To Snip or Not To Snip: The Politics of Male Circumcision

Patricia Salber

Published 11/27/11 on The Doctor Weighs In

Eighteen states, including Colorado and South Carolina have eliminated Medicaid coverage for male circumcision.  Furthermore,  ballot initiatives, including one attempted in my hometown San Francisco, are being discussed that would ban the procedure altogether.  I always worry when politics and political agendas start to mess with public health.

How about inserting some facts into the decision-making process?  Well, the American Academy of Pediatrics 1999 policy on circumcision, reaffirmed in 2005 and soon to be updated again, states that, although there could be medical benefits to male circumcision (including reduction of transmission of sexually transmitted diseases), “the procedure is not essential to the child’s current well-being, parents should determine what is in the best interest of the child. To make an informed choice, parents of all male infants should be given accurate and unbiased information and be provided the opportunity to discuss this decision.” Ok, that is sensible…informed choice should be an essential ingredient for all health decisions.

So here is some more useful information that the public and policy makers should consider.  Aaron Tobian, MD, PhD and Ronald Gray, MD, MSc, of John Hopkins School of Medicine and Bloomberg School of Public, respectively, reviewed recent medical evidence about the risks and benefits of Male Circumcision in their commentary, “The Medical Benefits of Male Circumcision” featured in the November 23, 2011 issue of JAMA.

Here is a summary of their key findings:

  • Studies in Africa have demonstrated that adult male circumcision decreases human immunodeficiency virus (HIV) acquisition in men by 51% to 60%.  They go on to say that “there is substantial evidence that removal of the foreskin reduces the risk of male heterosexual HIV acquisition, however, the effect of male circumcision on reducing HIV acquisition among men who have sex with men is unclear.”
  • Male circumcision reduces the risk of acquiring and transmitting certain heterosexually acquired sexually transmitted diseases (STDs), such as genital herpes, bacterial vaginosis, and trichomoniasis.
  • The risk of acquiring high risk human papillomavirus (a cause of penile and cervical cancers) is reduced by about a third.
  • Although these studies were conducted in Africa, STDs, including heterosexually transmitted HIV are common in the US.
  • Neonatal male circumcision provides other potential benefits during childhood such as prevention of infant urinary tract infections, meatitis, balanitis, and phimosis
  • The Joint United Nations Programme on HIV/AIDS (UNAIDS) and the WHO have adopted a policy advocating male circumcision in countries with heterosexual HIV epidemics and the US Centers for Disease Control and Prevention (CDC) found economic benefits to the procedure based on reducing HIV infections alone.

Opponents of male circumcision consider the procedure to be a form of genital mutilation sometimes comparing it to female circumcision which involves removing some or all of the clitoris, a procedure that is associated with a lot of morbidity and even mortality.   Newborn male circumcision, usually performed in the hospital a few days after birth, is a relatively simple procedure that involves snipping of the foreskin.  I have a attended couple of brit’s, the Jewish ceremonial circumcision that takes place when the boy baby is 8 days old.  Neither the hospital-performed nor the religious circumcision seem to cause much distress to the infant.  They cry for a bit, but are easily soothed by the parents (or by a drop of wine in the case of a brit) – it doesn’t seem any worse than the first sprained ankle or skinned knee.  That being said, I personally don’t know any circumcised men who are obsessed by the trauma of their early childhood penile operation or their sprained ankle/skinned knees, do you?

Some who oppose male circumcision say that male circumcision can cause sexual dysfunction.  However, Tobian and Gray state that “the male circumcision trials evaluated sexual satisfaction in adult men and their female partners before and after the procedure and compared men randomized to male circumcision with uncircumcised controls. There were no significant differences in male sexual satisfaction or dysfunction among trial participants, and in one trial, circumcised men reported increased penile sensitivity and enhanced ease of reaching orgasm.  In addition, 97% of female partners reported either no change or improved sexual satisfaction after their male partner was circumcised.”

As is true with all health care interventions, the consumer and policy makers needs to weigh the pros and cons – but they need solid information upon which to base their decision.  It would be a shame if, like the hysteria over vaccinations related to faked research, the politics surrounding male circumcision lead to public health policies that are not sound..and safe.

