Jeremy Laurance: Is this the start of a backlash against circumcision?

Medical Life

Sunday 23 October 2011 07:19

The Dutch have always had liberal views on sex. They led the world in developing open and frank sex education and were rewarded with one of the lowest rates of teenage pregnancy. But their tolerant nature has now hit the brick wall of religious conviction. The Royal Dutch Medical Association has officially adopted the view that the circumcision of underage boys is medically unnecessary and violates their human rights. It says the benefits are unproven and the complications underestimated, and advocates a "strong policy of deterrence".

No issue divides medical and lay opinion like male circumcision. It may be the oldest and commonest surgical procedure in the world but longevity and frequency are no guarantee of acceptability. So is the Dutch Medical Association's move the beginning of a backlash?

According to the World Health Organisation, about 30 per cent of men worldwide are circumcised. The procedure is more popular in the US (an estimated 65 per cent) than in the the UK (16 per cent) but rates are declining in both countries.

Most medical organisations in the West, recognising the strong feelings of parents, have stayed aloof from the issue, observing merely that the surgery is rarely medically necessary. However, an editorial in the New England Journal of Medicine in 2008 highlighted evidence about the protective effect of circumcision against HIV (50 to 60 per cent reduction in transmission) and other sexually transmitted infections, including Human Papilloma Virus (35 per cent reduction) and Herpes Simplex Virus (25 per cent reduction) and called for professional societies to review their policies.

In the US, the American Academy of Paediatrics is doing so – its report is still awaited. In the UK the Royal College of Paediatrics declined to follow suit on the grounds that there is little HIV heterosexual transmission in the UK (and no evidence circumcision protects men who have sex with men), a vaccine against HPV is currently being rolled out and HSV is a smaller problem here than in the US. There appears to be a developing split in international medical opinion.

What the evidence shows is that while circumcision may be hard to justify at the population level, at the individual level there is a medical benefit to the surgery, in addition to whatever religious or other function it fulfils. But evidence alone is unlikely to resolve this dispute. Eighteen months ago I visited Zambia to write about efforts there to roll out adult male circumcision, following trials in Africa showing it reduced transmission of HIV by at least half. The piece that appeared in The Independent sparked a flurry of responses complaining the trials had been fixed and the surgery amounted to assault. Yet when the same piece was re-printed in the Times of Zambia, responses were overwhelmingly positive. Many African readers complained the operation was not being rolled out fast enough.

Evidence is the touchstone in medicine. But it is meaningless out of context.

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