For anyone following the issue of genital cutting of minors in the United States, yesterday brought a plethora of new and misleading headlines:
- The Verge: Benefits of circumcision outweigh the risks, US CDC says
- PR: CDC Considers Counseling Males Of All Ages On Circumcision
- webmed: CDC Endorses Circumcision for Health Reasons – WebMD
- Salon: CDC: Circumcision is a very good idea - Salon.com
- The Raw Story: CDC to parents: Consider circumcising your sons, because...
- UPI: CDC recommends circumcision procedure, says benefits
- NYTimes (blog): Circumcision Guidelines Target Teenagers - NYTimes.com
Or is it that the media is hungry to present benefits and call for a universal endorsement, something that really hasn't happened?
It is our opinion that these headlines are nothing but a feeble attempt to manipulate the public opinion, under the assumption that everybody is too lazy to go to the source materials.
Anyone wishing to produce objective reporting on the CDC guidelines should start by fully reading and understanding the 8 pages draft document and the 60 pages technical report. It is unlikely that any of the reporters lending their names to the apparently carefully scripted articles, read any of the documents.
But we did, so let's share our interpretation.
The CDC guidelines refer to counseling. Counseling does not mean immediate and universal endorsement. Counseling means aiding a person through a decision-making process, and that is what the guidelines attempt to do, to counsel patients or parents through a decision-making process.
In this decision making process, the CDC considered 3 main categories of individuals based on the age range: neonates and children, adolescents, and adults.
The CDC also considered the sexual orientation and lifestyle choices as factors to be weighted during this decision making process. And for those willing to go deep enough (as deep as page 36 of the technical report), the CDC also gave consideration to the fact that parents deciding for a newborn raise concerns about autonomy, including the argument that "a man with a foreskin can elect to be circumcised but if circumcised as a newborn, cannot easily reverse the decision". The PHEC (Public Health Ethics Committee) subcommittee is, however, of the opinion that "both a decision to circumcise and a decision to not circumcise are legitimate decisions". This is one opinion that genital integrity promoters and people for the rights of the child would oppose though.
For those saying that the CDC is fully recommending circumcision, they probably need to read in detail where the technical report indicates that "There are advantages and disadvantages to performing male circumcision at various stages of life" and one of the listed disadvantages of neonatal circumcision is that "the newborn has no ability to participate in the decision".
The guidelines recognize that in the case of adolescents, both the adolescent and his parents should be involved in the decision-making process.
Let's make one thing clear. One of the main reasons for the CDC's discussion of circumcision has to do with the African trials on circumcision and HIV, considered to be evidence that circumcision could help reduce the risk of heterosexual transmission of HIV from infected females to males. The role of the CDC is not to discuss each one of those studies and their validity, strengths and flaws, but to make their recommendations based on currently accepted medical practices and standards. So of course an important premise of these guidelines is the so-mentioned potential benefit of reducing the risk of heterosexual transmission of HIV from infected females to males. As such, it is not within our current scope to discuss the African trials, something that has been already done by others in detail, but to discuss how the CDC interpreted those trials in reference to the U.S. conditions.
When discussing adult circumcision, the CDC recognizes both the documented benefits and limitations of circumcision as part of the prevention of HIV, that is:
- that circumcision does not replace the need for condoms and safe sex,
- that circumcision does not reduce the risk of male to female transmission
- that circumcision does not reduce the risk or male to male transmission,
- that circumcision does not reduce the risk of transmission through anal or oral sex, or for intravenous drug users.
So, with those premises, the guidelines recommend a discussion of the person's HIV risk behavior, HIV status, sexual preferences and gender of the sexual partner, in order to provide proper guidance depending on individual circumstances.
"The PHEC subcommittee concluded that the disadvantages associated with delaying male circumcision would be ethically compensated to some extent by the respect for the integrity and autonomy of the individual."And what are those "disadvantages"? A slightly increased risk of UTIs during the first year of life (risk of UTIs is low and they are generally easily treatable) and the possibility of the adolescent having a sexual debut prior to counseling and assessment of risks, which could potentially expose the adolescent to the risk of heterosexually transmitted HIV from infected female partners.
The CDC then states that:
"The prevalence of HIV infection in the United States is not as high as in sub-Saharan Africa, and most men do not acquire HIV through penile-vaginal sex. Targeting recommendations for adult male circumcision to men at elevated risk for heterosexually acquired HIV infection would be more cost effective than offering routine adult male circumcision. Men may be targeted according to sexual practices or an elevated prevalence of HIV within a geographic region or race/ethnicity group. "
Also, regarding sexually active individuals:
"All sexually active adolescent and adult males should continue to use other proven HIV and STI risk-reduction strategies such as reducing the number of partners, and correct and consistent use of male latex condoms, and HIV preexposure or postexposure prophylaxis among others."So, are these guidelines an immediate and universal recommendation for circumcision? No, as much as biased media and individuals would like it to be, it is not.
The CDC gave slight consideration to sexual effects of circumcision. Again, we need to consider that they are reviewing existing medical standards, practices and publications (and it is noteworthy that proper discussion of the male foreskin is so absent from American health books that even pictorial representations of the foreskin are missing most of the times except in the context of its removal through circumcision). So, the guidelines devote the full length of a single paragraph to the discussion of sexual effects from circumcision:
"The foreskin is a highly innervated structure and some authors have expressed concern that its removal may compromise sexual sensation or function. However, in one survey of 123 men following medical circumcision in the United States, men reported no change in sexual activity and improved sexual satisfaction, despite decreased erectile function and penile sensation. Furthermore, a small survey conducted among 15 men before and after circumcision found no statistically significant difference in sexual function or sexual satisfaction. Other studies conducted among men after adult circumcision have found that relatively few men report that there is a decline in sexual functioning after circumcision; most report either improvement or no change."
This paragraph acknowledges the histological studies of John Taylor and Sorrells' study on fine touch pressure thresholds, but not the European surveys of Bronselaer in Belgium and Frisch in Denmark (both of which showed sexual difficulties among circumcised males), preferring instead to refer to Krieger's Kenyan study (which does not show the same difficulties). This begs the question of why African studies are more relevant to the sexual function and satisfaction of American citizens than European studies, but we will leave such discussion for the readers to make their own conclusions.
Finally, missing from the guidelines is any discussion of the role and functioning of the foreskin, something that could be accomplished by simple observational studies of the sexual behavior of uncircumcised males. But one could argue that the role of the CDC is to counsel on control and prevention of diseases, and not on sexuality.
I can't avoid, however, citing this quote from the late Dr. Paul Fleiss, from his 2002 book:
"Accurate information about the foreskin itself is almost always missing from discussions about circumcision. How can parents make a rational decision about circumcision when they are told nothing about the part that will be cut off?" Fleiss. What your doctor may not tell you about circumcision.
Our conclusion is that the CDC draft is far from being the universal recommendation for circumcision that biased media, organizations and individuals may wish for, it is actually more balanced on its ethical aspects than the AAP's Policy Statement, however it is not unbiased as it still gives more relevance to African studies than European, in spite of the American circumstances being more comparable to those of Europe than to Sub Saharan Africa. The media however latches to key phrases like "benefits from circumcision" ignoring the harms and collateral effects and autonomy concerns, thus distorting the message and manipulating the public opinion.