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What Do the WHO, NIH and Other Health Organizations Say About Circumcision?

| June 8, 2011
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Or Chaim Nagar, eight-days-old, lies in his stroller after his circumcision. David Silverman/Getty

Or Chaim Nagar, eight-days-old, lies in his stroller after his circumcision. David Silverman/Getty

Debate has erupted over a November ballot initiative in San Francisco that aims to ban circumcision of minors.

In addition to ethical and religious concerns, the health implications of circumcision (and non-circumcision) are also part of the conversation.

But before we examine that debate, let’s start with some basics.

So, what would the bill do?

If passed, the proposed bill, Male Genital Mutilation, would make it “unlawful to circumcise, excise, cut, or mutilate the whole or any part of the foreskin, testicles, or penis of another person who has not attained the age of 18 years.”

The bill would provide an exemption if there is a “a clear, compelling, and immediate medical need with no less-destructive alternative treatment available.” It would not create a religious exemption.

If someone was caught performing a circumcision, it would be a misdemeanor charge with a maximum of a $1,000 fine, or no more than a year of imprisonment.

The San Francisco initiative was written by Matthew Hess, who has also written a federal version, 46 state versions, and another ballot initiative in Santa Monica.

Hess says that the bills are modeled on existing federal and state female genital mutilation laws, which is why much of the language is similar to those statutes.

You can read all the bills at MGMbill.org, an anti-circumcision organization run by Hess and 15 others.

Hess declined our request for an interview, but he got us in touch with Lloyd Schofield, who in addition to speaking with us, has spoken to many other media outlets on the subject.

Who, where, and how often?

The World Health Organization estimates that about 30 percent of men worldwide are circumcised. Both Jewish and Muslim groups often circumcise their boys. So while many Americans are circumcised, many countries in the Middle East have similar if not higher rates. Muslim men make up about two-thirds of all men circumcised in the world.

The number of circumcised men is growing worldwide, predominantly in Africa because of some new studies linking being uncircumcised to the spread of HIV.

Culturally, circumcision was never much of a thing in Europe, so rates are much lower there.

The Centers for Disease Control found that 79 percent of adult males in the U.S. report being circumcised, but, according to WHO circumcision is declining in America. The CDC confirms this in its most recent analysis, which shows that there was a decline in newborn circumcision, from 60 percent in 1998 to 55 percent in 2005. Also, the most recent National Hospital Discharge Survey estimates that 55.4 percent of infants were circumcised at the end of 2007 compared with 64.7 percent in 1980.

There are a multitude of reasons for this decline. It’s speculated that one of the main factors is the change in the makeup of race, ethnicity, and religious orientation in America over the years.

What do medical associations say?

Most medical organizations we’ve surveyed take a middle-of-the-road approach, characterizing the procedure as essentially a choice “in which there are potential benefits and risks.” Here’s what some have to say on the subject:

American Academy of Pediatrics

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.

Read more.

National Institutes of Health

The merits of circumcision have been debated. Opinions about the need for circumcision in healthy boys vary among health care providers. Some believe there is great value to having an intact foreskin, such as allowing for a more natural sexual response during adulthood.

Rather than routinely recommending circumcision for healthy boys, many health care providers allow the parents to make the decision after presenting them with the pros and cons.

There is no compelling medical rationale for the procedure in healthy boys, although some boys have a medical condition requiring circumcision.

Read more.
However, NIH also notes that circumcision can help stop the spread of AIDS.

CDC
The CDC have not issued a statement on circumcision, but one is in development, according to spokesman Scott Bryan.

British and Canadian Pediatric Associations
Both organizations says that circumcision is unnecessary as a routine procedure, but make allowances for cultural and religious reasons.
Read the British Medical Association’s statement
Read the Canadian Paediatric Association’s statement.

WHO

Male circumcision is one of the oldest and most common surgical procedures worldwide, and is undertaken for many reasons: religious, cultural, social and medical. There is conclusive evidence from observational data and three randomized controlled trials that circumcised men have a significantly lower risk of becoming infected with the human immunodeficiency virus (HIV).

WHO notes that studies have shown that circumcision can help prevent urinary tract infections, inflation of the glans and foreskin, penile cancer, some sexually transmitted diseases such as chancroid and syphilis, HIV, and from passing on HPV which causes cervical cancer to female partners.

It also points out that circumcision can cause harm:

As with any surgical procedure, [circumcision] carries a risk of post-operative infection. In inexperienced hands, penile mutilation and even death can occur.

