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Strengths and Weaknesses in the 2015 Canadian Paediatric Society Statement Regarding Newborn Male Circumcision

October 2015
Paediatrics & Child Health 20(8):433-434

Authors:

University of Oxford

In 2015, the Canadian Paediatric Society (CPS) updated its position statement on newborn male circumcision. Reaching a different conclusion from that of the American Academy of Pediatrics (AAP) in 2012, the CPS did not find that the benefits of the procedure outweigh the risks and harms. In this brief commentary, I discuss some of the main strengths and weaknesses of the latest CPS policy.

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Strengths and weaknesses in the 2015 Canadian Paediatric Society

statement regarding newborn male circumcision

Brian D. Earp

University of Oxford

Abstract

In 2015, the Canadian Paediatric Society (CPS) updated its position statement on

newborn male circumcision. Reaching a different conclusion from that of the American

Academy of Pediatrics (AAP) in 2012, the CPS did not find that the benefits of the

procedure outweigh the risks and harms. In this brief commentary, I discuss some of the

main strengths and weaknesses of the latest CPS policy.

Published manuscript—author’s personal copy. Please cite as:

Earp, B. D. (2015). Strengths and weaknesses in the 2015 Canadian Paediatric

Society statement regarding newborn male circumcision. Paediatrics & Child

Health, 20(8), 433-434.

Strengths and weaknesses in the 2015 Canadian Paediatric Society statement

regarding newborn male circumcision

To the Editor;

The latest statement from the Canadian Paediatric Society (CPS) regarding newborn male

circumcision exhibits both strengths and weaknesses. Strengths include:

1. Acknowledgement that the foreskin is not redundant skin; that it “serves to cover the

glans penis and has an abundance of sensory nerves”; that it is adherent at birth and may

take several years to become fully retractile; that this is normal and should not be

pathologized as phimosis; that true phimosis can be treated nonsurgically;

2. Acknowledgement that the absolute risk for urinary tract infections (UTIs) in boys is

low; that it would take >100 circumcisions to prevent one case; that UTIs may be

overdiagnosed in genitally intact boys; that UTIs can be treated nonsurgically; that “UTIs

in children with normal kidneys do not [ordinarily] result in long-term sequelae”;

3. Acknowledgement that the absolute risk for female-to-male heterosexual transmission

of HIV in countries such as Canada and the United States is low; that results from

African trials involving adult men may not translate to newborn boys in developed

countries; that circumcision does not reduce male-to-female transmission of HIV; that

safe sex practices must continue to be emphasized;

4. Acknowledgement that penile cancer is rare in developed countries; that its association

with intact male genitalia is primarily explained by the presence of phimosis; that human

papilloma virus vaccines are expected to “dramatically decrease the incidence rate of

cervical cancer”, thereby obviating a role for circumcision;

5. Acknowledgement that circumcision is painful; that this pain may have long-term

adverse sequelae; that circumcision is a procedure with “lifelong consequences ...

performed on a [healthy] child who cannot give [his] consent”; that the “authority of

substitute decision makers is ... usually limited [to] interventions deemed to be medically

necessary”; and that newborn male circumcision does not satisfy this condition. 

Weaknesses include:

1. Failure to engage seriously with the literature on negative sexual effects of

circumcision (1-3). This includes a recent analytic review by Bossio et al (4), as well as

several published critiques (5-7) of the studies by Kigozi et al (8) and Krieger et al (9),

both of which studied adult rather than infant circumcision (the CPS authors conflate

these in this passage); both of which involved insufficient follow-up for drawing long-

term conclusions; and the latter of which did not use validated instruments (5-7). 

2. Failure to state that the cited cost-effectiveness estimate concerning lifetime risk for

HIV acquisition did not demonstrate cost savings for circumcision in the majority

population of white males;

3. Failure to explain the inclusion of a brochure by an Australian procircumcision

lobbying group with no official status (10) as one of three 'selected resources', rather than

the official brochure of the Royal Australasian College of Physicians (11), which

advocates against neonatal circumcision;

4. Failure to consider analogous interventions in girls (12). The nontherapeutic removal

of any amount of tissue from the female genitalia before an age of consent, including

procedures that are less invasive than male circumcision, is a crime in Canada,

notwithstanding any health benefits that may or may not ensue (13).

References

1. Frisch M, Lindholm M, Grønbæk M. Male circumcision and sexual function in men and

women: A survey-based, cross- sectional study in Denmark. Int J Epidemiol 2011;40:1367-81.

2. Bronselaer GA, Schober JM, Meyer-Bahlburg H, et al. Male circumcision decreases penile

sensitivity as measured in a large cohort. BJU Int 2013;111:820-7.

