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A Seattle Medical Ethicist Tackles the Circumcision Question



Dr. Douglas Diekema, Director of Education at the Treuman Katz Center for Pediatric Bioethics at Seattle Children's Hospital

Courtesy of Seattle Children's Hospital

Every year, more than 1 million U.S. boys are circumcised shortly after birth. You'd think the most common surgery performed in this country wouldn't stoke much controversy, yet it does - and viciously so.

Staunch proponents argue that failing to remove a boy's foreskin exposes him to a lifelong minefield of health risks and hygiene hassles that could easily be avoided with a simple, low-risk procedure. Opponents consider male circumcision a form of genital mutilation, saying it's a traumatic and unnecessary surgery that strips the penis of perfectly functional tissue.

For the past decade, the American Academy of Pediatrics has taken a middle-of-the-road stance. While noting that scientific studies have shown various medical benefits to removing a baby boy's foreskin, the Academy has argued that those benefits aren't so compelling that they outweigh the risks of the circumcision.

Circumcised boys face lower rates of urinary tract infections and penile cancer than uncircumcised boys. Both conditions are extremely rare - so rare that in theory, hundreds of boys would have to be circumcised to prevent just one case of either illness. On the other hand, the risks of complications from circumcision also are extremely low, and most problems are minor, like local infections that can be treated with a topical ointment or antibiotics.

In a 1999 policy statement that remains its official stance today, the AAP concluded that the risks and benefits of circumcision are pretty evenly aligned, so there's no reason for doctors to recommend it routinely. Now an Academy committee is taking a look at all the research that's been done in recent years - paying especially close attention to studies showing that circumcision substantially lowers transmission rates of HIV and other sexually transmitted diseases.

Dr. Douglas Diekema, a professor of pediatrics at the University of Washington and director of education at the Treuman Katz Center for Pediatric Bioethics at Seattle Children's Hospital, is a member of that panel. Though he wasn't assigned to analyze the sexually transmitted disease studies, Diekema has reviewed them and believes that they are not likely to prompt a dramatic shift in the Academy's neutral stance.

He notes the HIV research was conducted in Africa, where the HIV infection rate is remarkably higher than it is in the U.S.

"In a place like Africa, where you can potentially reduce transmission of HIV dramatically by having men circumcised, you could argue that it's justifiable to implement a public health program to try to get as many men circumcised as possible," Diekema says. "There are strong reasons for doing that in that population. In the United States, it's not clear whether it reaches that level."

What do these studies mean for parents trying to decide what's right for their boys?

"For a parent for whom it's really important to optimize protection against transmission of infectious diseases like HIV, circumcision can make some impact there. It's not entirely protective, but it reduces the risk," Diekema says. "I wouldn't say you'd be doing your child a disservice not to circumcise him. But for parents who are sort of thinking about doing it, it's one more reason to consider it."

The National Organization of Circumcision Resource Centers, a group that opposes circumcision, questions various aspects of the HIV studies. In a statement on its Web site, NOCIRC argues that circumcision can give men a false sense of security that could actually increase the incidence of sexually transmitted diseases by diverting attention away from the importance of condom use.

On the other hand, in his recently published book, Circumcision, Sex, God and Science: Modern Health Benefits of an Ancient Ritual, Dr. Edgar J. Schoen cites a United Nations study that found a two- to ten-fold increase in HIV infections in parts of Asia and Africa where circumcision is not practiced compared to areas where it is.

Schoen, chairman of the AAP's 1987-1989 task force on circumcision, is a proponent of universal circumcision for infant boys. He has vehemently criticized the AAP for the neutral stance it adopted in 1999. In a 2006 article published in the journal Pediatrics, Schoen called the Academy's current position "misleading" and argued that "compelling evidence has accumulated warranting acknowledgment that the multiple medical benefits of newborn circumcision far outweigh the minor risks of the procedure."

Pay too much attention to the passionate arguments on the fringes of this heated debate, and you're bound to wind up confused and uncertain about what's right for your child. Diekema's advice: "Understand that this is controversial precisely because there isn't a right answer here," he says. "It's reasonable for parents to circumcise their children and it's reasonable for them not to."

Diekema's assignments on the AAP circumcision task force included analyzing the surgical risks of circumcision. He says they're very low, and that about half of the 3 percent to 5 percent of cases in which complications occur are minor problems like swelling or infections. Though extremely rare, there are cases when either too much foreskin or part of the head of the penis is clipped off. "They're pretty rare in the United States," Diekema says, "but you do find cases.
You just want to make sure the person who's going to do the circumcision knows what they're doing." Studies have shown higher rates of such errors among "cultural providers," such as the mohels who perform ritual circumcision for Jewish boys, than among doctors, Diekema notes.

Diekema also studied the impact circumcision has on sexual satisfaction. His take of the studies - which, as a whole he characterized as weak and conjectural - is that there is no solid evidence that circumcision diminishes or enhances sexual pleasure. Some studies have reported increases in sexual pleasure among men who have been circumcised as adults, while in other studies, uncircumcised men insist that most of their sexual pleasure feels centralized in their foreskins.

Members of the AAP's circumcision task force has not released a new policy statement regarding circumcision since 1999 but Diekema says the panel hopes to publish its conclusions soon. The current policy statement can be read here: http://aappolicy.aappublications.org/cgi/reprint/pediatrics;103/3/686.pdf


Elizabeth M. Gillespie is managing editor of Seattle’s Child magazine and mother of a toddler and a newborn baby boy.

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