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"You wanna do WHAT?!" Photo courtesy of Justyna Furmanczyk at sxc.hu. |
By Tara Haelle, DXS contributor
[Tara Haelle (www.tarahaelle.com) is a health and
science writer and a photojournalist based in Peoria, IL after years as a Texan,
where she earned her undergraduate degrees and MA in journalism at UT-Austin.
She’s the mental health editor for dailyRx.com in addition to reporting on
pediatrics, vaccines, sleep, parenting, prenatal care and obesity. This post first appeared on her blog,
Red Wine & Apple Sauce focuses on health and science news for moms (www.redwineandapplesauce.com), and you can follow her on Twitter
at @health_reporter and @tarasue. She’s also swum with 9 different species of
sharks, climbed Kilimanjaro and backpacked in over 40 countries, but that was
in the years of B.C. (Before Children). She finds that two-year-olds are
tougher to tussle with than tiger sharks.]
So you've likely heard by now that the American Academy of
Pediatrics issued their updated policy statement on circumcision, the first since
1999. I've been sitting on the statement and the task force technical report
for a week now, and even though I've written a news summary for dailyRx… I have many mixed
feelings.
I am grateful that their statement
was issued with the sensitivity and caution needed for such a controversial
practice and decision. Some of the headlines have been frustrating, implying that the AAP said
"Circumcision is better." Um, no. That's not what they said. They
said that the "preventive health benefits of elective circumcision of male
newborns outweigh the risks of the procedure." (To be fair, most headlines
basically ran with "benefits trump risks" or some variation thereof.)
In other words, if you choose to do
this procedure, the benefits you will gain are greater than the risks involved
in the procedure. This is very different from saying "It's better to be
circumcised." In fact, their policy explicitly points out that they do not
officially "recommend" the procedure routinely: "Although health
benefits are not great enough to recommend routine circumcision for all male
newborns, the benefits of circumcision are sufficient to justify access to this
procedure for families choosing it and to warrant third-party payment for
circumcision of male newborns." (That last part just means yes, insurance
companies, you should pay for it.)
An analogy: A child with obstructive
sleep apnea can have a tonsillectomy/adenoidectomy
(called an adenotonsillectomy) to remove their tonsils and adenoids
for treatment. The tonsils and adenoids (lumps of issue behind the nose)
generally cause the blockage that interferes with a child's breathing while
asleep, so removing them can usually cure the sleep apnea (in
75 to 100 percent of the cases).
There are risks to
adenotonsillectomy, namely infection and excessive bleeding. There are risks to
sleep apnea, including obesity, heart disease, diabetes, depression and death.
For a child with obstructive sleep apnea, the benefits generally outweigh the
risks of the procedure. A parent can still elect not to give their child the
surgery.
Is it better for the child with
sleep apnea to have the surgery? Probably. But perhaps not. It depends on the
situation and the child. Is it better for a child without obstructive sleep
apnea to have the surgery? Of course not. Why take any risk when there's no
benefit?
Now consider the two primary
benefits conferred by circumcision: lower risk of urinary tract infections
during the first year and reduced risk of HIV and a several other sexually
transmitted infections during heterosexual sex. The risks of circumcision are
most commonly bleeding, infection or the wrong amount of tissue snipped off,
and this happens in about 1 of every 500 newborn boys (0.2 percent). Other
studies found the rates higher, up to 2 to 3 percent, but these complications
were still just minor bleeding. They even offered a comparison of a similar
surgery as the one I discussed above: complications involving severe bleeding
from tonsillectomies occur about 1.9 percent of the time in kids age 4 and
under.
For parents with wild imaginations
about horror stories, fear not: "The majority of severe or
even catastrophic injuries are so infrequent as to be reported as case reports
(and were therefore excluded from this literature review). These rare
complications include glans or penile amputation, transmission of herpes
simplex after mouth-to-penis contact by a mohel (Jewish ritual circumcisers)
after circumcision, methicillin-resistant Staphylococcus aureus infection,
urethral cutaneous fistula, glans ischemia and death." Basically, yea,
there's a bunch of really bad stuff that can happen, but it's really, really,
really, really rare. Probably rarer than being struck by lightning. Twice. But that
happens too.
So, the risks are pretty low. How
beneficial are the benefits? Here's a condensed run-down from the AAP's technical report:
- Circumcision reduces the odds of contracting HIV during male-female sex by 40 to 60 percent… in Africa. When the CDC calculated that figure with the rate of contracting HIV by heterosexual sex in the U.S., they came up with a 15.7 percent reduction here. It's something, but nowhere near as good as a condom. Plus, if your kids turns out to be gay, there's not much evidence that circumcision helps him avoid contracting HIV. (And on the other side of the coin, circumcision can make it a little easier for women to contract HIV from a man, per one study cited in the AAP review.)
- Circumcised men are about 30 to 40 percent less likely to get any type of human papillomavirus (HPV), including both the relatively harmless strains and the ones that can lead to cervical cancer or raise your risk of cancer of the mouth, throat, penis and anus. Now, the CDC has recommended that boys get the HPV vaccine, but the vaccines available do not cover all the strains. Gardasil takes care of four of them, including the two responsible for about 70 percent of cervical cancer (HPV-16 and HPV-18) and the two responsible for 90 percent of genital warts. Cervarix only takes care of HPV-16 and HPV-18. So, circumcision would offer some protection against getting the HPV strains that the vaccines don't cover, most of which — but not all — are not linked to cancer or warts.
- There's some evidence that circumcision reduces risk of herpes (HSV-2) by about 28 to 34 percent, based on two studies in Africa.
- Evidence for protection against syphilis is weak. There's no evidence that circumcision decreases the risk of contracting gonorrhea or chlamydia.
