The Cut

04.02.14

New Study Says Benefits of Circumcision Outweigh Risks 100 to 1

A new medical review published by Mayo Clinic makes the strongest case yet for cirumcision. Is it time to take the decision out of parents’ hands and make the procedure mandatory?

The choice of whether to circumcise one’s son—a decision both aided and hindered by a deluge of readily available information on the Internet—is an increasingly fraught one for parents. A quick Google search for “Should I circumcise my baby?” retrieves millions of articles, blogs, and academic papers all weighing in on the risks and rewards associated with the surgical removal of a newborn’s foreskin. Now, a new review published in the journal Mayo Clinic Proceedings claims the health benefits of circumcision exceed any risks by at least 100 to 1.

The review’s outspoken lead author, Brian J. Morris, a circumcision advocate and Professor Emeritus at The University of Sydney, Australia, hopes this new data will silence the debate once and for all. It’s Morris’ provocative position that infant circumcision contributes to overall public health in the same way that vaccines do, and should be equivalent to childhood vaccinations. And as such, he says, it’s unethical for doctors not to routinely offer it to parents.

“Each have a major population level benefit, but carry a risk that affects a very small proportion of individuals who receive the intervention. There are also extremely rarely deaths from each,” he told The Daily Beast via email. Moreover, “a vaccine is highly specific, whereas the protective effects of circumcision cover a wide array of medical conditions.”

The health benefits of circumcision are numerous. According to a mountain of research, documented in Morris’ review and noted by the APA in its recently updated policy statement, the benefits of circumcision include “prevention of urinary tract infections, penile cancer, and transmission of some sexually transmitted infections, including HIV.” These statistics can be misleading, however. For instance, the actual or absolute risk of penile cancer is so small (about 1 in 100,000) that an increased risk is still hardly any risk at all.  

Many doctors, along with the American Academy of Pediatrics (AAP), agree that while health benefits of circumcision outweigh the risks, the decision is ultimately the parents’ to make. In 2012, the AAP changed its policy statement, discarding its neutral stance to weigh in heavily on the side of circumcision.  

Still, some parents and healthcare providers argue that newborn circumcision is not only painful, but also unnecessary, and medical ethicists in the U.S. and abroad continue to debate its moral permissibility. Thirty-eight European physicians formally replied to the “cultural bias” in AAP’s policy change in the journal Pediatrics, noting its “conclusions are different from those reached by physicians in other parts of the Western world.”

The loudest among the opposition are people who’ve branded themselves “intactivists.” These groups say circumcision is “genital mutilation” and argue it needlessly violates a child’s autonomy and, according to one website, can cause “serious health risks, including infection, hemorrhage, surgical mishap, and death.” (Problems like these, it should be noted, are extremely rare. For infants, complication rates are approximately 0.2% and even those are usually minor and easily managed symptoms like bleeding or infection.)

Morris said that the “intact movement” also has something to do with declining rates, and likens the debate over circumcision to the one raging over vaccines. “The anti-circers and the anti-vaxers are very similar, and often the same people,” he said.

Using data from the National Hospital Discharge Survey (which doesn’t include out-of-hospital circumcisions, e.g. brit milah in the Jewish faith) with parsed data from adult circumcisions from the National Health and Nutrition Examination Surveys, Morris and his colleagues find that infant circumcisions have declined from 83 percent in the 1960s to 77 percent by 2010. The findings contradict a 2013 report from The Centers for Disease Control showing a slight increase in circumcisions over the last decade. In fact, Morris finds rates had decreased six percentage points during that time.

Both Morris and the CDC cite changing demographics and cost cutting as the reasons behind declining circumcision rates. Since Hispanic children are less likely to be circumcised, the climbing birth rate within the Hispanic population is largely responsible for the West’s significantly lower circumcision rates. Additionally, circumcision rates are 24 percent lower in the 18 states where Medicaid doesn’t pay for elective circumcisions.

140402-newborn-infant-chart
cdc.gov

Morris’s analysis further notes that half of uncircumcised boys and men will require treatment for a medical condition associated with his retained foreskin. Still, while noting the positive health effects of circumcision, could the comparison of the uncircumcised to the unvaccinated be alarmist, and a stretch? Morris doesn’t think so.

“Just as vaccination, failure to circumcise will put your son at serious risk of adverse medical conditions and he could indeed die from some of them,” he said. “What’s more he will harm others, from sexually transmitted infections which include oncogenic HPV types that cause cervical cancer, a potentially lethal cancer.”

Morris’ impassioned stance, while perhaps medically sound, may alienate the very parents he hopes to persuade. Despite headlines to the contrary, and geographical pockets of dissent, national vaccine coverage meets target levels at or above 91 percent. In other words, vaccines are widely accepted. It’s not so for circumcisions. And, as Morris concedes, the hands of millions of moms and dads who choose to forgo the scalpel can’t be forced.

“Whereas parents can be coerced into vaccination by denying access to childcare for their son, there are fewer inducements to do the right thing and have him circumcised,” he said.

Still, he acknowledges parental choice, and hopes that this risk benefit analysis along with the AAP’s affirmative policy statement will have a positive effect on future rates.

“Denial of infant male circumcision is denial of his rights to good health, something that all responsible parents should consider carefully,” he said.