Read more

The HIV/AIDS Connection

WHO, NIH and the CDC have concluded that circumcision can help stop the spread of HIV, the virus that causes AIDS. However, the studies these organizations sponsored or reviewed have been interpreted differently, and are often the subject of criticism by anti-circumcision groups.

Anti-circumcision say the studies were flawed because they were stopped 1-2 years prematurely. The scientists involved in the studies, however, say they ended the research because the evidence was sufficiently conclusive, and that it would be unethical to continue.

Opponents also say that variations seen between two analysis of the same data lowers the credibility of the study.

WHO and the CDC note that circumcision should not be considered the only way to stop the spread of AIDS. Both organizations promote condom use and sex education.

The CDC also cautions that the results of the studies in Africa can not necessarily be applied to United States.

KQED will continue to cover the conversation around circumcision as we approach November.

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About the Author ()

Lisa Pickoff-White is KQED's Senior Interactive News Producer. Her work has been honored with awards from the Online News Association, Investigative Reporters and Editors, Society of Professional Journalists and SXSW Interactive. Lisa specializes in visual journalism, including photography and data. Reach Lisa Pickoff-White at lpickoffwhite@kqed.org.
  • Jonathon Conte

    What are the functions of the foreskin? How much tissue comprises the adult foreskin? What are the anatomical, physiological and psychological ramifications of circumcision? What are the potential complications? Approximately how many babies die each year due to complications? What are the ethical implications of amputating a healthy body part from a patient who cannot consent? These are some of the questions that this “debate over circumcision” missed. I wonder if the same media outlets that suggest that we should entertain a serious discussion about the benefits of the forced genital cutting of male minors would dare to foster a “debate over female genital cutting” in the same vein.

  • Jeff Brown

    It is extremely offensive for someone to say it is ethical to cut off a normal part of my penis without my consent because they think I am too stupid or too irresponsible or too lazy to practice safe sex. Whether you are circumcised or not, you always need to use a condom when you have sex outside of a long-term relationship, so why cut off a part of your penis that feels good?

  • http://www.youtube.com/user/Bonobo3D James Loewen

    If passed, the proposed bill, Male Genital Mutilation, would make it “unlawful to circumcise, excise, cut, or mutilate the whole or any part of the foreskin, testicles, or penis of another person who has not attained the age of 18 years.”

    The proposed bill sounds very good and very sane to me. It is time to protect all children from genital tampering from superstitious or poorly informed adults.

  • http://www.intactamerica.org Dan Bollinger

    There is very little substance to the article above. Most of it is copy-pasted content and does nothing to “make sense of the health debate. Maybe because the “debate” is really a smokescreen for greed.

    Circumcision was medicalized 150 years ago without supportive proof that it was efficacious at a time when medicine was more conjecture than science. Those “reasons” were been debunked. Other rationales were offerred, debunked, and so a century-long cycle began. The current one is HIV/AIDS. If circumcision were to be introduced today it would be laughed out of the surgery. Any prophylactic surgery is highly suspect, doubly so when there are treatment alternatives; amputation is a poor solution compared to hygiene, safe sex, and antibiotics.

    Circumcision and circumcision repair is a $2 billion market. Yes, that’s billions, not millions. The reason all those medical societies have a fence-sitting policy statement is because they know that male infant circumcision is medically unnecessary, but they want to protect the income streams for their membership.

    • Stan

      “It is difficult to get a man to understand something, when his salary depends upon his not understanding it!” ~ Upton Sinclair

  • Jack

    I am always astonished that there is talk about “circumcision” without any discussion of what the anatomy is of the penis parts cut off! What do all of those nerves do? What functions are lost? Why would anyone even talk of cutting off parts without a thourough investigation as to how the cutting of nerves affects the brain and how the removal of tissue affects function in general including sexual pleasure and function: of a young man, of a middle aged man; of an old man?

    I can see no flaws in the senosry map of the penis produced by Taylor, and yet these entities that talk about “circumcision” (penis parts removal) often don’t even consider this aspect. Please start with a FIRST DO NO HARM approach.

  • Bob

    Parents should research circumcision and make an informed decision for the health & well-being of their son.

    Circumcision is a safe, popular, healthy & beneficial procedure for individuals & parents to choose. It provides benefits such as 12x less likely for UTI, +22x less likely for cancer, 28% less risk for herpes, 35% for HPV & 60% for HIV/AIDS. The risks are about 0.2% and are typically minor & easily corrected.

