Academy of Pediatrics (AAP), which reads as follows:
‘Evaluation of current evidence indicates that the health benefits of newborn male circumcision outweigh the risks and that the procedure’s benefits justify access to this procedure for families who choose it. Specific benefits identified included prevention of urinary tract infections, penile cancer, and transmision of some sexually transmitted diseases, including HIV.’ You can read the short statement here and the full technical report here. This week the CDC has come out with a very similar statement, claiming the same ‘benefits’.
As a dear friend once asked me, ‘What mother wouldn’t want to protect her son from UTIs and especially cancer and HIV?!’ The question to ask is, DOES male infant circumcision protect against these things, and if so, how much?
Let’s start with UTIs. Certainly some studies have shown that circumcision reduces the risk of UTIs (although other, more recent studies have not) – but let’s look at the numbers. According to one study from 1985, of every 1000 boys who remain intact, 7 will be admitted to hospital for a UTI before the age of 1 year old. Of every 1000 boys who are circumcised, 2 will be admitted to hospital for a UTI before the age of 1 year old. We could look at those numbers in various ways: circumcision reduces the risk of UTIs by more than two-thirds! Or we could look at the absolute risk: 7/1000 is 0.7%. Circumcising reduces the chance of a hospital-bound UTI from one very tiny number to another very tiny number. We can flip that number around and look at it from the other side: of every 1000 boys circumcised, 993 would never have needed hospitalisation for a UTI in any case. Or you could look at it another way, and say that for every hospital-bound UTI prevented by this choice, about 141 circumcisions were performed needlessly (this is the ‘number needed to treat’ to achieve the goal). This point also highlights what we mean when we say that the health benefits of circumcision are potential rather than actual – they prevent (possibly) things that might happen. Before moving on we can also note that girls under the age of 1 have approximately as many UTIs as boys. We treat them with antibiotics.
The second health benefit listed by the AAP is the prevention of penile cancer. Let’s look at the numbers. Of every hundred thousand men who are intact, 3 will develop penile cancer. Of every hundred thousand circumcised men, 1 will develop penile cancer. So, we could indeed say that circumcising a baby boy reduces his risk of penile cancer by two-thirds. Or we could flip the numbers and see that 99,997 circumcisions were performed needlessly. Penile cancer is so incredibly rare that, in fact, more men die of breast cancer in the United States every year than of penile cancer. About 1 in EIGHT women will get breast cancer at some point in their lives. We do not remove the breast buds at birth. This argument for performing circumcision is so ridiculous that decades ago the American Cancer Society actually asked the AAP to stop using it and today the American Cancer Society recommends good hygiene and not smoking as far more effective methods of risk reduction.
Finally, the AAP suggests that circumcision can reduce the transmission of STDs including HIV. The link with HIV came out of three main studies performed in Sub-Saharan Africa about ten years ago. Adult men who chose (please note it was a choice) circumcision were found to have about 60% protection against contracting HIV. However, many scholars have found problems with these studies, mostly around the difference between correlation and cause. The men who chose to be circumcised had more clinic visits and thus access to lectures on safe sex and condoms than the men who did remained intact, for example. The studies were stopped early. The ‘protective effect’, even if considered ‘real’, is still only 60% (and the absolute reduction was just 1.3%), meaning that even the circumcised men should wear condoms to avoid infection or infecting others. We can also draw two national comparisons. Most HIV transmission in Africa is by male-female sex. Most HIV transmission in the USA is by male-male sex and contaminated blood (like sharing drug needles) – circumcision does not protect against these means of transmission and the risk of female to male HIV transmission in the USA is incredibly low anyway. Finally, if this link is causal, we would expect the USA, with its relatively high levels of circumcision, to have low rates of HIV, and countries with low rates of circumcision to have higher rates of HIV. That is simply not the case: Norway, for example, has almost zero male circumcision and much lower rates of HIV than the US – 0.47 per 1000 in the adult population compared to 3.7 per 1000 in the US. Once again ask what is the number of men circumcised for this reason who never would have contracted HIV in the first place – what is the number needed to treat? Some studies have shown that males are less likely to contract other STDs like genital warts if circumcised, while others have shown that they are more likely to infect women if infected themselves. You can read an overview (from an admittedly anti-circumcision site) here. One fundamental point to consider is this: is your baby boy going to be sexually active? Is he going to be engaging in activity likely to land him an STD? Could you teach him how to have sex safely, that is, by using a condom or avoiding promiscuity? Could you let him choose circumcision as a preventative measure if he so desires, in the knowledge that he would STILL need to wear a condom to have sex safely?
To sum up, the health benefits of circumcision are not at all clear. They are disputed. They are potential rather than actual.They are all either treatable by other means or avoidable by methods far less drastic. If any scientist or government committee suggested introducing any new surgical procedure (rather than one entrenched in this country’s culture) on the basis of these kinds of number, they would be laughed at.
One final note: all of these perceived and potential benefits are predicated on the notion that the foreskin is pointless – that there is no advantage to having one and that it serves no function. This is certainly the stance of the committee that prepared the AAP and CDC statements referenced above. That stance could not be further from the truth, but you will have to wait for another blog post to read about the wonders of the male foreskin.