Circumcision for All; Free Choice for None

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I was shocked, surprised, and flabbergasted to hear it. I’m sure that you’ll never believe it, either. The federal government is — get this, readers — butting into your most personal and private business.

OK, you’ve caught me in a rare moment of sarcasm. Maybe I wasn’t really that surprised. After all, government bureaucrats attempt to control what types of substances you put into your body, what kind of work you do with your body, and even how you can legally dispose of your body after death; it makes perfect sense that they would also scramble for power over what parts of your body should remain attached. Yes, that’s right. The CDC is now considering a campaign for universal circumcision in the US.

The reason for pushing this one-size-fits-all policy stems from the results of several studies, all done in Africa, which have demonstrated the benefits of male circumcision for reducing the transmission of HIV.

The studies on circumcision and HIV transmission are very interesting. They are large, randomized, controlled trials; the methodology is solid. They show, on average, a 40—60% reduction in the risk of a circumcised, HIV negative man contracting the virus from an HIV positive woman, as compared to an uncircumcised man. The precise mechanism of circumcision’s protective effect is unknown. There are many potential explanations, none of which are mutually exclusive. First, the foreskin has a relatively high population of cells that are receptive to being infected by HIV. Second, it acts as a reservoir which may trap infected secretions. Third, the foreskin has a higher propensity to ulcerate (become scraped) and become infected with other sexually transmitted infections that cause open sores. It seems that removing the foreskin also removes several potential avenues for HIV entry into the body.

However, when considering the benefits of circumcision, there are some significant caveats. For one, circumcision is not a panacea; it does not completely prevent transmission of HIV, it just lowers the probability that a man will contract the virus during any given sexual encounter with an HIV positive woman. It should be noted that these studies only examined the effect of circumcision on transmission of the virus from an HIV positive woman to an HIV negative man. While this is a relatively common scenario in Sub-Saharan Africa, HIV epidemiology in the US is different. Overall rates of infection are lower. Also, HIV in the US is relatively more common among men who have sex with men (MSM). There is no evidence that circumcision protects against HIV acquisition in MSM. Circumcision also does nothing to protect anyone against acquiring HIV via bloodborne routes, such as sharing needles with an HIV positive person. It should go without saying that men can protect themselves from acquiring HIV in other ways besides getting circumcised, such as practicing safe(r) sex and avoiding intravenous drug use. These methods are much more reliable than the 40 — 60% risk reduction conferred by circumcision.

Circumcision also has risks and demerits. My personal philosophy on medicine leads me to look skeptically at any procedure that removes a part of the body which is not causing harm, pain, or annoyance to the patient; in other words, don’t mess with success. As with any surgical procedure, infections and pain after circumcision are both possibilities that should not be ignored. Medical errors should be considered as a legitimate risk during circumcision, too. There are rare case reports of penile amputation that have occurred during botched circumcisions. There are also many more reports of less extreme, but still real, consequences resulting from circumcision mishaps.

Of course, the question on the minds of many who are considering circumcision is that of whether the procedure impacts sexual enjoyment and satisfaction. That question is, in my opinion, impossible to answer accurately. To distill the immense debate surrounding this issue to its barest essence, choice seems to play a significant role in how men view their foreskins (or lack thereof). Men who choose to get circumcised tend to be happy that they did so; those who did not have a choice in the matter because they were circumcised at birth are more likely to lament it.

That brings me to my main point in writing about the prospect of universal circumcision: the issue of choice. If my patient asked me about circumcision, I would discuss with him the information above. I would also encourage him to do his own research about the procedure if he felt interested. He would make his own decision about whether he wanted to have the surgery.

By contrast, the CDC’s attitude demonstrates a lack of consideration for patient autonomy and consent, two essential elements in all medical decisions. The CDC would like every baby boy born in America to be circumcised, no matter the opinion of his parents and, more importantly, without the boy’s consent. If circumcision were a medically necessary and life-saving procedure with no possible ill effects, things might be different. In reality, it is a surgical procedure that is not essential for the health of a normal man; furthermore, it has both risks and benefits. The relative importance of those risks and benefits is subjective. Every man may value them differently. For that reason, it’s essential that each individual be afforded the choice about what to do with his own foreskin.

To be perfectly blunt, I do not see any justification for removing a part of a baby boy’s body without his consent. Men can always get circumcised as adults if they wish; by contrast, once the foreskin is gone, it’s gone forever. Most people will concede that the procedure is painful even for babies, but they insist that the pain is justified because the baby will not remember it. I wince at the thought of causing pain to a newborn boy. I say that even if he does not remember the physical pain as an adult, he may still suffer from the psychological sting of having had a body part removed without his permission.

Another argument from the advocates of universal circumcision is that it makes good hygiene easier. This is a typical government one-size-fits-all solution: parents are too stupid, in the minds of government agents, to teach their sons good hygiene, so instead we should just circumcise everyone. People are also too stupid to practice safe sex, so we should circumcise them all because they will gain a marginal reduction in the overall risk of contracting HIV. I’ve also heard arguments for circumcision based in religious tradition and cultural norms. Sure, circumcision is common — and a very old tradition in some religions and cultures. But does that make it right? I don’t think that’s for us to decide. I think that each individual, the owner of his own body, should make the call about whether or not circumcision is appropriate for him.

It’s difficult for me to assume the mindset of statists who advocate for this kind of thing, so I raised the issue of universal circumcision in conversation with a few people whose opinions I thought would be unencumbered by that pesky philosophy of leaving others alone and letting them make their own decisions. In addition to the religious and culturally based arguments that several people trotted out, one colleague had an interesting comment. He thought that universal circumcision was a good idea, envisioning a world where no more would awkward teens have to worry about getting teased in the locker room, because “everyone would look the same.” Oh really? The last time I checked, people came in all shapes, colors, and sizes, and that was a good thing! I guess that if everyone looked alike, wore the same clothes, and had the same hairstyles, nobody would ever have to worry about not fitting in. Would this egalitarian also propose to redistribute the wealth from the best-endowed men to those who are not quite as blessed by Mother Nature? Ridiculous.

I certainly cannot agree with the CDC’s move toward making a blanket recommendation that all boys should undergo a medical procedure at birth, without their consent. I want each man to have the opportunity to make his own decision about what to do with his foreskin when he reaches an age at which he is capable of doing so, based on his understanding of the risks and benefits, and how much he personally values each. The bloated, overreaching federal government apparently does not want the same.

Stephanie R. Murphy [send her mail] is an MD/PhD student living in New Hampshire.

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