In the September issue of their journal Pediatrics, the American Academy of Pediatricians published a newly revised policy statement on circumcision. This was the first new statement on circumcision since 1999, and it took a much more strongly procircumcision stance, arguing that the benefits of circumcision outweighed the risk, and that the procedure should be covered by medical insurance so that parents were free to choose it regardless of their finances. The outcry from the intactivist community was loud indeed. Critiques were written of the policy, it was criticized as unethical and unscientific and the AAP was accused of being biased. See here, and here. In addition an initiative was begun which collected pictures of individuals with the phrase “AAP No Ethics” written on their palms.
I hope to devote future blog posts to a more thorough critique of each of the arguments against the AAP’s statement. There are so many allegations that I can’t address them all in one blog post, and I hardly know where to begin. Suffice to say that I don’t find the arguments against the science convincing; the evidence has been growing for real but moderate benefits to circumcision. Many of the criticisms show an ignorance about common scientific language or technique that invalidates their arguments. Some don’t seem familiar with the AAP’s accompanying technical report which explained their reasoning and fleshed out the recommendations in the official policy statement. I plan to go through some of these objections to the statement in later posts, and point out where the objections are flawed and why. However, I want to start by touching on where I agree with the intactivist criticisms. This doesn’t mean that I think the AAP statement is invalidated, but I do think there are some legitimate complaints about it.
So, some criticisms which I believe have some merit:
The AAP has a cultural bias.
Now, some of these criticisms claim that the AAP committee has a bias due to a reliance on scientific thinking, which I do think is absurd. In contradiction to the Circumcision Resource Center’s post, I think that the possible benefits and harms of circumcision are absolutely discernible through scientific inquiry, and controlled, replicable and falsifiable studies are a much better gauge of the truth than either feelings or common sense, which are far more subject to cultural bias. However, the researchers DO have a cultural bias: circumcision and the circumcised state are viewed as normal and acceptable, unless there are proven harms. I think that intactivists are somewhat correct in saying that scientists wouldn’t even be investigating circumcision and possible benefits if it weren’t already acceptable to a degree in Western society. However, just because this preexisting bias makes American doctors more willing to consider circumcision doesn’t mean that it doesn’t have real benefits, it just means that the researchers are more open to those benefits. And while there might be concern that this normalcy encouraged the researchers to be more procircumcision in their review of the scientific data, it is also possible that the cultural distaste for circumcision leads other groups to overlook or minimize possible benefits of circumcision. Bias goes both ways. It is definitely possible, however, that this bias influenced how much benefit the committee believes that one needs to see before circumcision is justifiable, and that leads to my next point.
The AAP placed no value on bodily integrity.
I think that this statement is true. I have seen this stated in a few sites or a few different ways, some more inflammatory than others. I agree that the AAP seemed to place no value on keeping the child’s body whole, rather they looked only for objective evidence of harms and benefits. Since the committee members view circumcision as normal and the circumcised state as normal as the intact state, they didn’t seem to require a large benefit to justify the procedure, evidence of greater lifetime benefits than lifetime harms seems to be sufficient for them. However, in this document they also stress parental choice, and acknowledge that different parents will bring different values to their decision making. I also do not believe that this means that the AAP does not care about ethics or about the well being of boys, it just means that in their decision making system the presence or removal of the foreskin had no value, no decision making weight, in and of itself. The value was determined solely on the effects, positive and negative, on the child’s health and well being. This is certainly different to the philosophy of ethics of intactivists, but it is not an absence of ethics. It is perhaps a more utilitarian ethics.
The AAP does not make clear the magnitude of the benefits of circumcision.
Although the AAP does try to quantify the magnitude of any benefits and likewise the magnitude of any risks, I don’t believe that it provides sufficient evidence for parental decision making. The most useful number is the “number needed to treat,” which indicates how many circumcisions are necessary to prevent one negative outcome in comparison to the intact state. This could be more easily compared with the numbers available on complication rates. The AAP technical report provided numbers needed to treat for the issues of urinary tract infection and penile cancer. For most other benefits, it provided information on relative risk ratios only. For instance, the report cites a CDC study which estimated a 15.7% reduction in the individual’s lifetime risk of HIV with neonatal circumcision but doesn’t provide information on the absolute risk of infection. A 16% reduction in a 1.87% absolute risk of contracting HIV may seem much less than persuasive to many. The CDC study did provide estimated numbers, which vary based on race. “The number of circumcisions needed to prevent one HIV infection was 298 for all males, and ranged from 65 for black males to 1,231 for white males.” This is the kind of information that is truly needed for a decision on the benefits of this procedure, and they suggest that the benefits for each individual are far from equal.
These listed criticisms are not minor. They are not, however, criticisms of the science itself, which I believe the AAP Technical Report shares in a fair manner. They are instead related to the application of those scientific findings to the decision of whether or not to circumcise. If one is going to argue against routine circumcision, then I feel that these are the points to focus on. I think it is important, however, to keep in mind that the question of “how much benefit is necessary to justify circumcision” is a question based on the parents’ own philosophy, and that different parents can make different decisions based on the same evidence, all while desiring the best for their son’s well being.