23 July 2013

Extenuating Circum Stances, Pt. 3: Science and Tradition

Since the 1970s, routine MGC has seen a steady increase in opposition. According to social anthropologist Kirsten Bell, “the anticircumcision movement began to gain ground in the 1980s, with the publication of Edward Wallerstein’s (1980) respected Circumcision: An American Health Fallacy.” Since Wallerstein’s work, several groups have sprouted in the U.S. dedicated to eradicating unnecessary MGC, such as the National Organization of Circumcision Information Resource Center, or NOCIRC,[1] and the National Organization to Halt the Abuse and Routine Mutilation of Males, or NOHARMM.[2] Both organizations claim that they are aiming to make the world safer for children through education and activism. In more recent years, the word intactivism has been used to represent those in the U.S. who oppose routine neonatal MGC. Many intactivists argue that the procedure is not only unnecessary, but that the practice is child abuse in the form of genital mutilation, and that it denies the child of his inherent right to an intact penis (D’Arcy 2012). Additionally, others may stress the significant physical and emotional trauma that occurs as a result of the procedure (Schwartzman 2013).

MGC presents a unique meeting place for science and tradition. In other fields of medicine, scientific inquiry and research results tend to influence practice. As evidence accrues for a particular outcome, old practices are discarded and new, and hopefully safer, practices take their place. Oddly enough, this model does not fit the history of MGC in the U.S. Instead, the American Association of Pediatrics (AAP) has gone back and forth on their views of circumcision over the years, resulting in confusion both in the medical community and the public at large. MGC became a standard practice for the prevention of disease, included among them the practice of masturbation, starting in the mid to late 19th Century. By 1920, the practice had become so standardized it wasn’t questioned and was considered standard practice without parental consent in many American hospitals (Gollaher 2000:172). Under pressure from opposition in the 1970s, the AAP reviewed what little evidence there was and decided that there was no absolute medical reason to circumcise (Bell 2005: 128). The AAP maintained this position, with some slight variations across the years, until mid-2012, when the group released the following stance: “A recent analysis by the AAP concluded that the medical benefits of circumcision outweigh the risks” (AAP 2013). The group stopped short of actually endorsing the practice of routine neonatal MGC, but its change in position incited fury amongst those who oppose MGC. The change in statement also meant that the AAP’s position now stands in opposition to the positions of national programs in other medically advanced societies including Canada, the U.K., Sweden, and Australia.

Additionally, the AAP’s stance seems to go against the evidence of modern medical research. While there is a positive correlation of MGC with a reduction in penile cancer rates in clinical research, worldwide rates of such cancer are so low, that the results are mixed. The majority of Swedish men, for example, are uncircumcised and have some of the lowest rates of penile cancer in the world. Additionally, penile cancer is so rare, that using it as justification for prepuce removal is a less rational argument than encouraging the removal of breast tissue to prevent breast cancer in females. As medical TV show co-host and pediatrician Jim Sears stated, “More babies die from getting circumcised than men die from getting penile cancer.” To risk not pointing out the obvious: penile cancer is a skin cancer; surely removing one-third to one-half of the total skin of the penis reduces the risk of contracting the disease.

In 1993, Edgar Shoen of the AAP stated the MGC should be considered “analogous to immunization in that side effects and complications are immediate and usually minor, but the benefits accrue for a lifetime” (Shoen 1993). This statement was made in direct relation to “conclusive evidence” that MGC resulted in a reduction of the risk of urinary tract infection (UTI) in males. While this appears to be the case, UTIs are much less common in men than women – “By one year, UTIs become ten times more common in girls… [and between] twenty and fifty years of age, women’s incidence of UTIs is fifty times greater than men’s” (Gollaher 155) – and the AAP does not recommend genital cutting of females for prevention.

Looking at the arguments for MGC and the prevention of other diseases, including HIV, cervical cancer, and gonorrhea, the evidence is problematic at best. Within certain regional or cultural groups, men who have undergone MGC may show lower rates of HIV and other sexually transmitted infections (STIs), but this does not hold looking across or comparing between cultural groups. For instance, the U.S. has higher rates of MGC and STIs compared to European countries such as Germany and the U.K. Additionally, cut men tend to have more partners and perhaps even participate in more adventurous sexual activity, which increase risk the of contracting and spreading STIs. This makes finding a direct causal relationship with MGC tenuous.

MGC’s secular history in the U.S. is rooted in the late Victorian era when a number of doctors and other medical professionals endorsed the practice as a cure for many things, among them masturbation. The inventor of the corn flake, John Harvey Kellogg, is an important player in both MGC and FGC practices in the U.S., as one of the staunchest defenders of both practices for moral hygiene. He also advocated for the surgery to be administered without anesthesia, so the patient associated pain with his or her genitals (Bell 2005; Gollaher 2000). Attitudes about masturbation, and the wide array of mental and emotional disorders that genital cutting was believed to cure, have evolved significantly since the late 19th Century, and while the practice of clitoral cauterization and other forms of FGC have disappeared in the U.S. over time, MGC remains a tradition of birth medicine.

Despite the lack of conclusive evidence that MGC has any medical benefits that would justify its persistence, the U.S. stance on circumcision emphasizes placing trust in the hands of the medical establishment. This becomes an issue when doctors and surgeons are seen as having authoritative knowledge, yet when discussing this surgery, they stress the benefits and not the risks. Where scientific authority has failed to confirm the benefits, they place the onus on the parents, who turn back to the medical establishment for guidance. This vicious cycle benefits no one and may result in the continuation of an unnecessary surgical practice.

[1] http://www.nocirc.org/
[2] http://www.noharmm.org/

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