As the 2012 American Academy of Pediatrics (AAP) circumcision policy receives further volleys of grapeshot, a new question arises: Why do we need a policy on circumcision at all?

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“Inadequate, inaccurate, misleading, self-interested, subjective, biased” … are just a few of the more complimentary terms applied by pediatrician Robert Van Howe to the controversial circumcision policy statement put out by the American Academy of Pediatrics (AAP) in 2012.

There was no shortage of critiques four years ago, when the policy first came out, but in a just-released analysis Professor Van Howe applies a microscope to every individual statement in the policy and background report and finds very little that deserves a tick.

Hot on the heels of this assault comes an exhaustive study showing that the vast majority of genitally intact (uncircumcised) boys never experience any foreskin problems and – what is more – that only a minority of the unlucky ones require a circumcision to fix it.

This study was actually published in the AAP’s own journal, accompanied by an editorial by a member of the circumcision policy taskforce who made a number of surprising admissions, such as:

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Circumcision is usually a religious or cultural preference on the part of the parents, not a medical decision.

Circumcision is not necessary for optimum health.

An underlying aim of the 2012 circumcision policy was to thwart calls to prohibit non-therapeutic circumcision of minors (then gathering steam in Europe).

The risk/benefit equation that was devised (“benefits outweigh risks”) is relevant only to those who have non-medical (cultural, religious, social) reasons for circumcision.

The AAP evidently appreciates that the new study, coming on top of Professor Van Howe’s critique, makes their policy look less evidence-based than they originally claimed, and pretty tattered overall. They may be realizing that they are quite isolated in their support for circumcision, along with American society as a whole.

By now you may be wondering how the USA developed its strange addiction to cutting off infants’ foreskins in the first place. I’ll offer some answers to that question as we go along. In the meantime, readers can judge for themselves the quality of the AAP policy and Van Howe’s line-by-line response by browsing through the full (open access) critique available on his academic website. The foreskin study and the AAP editorial are behind a paywall, but you can find a summary here.

These differences of opinion are significant, but I want to focus on a more fundamental question: Why do we need a policy on circumcision in the first place? Or do we?

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The AAP’s weird obsession

Consider this to begin with. No other AAP policy document focuses so obsessively on a single component of a bodily organ, much less a particular procedure designed for removing it from healthy children who cannot consent.

The AAP takes the surgery (circumcision) as its starting point, and hardly even mentions the body part in question. There is no description of the foreskin’s anatomy or physiology, its various functions or its role in sex.

For make no mistake, any circumcision policy is really a report card on the foreskin itself.

We don’t see policy statements on the liver, the nose, the heart, or the eyeball, but rather on the diseases and other problems that affect those organs, and on the most conservative and effective ways of preventing them, or treating them should they arise.

Typically, the goal is to address problems if and when they come up in a way that protects and preserves healthy tissue.

The AAP has policies on the management of sinusitis, urinary tract infections, infantile hemangioma (a kind of tumor), dermatitis, etc. – and a policy on the foreskin, as though it was some sort of cancerous growth or birth defect that needed to be “dealt with.” Clearly, something strange is going on here.

The AAP takes the surgery (circumcision) as its starting point, and hardly even mentions the body part in question. There is no description of the foreskin’s anatomy or physiology, its various functions or its role in sex.

What is the foreskin, you ask? If you’re an American reader, you might have a vague idea that it’s some unnecessary skin that covers the end of the penis before the baby gets circumcised. In fact, at a conference in 2013, a leading member of the AAP circumcision taskforce claimed that “nobody knew” what the functions of the foreskin were.

European doctors are better informed. As they will tell you, the foreskin is a mobile sleeve of erogenous penile tissue (see here for a NSFW video), with a surface area of about 50 square centimeters in the adult member. It has been described as the principal sensory platform of the penis. (A recent study on circumcision and penile sensitivity that’s been getting coverage this week found that “the foreskin of intact men was more sensitive to tactile stimulation than the other penile sites” that were tested, even though news outlets are misreporting this finding).

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The question is: how can you have a policy about a particular body part if you don’t understand why it’s there in the first place? It’s not as though the question hasn’t been studied.

