Circumcision: Divided we fall
BMJ 2010; 341 doi: https://doi.org/10.1136/bmj.c4266 (Published 17 August 2010) Cite this as: BMJ 2010;341:c4266
Opinion on routine circumcision for boys is already divided across the world, but recent research is sparking fresh debate. The American Academy of Pediatrics is assessing the mass of evidence that has become available since it took the position, in 1999, that although there may be “potential medical benefits . . . these data are not sufficient to recommend routine neonatal circumcision.” The academy plans to publish its updated position later this year amid growing pressure from both sides of the debate.
Campaign groups have emerged worldwide, both within religious communities who traditionally practise circumcision and outside, where groups argue that the tradition of circumcising infants for non-medical reasons amounts to a violation of the rights of the child.
In May this year, the Royal Dutch Medical Association became the first to decide that the procedure is not only medically unnecessary but also an abuse of the rights of the child in a similar way to female genital mutilation. Under the Dutch constitution, altering a child’s body without medical reasons is illegal, and the Dutch medical body therefore argues there are grounds for banning routine circumcision of babies and children. It has not, however,
called for a legal ban on the procedure for fear that it would drive circumcision underground. Only around 15 000 infants have routine circumcisions in the Netherlands each year, and the hope is that concerted discouragement by doctors in consultation with parents could wipe out the practice.
An estimated 30% of the world’s male population are circumcised, and traditionally the operation is carried out on newborn children or infants because it is a simpler procedure at that stage and less likely to lead to complications. In countries as varied as Angola, the Philippines, and the US, the procedure is seen as socially normal and most men are circumcised for non-religious reasons—99% in Angola, 90% in the Philippines, and 75% in the US, according to a UNAIDS (Joint United Nations Programme on HIV/AIDS) report in 2007.1
Circumcision is considered hygienic by those who accept it for cultural or religious reasons. The procedure is thought to protect against urinary tract infections, syphilis, chancroid, invasive penile cancer, and HIV.
But most medical bodies in Western countries agree that although there may be health benefits, there is no medical justification for routine circumcision in neonates or children. They do, however, take a neutral stance and allow parents to decide.
The British Medical Association’s guidance, for, example, states that the evidence on health benefits was “insufficient for this alone to be a justification,” but says that “As a general rule, however, the BMA believes that parents should be entitled to make choices about how best to promote their children’s interests.”2 The Australasian Association of Paediatric Surgeons (AAPS) takes a similar approach, stating “It is considered to be inappropriate and unnecessary as a routine,” but allowing for elective circumcision in children over 6 months old when parents “hold a very strong opinion.”3
Sweden attempted to ban circumcision after the death of a child from complications in 2001. The initial ban was watered down, and the operation is illegal in Sweden in the first two months after birth.
Recent evidence
Trials in Kenya, Uganda, and South Africa led the World Health Organization and UNAIDS to declare in 2007, that circumcision can help prevent the spread of HIV and should be considered in prevention programmes in countries with high HIV prevalence and low numbers of circumcised men. The trials showed that the procedure reduced the risk of infection by 38% to 66% over 24 months and were all stopped mid-way because the results seemed so conclusive that it was deemed wrong to allow the non-circumcised men to continue.4 5 6
But the Dutch view is that the African trials are flawed in several ways and, if anything, they show that circumcision can delay infection for heterosexual men, not prevent it. “There is no convincing evidence on this,” says Gert van Dijk, medical ethicist at the Royal Dutch Medical Association. The association refers to three reports presented at the 14th and 15th international AIDS conferences in 2002 and 2004, which reached different conclusions from the later African trials.7 8 9
“And at the same time there is no reliable evidence on complications,” he adds. “It’s clear that it’s at least 2%. It could be as high as 20%. We say this is a medically futile operation so not one complication can be justified.”
Figures on the health risks of circumcision in neonates vary, but most suggest that it is much safer than in adults, with a complication rate below 1%. In the US and Israel, rates of complication in neonatal circumcisions have consistently been reported at between 0.2% and 0.4%.
But research published in BMC Urology in February concluded that side effects such as bleeding and swelling occurred in roughly 1.5% of all procedures carried out by a medical professional on infants in 12 countries.10
Dr van Dijk hopes that the Dutch decision may prompt a widespread debate and ultimately stronger rejection of infant circumcision as a human rights abuse. He argues that there are many complications—psychological or mild (such as having difficulty urinating)— that are not systematically reported. Dr van Dijk says he has received sympathetic messages from medical professionals from many different countries, including the Middle East.
