To circumcise or not to circumcise? That's a question that few people ever ponder -- until their little bundle of joy is about to arrive and it's a boy.
For years, the American Academy of Pediatrics has said that "the existing scientific evidence is not sufficient to recommend routine circumcision."
But that may change any day now, according to Dr. Doug Diekema, who sits on a task force that was created in 2007 to revisit the academy's stance.
We caught up with a him a few weeks ago to research this week's feature story on circumcision and asked what the heck was taking the panel so long to come to a conclusion.
"Your frustration is shared by many," Diekema said. He said that it had been hard to coordinate schedules of the busy task force members but that they had finally completed an exhaustive review of all relevant studies, and now "our work is 95 percent done. To my knowledge, the [new] statement and technical report have been drafted and are being reviewed by other members of the task force. We expect that this will be released sometime this spring."
Said Diekema: "Our starting point was the existing policy statement from 1995, which took a fairly neutral stance -- it said there were modest medical benefits and some risks. Since then, data has been generated that might alter that recommendation. It's fair to say that there are much more clear medical benefits than there were at the time of the last report, although no radical change in the data regarding risk. I expect that the academy will come out with a somewhat stronger statement."
Most notably, he said, studies indicated that circumcision had a protective effect against some sexually transmitted diseases. "The big ones are HIV and HPV," he said. "The data is the clearest." In addition, he said, "There is some good evidence for a protective effect against herpes as well as syphilis... and circumcision does reduce the likelihood of urinary tract infections in little boys who are circumcised as infants."
He went on to say, "If you talk to reasonable people about what the data shows... it's real. [Circumcision] does carry some risk and does involve the loss of the foreskin, which some men are angry about. But it does have medical benefit. Not everyone would trade that foreskin for that medical benefit. Parents ought to be the decisionmakers here. They should be fully informed.
"Based on the data, last time around, the academy said there was no real compelling reason for the procedure. Some insurance companies and Medicaid [in some states] stopped paying for it. So one of the changes you may see this time around is that there is sufficient data to suggest a substantial public health benefit -- that it's the sort of thing that insurance should be paying for."
Diekema is aware that there is a movement of "intactivists," or people who believe that it's wrong to cut off part of a baby's body if not medically necessary. "I get huge mailings with FedEx boxes, summaries. I do look at it -- I have a file of all of that -- but I am not about to let them do the evaluation for me."
Diekema said that "hundreds of papers were reviewed and judged for their quality" and that people from the anticircumcision camp "will quote you all kinds of studies -- which were frequently terrible and didn't prove anything because they were so methodologically flawed."
"They don't like what we're doing. I get hate mail from them all the time, trying to paint what we're doing as pro-circumcision. I am conflicted about circumcision personally. It's a hard choice; it's a hard decision, and there are good reasons for almost any decision you want to make." He described his task force as "a moderate group -- not pro, not anti. We're trying to uncover what's real here."
He did concede a few points to the anticirc crowd: "It's true that many pediatricians leave training without adequate training in circumcisions to be really be good at doing them, but it varies from program to program, resident to resident... [Generally, medical students] don't have a lot of opportunity to do these."
He acknowledged that some circumcisers do not use any sort of pain control to numb the baby's skin before performing the procedure, particularly Jewish mohels who let the baby suck on a rag with wine or sugar water. "Circumcisions should not be done without lidocaine or some kind of local anesthetic," Diekema said.
And he noted that circumcision became popular in the United States because "at the turn of the century, a few fairly influential individuals were convinced it would be an antimasturbation technique -- like eating Kellogg's corn flakes and graham crackers. Kellogg and Graham -- the inventors of those products -- said it would prevent masturbation if you feed young boys bland food. Those products were no accident."
He said that circumcision removes "maybe 1/3" of the skin on a male's penis but said that may or may not affect sexual experience. "What you really want to know -- ," he says, "it's fine and dandy to say circumcision removes all kinds of nerve cells, but more nerves doesn't necessarily equate to more pleasure -- so what you really want to know but can't look under a microscope and get the answer is: How has the sexual experience changed?"
Ultimately, "we don't have any good data. Circumcised men may experience sex differently than uncircumcised men -- intuitively that makes sense -- but it's simply not the case that we have an epidemic of uncircumcised men that don't get pleasure or can't function sexually." When some men who were circumcised as adults in Africa were asked about the change in sexual function, Diekema says, "most men reported no difference -- a small percentage report that it's worse, and a small percentage report that it's better. There's such a psychological component."
For Diekema, who practices emergency medicine at Seattle Children's Hospital and has never performed a circumcision outside of his medical residency, it's been a long five years thinking about the subject.
"It comes up at parties. People do want to talk about it. People find it fascinating."