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Purpose of circumcision policies

A little history will put this issue in context. You may be surprised to learn that the original purpose of circumcision policy statements issued by pediatric societies, including the AAP – way back in the early 1970s – was to stop circumcision. Routine circumcision had become entrenched in the medical practice of English-speaking countries during the first half of the twentieth century. But by the 1960s pediatricians had become aware that the operation was causing much harm and not doing any obvious good.

Circumcision policy statements issued by pediatric bodies in Australia, Canada and the United States were intended to halt this butchery by reassuring parents and doctors that the foreskin was not a disease, deformity, or any other kind of problem.

The harms were not merely a stream of complications, but a flood of damaged penises, so scarred and distorted that one Australian doctor was “appalled at the phallic mutilations exhibited by many of these children, some of whom have even been subjected to a subsequent ‘tidying up’ procedure after being badly mauled in infancy” (A. Clements, Medical Journal of Australia, 29 April 1972, 946).

Circumcision policy statements issued by pediatric bodies in Australia, Canada and the United States were intended to halt this butchery by reassuring parents and doctors that the foreskin was not a disease, deformity, or any other kind of problem. Instead, they argued, it is a normal element of the male genitals that could safely be left to its own devices.

These statements had a substantial impact in Australia, where circumcision incidence plummeted from more than 80% in the 1950s to less than 12% by the mid-1990s. There was a moderate decline in Canada, but only a slight fall in the USA, where the rate actually rose after the AAP’s first policy statement in 1971.

It did not begin to decline until the mid-1980s, and even then only after agitation by community-based anti-circumcision groups.

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Why is the United States different?

One of the reasons for this American exceptionalism is that, unlike the situation in most other countries, circumcision in the USA is not primarily the responsibility of pediatricians (who are left with the sad job of repairing the botches), but rather of obstetricians and gynecologists.

If you think it’s a bit strange that specialists in women’s reproductive health became responsible for a routine surgery carried out on the genitals of boys, you’ve stumbled onto a key question.

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This is how it happened. Obgyns had taken over the operation in the 1930s, assisted by the invention of the Gomco circumcision clamp by obstetrician Hiram Yellen: they made it a routine step in the childbirth process – no more optional or problematic than tying off the umbilical cord. Their strategic position at a time when both mother and baby were vulnerable allowed them to ask the woeful, leading question: “Do you want him circumcised?”

Sometimes they did not even bother to ask. As leading obgyns Miller and Snyder wrote rapturously in 1953, “the obstetrician finishes his episiotomy, walks across the hall and circumcises the infant, and is finished with the whole business. The time saved for both the physician and nursing staff is considerable.” Even better, “no babies are forgotten and left uncircumcised” (Immediate circumcision of the newborn male, American Journal of Obstetrics and Gynecology 65, 1953, 1-11).

For reasons of professional pride, emotional commitment and financial advantage, American obgyns have not been keen to give the practice up.

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As now admitted by the AAP – the role of religion

Another factor is pressure from religious sub-cultures – with Jewish and Muslim minorities worried that if circumcision was generally abandoned it would become difficult to maintain traditional circumcision practices within their own communities.

(Translation: if Jewish or Muslim boys saw that other boys their age still had their foreskins, they might want one too.)

This fear became more intense after the passage of the United Nations Convention on the Rights of the Child (CRC) in 1989, with its threatening provision in Article 24 (3): “State Parties shall take all effective and appropriate measures with a view to abolishing traditional practices prejudicial to the health of children.”

Even worse, this was followed by the passage of legislation in many countries to prohibit and criminalise any form of non-therapeutic female genital cutting, no matter how minor or sterilized. Just to be clear, that includes forms that are less invasive than male circumcision.

Jewish and Muslim religious leaders were afraid that such legislation would lead to demands that similar protection be given to boys – a fear that has proved well-founded.

In response to this threat, religious conservatives took advantage of the obvious loophole in the CRC – the reference to “prejudicial to health.” If it could be shown that circumcision was not prejudicial to health (i.e. harmful) or, even better, that it was beneficial, the problem would go away: genital cutting of girls could be banned as harmful (and condemned as FGM), while circumcision of boys could be preserved, and even promoted as good for your health.

