The arm of the US Government tasked with disease reduction has announced plans to actively encourage male circumcision, which they say would reduced transmission of HIV. Here Oxford University academic Brian D Earp critiques both the evidence and ethics that underpin the proposals.
The Centers for Disease Control and Prevention (CDC) has announced a set of provisional guidelines concerning male circumcision, in which they suggest that the benefits of the surgery outweigh the risks (CDC, 2014). In this brief comment, I highlight a few of the key scientific and ethical issues worth considering in interpreting the CDC recommendations.
First, the CDC appears largely to be following the American Academy of Pediatrics (AAP), whose 2012 policy statement and technical report have already been subjected to numerous international critiques (e.g., Frisch et al., 2013, Svoboda & Van Howe, 2013; Garber, 2013; Hartmann, 2012; Lawson, 2012; Booker, 2012; Bewley & Stranjord, 2012; Guest, 2012; Androus, 2013; Earp & Darby, 2014).
While these critiques are not necessarily definitive, they do raise a number of concerns about the manner in which the AAP, and by extension, the CDC, conducted its analysis of the available literature on male circumcision, and presented its findings to the public.
Among other issues, critics have pointed out that the bulk of the data used to justify the AAP/CDC policies was derived from studies of adult circumcision carried out in sub-Saharan Africa—a geographic region whose epidemiological environments and patterns of disease transmission are dissimilar, along numerous dimensions, to those elsewhere in the world (see, e.g., Lyons, 2013).
This is important, because the spread of disease is determined much more by socio-behavioral and situational factors than by strictly anatomical-biological factors, such as the presence or absence of a foreskin (see, e.g., Ramos et al., 2009, Darby, 2014).
In other words, the apparent findings from these studies cannot be simply mapped on to non-analogous public health environments, nor to circumcisions performed earlier in life, i.e., before an age of sexual debut (see Earp, in press). As Bossio et al. (2014) argue in a recent comprehensive review, not referenced by the CDC, “At present … the majority of the literature on circumcision is based on research that is not necessarily applicable to North American populations” (p. 2847).
In addition to such empirical limitations, the proposed CDC guidelines exhibit conceptual and ethical limitations as well. Conceptually, the CDC relies on an inappropriate construal of risk in its benefit vs. risk analysis, since it appears to interpret “risk” as referring (primarily or exclusively) to the “risk of surgical complications.”
'Loss of a healthy, functional, and erotogenic penile structure'
To begin with, the actual incidence of surgical complications is not known, due to the poor quality of the available data on this question as well as conflicting definitions (and ways of measuring) “complications” (see AAP, 2012). Thus, as Garber (2013) has noted, “it is inconceivable that the AAP [and by extension, the CDC] could have objectively concluded that the benefits of the procedure outweigh the risks when the ‘true incidence of complications’ isn’t known” (p. 69).
Even if this figure were known, however, the CDC test would still be ill-conceived. This is because the standard heuristic for evaluating non-therapeutic surgery (i.e., surgery performed in the absence of disease or deformity) is not benefit vs. “risk of surgical complications” but rather benefit vs. risk of harm (cf. UC Irvine Office of Research, 2014).
In this case, at least one relevant harm would be the necessary loss of a healthy, functional, and erotogenic penile structure (Cold & Taylor, 1999; Taylor et al., 1996), amounting to approximately 30-50 square centimeters of richly innervated, elastic genital tissue in the adult organ (see Earp, in press; Earp & Darby, 2014). To its discredit, the CDC nowhere in its proposed guidelines mentions, much less explores in any detail, the actual anatomy or functions of the penile prepuce—i.e., the part of the penis that is removed by circumcision (see Guest, 2012 for a related discussion).
'Even successful surgery, if non-consensual, causes harm'
As Fleiss and Hodges (2002) ask, “How can parents make a rational decision about circumcision when they are told nothing about the part that will be cut off?” (p. xii). For a point of comparison, imagine a report by the CDC discussing the health benefits of prophylactic mastectomy, in which the only implied harms of the procedure were “surgical complications,” and in which the anatomy and functions of the breasts were nowhere described.
Indeed, the CDC’s approach runs counter to the conventional bioethical (and legal) view that unnecessary surgeries, and especially those that remove non-diseased tissue from an individual without his consent, are in and of themselves harmful. As a California Appeals Court recently held (see Adler, 2012), “[I]t seems self-evident that unnecessary surgery is injurious and causes harm to a patient. Even if a surgery is executed flawlessly, if the surgery were unnecessary, the surgery in and of itself constitutes harm” (p. 496).
The only other potential harm that the CDC appears to have entertained is the possibility of diminished sexual experience, finding that: “Adult men who undergo circumcision generally report minimal or no change in sexual satisfaction or function” (CDC, 2014, p. 7).
However, the CDC’s appraisal of the literature on this point is as superficial as it is selective. As Bossio et al. (2014) noted in their recent review: “Adverse self-reported outcomes associated with foreskin removal in adulthood include impaired erectile functioning, orgasm difficulties, decreased masturbatory functioning (loss in pleasure and increase in difficulty), an increase in penile pain, a loss of penile sensitivity with age, and lower subjective ratings of penile sensitivity” (p. 2853, internal references omitted).