3. Dias J, Freitas R, Amorim R, et al. Adult circumcision and male sexual health: A retrospective

analysis. Andrologia 2014;46:459-64.

4. Bossio JA, Pukall CF, Steele S. A review of the current state of the male circumcision

literature. J Sex Med 2014;11:2847-64.

5. Earp BD. Sex and circumcision. Am J Bioeth 2015;15:43-5.

6. Frisch M. Author's response to: Does sexual function survey in Denmark offer any support for

male circumcision having an adverse effect? Int J Epidemiol 2012;41:312-4.

7. Boyle GJ. Does male circumcision adversely affect sexual sensation, function, or satisfaction?

Critical comment on Morris and Krieger (2013). Advances Sex Med 2015;5:7-12.

8. Kigozi G, Watya S, Polis CB, et al. The effect of male circumcision on sexual satisfaction and

function, results from a randomized trial of male circumcision for human immunodeficiency

virus prevention, Rakai, Uganda. BJU Int 2008;101:65-70.

9. Krieger JN, Mehta SD, Bailey RC, et al. Adult male circumcision: Effect on sexual function

and sexual satisfaction in Kimumu, Kenya. J Sex Med 2008;5:2610-22.

10. Earp BD, Darby RJ. Does science support infant circumcision? A skeptical reply to Brian

Morris. Skeptic 2015;25:23-30.

11. Royal Australasian College of Physicians. Policy statement and brochure for parents.

<https://members.racp.edu.au/page/paed- policy> (Accessed November 10, 2015).

12. Earp BD. Female genital mutilation and male circumcision: Toward an autonomy-based

ethical framework. Medicolegal and Bioeth 2015;5:89-104.

13. Earp BD. Do the benefits of male circumcision outweigh the risks? A critique of the

proposed CDC guidelines. Front Pediatr 2015;3:1-6.

Genital Autonomy and Sexual Well-Being

Article

Full-text available

Mar 2018
Curr Sex Health Rep

Purpose of Review The purpose of this study is to survey recent arguments in favor of preserving the genital autonomy of children—female, male, and intersex—by protecting them from medically unnecessary genital cutting practices. Recent Findings Nontherapeutic female, male, and intersex genital cutting practices each fall on a wide spectrum, with far more in common than is generally understood. When looking across cultures and comparing like cases, one finds physical, psychosexual, and symbolic overlaps among the three types of cutting, suggesting that a shared ethical framework is needed. Summary All children have an interest in genital autonomy, regardless of their sex or gender.

Does Circumcision Reduce Penis Sensitivity? The Answer Is Not Clear Cut

Article

Full-text available

Apr 2016

Brian D. Earp

Bossio et al. (in press) report that circumcision does not reduce sensitivity of the penis. However, their own results show that the foreskin is the most sensitive part of the penis to tactile stimulation, as well as more sensitive to warmth than the penile glans. Since the foreskin is (a) the most touch-sensitive part of the penis, and (b) it is removed by circumcision, circumcision reduces sensitivity of the penis by definition. Further problems with the study by Bossio et al. are discussed.

In Defence of Genital Autonomy for Children

Article

Full-text available

Jan 2016

Brian D. Earp

Arora and Jacobs (2016) assume that liberal societies should tolerate non-therapeutic infant male circumcision, and argue that it follows from this that they should similarly tolerate—or even encourage—what the authors regard as ‘de minimis’ forms of female genital mutilation (as defined by the World Health Organization). In this commentary, I argue that many serious problems would be likely to follow from a policy of increased tolerance for female genital mutilation, and that it may therefore be time to consider a less tolerant attitude toward non-therapeutic infant male circumcision. Ultimately, I suggest that children of whatever sex or gender should be free from having healthy parts of their most intimate sexual organs either damaged or removed, before they can understand what is at stake in such an intervention and agree to it themselves.

Between Moral Relativism and Moral Hypocrisy: Reframing the Debate on “FGM”

Article

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Jul 2016
KENNEDY INST ETHIC J

Brian D. Earp

The spectrum of practices termed “Female Genital Mutilation” (or FGM) by the World Health Organization is sometimes held up as a counterexample to moral relativism. Those who advance this line of thought suggest the practices are so harmful in terms of their physical and emotional consequences, as well as so problematic in terms of their sexist or oppressive implications, that they provide sufficient, rational grounds for the assertion of a universal moral claim—namely, that all forms of FGM are wrong, regardless of the cultural context. However, others point to cultural bias and moral double standards on the part of those who espouse this argument, and have begun to question the received interpretation of the relevant empirical data concerning FGM as well. In this article I assess the merits of these competing perspectives. I argue that each of them involves valid moral concerns that should be taken seriously in order to move the discussion forward. In doing so, I draw on the biomedical “enhancement” literature in order to develop a novel ethical framework for evaluating FGM (and related interventions—such as female genital “cosmetic” surgery and non-therapeutic male circumcision) that takes into account the genuine harms that are at stake in these procedures, but which does not suffer from being based on cultural or moral double standards.