    • Stan

      “Infant male circumcision was once considered a preventive health measure and was therefore adopted extensively in Western countries. Current understanding of the benefits, risks and potential harm of this procedure, however, no longer supports this practice for prophylactic health benefit. Routine infant male circumcision performed on a healthy infant is now considered a non-therapeutic and medically unnecessary intervention.” ~ The College of Physicians and Surgeons of British Columbia

    • Locuta

      All of these “facts” are outdated and false. The risk of complications is 2% to 30%, depending on whose study and definition of “complication” you use. Also, every circumcision has the negative outcome of the permanent loss of the foreskin and about 50% of the skin of the penis.
      To propose using the amputation of a healthy, normal, necesary protective and functional structure from a child’s genitals as a prophylactic measure against STDs is immoral and unethical. How does any one know what a boy’s risk behavior profile is going to be in 15-20 years when he starts having sex, or even if he will have sex? The medical industry is pushing the STD/HIV drivel as the latest “reason” or “benefit” to try to keep their lucrative circumcision machine humming along.
      “Routine” or prophylactic circumcision assumes that a young man is too stupid to learn and implement safe sex practices and to manage to wash his genitals. Really? If he’s capable of deciding to have sex, he’s capable of figuring out how to protect himself and how he wants his genitals to be configured. It’s his body, and it should be his choice AS AN ADULT.

    • http://www.circumstitons.com Hugh7

      “Circumcision is a .. procedure for individuals … to choose.” is correct. And if their parents choose for them, that takes away their choice forever. The proposed bill would just delay that choice till HE is old enough to make it. The experience of most of the rest of the world, and virtually all of the developed world, is that if he is allowed to experience it as an adult, he will almost always choose to keep all he was born with.

      “X% less likely” is a good way of magnifying a tiny difference in a rare risk. If I move away from a tall building, I can be thousdands of % less likely to be hit by a falling piano! It would take hundreds of circumcisions, the vast majority of them in vain, to prevent even one case of UTI or cancer. The HPV and HIV claims are debatable, and nor borne out by the rates of those diseases in countries where circumcision is rare. In 10 of 18 countries for which USAID has figures, more of the circumcised men have HIV than the non-circumcised.

  • http://www.circumstitons.com Hugh7

    The Royal Dutch Medical Association (KNMG) says:

    * There is no convincing evidence that circumcision is useful or necessary in terms of prevention or hygiene. Partly in the light of the complications which can arise during or after circumcision, circumcision is not justifiable except on medical/therapeutic grounds. Insofar as there are medical benefits, such as a possibly reduced risk of HIV infection, it is reasonable to put off circumcision until the age at which such a risk is relevant and the boy himself can decide about the intervention, or can opt for any available alternatives.
    * Contrary to what is often thought, circumcision entails the risk of medical and psychological complications. The most common complications are bleeding, infections, meatus stenosis (narrowing of the urethra) and panic attacks. Partial or complete penis amputations as a result of complications following circumcisions have also been reported, as have psychological problems as a result of the circumcision.
    * Non-therapeutic circumcision of male minors is contrary to the rule that minors may only be exposed to medical treatments if illness or abnormalities are present, or if it can be convincingly demonstrated that the medical intervention is in the interest of the child, as in the case of vaccinations.
    * Non-therapeutic circumcision of male minors conflicts with the child’s right to autonomy and physical integrity.
    * The KNMG calls on (referring) doctors to explicitly inform parents/carers who are considering non-therapeutic circumcision for male minors of the risk of complications and the lack of convincing medical benefits. The fact that this is a medically non-essential intervention with a real risk of complications makes the quality of this advice particularly important. The doctor must then record the informed consent in the medical file.
    * The KNMG respects the deep religious, symbolic and cultural feelings that surround the practice of nontherapeutic circumcision. The KNMG calls for a dialogue between doctors’ organisations, experts and the religious groups concerned in order to put the issue of non-therapeutic circumcision of male minors on the agenda and ultimately restrict it as much as possible.
    * There are good reasons for a legal prohibition of non-therapeutic circumcision of male minors, as exists for female genital mutilation. However, the KNMG fears that a legal prohibition would result in the intervention being performed by non-medically qualified individuals in circumstances in which the quality of the intervention could not be sufficiently guaranteed. This could lead to more serious complications than is currently the case.

    This viewpoint by the KNMG is jointly endorsed by the following scientific associations:

    * The Netherlands Society of General Practitioners
    * The Netherlands Society of Youth Healthcare Physicians
    * The Netherlands Association of Paediatric Surgeons
    * The Netherlands Association of Plastic Surgeons
    * The Netherlands Association for Paediatric Medicine
    * The Netherlands Urology Association
    * The Netherlands Surgeons’ Association

    To a pdf of the full policy in English