Patricia Salber, MD, MBA has served as Medical Director or Chief Medical Officer for several large health plans, and now writes at The Doctor Weighs In.

About Brian Klepper

Brian Klepper is a health care analyst and the Chief Development Officer of WeCare TLC onsite clinics.
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14 Responses to To Snip or Not To Snip: The Politics of Male Circumcision

  1. Peter says:

    After reading this article, it looks like the foreskin is a birth defect, despite the fact countries with low rates of circumcision are just doing fine.
    If circumcision has so many medical benefits, why these benefits don’t manifest into the real world? Why Europe, Asia, Scandinavia, South America etc. with very low rate of circumcision are aren’t suffering from all the diseases circumcision is supposed to cure ?
    The fact you don’t know any man regretting their circumcisions means nothing. Just visit any “foreskin restoration forum”, some of them have more than 10,000 members.

  2. Hugh7 says:

    This article has a Coefficient of Objectivity and Circumcision Knowledge of 5. To see how the Coefficient of Objectivity and Circumcision Knowledge is calculated, visit http://www.circumstitions.com/write.html .

    You are especially to be congratulated for combining the flippancy of “snip” with the standard Shakespearean heading #1. (With a Gomco or Mogen Clamp it’s sliced – and a Mogen may take more than just the foreskin, which has led to successful claims worth millions and the Mogen company going out of business. With a Plastibell it’s crushed and allowed to die. With an Accu-circ it’s chopped. But never “snipped”.)

    “increased penile sensitivity and enhanced ease of reaching orgasm.” Yet time after time, circumcised men say “If I had any more sensitivity, I’d (have a heart attack, die, never hold out till after dinner)” and one man’s “enhanced ease of reaching orgasm” is another man’s PE. Those trials were of adult volunteers for circumcision, hardly a random sample – men who enjoy their foreskins would run a mile from such a trial.

    “…informed choice should be an essential ingredient for all health decisions.” Absolutely! But the question is, WHOSE choice. How about waiting to ask the owner, when he is old enough to make an informed choice?

    You can find men who resent being circumcised here: http://www.circumstitions.com/Resent.hmtl

  3. Petrina says:

    As a physician who either benefits financially from performing infant circumcisions or whose colleagues benefit financially from performing circumcisions, it is not surprising to read Dr. Salber promoting circumcision in this article. No national medical association in the world recommends routine circumcision, but Dr. Salber seems to think she knows better. Of course, being a woman in the U.S., it is clear that she was never forced to undergo genital cutting, so forced genital cutting doesn’t affect her. It does adversely affect male children, but then she’s not one of them.

    Dr. Salber mentions nothing about the anatomy and functions of the foreskin, probably because she never learned about that in medical school. Here is a case of the uninformed or the misinformed trying to portray herself as informed. No doctor should be cutting off healthy body parts from another person (including children) without his or her consent, especially since that violates the dictum to “First, Do No Harm”. Didn’t they teach that in medical school either?

    Circumcision unnecessarily adds many millions of dollars to medical costs each year, money that could be better spent on necessary medical costs. This drives up health care costs for everyone! Profits for doctors should never trump the human rights of the child, or the wasteful spending on this non-therapeutic surgery.

  4. Petrina,

    I know Dr. Salber well, and I can vouch that she 1) has no financial interest in circumcision and 2) has spent her career focused on ways to assure the appropriateness of care and cost. I will also tell you that she has a son (and grandchildren), so she is not insensitive to children’s welfare.

    I would urge you to not elevate your disagreement with Dr. Salber from philosophical and scientific to personal, While your arguments against circumcision have merit, you make several assumptions about Dr. Salber which are categorically not true and therefore offensive.

  5. Matt D says:

    “…informed choice should be an essential ingredient for all health decisions.”

    Those were her exact words. She just deosn’t get it AT ALL. **facepalm**

  6. Matt D says:

    Should a womean decide if she wants a labia reduction or should it be forced on her when she is a day old?

  7. Roland Day says:

    To know or not to know: that is the question.

    In this case, it appears that Patricia Salber has chosen not to know.