Female Genital Mutilation and Male Circumcision: Toward an Autonomy-based Ethical Framework

Article

Full-text available

Oct 2015

Brian D. Earp

The non-therapeutic alteration of children's genitals is typically discussed in two separate ethical discourses: one for girls, in which such alteration is conventionally referred to as "female genital mutilation" (or FGM), and one for boys, in which it is conventionally referred to as "male circumcision." The former is typically regarded as objectionable or even barbaric; the latter, benign or beneficial. In this paper, however, I call into question the moral and empirical basis for such a distinction, and I argue that it is untenable. As an alternative, I propose an ethical framework for evaluating such alterations that is based upon considerations of bodily autonomy and informed consent, rather than sex or gender.

Does Male Circumcision Adversely Affect Sexual Sensation, Function, or Satisfaction? Critical Comment on Morris and Krieger (2013)

Article

Full-text available

May 2015

Gregory J. Boyle

Morris and Krieger (2013) have argued that male circumcision does not impact adversely on sexual sensation, satisfaction, and/or function. In the present paper, it is argued that such a view is untenable. By selectively citing Morris' own non-peer-reviewed letters and opinion pieces purporting to show flaws in studies reporting evidence of negative effects of circumcision, and by failing adequately to account for replies to these letters by the authors of the original research (and others), Morris and Krieger give an incomplete and misleading account of the available literature. Consequently, Morris and Krieger reach an implausible conclusion that is inconsistent with what is known about the anatomy and functions of the penile foreskin, and the likely effects of its surgical removal.

Does Male Circumcision Adversely Affect Sexual Sensation, Function, or Satisfaction? Critical Comment on Morris and Krieger (2013)

Article

Full-text available

May 2015

Gregory J. Boyle

Do the Benefits of Male Circumcision Outweigh the Risks? A Critique of the Proposed CDC Guidelines

Article

Full-text available

Mar 2015

Brian D. Earp

The Centers for Disease Control and Prevention (CDC) have announced a set of provisional guidelines concerning male circumcision, in which they suggest that the benefits of the surgery outweigh the risks. I offer a critique of the CDC position. Among other concerns, I suggest that the CDC relies more heavily than is warranted on studies from Sub-Saharan Africa that neither translate well to North American populations nor to circumcisions performed before an age of sexual debut; that it employs an inadequate conception of risk in its benefit vs. risk analysis; that it fails to consider the anatomy and functions of the penile prepuce (i.e., the part of the penis that is removed by circumcision); that it underestimates the adverse consequences associated with circumcision by focusing on short-term surgical complications rather than long-term harms; that it portrays both the risks and benefits of circumcision in a misleading manner, thereby undermining the possibility of obtaining informed consent; that it evinces a superficial and selective analysis of the literature on sexual outcomes associated with circumcision; and that it gives less attention than is desirable to ethical issues surrounding autonomy and bodily integrity. I conclude that circumcision before an age of consent is not an appropriate health-promotion strategy.

Does Science Support Infant Circumcision?

Article

Full-text available

Apr 2015
Skeptic

According to Brian Morris (2013), "Science supports infant circumcision" and "so should skeptics." It would be more accurate to say that 'Brian Morris supports infant circumcision,' and that skeptics can think for themselves. In this paper, we critically assess the arguments and evidence presented by Morris in his recent article, and draw some general lessons for the ongoing debate about the science and ethics of infant male circumcision. ** Note that the online and print versions of this article have been edited for length; the present document is the original, full-length version, and should be referred to in case of any discrepancies.

Sex and Circumcision

Article

Full-text available

Feb 2015
AM J BIOETHICS

Brian D. Earp

What are the effects of circumcision on sexual function and experience? And what does sex—in the sense related to gender—have to do with the ethics of circumcision? Jacobs and Arora (in press) give short shrift to the first of these questions; and they do not seem to have considered the second. In this commentary, I explore the relationship between sex (in both senses) and infant male circumcision, and draw some conclusions about the ongoing debate regarding this controversial practice.

Male circumcision decreases genital sensitivity as measured by self-assessment in a large cohort

Article

Dec 2010

A Review of the Current State of the Male Circumcision Literature

Article

Nov 2014
J SEX MED

Introduction: Male circumcision is one of the most commonly performed surgical procedures worldwide and a subject that has been the center of considerable debate. Recently, the American Association of Pediatrics released a statement affirming that the medical benefits of neonatal circumcision outweigh the risks. At present, however, the majority of the literature on circumcision is based on research that is not necessarily applicable to North American populations, as it fails to take into account factors likely to influence the interpretability and applicability of the results. Aims: The purpose of this review is to draw attention to the gaps within the circumcision literature that need to be addressed before significant changes to public policy regarding neonatal circumcision are made within North America. Methods: A literature review of peer-reviewed journal articles was performed. Main outcome measures: The main outcome measure was the state of circumcision research, especially with regard to new developments in the field, as it applies to North American populations. Results: This review highlights considerable gaps within the current literature on circumcision. The emphasis is on factors that should be addressed in order to influence research in becoming more applicable to North American populations. Such gaps include a need for rigorous, empirically based methodologies to address questions about circumcision and sexual functioning, penile sensitivity, the effect of circumcision on men's sexual partners, and reasons for circumcision. Additional factors that should be addressed in future research include the effects of age at circumcision (with an emphasis on neonatal circumcision) and the need for objective research outcomes. Conclusion: Further research is needed to inform policy makers, health-care professionals, and stakeholders (parents and individuals invested in this debate) with regard to the decision to perform routine circumcision on male neonates in North America.

Adult circumcision and male sexual health: A retrospective analysis

Article

Apr 2013
ANDROLOGIA

We aimed to evaluate possible associations of circumcision with several sexual dysfunctions and to identify predictors for the development of these outcomes post-operatively. Telephone surveys about sexual habits and dysfunctions before and after intervention were conducted post-operatively to patients that underwent circumcision in Centro Hospitalar Vila Nova de Gaia/Espinho during 2011. McNemar test was used for a matched-pairs analysis of pre- and post-operative data. Odds ratios, adjusted in a multivariate analysis, explored predictors of de novo sexual dysfunctions after circumcision. With intervention, there was an increase in frequency of erectile dysfunction (9.7% versus 25.8%, P = 0.002) and delayed orgasm (11.3% versus 48.4%, P < 0.001), and a significant symptomatic improvement in patients with pain with intercourse (50.0% versus 6.5%, P < 0.001). Significant predictors for de novo erectile dysfunction were diabetes mellitus (OR 9.81, P = 0.048) and lack of sexual desire (OR 8.76, P = 0.028). Less than three sex partners (OR 7.04, P = 0.007) and low sexual desire (OR 7.49, P = 0.029) were significant predictors for de novo delayed orgasm.

Male circumcision decreases penile sensitivity as measured in a large cohort

Article

Feb 2013
BJU INT

Unlabelled: WHAT'S KNOWN ON THE SUBJECT? AND WHAT DOES THE STUDY ADD?: The sensitivity of the foreskin and its importance in erogenous sensitivity is widely debated and controversial. This is part of the actual public debate on circumcision for non-medical reason. Today some studies on the effect of circumcision on sexual function are available. However they vary widely in outcome. The present study shows in a large cohort of men, based on self-assessment, that the foreskin has erogenous sensitivity. It is shown that the foreskin is more sensitive than the uncircumcised glans mucosa, which means that after circumcision genital sensitivity is lost. In the debate on clitoral surgery the proven loss of sensitivity has been the strongest argument to change medical practice. In the present study there is strong evidence on the erogenous sensitivity of the foreskin. This knowledge hopefully can help doctors and patients in their decision on circumcision for non-medical reason. Objectives: To test the hypothesis that sensitivity of the foreskin is a substantial part of male penile sensitivity. To determine the effects of male circumcision on penile sensitivity in a large sample. Subjects and methods: The study aimed at a sample size of ≈1000 men. Given the intimate nature of the questions and the intended large sample size, the authors decided to create an online survey. Respondents were recruited by means of leaflets and advertising. Results: The analysis sample consisted of 1059 uncircumcised and 310 circumcised men. For the glans penis, circumcised men reported decreased sexual pleasure and lower orgasm intensity. They also stated more effort was required to achieve orgasm, and a higher percentage of them experienced unusual sensations (burning, prickling, itching, or tingling and numbness of the glans penis). For the penile shaft a higher percentage of circumcised men described discomfort and pain, numbness and unusual sensations. In comparison to men circumcised before puberty, men circumcised during adolescence or later indicated less sexual pleasure at the glans penis, and a higher percentage of them reported discomfort or pain and unusual sensations at the penile shaft. Conclusions: This study confirms the importance of the foreskin for penile sensitivity, overall sexual satisfaction, and penile functioning. Furthermore, this study shows that a higher percentage of circumcised men experience discomfort or pain and unusual sensations as compared with the uncircumcised population. Before circumcision without medical indication, adult men, and parents considering circumcision of their sons, should be informed of the importance of the foreskin in male sexuality.