The most masterly exponent of this strategy was Edgar Schoen, an MD employed by Kaiser Health (a leading supplier of circumcision equipment and services), a fervent believer in circumcision, and a prolific contributor to medical journals.

His presence on the AAP taskforce that produced the 1989 policy statement ensured that the document adopted a more positive stance towards circumcision. Basically, it asserted that the procedure had definite health advantages, while not going so far as to recommend it outright.

The tone of the policy was, however, more hostile than earlier policies towards the foreskin itself, tending to paint it as a potential source of disease and a difficult problem for parents to have to deal with.

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Skin wars

The battle between pro-circumcision and anti-circumcision forces intensified during the 1990s. As the critics grew more confident, the conservative believers in circumcision scratched around for additional medical benefits to bolster their case.

Evidence that urinary tract infections were slightly more common in genitally intact (“uncircumcised”) boys were played up and exaggerated, while the arrival of HIV-AIDS offered hope that a foreskin-HIV link could be detected if the researchers were given enough money and worked hard enough to find it.[1]

Even so, the AAP’s 1999 policy statement was less pro-circumcision, reflecting the waning influence of Schoen (by then retired), and the rising importance of bioethical and human rights issues, like the right to bodily integrity.

There was also the growing presence of the anti-circumcision movement, and an increasing body of circumcision-critical material in the professional literature. It was this Cold War-style stand-off that probably accounted for the long delay in the production of the next statement, not finalised and released until 2012.

By then there had been two contradictory developments.

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Circumcision contradiction: movement on opposite fronts

On the anti-circumcision front, both the Royal Dutch Medical Association and the Royal Australasian College of Physicians (RACP) released statements critical of circumcision. The Dutch policy was particularly firm, finding little positive to say about circumcision, and forcefully rejecting it as medically harmful and ethically impermissible.

The RACP statement was more cautious, but nonetheless in agreement with Dutch concerns about bioethical and human rights issues, concluding that routine circumcision was not justified and should not be recommended.

On the pro-circumcision front, researchers who had been looking for a foreskin-HIV connection for years, and even pushing for circumcision in advance of firm proof, finally managed to find evidence that circumcision of adults in some regions of sub-Saharan Africa could reduce the risk of female to male transmission of HIV during unprotected intercourse.

These data, derived from Randomized Control Trials (RCTs), led almost immediately to the roll-out of massive circumcision programs in epidemic areas. Money and publicity came fast and furious, especially after a well-meaning geek named Bill Gates was persuaded to provide a few hundred million dollars from his charitable foundation.

The question then became whether the African revelations were relevant to infants and boys in developed countries, where HIV was not a heterosexual epidemic, but rather a relatively rare disease largely confined to communities of injecting drug users and men who have sex with men.

The RACP statement was more cautious, but nonetheless in agreement with Dutch concerns about bioethical and human rights issues, concluding that routine circumcision was not justified and should not be recommended.

Considering that the African RCT results were released in 2007 and the Dutch and Australian circumcision policies in 2010, it is clear that, after due consideration, the health authorities in these countries judged the answer to be NO.

This attitude was soon shared by health authorities in other developed countries, with one exception: yes, the United States (as usual).

A series of softening-up articles on the benefits of circumcision published in the Journal of the American Medical Association and other forums prepared the way for the AAP’s 2012 statement.

This policy claimed that the results of the African RCTs, plus a few related studies, constituted enough “new evidence” to justify a more positive stance towards circumcision. And while the AAP could not go so far as to actually recommend it, the Task Force asserted that “the benefits exceeded the risks.”

This left the impression (by insinuation and omission, rather than outright statement) that any parent who failed to take the hint and get his boys circumcised was really pretty irresponsible.

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AAP strategy backfires

It did not take long for the gaps in the policy’s evidence, and the flaws in its reasoning, to become obvious. Many of these were highlighted in a barrage of professional rebuttals to the policy, including a critique signed by 38 leading physicians from Europe and Canada.

This reaction rather surprised the Task Force, which seems to have thought that the authority of the AAP (as a powerful American institution) would crush opposition in the Unites States and impress medical organizations in other countries.

