Jesse Bering, PhD, is regular contributor to Scientific American, Slate, and other publications. He is the author of the recently released book, Why Is the Penis Shaped Like That? And Other Reflections on Being Human and The Belief Instinct, which the American Library Association named one of the “25 Best Books of 2011.” You can find him here.
For the past seven years, I’ve been in an “interpenile relationship”—I, the lesser of the two you might say, am circumcised; my partner is not. This contrast between our members is not exactly at the top of our list of concerns. But it is nonetheless interesting how my prepuce came to disappear into a medical waste bin in a bustling New Jersey hospital on some springtime day in 1975, whereas his, by contrast, has remained a fellow traveler all the long way from that tiny Mexican village where he slipped from his young mother’s womb on a chilly December morning in 1981. That womb, incidentally, belonged to a Roman Catholic. The one that I bathed in, the place in which I had my “bones and sinews knitted together,” in the words of Job, was the property of a Jew. So despite neither of us being particularly patriotic nor, certainly, religious today, the organs dangling so differently between us are nevertheless the very incarnations of our parents’ vast cultural differences.
Whatever the reasons that previous generations may have had for choosing to remove their infant sons’ foreskins, they were almost always unconvincing. All else being equal—and let me reiterate that caveat because it’s likely to go unnoticed, with some readers eagerly pointing out to me those rare cases of congenital defects in which circumcision can legitimately improve the quality of life for some males, which is of course true—all else being equal, any dubious benefits derived from religious, social, hygienic, or aesthetic reasons are clearly outweighed by the costs of male circumcision. Because of some rabbi in Hackensack shaking his head over my intact genitalia, my parents went unblinkingly along with the amputation of a fully operational, perfectly healthy, and probably adaptive body part, all to sacrifice an ounce of their son’s tender flesh to a god that he would never believe in anyway.
Today, however, all is no longer equal, and the balance between the relative risks and benefits of male circumcision has clearly shifted in the other direction. That is, it has according to the American Academy of Pediatrics, which just earlier this week put out its revised position statement on infant male circumcision. Here’s the money quote:
Systematic evaluation of English-language peer-reviewed literature from 1995 through 2010 indicates that preventive health benefits of elective circumcision of male newborns outweigh the risks of the procedure. Benefits include significant reductions in the risk of urinary tract infection in the first year of life and, subsequently, in the risk of heterosexual acquisition of HIV and the transmission of other sexually transmitted infections.
Many of our parents, it seems, may have actually made the right decision for the wrong reasons. Although the task force behind the Academy’s reassessment stopped short of advising “routine” and “universal” removal of the foreskin for all newborn males, and stressed that it remains a personal decision to be made by informed parents, its language represents an increasingly unambiguous endorsement of male circumcision among the world’s leading health organizations (including the World Health Organization and UNAIDS) . By contrast, many of the world’s leading parents remain skeptical of the findings reviewed by the Academy, questioning both the methodologies and the generalizability of studies conducted overwhelmingly with African populations, in which rates of infection are dramatically higher than those in the US. (For more information on this research, as well as a description of the physical factors responsible for the reduction of HIV acquisition in circumcised males, see my earlier discussion at Scientific American.) The more vocal “intactivists,” who’ve long been protesting what they regard as an antiquated, cruel and unnecessary ritual act against little boys that is just as abhorrent as female clitoridectomy, have also responded bitterly to this newest AAP development, seeing fresh strands in an ongoing web of conspiracy between the major health organizations, third-party insurance companies implementing the policy views of these organizations, and greedy practitioners who mislead parents about the benefits of circumcision only to reap insurance payouts for “mutilating” children’s genitals.
Some people have taken issue with the conclusion and analysis in my previous post, “Should Boys Be Given the HPV Vaccine? The Science Is Weaker Than the Marketing,” including epidemiologist Tara Smith in her blog, Aetiology, at ScienceBlogs. Here’s a clarification of some of the points in my post, and a response to some of hers.
First I’ll reiterate the key point of my post: There are many, many instances in which researchers have promised cures and interventions that were expected to work based on eminently reasonable logic, but did not pan out. Take one recent recent example: bypass a clogged artery and you will prevent strokes (see Sharon Begley’s excellent blog post on “When Biology Refuses to Listen to Medical Logic”). And now comes one more eminently logical assumption: prevent cervical lesions from some strains of HPV in some people for some period of time, and you will save lives from cervical cancer overall. Unfortunately, while the two HPV vaccines on the market may decrease the serious illness and death from cervical cancer, no study has proved that at this point, since no study has been conducted long enough to observe the development of cervical cancer or cervical cancer deaths.
Conclusive studies with the most important, clinically relevant end points should precede wide uptake of any intervention. The data currently rely on surrogate end points (markers of possible cancer) and are simply not conclusive. So we can’t truly say how effective the vaccine is.
Wake Forest medical researcher Curt Furberg, a former FDA advisor and co-author of the textbook Fundamentals of Clinical Trials, told me, “Getting data from markers is a first step. But we have burned our fingers too many times with surrogate markers. You should try to determine the real health benefit. Everything will be up in the air until we have the answer to the question: Will it prevent cancer? And until we have that answer, we should limit its use to girls enrolled in studies of the vaccine.”
Here are some other reasons why the HPV vaccines may not be as effective as advertised: