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Hanna Rosin Is Mistaken On Circumcision

Hanna Rosin, guest-blogging for Andrew Sullivan, attempts to dismiss opposition to yesterday's news about the CDC potentially recommending infant male circumcision.

But the procedure is only "controversial" because people have emotional, psychological and religious reactions to it. Scientifically speaking, it's not remotely controversial. ...

Ms. Rosin's statement is nonsense because she ignores the ethics of implementing the findings. Her statement is nonsense because it ignores the evidence-based reality for infant males. The child's genitals are healthy at the moment of surgery. This is not "emotional," it is fact. Potential benefits do not make the surgical intervention on healthy infant males any more defensible.

Ms. Rosin continues:

... The anti-circumcision sites always refer to the American Academy of Pediatrics' 1999 policy statement on circumcision, which declined to recommend the procedure. But that statement was issued before the most compelling studies emerged about the role circumcision plays in reducing the risk for transmission of HIV and other STD's. ...

The "most compelling studies" from Africa were performed on adult volunteers, which is the key point before we get to an assessment of the significant differences in the HIV epidemics in sub-Saharan Africa and the United States. The ethical issue can't be resolved simply by noting that American culture already values the circumcision of males. American culture gets it wrong on what should be permitted on healthy children who do not need medical intervention and can't consent to cosmetic surgery. Proxy consent must require medical need first, and medical ethics should demand only the least-invasive effective treatment for sick children. Prophylactic infant male circumcision fails both standards.

Ms. Rosin later acknowledges the differences between Africa and the United States, but she seeks to pretend that "the evidence is still pretty strong, and even stronger for STD's" qualifies as a rebuttal. It doesn't. The only supported suggestion is that adult male circumcision reduces the risk of female-to-male HIV transmission. Even if that accurately described the American situation, which it doesn't, wasting finite medical resources on infant males who will not be engaging in any sexual activity, protected or not, for many years is asinine. And unethical, since we must loop back to the evidence-based reality that healthy infant males do not need circumcision.

**********

At the end of her post, Ms. Rosin raises a separate issue, apparently as a "gotcha".

Over on DoubleX, KJ Dell'Antonia makes the good feminist point. With the HPV vaccines, conservatives raise a fuss that removing the risk of STD's will make girls more sexually promiscuous. In the circumcision debate, silence on the promiscuity front.

There's a double standard. What does that prove with respect to justifying infant male circumcision? Because a group of people make a stupid, sexist assertion about one point, their silence on another human sexuality topic confers credibility to the intervention? Focusing on this gives the unserious nutters too much credit.

Anyway, it's far more logical to highlight the double standard inherent in having anti-FGM laws in America that prohibit parents and doctors from altering the genitals of female minors for any reason other than medical need, including the cultural and religious claims of the parents, while leaving open the option for parents to circumcise healthy male minors for any reason. There are important caveats to raise in the differences in male and female genital cutting, but the ethical question involves basic human rights. When considering that less invasive cutting is prohibited on female minors compared to what is permitted (and potentially encouraged) on male minors, the difference is in degree, not in kind, and can't be swept away with the same tired deference to potential benefits. But that would involve addressing the issues rather than side-stepping them to score cheap rhetorical points and declaring victory.

Comments

If I recall Andrew Sullivan is pretty anti-circumcision. I wonder what he thinks of this substitute's contribution. And I don't see anywhere to comment, coward.

She is quite wrong about the controversy scientifically. Perhaps she hasn't heard that no other Western HIV/AIDS agency believes this is even remotely useful in their low prevalence contexts where the epidemic is driven largely by homosexual transmission and iv drug users.

In defense of Mr. Sullivan, he's debated comments and taken e-mail input from readers on the subject. He's decided against comments based on this and his desire to keep the conversation civil. And he posts a fair number of viewpoints, including a "Dissent of the Day" feature. (Often updated multiple times per day.)

On circumcision, he is against it, though he's mistakenly softened his stance since the HIV news began.

Hello Tony, as excellent blog as I remembered.

We do not remove the breasts pre-emptively to 100% prevent breast cancer in women, which is a far more lethal then your average STD. And much less preventable if it runs in the family. It sickens me that anyone would even consider this procedure for anything other then immediate medical need. It just shows how much Americans really do try to be different then the rest of the world creating our own unique herd of sheep.

I have three points to make.

First, in the US the foreskin is almost considered a birth defect -- this is what the medical establishment has conditioned the public to believe. I think profit is the motivating factor for to push for male circumcision (whose rates have been falling lately).

Second, the view that male circumcision is needed for hygiene bothers me -- especially coming from women who essentially rely on a fair number of feminine hygiene products (that take up many shelves in a drug store isle). Wouldn't it sound ludicrous to suggest that women should get a "surgery" in their genital area for hygiene/disease prevention (ie. urinary tract infection, etc.)? It's equally ludicrous to suggest that men need a "surgery" for hygiene / disease prevention when there are much more reliable methods (ie. condoms, etc.).