On the contrary, as Professor Van Howe points out in his latest critique, the most striking result of the AAP’s efforts has been to reanimate the anti-circumcision forces:

One of the unintended consequences of the release of the 2012 Report of the AAP Task Force on Circumcision is that it helped rally European physicians, ethicists, and legal scholars to protest the human rights abuses associated with the practice. In the wake of the report’s release, the Council of Europe and a number of national medical organizations in a variety of European countries have condemned the practice of newborn circumcision as a human rights violation. They have found the “benefits” of circumcision to be inconsequential. When responding to [the] letter written by 38 leading European medical experts that characterized the Task Force as “culturally biased,” instead of addressing the substantive issues raised, the Task Force responded with righteous indignation and issued a thinly-veiled accusation that the writers were anti-Semitic.

It was not only European physicians who were underwhelmed: papers published by Australian child health experts have tacitly rejected the AAP position as well. The cruelest blow was delivered by the Canadians: far from endorsing or following the US position, as was widely expected, the updated policy of the Canadian Paediatric Society, released just last year, maintained its recommendation against routine circumcision.

Et tu, Brute?

Now that the AAP is so isolated in its support for circumcision, the question is how long the 2012 policy can survive. If its flaws are as great as Professor Van Howe and other experts contend, and if circumcision is as unnecessary as the new foreskin study demonstrates, our conclusion must be that the policy should never have been issued in the first place. What the AAP ought to do is get to work on a new one as soon as they can muster a representative team.

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Why have a policy on circumcision at all?

But this brings us back to the question I raised earlier. Why have a policy on circumcision at all?

It must be remembered that any such policy is really a policy on the foreskin: should a boy be allowed to keep it intact, or should it be condemned as a serious threat to health and welfare, as Dr. Peter Charles Remondino insisted in the 1890s?

As I said before, health authorities do not usually prepare policies on other bodily organs – liver, spleen, scrotum, breast, etc. – but instead ask how to manage specific disorders that might affect them. The only comparable policies are those condemning any form of female genital cutting, but these do not single out the clitoris, labia or female prepuce as objects of suspicion (or celebration).

What makes the male genitals so special? Could it be, as Professor Van Howe suggests, and the AAP editorial concedes, that it is their cultural, religious and social significance, rather than their medical implications or their role in the physiology of the body, that makes the difference?

Had circumcision not been introduced by anti-sex doctors in the nineteenth century it would not, of course, be necessary to have a policy on circumcision at all.

Countries outside the English-speaking world, where non-therapeutic circumcision did not become established, have never felt the need for a such a policy – at least, not until the increasing Muslim presence and the recent provocation from the AAP provoked second thoughts.

But in the English-speaking world doctors did introduce prophylactic circumcision, and it is only right and proper that they should take responsibility for putting a stop to it.

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Some final thoughts

Jonathan Hutchinson’s claim about the value of circumcision as a preventive of masturbation and syphilis was first aired in the mid-1850s. If we regard that as the starting-point of circumcision advocacy, we can see that it took about a century of medical propaganda for circumcision to become routine and ubiquitous, reaching its zenith of popularity in the 1950s and 60s.

With that example in mind, we might predict that it will take another century for the practice to die out, along with the Old Guard of true believers.

If we now take Douglas Gairdner’s influential paper of 1949, showing that circumcision was both harmful and unnecessary, as the beginning of the end, it follows that we may reasonably expect medically-rationalized circumcision to have largely died out by the middle of this century.[2]

That may seem like the distant future, but there are only 34 years separating us from 2050, almost exactly a single generation. It took well over 100 years to abolish slavery – once taken for granted as part of the natural social order. I think we can be confident that a profoundly smaller injustice such as circumcision will fade away without the need for a civil war.

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[1] In saying this I do not wish to impugn the motives of those who devoted their lives and careers to finding ways to defeat this new and terrifying disease. It may well be true that men circumcised as adults are at less risk of infection with HIV by female partners in sub-Saharan Africa, as evidence currently suggests; but it is only in a foreskin-hostile environment that this discovery could be seen as leading automatically to an argument in favour of circumcising infants in developed countries.

[2] Culturally and religiously motivated circumcision may survive longer, but without the underpinning provided by the claim of “medical benefit,” its future is far from assured.

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