The Circumcision Debate: Beyond Benefits and Risks

In 2007, following a flurry of reports describing a benefit of circumcision in the fight against HIV, the American Academy of Pediatrics reconvened the task force on circumcision to update its policy statement of 1999.¹ Rather than simply incorporating this new information, the committee chose to start from scratch and rereview the medical literature. The task force’s work culminated in a policy statement published in 2012, the centerpiece of which was the statement that “the health benefits of newborn male circumcision outweigh the risks.”² This formulation of the debate, “benefits versus risks” rather than “medical necessity,” resulted in wide-ranging ramifications.

To many, especially in the lay press, this was interpreted as moving the needle from a neutral stance, as the 1999 guidelines were viewed, to being pro circumcision. It was vigorously criticized by anticircumcision activists, as well as many, primarily European, physicians and medical societies. Difficulties with this approach included the lack of a universally accepted metric to accurately measure or balance the risks and benefits. In particular, there was insufficient information about the actual incidence and burden of nonacute complications.³ In this issue, Sneppen and Thorup⁴ use meticulous epidemiologic technique to assess the likelihood of needing a circumcision in a society in which the cultural norm is to preserve the prepuce. Work such as this, along with the subsequent avalanche of reports evaluating the risks and benefits, has helped to inform and animate the dialogue among physicians with a stake in the circumcision debate. But has this really helped to inform the public? Or are we just arguing among ourselves?

What is often lost in the reporting on the American Academy of Pediatrics guidelines was the second half of the benefits/risk sentence, “the procedure’s benefits justify access to this procedure for families who choose it,” and later “health benefits are not great enough to recommend routine circumcision.”² What was the task force really saying?

To understand the recommendations, one has to acknowledge that when parents decide on circumcision, the health issues are only one small piece of the puzzle. In much of the world, newborn circumcision is not primarily a medical decision. Most circumcisions are done due to religious and cultural tradition. In the West, although parents may use the conflicting medical literature to buttress their own beliefs and desires, for the most part parents choose what they want for a wide variety of nonmedical reasons. There can be no doubt that religion, culture, aesthetic preference, familial identity, and personal experience all factor into their decision. Few parents when really questioned are doing it solely to lower the risk of urinary tract infections or ulcerative sexually transmitted infections. Given the role of the phallus in our culture, it is not illegitimate to consider these realms of a person’s life in making this nontherapeutic, only partially medical decision. The task force was sensitive to the fact that as physicians, although we claim authority in the medical realm, we have no standing to judge on these other elements. The ethical standard used was “the best interest of the child,” and in this setting the well-informed parent was felt to be the best proxy to pass this judgment. Protecting this option was not an idle concern at a time when there are serious efforts in both the United States and Europe to ban the procedure outright.

These guidelines recognize that there will never be a simple single formula. Even if there was, we all often choose to ignore doing what may be beneficial or likewise choose to engage in risky activity depending on our immediate desires. In circumcision, what we have is a messy immeasurable choice that we leave to parents to process and decide for themselves rather than dictate to them. This may seem odd in a society in which circumcision is rarely sought, but makes perfect sense in the multicultural world in which many of us live.

To the medical community, your efforts to improve our ability to accurately educate parents are needed. But we have to accept that there likely will never be a knockout punch that will end the debate. It is inconceivable that there will ever be a study whose results are so overwhelming as to mandate or abolish circumcision for everyone, overriding all deeply held religious and cultural beliefs.

To the anticircumcision activists, I would suggest that rather than directing an angry focus on the negative and the courts, your efforts would be better spent to educate and promote the prepuce positively, to win in the court of public opinion, and to change the culture, so as to make having a foreskin be the “popular thing to do.”

I know it sounds naïve, but my challenge to all of us is to imaginea day we can peacefully live in a world in which not all penises have to look the same.

• Copyright © 2016 by the American Academy of Pediatrics