Would the arguments hold if we swapped the genders?
While “other studies have found no significant differences in self-reported sexual functioning following adult circumcision” (ibid.), it must be remembered that a lack of statistical significance does not entail a lack of effect (Aberson, 2002). For example, in one of the studies cited by the CDC, “several questions were too vague to capture possible differences between circumcised and not-yet circumcised participants [such that classification] of sexual outcomes … probably favoured the null hypothesis of no difference, whether an association was truly present or not” (Frisch, 2012, p. 313). More generally, studies of adult male circumcision often fail to achieve long-term follow-up, and assess only a limited range of sexual of outcome variables (Bossio et al., 2014; Earp, in press).
On the question of health benefits, suppose it could be shown that removing the labia majora of infant girls reduced their risk of acquiring a urinary tract infection (since there would be fewer folds of moist genital tissue in which bacteria could find a home), as well as, say, cancers of the vulva.
It is not implausible, and in fact in countries in which female “circumcision” is culturally normative, it is often thought to be "more hygienic" as well as more aesthetically pleasing (Lightfoot-Klein, 1997). Now, it is usually not recognized that female "circumcision" falls on a spectrum; that some forms of it are less invasive than male circumcision (including several forms that do not involve modification of the clitoris); and that it is sometimes done for reasons other than (attempted) control of sexuality (Shell-Duncan & Hernlund, 2000; Davis, 2001; Earp, 2014; Earp, 2013).
Right to bodily integrity
Nevertheless, it is actually illegal in Western countries to conduct the very research by which such "health benefits" could be “discovered” in the first place. This is because non-therapeutic surgeries performed on the genitals of healthy girls—no matter how slight, nor under what material conditions—are deemed to be impermissible mutilations in Western law (Davis, 2001).
Presumably, this is due to concerns about respect for sexual self-determination, a desire to protect children’s (future) autonomy (see Maslen et al., 2014; Darby, 2013), and a recognition of widely-upheld moral and legal rights to bodily integrity and to security of the person (see, e.g., Ungar-Sargon, 2013; Merkel and Putzke, 2013).
Taken together, these considerations suggest that little girls should be free to grow up with their genitals intact, and to decide, at an age of understanding, whether they would like to undergo permanent alterations to their "private parts," and if so, for what reasons (and what kind). The same principles apply equally to boys (DeLaet, 2009; Johnson, 2010; Svoboda & Darby, 2008; Earp, 2014).
Whether a minor reduction in the (absolute) risk of certain infections or diseases (whose prevalence in developed nations is low, and whose occurrence can be prevented and/or treated in much less invasive ways than surgery; see Earp & Darby, 2014; Frisch et al., 2013) is worth the trade-off of losing a non-trivial part of one’s external sex organs is a complex question.
What is certain, however, is that the answer to this question is likely to be highly subjective, and to depend upon numerous, unpredictable, and ultimately personal factors. Therefore, it should be up to the affected individual to decide about permanent genital-modification surgeries at such a time as he or she can factor in his or her own preferences and values (see Maslen et al. 2014).
Circumcision before an age of consent is not a desirable health-promotion strategy, given more effective—and less ethically problematic—alternatives.
Foot notes:Replies and counter-replies to some of these critiques have been published; see the relevant journal websites. The CDC does acknowledge this "translation" problem, although the caveat was rarely emphasized in the initial flurry of media coverage following the release of the CDC draft guidelines: “Much of the data related to HIV and STI prevention are from randomized clinical trials (RCTs) conducted among men in sub-Saharan Africa in regions with high rates of heterosexually acquired HIV infection. In the United States [by contrast] the prevalence of HIV and lifetime risk of HIV infection are generally much lower than [in] sub-Saharan Africa. Also, most new HIV infections in the United States are attributed to male-male sex, a population for whom male circumcision has not been proven to reduce the risk of HIV acquisition” (CDC, 2014, p. 1). In the 61-page technical report which forms the basis for its proposed recommendations, the CDC dedicates a total of four sentences to the possible effects of circumcision on sexual sensation, function, and/or satisfaction: see http://arclaw.org/sites/default/files/CDC-2014-0012-0002.pdf. Moreover, it fails to reference, much less discuss, several of the most well-known, good quality studies providing evidence of negative effects of circumcision on sexuality (e.g., Kim & Pang, 2007; Frisch et al. 2011; Dias et al., 2014; Bronselaer et al., 2013), and instead relies on other reports without mentioning published critiques of their methods. For a recent, comprehensive, and nuanced discussion of the available literature on the various sexual effects of circumcision, see Bossio et al., 2014.  Of course, the CDC ignores the fact that any sensation in the foreskin itself is necessarily eliminated by circumcision, as are any sexually-relevant (e.g., masturbatory) functions that require its manipulation. As I have argued elsewhere: “To say that circumcision has ‘little or no effect’ on sexual experience … is to adopt an extremely narrow conception of that term” (Earp, in press).