    She makes no mention of the anatomy or functions of the human foreskin, which is a complex, multifunctional structure, composed of mucosa, normal skin, muscle fiber, blood vessels, and a huge number of nerves. The foreskin provides physical protection, several immunological functions, several mechanical functions aiding intercourse, and sensation to the autonomic and central nervous systems. It is essential for normal sexual function. Salber apparently has no knowledge of this at all.

    Removal of the foreskin from a child leaves the child with a lifelong burden and violates his legal and human rights to bodily integrity and security of his person. Consequently, the amputation violates many rules of medical ethics.

    Salber commits a logical fallacy by appealing to the authority of the American Academy of Pediatrics (AAP), a highly biased source, since many of its members profit by performing the operation. It is now well established that the AAP overstates the unproved alleged benefits and understates the complications, risks, certain injury, and other disadvantages and drawbacks to the amputative surgery.

    Salber properly reports that 18 state Medicaid plans have discontinued payments for the non-therapeutic operation. She fails to report the British National Health Service does NOT provide the non-therapeutic operation. She does NOT report that all fourteen Canadian Health Insurance Plans have, one-by-one, discontinued payments for non-therapeutic circumcision. She does NOT report that the New Zealand Health Plan long ago discontinued payments for non-therapeutic circumcision. She does NOT report that public hospital in Australia have discontinued providing non-therapeutic circumcision.

    Salber fails to see the trauma of circumcision when the evidence of it is before her eyes. Circumcised doctors usually are the advocates and performers of infant circumcision. In so doing, they are re-experiencing and re-enacting their own trauma.

    Salber then confuses a religious practice with medical science. The practice of circumcision as a religious rite does NOT justify its practice as a medical procedure.

    Salber then cites a polemical argument by two notorious advocates of male circumcision and claims that male circumcision does not impair sexuality. In actuality, several recent studies have reported adverse effects for both the male and his female partner.

    West Virginia circumcises about 85 percent of its boys. Washington circumcises about 13 percent. Does Salber have any evidence to show that boys in West Virginia are healthier than boys in Washington? I suggest that she has NO such evidence.

    Salber concludes by citing the necessity for “solid information.” Unfortunately, it WON’T come from Salber.

  8. Roland Day says:

    Salber fails to understand that the the funds for medical services are finite. Any funds expended on medically-UNnecessary, NON-therapeutic services takes funds away from medically-necessary, therapeutic services.

    The 18 states that have discontinued provision of payments for non-therapeutic circumcision have acted wisely in conserving their scarce dollars.

  9. Petrina says:

    Perhaps what you say about Dr. Salber is true. However, this cannot be said of all physicians, including those who receive untold millions of dollars in grant money from taxpayers to conduct studies promoting circumcision in Africa. Continuation of these funds requires that they find a benefit to circumcision.

    In addition, healthy amputated foreskins from infants are sold to researchers to be used as feeder cells for embryonic stem cell research, for use in Oprah’s skin care products, and for developing skin for skin grafts. There is money involved in circumcision.

    The June 22, 1987 Boston Globe quoted Thomas Wiswell, M.D., as saying: “I have some good friends who are obstetricians outside the military, and they look at a foreskin and almost see a $125 price tag on it. Each one is that much money. Heck, if you do 10 a week, that’s over $1,000 a week, and they don’t take that much time.” (Lehman 1987)

    The 18 states that have defunded medically unnecessary circumcisions have recognized that this tax money should be used only for medically necessary purposes. Medicaid funds by law are to be used for only medically necessary services. No one can validly make the case that amputating a healthy body part from another person is a medical necessity. All 50 states should stop wasting tax dollars on non-therapeutic circumcisions.

    Medicaid and private health insurance funds should not be wasted on unnecessary surgeries, driving up health care costs today in hard economic times. It is far more important to be using funds for necessary costs like insulin to keep a diabetic alive or chemotherapy to treat cancer patients than it is to pay physicians to cut off healthy foreskins from infants so that male children will “look like” their circumcised fathers. This is the most common reason given by parents today for choosing circumcision. This is not a medical reason, and the heatlhy foreskin is not a birth defect.

