Tag Archives: JAMA

Circumcision by Deborah Tolmach Sugerman, the usual crap

Another day, another circumcision post.

Today’s post by Deborah Tolmach Sugermen, MSW, with the JAMA (Journal of American Medicine Association) Network, starts, as they always do, reminding us that the procedure goes back thousands of years in time (in this case, to “prehistoric times“).

The article then says that “People worldwide continue to circumcise their sons for hygienic, cultural, and religious reasons“. The hygienic reasons are quite debatable, as it is generally accepted that “uncircumcised boys can learn how to clean beneath the foreskin once the foreskin becomes retractable” (after all, it’s easier than brushing teeth and more fun). As for cultural and religious reasons, one could also argue that people worldwide continue to circumcise their daughters for cultural and religious reasons (and those who do it argue that it’s not mutilation when they prick the hood of the clitoris to draw some blood, a procedure the AAP admitted is “less extensive than the newborn male circumcision commonly performed in the West” in their now retracted Policy Statement on “Ritual Genital Cutting of Minors”), and yet the law in the United States leaves no cultural or religious exceptions for non-therapeutic procedures on a female minor’s genitals.

Deborah then writes that “Circumcision in infancy is very safe“, which is in contrast with the AAP’s assertion that “The true incidence of complications after newborn circumcision is unknown“. She then states that “When it is performed by a trained professional under sterile conditions, few babies have complications“. I would challenge this statement given that some complications, such as the development of adhesions, buried penis and meatal stenosis, have little to do with the way the procedure is performed. But perhaps we are running into what the AAP considers “differing definitions of “complication” and differing standards for determining the timing of when a complication has occurred (i.e., early or late)“.

Parents should be told about these possible post-operative complications (which are not even mentioned in Deborah’s article), since they can result in the need for further “revision” surgeries, particularly when the AAP warned about a 119% increase on revision surgeries from 2004 to 2009.

She then states that “There are no long-term studies of the health benefits of children who have been circumcised” – which is particularly striking given that the practice of “medical” circumcision in the United States goes back to 1870, plenty of time for such studies to have been done. In lack of those studies, it could be easily argued that circumcision should be left to be a personal decision of the person, since it’s not demonstrated that circumcision improves the health of the children.

Following this, Deborah mentions the African studies on HIV, and uses this to support the idea that “male circumcision provides substantial medical benefits“. By contrast, Andrew Freedman, member of the AAP Task Force that wrote the 2012 Policy Statement on Circumcision, has publicly called circumcision a procedure with “modest benefits and modest risks“, which shows something that has been known for years, that those interested in promoting circumcision will “dismiss the harm and exaggerate alleged benefits“.

She then moves on to explain the benefits. Reduction of UTIs (no mention that after the first year, boys have less risk of UTIs than girls regardless of their circumcision status), risk reduction of HIV (no mention that this is only considered to be so for heterosexual transmission from female to male, not for male to male, not for male to female and not through non-sexual paths such as blood transfusions, and that the total risk reduction attributed to circumcision is 1.8% of the already small risk of transmission from female to male, and no mention of condoms and safe sex as better alternatives to HIV prevention), and of course, penile cancer (no mention that penile cancer is a very rare disease that occurs in old age, mostly related to phimosis during adulthood and to HPV, and that according to the AAP’s own Technical Report on circumcision “The clinical value of the modest risk reduction from circumcision for a rare cancer is difficult to measure against the potential for complications from the procedure” as 909 to 322,000 circumcisions would be needed to prevent one penile cancer event, at a cost of 2 to 644 complications ranging from mild to severe).

She then goes to explain that “Male circumcision does not appear to affect sexual function, sensitivity, or sexual satisfaction“, a statement that has been the subject of an intense information war, with circumcision promoters such as Brian Morris rabidly attacking or willfully dismissing the studies that contradict this view, such as Sorrells (2007), Frisch (2011), Bronselaer (2013), histological studies explaining the anatomy of the foreskin such as Taylor (1996-1999), or Tim Hammond’s preliminary poll of men circumcised in infancy or childhood.

The author then says that the AAP recommends that “Doctors talk to parents about the health risks and benefits” (one would hope doctors would be more forthcoming on the actual risks and complications than Deborah, a Master of Social Work who is potentially biased for religious reasons – as it’s simple to find that she is a member of the Adath Jeshurum Congregation- has just been) and that “Parents weigh this information together with their religious, ethical, and cultural beliefs and practices“.

This final statement deserves a little bit more of attention.

Circumcision is a surgery. It’s the excision (amputation) of normal healthy genital tissue with sexual functions (the article doesn’t mention that the foreskin is normal sensitive genital tissue or that it has sexual functions).

In most cases this is done for “religious and cultural reasons” (including Deborah’s religion).

Religion and culture are not medical indications for surgery.

Circumcision is “elective” surgery, that does not treat a condition, disease or abnormality. But the patient, a minor, is not given the chance to “elect” or “refuse” the procedure.

In a recent article in the Journal of Medical Ethics, Robert Van Howe and Steven Svoboda declare that “When physicians decide whether to do a procedure, they must, and normally do, exclude from their medical decisions non-medical factors regarding the parents’ culture. Contrary to what the AAP suggests, doctors are not cultural brokers. Their duty is promoting and protecting the health of their patients, not following practices lacking a solid ethical and medical foundation.

But Tolmach Sugerman makes no mention of this ethical issue.

Why Deborah? Why?