Rising trend
But in Africa, in particular, things are moving in the opposite direction. Some 14 countries in southern Africa are promoting circumcision with radio and television campaigns as an official part of their HIV prevention campaigns. Swaziland, where 45% of the population has HIV, sees it as crucial to the survival of the state.
Circumcision has become fashionable among men in these African countries—not just because they believe it can help save their life but because many consider the resulting reduction in sensitivity makes them perform better during intercourse. South Africa’s president, Jacob Zuma, recently made a point of getting circumcised to encourage others.
Many African countries are also starting to introduce the operation as routine in their maternity wards because the risk of complications is lower than in adults and, crucially, it is cheaper. Botswana aims to be circumcising all newborns by 2012.
Even Rwanda, which has an HIV prevalence of only 3%, is assessing the cost effectiveness of circumcising all newborn boys to prevent the spread of HIV. A recent study found that neonatal male circumcision in Rwanda costs $15 (£9; €11) per child compared with $59 for an adult.11 In addition, thousands of dollars will be saved for each HIV infection avoided.
The authors concluded: “Rwanda should be simultaneously scaling up circumcision across a broad range of age groups, with high priority to the very young.
“Infant male circumcision can be integrated into existing health services . . . and over time has better potential than adolescent and adult circumcision to achieve the very high coverage of the population required.”11
International divide?
So are other Western countries likely to follow the Netherlands (as so often happens) and move towards greater recognition of the human rights concerns? And if so, would international organisations continue to recommend the procedure for poorer countries battling HIV?
The decision of the American Academy of Pediatrics will be closely watched, particularly by the Muslim and Jewish populations. Circumcision is more common in the US than in many other Western countries. A US National Health and Nutrition Examination Survey in 2007 found that 88% of non-Hispanic white men are circumcised, 73% of non-Hispanic black men, and 42% of Mexican Americans.12 The numbers of neonates being circumcised are falling though—56% were circumcised in 2003 compared with 85% in 1965.
In the past decade, thanks to the internet, those for and against the practice have been able to raise their voices in the debate. The number of clinics offering reparation surgery for men regretting their parents’ decision has increased, and circumcision in industrial countries is generally on the wane. In the UK, for example, 35% of newborns were circumcised in the 1930s compared with 3.5% in 2000; in Australia, the number fell from 90% in 1955 to 12% in 2000.
At the same time the pressure has been growing on the American academy to take a stronger position in favour of the health benefits circumcision may offer.
In January, a review by experts at Johns Hopkins University and the National Institutes of Health argued in favour of neonatal circumcision for health reasons and concluded “it is time for the AAP policy to fully reflect these current data.”13 In 2007, a Centers for Disease Control and Prevention consultation on male circumcision for the prevention of HIV infection concluded that heterosexual men should be advised on the potential health benefits and risks and that financial barriers to accessing circumcision should be removed.14
Douglas Diekema, medical ethics expert on the task force carrying out the academy’s review, says the 1999 position is unlikely to move in the Dutch direction.
“The data generated in the last 10 years are more supportive than not,” says Dr Diekema. “There is evidence of medical benefits that were not recognised in 1999. And there is nothing to suggest that there has been an increase in complications.”
Critics of the medical trials that led to WHO recommending circumcision as part of HIV prevention argue that something shown to work in Africa, where HIV prevalence is high and circumcision is not common, may not necessarily work equally well in countries where HIV is less widespread and large proportions of the population are already circumcised. The benefits of circumcision apply to heterosexuals whereas most new HIV infection in the US today is among men who have sex with men.
Dr Diekema says that although the American Academy of Pediatrics has not taken a formal position on the data from Africa, there is general agreement that although the benefits of circumcision in preventing the spread of HIV may be smaller in the US, any degree of risk reduction is a good thing.
Notes
Cite this as: BMJ 2010;341:c4266
Footnotes
Competing interests: The author has completed the unified competing interest form at www.icmje.org/coi_disclosure.pdf (available on request) and declares no support from any organisation for the submitted work; no financial relationships with any organisation that might have an interest in the submitted work in the previous three years; and no other relationships or activities that could appear to have influenced the submitted work.
Provenance and peer review: Commissioned; not externally peer reviewed.