    Dr. Salber and others can learn more about the anatomy and functions of the foreskin at:

    http://www.cirp.org/pages/parents/lostlist/

    http://mensightmagazine.com/Articles/Northrup/lovecirc.htm

  10. Petrina says:

    A new Danish study found that “Circumcision was associated with frequent orgasm difficulties in Danish men and with a range of frequent sexual difficulties in women, notably orgasm difficulties, dyspareunia and a sense of incomplete sexual needs fulfilment. ” See:

    http://www.ncbi.nlm.nih.gov/pubmed/21672947

    http://sciencenordic.com/male-circumcision-leads-bad-sex-life

    Those who are interested in the welfare of children should learn how circumcision has impacted children through botched circumcisions and circumcision deaths. These sad cases are brought to light every time a new lawsuit is filed. These are all tragedies that did not need to happen, because circumcision is not a necesssary surgery. See:

    http://www.glorialemay.com/blog/?p=581

  11. Dan Bollinger says:

    Safe? More than 100 American baby boys die each year from circumcision-related causes.
    Sex? Circumcised men are 4.5 times as likely to acquire erectile dysfunction.

    Both of the above are conclusions from two new studies the author failed to mention.

  12. Lathan Ross says:

    Dr. Salber (and many others) needs to truthfully identify the real reason why she advocates circumcision: UNcircumcised penises are ugly, and I don’t want my sons, grandsons, or anyone else’s sons and grandsons walking around with ugly penises. As with many others, the decision to circumcise is purely cosmetic, nothing more. To Dr. Salber and your pal, Brian Klepper: Condoms work, even in Africa if they’d use them!

  13. Ron Low says:

    When you interviewed Dr. Gray for this article did he mention that HIS OWN 2009 research suggested that the Ugandan men he circumcised were 50% MORE likely to infect their female partners with deadly HIV than the men he left intact were? Did he explain why in his report on those findings he endorsed circumcising HIV+ men, definitively placing their partners at greater risk? Did you ask him why the trial was terminated before it could rise to statistical significance or why neither he nor the WHO have followed up to rule out this grave threat to women before racing ahead with mass circumcision campaigns?

    Most of the US men who have died of AIDS were circumcised at birth.

  14. Roland Day says:

    Dr. Salber cites the American Academy of Pediatrics statement on male circumcision, which was drafted in 1998 and published in 1999. That statement is now 13 years old. It is highly biased in favor of circumcision because of the inherent conflict of interest between the purses of the members of the AAP and the real needs of children.

    A newer statement by the Royal Dutch Medical Association and several specialist Dutch medical societies (2010) now exists and is much to be preferred. That statement may be found at:

    http://knmg.artsennet.nl/web/file?uuid=579e836d-ea83-410f-9889-feb7eda87cd5&owner=a8a9ce0e-f42b-47a5-960e-be08025b7b04&contentid=77976&elementid=771754

    The Dutch statement says that child circumcision violates human rights. The statement says in part:

    π There is no convincing evidence that circumcision is useful or necessary in terms
    of prevention or hygiene. Partly in the light of the complications which can arise
    during or after circumcision, circumcision is not justifiable except on medical/therapeutic
    grounds. Insofar as there are medical benefits, such as a possibly reduced
    risk of HIV infection, it is reasonable to put off circumcision until the age at which
    such a risk is relevant and the boy himself can decide about the intervention, or
    can opt for any available alternatives.
    π Contrary to what is often thought, circumcision entails the risk of medical and psychological
    complications. The most common complications are bleeding, infections,
    meatus stenosis (narrowing of the urethra) and panic attacks. Partial or complete
    penis amputations as a result of complications following circumcisions have also
    been reported, as have psychological problems as a result of the circumcision.
    π Non-therapeutic circumcision of male minors is contrary to the rule that minors
    may only be exposed to medical treatments if illness or abnormalities are present,
    or if it can be convincingly demonstrated that the medical intervention is in the
    interest of the child, as in the case of vaccinations.
    π Non-therapeutic circumcision of male minors conflicts with the child’s right to
    autonomy and physical integrity.

    Dr. Salber clearly needs to do her homework before writing about male circumcision again.

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