On October 7, Crikey ran a brief report on a commentary, The Medical Benefits of Male Circumcision, published in the Journal of the American Medical Association. The authors, Aaron Tobian and Ronald H. Gray, were apparently prompted by the continuing decline in infant circumcision in the US, the stymied San Francisco ballot to ban the procedure and the decision of two more states to join 16 others in eliminating Medicaid insurance for it.
However, circumcision is not a “surgical vaccine”, but a waste of health resources and a violation of medical ethics.
It comes as no surprise to find American medicos recommending that parents have their baby boys circumcised; they have been doing so for more than a century. But there is no evidence that routine circumcision has improved child health: according to a 2009 OECD report, many US child health indicators are on a par with Turkey and Mexico.
Since Crikey is an Australian publication, it would have done better to inform readers that Tobian and Gray’s proposal had already been comprehensively refuted in a paper published in an Australian public health journal. Since the US is a circumcising culture, many doctors retain faith in its prophylactic value. Tobian and Gray did a nice job cherry picking the evidence in favour of their belief and ignoring arguments to the contrary.
A similar exercise published in the Medical Journal of Australia last year received so much criticism that the journal published eight letters in reply. After an exhaustive review of the evidence, the Royal Australasian College of Physicians found that “in low prevalence populations … circumcision does not provide significant protection against STIs and HIV”, and concluded that there was no medical case for neonatal circumcision in developed countries such as Australia.
The comprehensive analysis just published in the Australian and New Zealand Journal of Public Health finds the pro-circumcision argument fatally flawed because it (1) it ignores doubts about and critiques of the African clinical trials and the interpretation of the WHO recommendations arising from them; (2) is irrelevant to the specifics of Australia’s HIV problem; (3) departs from the principles of evidence-based medicine; (4) underplays the harm and risks of circumcision; (5) ignores basic principles of medical ethics and human rights; and (6) is marred by unscientific thinking in describing circumcision as a “surgical vaccine“.
The JAMA article suffers from the same flaws. Evidence of circumcision as an acceptable tactic from underdeveloped countries with high levels of HIV infection and predominantly female to male transmission in unprotected intercourse cannot be transposed to developed countries with low sero-prevalence and transmission predominantly in male-male s-x or injecting drug users. These groups receive no risk reduction from circumcision.
There is no evidence from the US that uncircumcised men are at greater risk of HIV. Figures in one study showed that while African Americans were far more likely to be circumcised (73%) than Hispanics (42%) their lifetime risk of HIV infection was much higher (6.23% compared with only 2.88%).
This suggests that there is no connection between circumcision and reduced susceptibility to HIV; that circumcision increases the risk of HIV; or that being African American in the US is a far greater risk factor for HIV than possessing a for-skin.
Evidence that circumcision of adult men has a protective effect against HIV cannot be extrapolated to children, and the same is true of T&G’s hopeful claim that the Africans who consented to be circumcised experienced no loss of s-xual sensation (or not yet); there is evidence that circumcision in infancy has a different impact from circumcision after s-xual maturity.
Tobian and Gray assert that surrogate consent from parents overcomes the ethical and human rights problem because they can consent to child vaccination.
This hackneyed analogy fails because children are vaccinated against diseases that affect them as children and, unlike circumcision, it does not entail the amputation of a normal body part. Children are not at risk of HIV or any other STIs: since there is no urgency to intervene, we can safely wait until they are old enough to provide their own informed consent.
People whose grasp of social geography is so weak that they confuse conditions in Africa with those in the US also seem unable to tell the difference between a needle and a scalpel.
Contrary to Tobian and Gray’s assertion, parents do not have an unfettered right to impose “medical treatment” on children. What they have is an obligation to provide a child with appropriate, recommended and needed treatment that is demonstrably in his/her best interests as a child, and consistent with his/her likely choice as an adult, as required by the principle of the child’s right to an open future.
The best service a parent can perform for their children is to preserve their right to an open future by treating their bodies with respect. This means not taking irreversible steps that deprive them of the right to make their own decisions when they reach maturity.
*Dr Robert Darby is a medical historian and the author of A Surgical Temptation: The Demonization of the Foreskin and the Rise of Circumcision in Britain (with Robert Van Howe)