Circumcision Of Male Infants And Children As A Public Health Measure In Developed Countries: A Critical Assessment Of Recent Evidence

By Mike Buchanan: Another excellent paper on MGM, by Brian D Earp – who has written extensively on the subject – and Morten Frisch. The start of the paper:

ABSTRACT
In December of 2014, an anonymous working group under the United States’ Centers for Disease Control and Prevention (CDC) issued a draft of the first-ever federal recommendations regarding male circumcision. In accordance with the American Academy of Pediatrics’ circumcision policy from 2012 – but in contrast to the more recent 2015 policy from the Canadian Paediatric Society as well as prior policies (still in force) from medical associations in Europe and Australasia – the CDC suggested that the benefits of the surgery outweigh the risks. In this article, we provide a brief scientific and conceptual analysis of the CDC’s assessment of benefit versus risk, and argue that it deserves a closer look. Although we set aside the burgeoning bioethical debate surrounding the moral permissibility of performing non-therapeutic circumcisions on healthy minors, we argue that, from a scientific and medical perspective, current evidence suggests that such circumcision is not an appropriate public health measure for developed countries such as the United States. [my emphasis]

Introduction
Male circumcision is the surgical removal of part or all of the penile foreskin (Cold & Taylor, 1999). When circumcision is performed on children in the absence of penile disease, it raises a number of complex ethical issues, some of which have been discussed in the recent literature (e.g. Darby, 2015; Earp, 2015a, 2015b; Foddy, 2013; Frisch et al., 2013; Mazor, 2013; Munzer, 2015; Savulescu, 2013; Ungar-Sargon, 2015). Here, however, we focus exclusively on the empirical aspects of circumcision as they pertain to a published draft of the first-ever U.S. government policy on the subject, released in December of 2014.[1] Our central aim is to analyse the contention of the U.S. Centers for Disease Control and Prevention (CDC) that the prophylactic benefits of non-therapeutic male circumcision, as carried out prior to an age of consent, outweigh its associated risks in developed settings such as the United States, in light of the available evidence pertaining to this question.
Benefits versus risks
Do the benefits of circumcision outweigh the risks?[2] In recently proposed recommendations and an accompanying background report, an anonymous CDC working group has suggested that they do (2014a, 2014b). A similar claim was made in 2012 by an eight-member American Academy of Pediatrics (AAP) task force (2012a, 2012b), despite contrary policies from British, mainland European, and Australasian medical associations, all of which remain in force (e.g. British Medical Association, 2006; Royal Australasian College of Physicians, 2010; Royal Dutch Medical Association, 2010; see also National Health Service of England, 2016). In addition, the Canadian Paediatric Society (CPS), which has historically endorsed the AAP position, instead explicitly rejected it in its most recent policy (Sorokan, Finlay, & Jefferies, 2015).
What could explain this lack of international agreement with the U.S. view? There are several possibilities. At least one concerns the fact that ‘The true incidence of complications after newborn circumcision is unknown’, as acknowledged by the AAP task force (2012b, p. e772). But since ‘complications’ are one of the foremost risks of circumcision, and since their ‘true incidence’ has not been firmly established (see below), it becomes difficult to see how the benefits of the surgery could logically be asserted to outweigh them (Darby, 2015). This is especially the case given that, on the other side of the scale, the likelihood as well as the magnitude of the purported benefits of circumcision themselves are in dispute.
A further possibility has to do with ongoing disagreements over how to define ‘complications’ in the first place (see AAP, 2012a), as well as with differences of opinion concerning the relative weight or value to assign to individual benefits and risks. As AAP task force member Dr Andrew L. Freedman stated in a recent editorial, in addition to having ‘insufficient information about the actual incidence and burden of nonacute complications’, the AAP’s 2012 assessment of benefits versus risks also suffered due to the ‘lack of a universally accepted metric to accurately measure or balance the risks and benefits’ (Freedman, 2016, p. 1).
To see the significance of this problem, which applies equally to the 2014 analysis by the CDC, consider the example of a modest reduction in the absolute risk of contracting certain sexually transmitted infections, a health benefit that is frequently attributed to – primarily adult – circumcision (see below). Considering that (1) children are not at risk of contracting sexually transmitted infections prior to sexual debut (an event that typically comes after the development of a capacity to provide informed consent to self-affecting interventions); (2) there are alternative modes of prevention that are less invasive, as well as less risky and more effective, than circumcision (i.e. safe sex practices when one does become sexually active); and (3) many of these infections can be treated effectively if they do occur, what is the weight or value that one should assign to this particular  benefit?
For example, should it be considered ‘worth’ the risk, however slight, of a surgical mishap that causes permanent damage to the penile glans? Is it ‘worth’ the loss of the penile prepuce itself, which is a 100% risk of circumcision? Is it ‘worth’ the risk of removing too much penile skin (i.e. more than was intended), leading to painful erections later in life (see e.g. van Duyn & Warr, 1962; Krill, Palmer, & Palmer, 2011; Thorup, Thorup, & Ifaoui, 2013)? The answer to these questions cannot be ‘objectively’ determined (see Johnsdotter, 2013). Instead, they will depend upon such factors as how much value one places on having intact versus modified genitalia, how willing one is to engage in safe sex practices (even if one is circumcised), and how much risk one feels comfortable taking on when it comes to a surgery performed on a physically and symbolically sensitive part of one’s body (Adams & Moyer, 2015, p. 723; see also Earp, 2016).[3]
Finally, it has been argued that the appropriate counterbalance to the potential benefits of circumcision is not only the risk of surgical complications (whatever those turn out to be), but also its short-term, intermediate, and long-term adverse consequences, both physical and psychological (Darby, 2015). Due to a lack of adequate research into these questions, however, the entire spectrum of potential circumcision harms (i.e. surgical risks plus additional negative consequences) has never been fully described. Moreover, at least some of these potential harms are likely to be subjective in nature (e.g. feelings of loss or resentment; see Darby & Cox, 2009; Goldman, 1999; Hammond, 1999), and therefore highly variable across individuals, as well as difficult to quantify in a meaningful way (Darby, 2015; Darby & Cox, 2009; Johnsdotter, 2013).

