Brian D. Earp on the AAP’s Flawed Circumcision Policy Statement

If you read only one analysis on the AAP’s revised policy statement on infant circumcision, make it this fantastic deconstruction by Brian D. Earp. It’s almost too perfect to excerpt. This is a great sample, but his entire post is required reading.

Here they depart from their 1999 statement in asserting that (1) the benefits of the surgery definitively outweigh the risks and costs and (2) that it is therefore justifiable to perform the operation without the informed consent of the patient. This does not follow. In medical ethics, the risk/benefit rule was devised for therapeutic procedures aimed at treating an extant pathological condition, and for minor prophylactic interventions such as vaccination. It has no relevance to nonessential amputative surgery, especially when it involves the painful removal of healthy, functional erogenous tissue from the genitals, and when safer, more effective substitute strategies exist for achieving the same ends.

You may be surprised to learn that the word “condom” does not appear even once in the 28 page AAP report.

In making their risk/benefit calculations, then, the AAP simply leaves out a critical bulk of factors relevant to the equation, including the existence of a range of proven healthcare tools like condoms, vaccines (including an effective HPV vaccine), and antibiotics. If they had bothered to consider human rights and bodily integrity issues, the function of the foreskin, its value to the individual, and his possible wishes in later life, as well, their computations would quite plainly yield a very different answer.

Seriously, it’s worth the time. And share it far and wide.

Infant Male Circumcision and Current Human Rights Disparities

Another focused post for a story on which I’ll have more to say.

In a study published Monday in the Archives of Pediatric and Adolescent Medicine, a team of economists and epidemiologists estimated that every circumcision not performed would lead to significant increases in lifetime medical expenses to treat sexually transmitted diseases and related cancers — increases that far surpass the costs associated with the procedure.

I strongly suspect the study is flawed because it makes estimates. I’ll withhold further comment until I know more. For now, there’s enough to discredit the embarrassingly incomplete approach used to justify the study and its estimates.

That sentiment [that Medicaid should cover non-therapeutic child circumcision] was echoed in an editorial accompanying the study. UCLA health economist Arleen Leibowitz wrote that by failing to require states to cover circumcision in Medicaid plans, the U.S. reinforces healthcare disparities.

“If we don’t give poor parents the opportunity to make this choice, we’re discriminating against their health in the future,” she said in an interview. “If something is better for health and saves money, why shouldn’t we do it? Or at least, why shouldn’t we allow parents the option to choose it?”

We shouldn’t do it or allow it because non-therapeutic genital cutting on a non-consenting child is unethical. Male circumcision on a healthy child violates his basic human rights to bodily integrity and self-determination. It is indefensible, even if it’s possibly “better” for his health in someone else’s subjective evaluation or because it saves money when individuals are considered statistics rather than human beings with their own rights and preferences.

The abstract makes it clear the study is speculative. Yet, we already have rights-based law for females without absurd exemptions we refuse to touch for males, so the idea that rights trump speculative benefits isn’t foreign. The ability to do something or to possibly achieve some population-level result without concern for the individuals involved cannot – must not – be viewed in a bubble that contains only the factors one is interested in (e.g. male circumcision is currently practiced, so it’s acceptable).

There are no doubt many non-therapeutic surgeries we could perform on children that might result in some decreased prevalence of disease x, y, or z. Infant mastectomies to remove breast bud tissue might reduce the risk of breast cancer. Shouldn’t we study that, at least, since it might reduce cancer? Reducing cancer is “good”, whatever the means, right? No one is foolish enough (yet?) to think such a thing, which highlights the flaw in thinking by those making excuses for circumcision, such as Ms. Leibowitz here. Society should stop ignoring the costs to the individual who must bear the outcome of the decision. Ignoring them is unacceptable. The ethics of circumcision are not divisible from any other basic human rights consideration or proper medical analysis based on therapeutic need, or lack thereof.

Finally, that non-poor families can afford to violate their children’s sons’ rights is not a reason to use taxpayer funds to let poor parents violate their children’s sons’ rights. That’s a political question rather than a medical question. It is inexcusable to sacrifice the bodies of male children (only!) because we’re too cowardly to honestly evaluate the mistake of non-therapeutic circumcision on non-consenting individuals. This is the same idiotic approach Dr. Edgar Schoen pushed in his 2005 propaganda book, “Ed Schoen, MD on Circumcision”. Somehow, not using public funds to violate a child’s body and rights is discrimination. It isn’t because circumcision is not a valid parental choice. UCLA health economist Arleen Leibowitz is wrong.

None of this is a surprise, based on the editorial by Ms. Leibowitz and Katherine Desmond, “Infant Male Circumcision and Future Health Disparities”. The first two sentences reveal so much.

