Unnecessary alarm over circumcision

The idea that parents should defer circumcision until their sons can make their own decisions is impractical and unnecessary, argue two medical experts.

In his article Why I didn’t circumcise my second son Dr Ariel Kagan writes about why he came to oppose infant circumcision.

The writer’s concern about “damaging” his son is unwarranted as long-term adverse effects are known to be exceedingly rare, as attested to by the Centers for Disease Control and Prevention (CDC)¹ and the American Academy of Pediatrics² . There are also health benefits of infant male circumcision (IMC) which include reduction in the risk of urinary tract infection, cancer of the penis and possibly prostate cancer.  While effective vaccines to prevent human papilloma virus (HPV) are available not all children receive these; circumcised men are less likely to acquire HPV from an infected sexual partner or transmit it if they are carriers³.  The duration of vaccine protection is not known but there is good evidence that the protection enjoyed by circumcised men (and their sexual partners) is life-long. The long-term benefits include, of course, the cultural issues of “looking like Dad” and enhancing the belonging to a Jewish community.

He states that “medical interventions” should cause no harm and patients should make their own decisions about what happens to their bodies. Circumcision for cultural, religious or social reasons is most appropriately performed in early infancy when it does not require general anaesthesia and the associated risks, costs and logistic burden are minimised.  Deferral of circumcision to provide autonomy is impractical for these reasons; the health benefits of course are not achieved till the procedure is performed. Circumcision must always be performed with local or general anaesthetic to achieve adequate pain control but serious complications of infant male circumcision performed by an appropriately trained physician are almost unknown⁴. Parents have the responsibility and the opportunity to make the decision for IMC for their newborn son.

Beneficence

Dr Kagan also claims that “there is weak data suggesting prophylactic health benefits from circumcision”.  The evidence for life-long health benefits is actually quite strong as pointed out above⁵. As the author points out, circumcision protects male adults from HIV infection. This has been demonstrated in high prevalence areas and there is no plausible reason to assume the manner of this protection is location dependent.

Non-maleficence

When circumcision is performed for an infant aged less than 3 months it can be a brief procedure performed in an office or clinic using local anaesthesia.

He claims that between 1.5 and 2% of babies may suffer serious complications. That risk is grossly exaggerated for IMC performed by an appropriately trained physician. Under those circumstances the risks are very small, complications are almost always minor and short term⁶.

Many statistics for complications are not applicable for IMC performed appropriately and these concerns are reasons for the procedure to be performed in early infancy by appropriately trained physicians. Mohelim who lack medical training and qualifications should not perform IMC.

As far as psychological trauma is concerned, studies do not show IMC to cause long term effects⁷.

In relation to the question of lack of adequate anaesthesia, IMC should not be performed without local anaesthesia. In infants aged less than three months general anaesthesia is not required or appropriate.

The author claims that IMC is an elective procedure in a minor with no medical benefit. While most parents probably would not consider the health benefits to be their major concern when arranging IMC, it is fortunately not correct that health benefits do not accrue to the child.

Autonomy

Dr Kagan states that the ability to make medical decisions for infants is granted by proxy to their parents who are expected to make decisions in the best interests of the child. Parents are usually and appropriately entrusted to consent on behalf of the infant and, since the benefits are much greater for reasons detailed above, it is not appropriate to defer IMC until the boy reaches an age of autonomy⁸.

A better way

Fortunately, as explained above, re-examination of the practice of IMC for Jewish families is not necessary as long as parents are given the opportunity to provide informed consent.

In most Jewish communities the Brit Milah ceremony and procedure, when performed by a trained professional, is considered appropriate and desirable; as explained above new parents have no reason to be concerned that their newborn son will be exposed to short or long-term harm from the process as is clearly demonstrated from the medical literature⁹.

RELATED STORY

Why I didn’t circumcise my second son (The Jewish Independent

References