From pp.9,10 of the paper:

Summary and conclusion
In this brief analysis, we have identified numerous scientific and conceptual shortcomings in the 2012 circumcision policy from the AAP, as well as the more recent draft guidelines issued by the CDC. With respect to the latter, these included: (1) failure to provide a thorough description of the normal anatomy and functions of the penile structure being removed at circumcision (i.e. the foreskin); (2) failure to consider the intrinsic value to some men of having an unmodified genital organ; (3) undue reliance on findings from sub-Saharan Africa concerning circumcision of adult males (as opposed to infants or children); (4) uncritical reliance on a prima facie implausible benefit-risk analysis performed by a self-described circumcision advocate (see Davey et al., in press); (5) reliance on misreported statistics to downplay the problem of pain in the youngest of boys; (6) reliance on incomplete register data to assess the frequency of short-term post-operative complications associated with circumcision, leading to a likely underestimation of their true frequency; and (7) serious underestimation of the late-occurring harms of circumcision presenting months to years after the operation (most notably meatal stenosis). In light of these considerations, we believe that the CDC’s overall assessment of benefits versus
harms (‘risks’) of the surgery should be interpreted with extraordinary caution.
The apparent underassessment of meatal stenosis alone, possibly the most common lateoccurring complication after neonatal circumcision, means that the CDC’s claim of markedly lower complication rates in boys circumcised as infants (‘less than ½ per cent’), compared to boys circumcised at ages 1–9 years (‘approximately 9%’) and those circumcised at age 10 years and older (‘approximately 5%’) (2014a, 2014b), is almost certainly inaccurate.
Indeed, with reported rates of meatal stenosis in neonatally circumcised boys in the 5–20% range, and with estimates of clinically significant procedural pain in around 30% (and some level of post-operative pain and discomfort in most, if not all newborn boys undergoing the operation), the least problematic age to circumcise a boy (if at all), even from a purely medical standpoint, may well be when he is old enough to decide for himself. This conclusion is supported by the recent evidence showing that very few genitally intact boys – 0.5% according to the new population-based study in Denmark (Sneppen & Thorup, 2016) – will need a circumcision for medical reasons before the age of 18.