It's interesting to read a take on the American "obsession" with circumcision from outside the country. Here is a British news article:

http://news.bbc.co.uk/2/hi/health/7960798.stm

True, the strongest counter-point to Hanna Rosin's guest blog is still ethics -- surgery on healthy children for diseases they don't have and very likely won't even encounter crosses a medico-ethical line that must not be violated. Circumcision also remains enormously cost-ineffective compared to just about any other intervention, even if commonly accepted health statistics are to be believed. This is true everywhere, including Africa.

However, Ms. Rosin made two great factual mistakes in her conclusion. She merely accepted that the African RCT data are "strong" and also noted that Medicaid no longer pays for infant circumcision. Let's take these in reverse order.

First off, Medicaid in several Western states has long not paid for circumcision, because it is clearly not a surgery necessary for excellent health. There is mountains of evidence from Europe, South America, Asia and now Canada and Australia to back this up. The number of states -- all in severe budget crisis -- that now decline to pay for this unnecessary surgery has roughly doubled in recent years from 7 to 16, meaning 34 states still automatically pay for infant circumcision. These major states that pay include New York, Illinois, Massachusetts and many others with large urban populations. California has never paid for circumcision; this is nothing new. Ms. Rosin's observation is gross exaggeration at best and hysteria at worst.

Second, the African RCTs really should not be taken at face value. They were designed and carried out by teams that have been pushing a strong circumcision agenda for more than 20 years in the face of truly compelling data that infant circumcision simply does not make a health difference, even in HIV. In fact, a meta-analysis of the published studies from the past roughly 35 years shows it is circumcised males who have a statistically higher likelihood of contracting every common type of STI, including syphilis, gonorrhea, HIV and particularly chlamydia, when proper adjustments are made for comparable conditions and populations.

The African trials contained numerous deeply troubling methodological flaws, so significant that their conclusions could not have been reached otherwise. In other words, they were engineered.

It is curious why the African trials were done in the first place. It's not as if those areas of Africa that predominantly don't circumcise had higher rates of HIV than those that do -- they actually do not. And in the developed world, it is clear that the US has higher rates of just about every single STI than Western Europe, including more than double the HIV transmission rate from vaginal intercourse.

The latest "statistic" to be put forth by the proponents of circumcision is that African Americans have a low circumcision rate and a high HIV rate. That this is being accepted as fact is really alarming. In fact, throughout the 20th century the circumcision rate among blacks was very close to that of whites in the US, and both were markedly different from rates among Hispanics and Asians. In the 21st century, the rate among blacks actually moved ahead of whites. But by simply repeating the mantra that black community is being "denied" circumcision by Medicare (and it's not a black program, by the way), those pushing infant circumcision the hardest can conveniently mask the fact that HIV is not a major problem among noncircumcising Asians and not nearly nearly as prevalent among Hispanics, who also don't clamor for circumcision.

The amount of disinformation and noise is staggering, all in an effort to prop up a cultural practice without science behind it. Infant circumcision really took off in the Cold War USA with the satisfaction that it was predominantly godless communists and assorted socialists who failed to practice it. Once it got into the insurance system (public and private), it has proven almost impossible to get out again. Put simply, the circumcision "machine" is in place in the US -- every hospital is equipped to do dozens daily, if necessary -- while this is not true in most other countries.

Worldwide only 3 boys in 100 get circumcised by their first birthday, and 2/3 of these are in the United States. (It is true that Moslems circumcise routinely, but this is not a surgery on infants in their culture.) The fad of circumcision has never resulted in improved health outcomes, but that doesn't deter its adherents from fighting tooth and nail for every percentage point.

It will be interesting to see how other countries' medical associations react if the CDC and AAP move as speculated.

Infants don't have sex. There is no emergency that warrants over-riding HIS chance to decide about HIS own body when he's older based on the best info then available.

Should he decide to do it later, he'll get a better job, full anesthesia, and similar recoevery time, plus a say about his own body, input as to style of cut, and someone not long dead to sue if he doesn't like the outcome.

Foreskin feels REALLY good. It includes over half the sensual pleasure-receptive nerve endings.

Circumcision is not without risk. Between 100 and 200 US babies die every year, which makes infant circumcision 27 times deadlier per procedure than the Gardasil vaccine. Google "circumcision damage" to see the other horrific functional and cosmetic side effects which the CDC has never tried to measure.

FGM is scientifically shown to protect from HIV, and amputating one female breast bud at birth would literally and indisputibly cut breast cancer deaths by about 30%. We don't do those things because people have a right to enjoy their intact bodies.

Protect boys too.

