Tag Archives: study

NEW CIRCUMCISION “STUDY”: Complication Risks May Increase With Age – Does Medical Necessity?

“Circumcision fails to meet the commonly
accepted criteria for the justification of preventive
medical procedures in children. The cardinal
question should be not whether circumcision can
prevent disease, but how can disease best be
prevented.”
Frisch et al, Cultural Bias in the AAP’s 2012
Technical Report and Policy Statement on
Male Circumcision

Another day, another article. This time, it’s about a study by Charbel El Bcheraoui  published in JAMA Pediatrics, funded by the US Centers for Disease Control and Prevention (CDC). The study claims that “Male circumcision had a low incidence of AEs (adverse events – a euphemism for complications) overall, especially if the procedure was performed during the first year of life, but rose 10-fold to 20-fold when performed after infancy.

The question that El Bcheraoui circumvents is, however, are those circumcisions necessary? Without medical or clinical necessity, are those circumcisions ethical?

Without those considerations, this is nothing more than a sales pitch. “Circumcision! Buy now, or tomorrow it will be 20 times riskier,” El Bcheraoui seems to urge.

But, what are the chances a child will need to be circumcised later on in his lifetime?

What are the reasons a man would have to be circumcised at a later age? Do they increase with time? (Answer: No, they don’t. The majority of men who are left intact, stay that way.)

El Bcheraoui concludes that “Given the current debate about whether MC should be delayed from infancy to adulthood for autonomy reasons, our results are timely and can help physicians counsel parents about circumcising their sons” but this is nothing more than self-interested hogwash. The argument of bodily autonomy is mentioned but not expanded on. In effect, what the author is saying, without daring to say it, is that bodily autonomy can be violated in order to decrease the risk of complications; a risk the author already considers to be low.

If we were to extrapolate the reasoning behind this conclusion, it would be possible to argue that removing the breast buds from baby girls is easier, less traumatic and has less complications than waiting for breast cancer to develop and then perform mastectomies, where breast cancer is the second leading cause of cancer death in women.

The authors did not declare any conflict of interest. But of course it is not surprising that El Bcheroui is affiliated with the Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention. Let’s just quickly remember that in 2009 the CDC was considering promoting universal circumcision to prevent the spread of HIV in the United States, despite pre-existing evidence (from the CDC nonetheless) that the high rates of circumcision in the United States had no effect over transmission of HIV.

It seems nowadays no circumcision article or “study” is complete without the obligatory “benefits outweigh the risks” soundbite from the 2012 AAP policy statement on circumcision. Of course, what is never mentioned is that this is only part of the statement, which is rarely ever quoted in its entirety:

“The American Academy of Pediatrics found the health benefits of newborn male circumcision outweigh the risks, but the benefits are not great enough to recommend universal newborn circumcision” - http://www.aap.org/en-us/about-the-aap/aap-press-room/pages/Newborn-Male-Circumcision.aspx

Circumcision advocates love to quote the AAP, but they could not recommend circumcision in their last statement because, in their own words “the benefits were not great enough.” How is it lay parents are expected to analyze the same “benefits” which couldn’t convince an entire body of medical professionals, and somehow come to a more reasonable conclusion? Why are doctors expected to act on it, and why is the public purse expected to pay?

The AAP said in their last statement that “The true incidence of complications after newborn circumcision is unknown, in part due to differing definitions of “complication” and differing standards for determining the timing of when a complication has occurred (ie, early or late)” and catastrophic injuries were excluded from the report because they were reported only as case reports, not as statistics. The statement also indicates that “Financial costs of care, emotional tolls, or the need for future corrective surgery (with the attendant anesthetic risks, family stress, and expense) are unknown.”

In the opening statements of this study, El Bcheraoui estimates that 1.4 million circumcisions are performed in medical settings annually in the United States. This appears to contradict a previous statement by none other than El Bcheraoui himself, claiming a rate of 32.5% in 2009. Perhaps he expects the 2012 AAP Policy Statement to result in the resurgence of circumcision rates.

The study reviewed the medical history of approximately 1.4 million males circumcised between 2001 and 2010, and found that approximately 4,000 infants had suffered complications, leading them to calculate a rate of complications (adverse events) of less than 0.5%

This would mean, using the data they present, that every year, between 5,600 (0.4%) to 7,000 (0.5%) infant males will suffer complications from circumcision; circumcisions that will in all likelihood be medically unnecessary.

This would not include those complications that can be minor or undetected by the parents (skin tags, skin bridges, uneven scarring) or those that will not be detected until much later (pain caused by tight erections, lack of sensitivity).

The researchers note that some complications might not have been picked up because they were reviewing claims data on problems that typically occurred within the first month following the circumcisions.

This would likely exclude meatal stenosis. High prevalence of meatal stenosis has been found in circumcised males (see here and here), possibly as consequence of ischemia (poor blood supply) to the meatus or permanent irritation of the meatus caused by friction with the diaper and resulting in scarring.

A recent ecological analysis by Ann Z. Bauer and David Kriebel found a correlation (but not causation – further studies are needed) between early exposure to paracetamol and other analgesics, and autism spectrum disorders (ASD). This took into consideration that most newborn circumcisions before 1995 used no pain relief at all, but with growing awareness of the pain of circumcision and increasing use of paracetamol, a sudden rise on the rates of male ASD occurred.  According to this analysis a change of 10% in the population circumcision rate was associated with an increase in autism/ASD prevalence of 2.01/1000 persons (95% CI: 1.68 to 2.34) ”

These findings of course would not have been included in El Bcheraoui’s paper, as this would be out of existing billing codes and administrative claims within the first month from the procedure.

So, let’s just think for a moment, if these circumcisions are not necessary, if these circumcisions are “elective,” then what is the tolerance for errors and complications? El Bcheraoui claims that a 0.5% complication rate is low. But how low is it when it means 5,600 to 7,000 babies who will suffer complications annually? And what kind of complications are we talking about?

These low rates fail to explain the increasing rates of circumcision revisions as well.

How many cases like the one of David Reimer can we afford to have before it is ethically wrong, morally wrong? How many more like Jacob Sweet?

How many MRSA infections?

How many partial or full ablations of childrens’ penises, like that baby in Memphis and that other baby in Pittsburgh last year?

How many infections with Herpes?

How many deaths?

Catastrophic complications, rare or not, mean destroyed lives. Not numbers. And to destroy lives of innocent babies in the name of “religious, ethical and cultural beliefs” is simply not right. Because there is no medical indication for surgery in healthy, non-consenting minors, any complications above zero is ethically unconscionable.