- There's good evidence that uncircumcised boys get more urinary tract infections that circumcised boys, in part because bacteria can hang out in that moist area under the hood. The AAP estimates that 7 to 14 of every 1,000 uncircumcised boys will get a UTI before their first birthday, compared to 1 to 2 out of 1,000 circumcised boys. With such a low rate overall, in either population, the AAP notes that "the benefits of male circumcision are, therefore, likely to be greater in boys at higher risk of UTI, such as male infants with underlying anatomic defects such as reflux or recurrent UTIs." (These are mostly the boys that get UTIs anyway.)
So, those are definitely some
benefits to circumcision, especially if your little guy will have sex one day
(which, presumably, you want him to do at some point in the far off,
I-don't-want-to-think-about-it future). It's also fair to say that good sex
education and condom use would make those benefits almost moot (not the UTIs,
which are pretty low risk, and not all HPV strains, which sometimes infect even
with condom use).
In any case, these two benefits, a
lower risk for UTIs and some STIs, then become the risks of not being
circumcised. The former is — usually — not very serious. There are some very
serious urinary tract infections, and untreated ones can damage the kidneys.
And they're certainly not fun. They aren't, however, usually life or death
situations. HIV (somewhat still) is. Of course, boys are still at a pretty high
risk for getting HIV if they sleep with someone who has it and don't use a
condom, circumcised or not. But every bit of protection helps, right?
Unless it requires lopping off part
of a little boy's penis. There. I said it. Because that's what many parents are
simply uneasy about, regardless of the health benefits, which are great or
marginal, depending on your perspective. And that's why the AAP stopped short
of recommending circumcision as a routine procedure.
They did include in their review
several studies related to sexual satisfaction and sensitivity, one of the
complaints that "intactivists"
bring up. The AAP summarizes it pretty nicely: "The literature review does
not support the belief that male circumcision adversely affects penile sexual
function or sensitivity, or sexual satisfaction, regardless of how these
factors are defined."
But it's not possible to take into
consideration, in scientific, mathematical terms, the primary complaint of
those who oppose circumcision, which is that the man these little boys become
may have wanted that little flap over the tip. And this is one of those gray
areas that give parents pause. Once you cut that hood, you can't put it back.
How many circumcised men regret what their parents did? Well, probably not vast
numbers, or circumcision rates would have plummeted.
Rates have, in fact, decreased, from
somewhere around three-quarters of all boys in the 1960s to around 55 to 59 percent in 2010. (Here's a nifty map to see
where your states' rates are.) But they haven't plummeted.
So, this is where we end up. There
are some decent benefits. There are very few and mostly minor risks to the
procedure. And there's big, giant, gray unknown area of "what if's"
and "could have been's" for the boys who get snipped. It's
disingenuous to compare the practice to female circumcision, as some do, since
neither its intent nor its effect is to influence sexual satisfaction. But
whether it's the right thing to do…? The AAP says it's up to mom and dad.
(Which, in many households, like mine, probably means mostly dad.)
"Parents ultimately should
decide whether circumcision is in the best interests of their male child,"
they wrote. "They will need to weigh medical information in the context of
their own religious, ethical, and cultural beliefs and practices. The medical
benefits alone may not outweigh these other considerations for individual
families."
What are those other considerations?
Well, whether you want your little guy to have a foreskin. Or, whether you
don't know if he does or doesn't want it and figure he should decide that in 18
years. Maybe daddy's not circumcised and you both want him to look like daddy.
(I know many people who circumcised for this reason alone.)
About the only certain thing that
can be said about circumcision, based on the AAP's policy statement and
research and what we know about opposition to the practice, is that this
controversy will be with us for years to come.
The opinions in this post do not necessarily reflect or disagree with the opinion of the DXS editorial team.
I find the "sleep apnea" compassion disingenuous, we don't remove all children’s tonsils because it will help some people in the future. We remove tonsils after the problem has been identified. One is a solution the other is "preventive".
ReplyDeleteAlso for the percentage improvement, what are they raw numbers, “2 in 100,000” to “1 in 100,000” is a 50% improvement, but a small real change. When only talked about as 50% is seems wonderful.
Possibly the saddest point "to look like dad". To avoid awkward questions form children or avoid questioning your parent’s actions and avoiding question the act itself.
The female topic, is mechanically the same to me.
my thoughts exactly. thanks!
ReplyDeleteSimeon, thanks for your thoughts. Yes, using relative risk is not terribly helpful. In this case, I used it for two reasons - one, I have not looked up every study that the Pediatrics committee looked up, and they provided numbers that they crunched in their meta-analyses. Short of gathering all those studies and doing that number crunching myself across the studies, I can't provide the specifics, but at least the relative risk provides a general idea. I don't think the relative risk numbers are terribly convincing anyway (one of the things I tried to convey) because a condom is so much more effective with STDs. For the one risk that's not preventable by a condom - UTIs - I did provide the raw numbers instead of relative risk.
ReplyDeleteThe sleep apnea comparison is intended to show what it means, scientifically, to say benefits do or don't outweigh risks, not to compare a tonsillectomy to circumcision. I included it because of headlines which erroneously interpreted the study as saying that "circumcision is better." As I point out, the "risks" of not circumcising are simply the higher risks of UTIs and STDs. Those may not be convincing enough for many people to circumcise.
Whether it's sad that someone wants to "look" like their father is one I don't pass judgment on. There are plenty of identity and self-esteem issues to consider here, and it's not my place to judge those. However, there is a significant mechanical difference between male and female circumcision. Female circumcision removes the physical ability for a woman to achieve an orgasm by the clitoris. Even aside from the differences of intention (female circ does not prevent any health ailments and can cause infection, so prevention of sexual satisfaction is its only purpose), male circumcision does not prevent a man from enjoyment of sex, achieving orgasm or ejaculation.