Circumcision, is particularly wrong due to the ethical problems involved in destroying medically normal parts of boys penises. Since the boy is healthy and normal, its not medically justified and violates medical ethics, just as much as FGM does. To say that the pro-genital integrity advocates are founded on emotion is inaccurate, since there are clear ethical principles against genital mutilation, although emotions are healthy and important and give us a clue when something isnt right. This is the reason FGM is wrong, and hence, if we came along and did studies that circumcising girls would reduce HIV, would those who know support male circumcision support female circumcision. Many types of female circumcision are not more harmful than male circumcision and male circumcision as commonly done is much more severe than the least severe forms of female circumcision. So dont even try to say female circumcision is more harmful. The fact is, its wrong to cut a childs genitals, no matter if its to pierce or take a small snip, or to remove 50% of the skin from a boys penis as circumcision does.

I'm so sick of hearing about all the reasons that people have for cutting parts of infant males off! children may get ear infections, why don't we just drill them out at birth so they don't get them. they may get a chest infection... lets just remove the lungs and keep them in an Iron lung for their whole life? I got a big toe infection when I was in grade school and it hurt like hell. I sure wish someone smart like Ms Rosen had been there to make sure my toes were removed at birth so I didn't have to go through that.
I guess HIV is a serious illness. Maybe if we are really serious about doing something about it we shouldn't stop at the foreskin, just lop the whole damn thing off... that should do it.
If you try to get your doctor to circumcise your infant daughter in the hospital, they will put you in jail and take away your daughter. If you try to get out of there without letting the hospital perform one of the most extreme body modification procedures, you have to run a gauntlet of nurses and lawyers and doctors telling you how dirty and infected a penis can be. Funny, they don't ever just tell you how to wash the damn thing!
Circumcision is criminal and parents and circumcised individuals should start bringing legal actions against the hospitals, doctors and insurance agencies who perform this barbaric ritual.

Rosin doesn't get it, only because the medical studies aren't suggesting - yet - that part of *her* genitals be removed without her consent. Then we'd see the real definition of "hysteria" coming from her camp.

The oft-repeated lie that circumcision provides an absolute 50% reduction is a measure of gullibility or lack of intelligence. Look: it's a 50% reduction in a two year period (the study period), which is not the same as the lifetime risk reduction of a vaccine. Half the men supposedly spared HIV infection in the first two years will become infected in the second two year period. That is hardly a personal plan for avoiding HIV. Only in the world of mathematical models, where parameters can be tweaked to get answer you want, can this percentage rate make any difference in a population.

Circumcisers like Rosin used to insist that there were no men dissatisfied with their forced circumcisions. Now they just make fun of us. It is infuriating, and maybe that is her intention. There is more than a hint of malice in her writing.

Circumcisers will not address the product of "small risk" with millions of circumcisions. The result is that thousands of men in the U.S. *are* genitally mutilated, including partially missing glans, skin bridges, horrific scars, insufficient skin for erection, buried penis, loss of penis. It's a fact that deaths do occur annually.

Years from now, when it becomes clear that the circumcision frenzy of our time did nothing to prevent HIV, Rosin and her ilk will have a new reason to cut.

I think much of the circumcision advocacy is driven by personal feelings of circumcised men and women from circumcising cultures. Their unspoken attitude is: All must be circumcised if some are. Otherwise we must admit that circumcision has harmed the circumcised. That we can never do.

And shame and attempted humor is often used to browbeat others into conformity.

Here is an example: I attended the CDC National HIV/AIDS Conference here in Atlanta this week. The assembled CDC worthies were promoting circumcision on the basis of the African RCTs, the conclusions of which were presented by one speaker as being "beyond a reasonable doubt." Katrina Kretsinger, MD, of the CDC was asked if the RCTs would be repeated in the U.S. She replied that they would not be because it would be unethical to do so! Then how were they ethical to start with? When I attended the session where Deborah Gust of the CDC presented a paper demonstrating that circumcision made no difference in the acquisition of HIV by insertive gay males, I asked why these results did not bring into question the conclusions of the RCTs since the anus supposedly contains more HIV than the vagina. The reply, as I understood it, was that since the insertive males also were sometimes receptive males you could not say how they got HIV. Of course, if that is the case, then the study was worthless. But since it was presented as being worthy (otherwise why present it?), I am of the opinion that it does bring into question the validity of the RCTs, as does the known fact that the U.S. has the highest rate of HIV in the industrialized world (a fact one speaker brought up), the highest STD rate in that same world, and the highest rate of male circumcision in that same world. So much for the great American circumcision experiment!