The health benefits of male circumcision (MC) have been extensively documented in observational studies and by randomized controlled trials in Africa showing that MC reduces heterosexual transmission of human immunodeficiency virus (HIV) infection from women to men by 55% to 76% …

The trials showed that voluntary, adult male circumcision reduces female-to-male HIV transmission in high risk populations with a heterosexual epidemic and a low rate of circumcision among adult males. That’s quite different, since it doesn’t describe the United States. It also fails to describe the circumcision they’re advocating. Children are not adult volunteers. That’s the ethical flaw in their analysis.

… and provides significant protection against human papillomavirus infection. …

Gardasil is approved for girls and boys. Circumcision is unnecessary for this possible benefit, as it is for nearly every possible benefit.

… Male circumcision is negatively associated with prostate cancer in men and with cervical cancer in female partners of men infected with human papillomavirus.

Negatively associated. Correlation is not causation. The study’s authors acknowledged this when they stated that it was an observational study. “Negatively associated” is not sufficient.

“May Help” Is Speculation, Not Science

This article in The New York Times covers the basic summary of the recent re-analysis that voluntary adult male circumcision in Africa can reduce the transmission of HPV to females. It has one inexcusable problem and an inference a thinking person should draw from it.

First, the problem:

Male circumcision, which has been shown to decrease a man’s risk of contracting the virus that causes AIDS, also appears to help protect his sexual partners against cervical cancer.

The study, led by researchers from Johns Hopkins University, did not last long enough to see how many women actually developed cancer; that can take years or decades.

HPV doesn’t appear in the article. Instead, voluntary adult male circumcision “appears” to help protect against cervical cancer. Yet, the reporter then states that the researchers didn’t actually study whether or not circumcision reduces the risk of cervical cancer because studying cancer can take years or decades. So why does the reporter write that circumcision protects against cervical cancer, rather than writing the actual suggestion that circumcision appears to reduce the risk of HPV transmission? HPV is not one virus, and not all strains cause cancer. This is irresponsible journalism based on the myth that circumcision is “good”.

The inference:

Cervical cancer was once a major killer in wealthy countries, but because of Pap smears it is now much rarer. In poor countries, it kills almost 250,000 women a year, according to the National Cancer Institute.

Papilloma vaccines like Gardasil and Cervarix provide much greater protection than circumcision does, but they are too expensive for most poor countries.

Cervical cancer is now much rarer in the Western nations because we have methods to detect it earlier. It is also less likely to kill in the future because now there are non-surgical vaccines that provide much greater protection than circumcision. So, the findings aren’t nearly as impressive for the readers of The New York Times because there are better detection and prevention methods. And the target audience for circumcision among the readers of The New York Times are parents of infants today. Those children will grow up in the same world where better detection and prevention methods exist, and will likely improve further by the time they’re at risk for sexual transmission of HPV.

Medically and ethically, this finding is irrelevant to the question of whether or not parents should consider forcing circumcision on their children.

Concern for Individual Health

From last week’s headlines:

Researchers have documented yet another health benefit for circumcision, which can protect men against the AIDS virus, saying it can protect their wives and girlfriends from a virus that causes cervical cancer.

This doesn’t accurately qualify for the term yet another. It’s merely a sales tactic by an ignorant reporter. This potential benefit has been reported for decades.

Regardless, this should change nothing in anyone’s analysis about whether or not parents may legitimately force circumcision on their healthy sons. Their sons are not engaging in sexual activities, and will not for many years. When they do, they would still need t practice safe sex. (Their partners will still need to do the same.) The decision does not need to be made at the child’s birth.

There are several additional points to remember:

GlaxoSmithKline and Merck make vaccines against HPV but they are not available to most women in developing countries.

The ethics of these vaccines involve many of the same issues involved in male circumcision, but the key fact from this excerpt is that these vaccines are available in the United States. Combined with safe sex practices, there are alternatives. There is no reason to continue pushing infant male circumcision instead.


“We are not at all mandating that everyone should be circumcised, but we disagree that the evidence is ‘conflicting’ as the AAP says. We believe the public should be aware of the existing evidence and it should be a decision among parents that are informed of this evidence,” [Dr. Aaron] Tobian says.

The issue isn’t whether the evidence is conflicting. It’s hubris to assume we know the answers, as the constantly-changing nature of scientific findings shows. Still, if we assume that these findings are accurate and definitive, it doesn’t change the correct conclusion against non-therapeutic child circumcision. The boy is healthy, so he doesn’t need the surgery. He may not want it when he can comprehend the unavoidable negatives of the surgery. It is, therefore, unethical to impose it on him for some potential, possibly-never-to-be-realized benefit.

For final consideration:

“There’s no doubt that male circumcision provides a certain degree of protection against sexually transmitted diseases,” adds [Dr. Thomas] Quinn, “and male circumcision needs to be reevaluated by leading health authorities as to its true public health benefit, not just to men but to future female partners.”

Imagine the reaction if scientists suggested cutting female children to protect the health of adult males. That would correctly generate outrage. Accepting the sexism inherent in the opposite scenario, as embraced in articles like the two above, is no more justifiable.