At one of the last sessions the speaker from "Operation Abraham", a Jerusalem, Israel group that apparently hopes to be engaged to assist the U.S. in circumcising the black and Hispanic males who are not circumcised, put a photo of an intact male up on the screen. The figure of an elephant had been drawn around the penis so that the intact penis looked like an elephant's trunk. The words "Help circumcise me" or something similar had been added to the photo. I remonstrated loudly until this smear on all intact boys and men was taken down and then promptly left the session. I am still awaiting a deserved, written, direct apology from Dr. Peter Kilmarx, Chief of the Epidemiology Branch of the Division of HIV/AIDS Prevention of the CDC, who was in attendance and from whom I demanded an apology. I think this shows the mindset of the CDC. They seem to have abandoned all scientific objectivity to promote a useless and mutilating surgery. I expect the men are all circumcised and the women are all married to circumcised men. So the trauma repeats itself and those who have been traumatized fulfill their need to traumatize others. And apparently they think it is socially and ethically acceptable to denigrate a normal body part and to attempt to humiliate all intact boys and men into submitting to circumcision.

Those who are as outraged as I can write appropriate letters to the CDC. Addresses can be found at www.circumcisionandhiv.com. The main snail mail address for all employees of the CDC is
Centers for Disease Control and Prevention
1600 Clifton Rd
Atlanta, GA 30333.

You should write Kevin Fenton, M.D., Ph.D., FFHP, Director, The National Center for HIV/AIDS, Viral Hepatitis,STD, and TB Prevention (NCHHSTP) (his e-mail is kevin.fenton@cdc.hhs.gov), Peter Kilmarx, M.D., Chief, Epidemiology Branch, Division of HIV/AIDS Prevention, and Thomas R. Frieden, MD, MPH, Director.


And since the CDC is consulting with the AAP (indeed Operation Abraham's abstract for its presentation mentioned "lobbying" the AAP), a letter to the Circumcision Task Force is needed. You can get the AAP's address at its website.

How about the health benefits of not cutting nerves and blood vessels and getting to have a natural member? 20,000 FINE TOUCH AND STRETCH nerve endings should NOT be amputated from baby boys without asking the owner. This is such crap.

There is a greater chance of the baby boy getting MRSA staph from this in a US hospital than the same kid getting HIV through his life. This is such a strange idea that one wonders why the US Meds have this obsession. We have higher HIV and very high Circ rate as compared to natural uncut EU and JP. Could it be cut male Drs and female MDs that are from cut tradition are trying to find a way to keep this barbaric practice going in the US? No other developed country is saying this! They think we are obsessed with choping off baby boy genitals.

The alleged risk change (not seen in non african studies) is from 3.2% risk to about 1.78 % risk. Oh and BTW, circumcision raises (makes transmission more likely) the HIV for women. Look it up the same africa studies found cut transfered HIV at a much higher rate. The individual does not get much from this. One needs to avoid risk and use a condom.

This is a fraud pushed by people that don't have it or don't know the main male pleasure zones are in the parts cut off by circumcision. One thing is certain, no person should have pleasure zones amputated without being asked. Stop doing this to babies.

how can americans not see how out of step they are with western ethical standards in pushing RIC?

the medical establishment in your country needs to take a long look at its subconscious motives and assumptions, and maybe attend a bioethics primer while they're at it.

CDC involvement in sponsoring this quackery: offensive, suspicious and WRONG.

The most important point is missing from the whole discussion: the ritual (I cannot call it anything else) reduces sexual pleasure. This has been well known already in the middle ages (see Maimonides' Book of the Perplexed) and probably before.

The equivalent for a girl would be to remove the inner labiae and the sensitive spot where they connect to the clitoris, as well as the hood. If Mrs. Rosin wants to try this out, I will pay the surgery for her!

Hi,

There is an ongoing petition against this madness. Please stop by and sign it (less than a minute):
http://www.thepetitionsite.com/campaign/signatures/760537185/198

No system of socialised medicine pays for routine neontatal circ, except for Medicaid in 34 USA states. Congress just past a law enacting some sort of socialised medicine in the USA. There is a possibility that the resulting bureaucratic system will decline to fund routine circ, if only because the socialised medicine in the other English speaking countries have done just that. If the new Federal health care system defunds routine circ, BC/BS and private insurers are likely to follow suit, and American circ will die on the vine. Only a minority of families will do it if they are out of pocket for it.

The CDC is coming to the rescue, starting a hue and cry that routine circ can stop the HIV train wreck. Their call for universal cutting of all babies is only a negotiating tactic. What American medicine really wants is coverage of routine circ by third party payers. American doctors and hospitals accept that parents should have the last word on whether their baby boys are cut. But they are confident that many will chose cut if the cost to the choosers is nominal or zero. Reader, please understand that the profit margin on routine circ is high.

If public and private insurers emerge from this brouhaha agreeing to cover routine circ, the disappearance of routine circ will require a continued struggle to make it unfashionable among young parents. This is happenening, but could take another 30+ years. Defunding routine circ could wipe it out by 2020.

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