Below are the comments NORM submitted to the CDC in response for their call for comments on a draft document titled “Recommendations for Providers Counseling Male Patients and Parents Regarding Male Circumcision and the Prevention of HIV Infection, STIs, and other Health Outcomes”.
NORM’s comments on the CDC draft policy on circumcision (2015)
The National Organization of Restoring Men is a national non-profit organization focused on helping men who have been harmed by circumcision. We have educated and counseled tens of thousands of men over more than two decades on the functions of the foreskin as well as methods to heal some of the detrimental effects of circumcision. Based on our interactions with these men, public health would best be served if instead of recommending circumcision the CDC would focus on the numerous prevention strategies and treatments that are already available for the various diseases and conditions listed in the CDC recommendation. The recommendations do not adequately inform patients of what is being lost due to circumcision and what the alternatives are, nor do they present the risks and benefits in a way easily understood by the layperson. The foreskin is composed of multiple structures and tissue types, including numerous sexually important nerves, and serves numerous sexual functions including protection of the glans. Without information on the benefits and function of the foreskin, men or the parents and guardians of male children cannot make an informed decision regarding the pros and cons of the procedure. Clearly the research on the anatomy of the foreskin and it’s sexual function has either been intentionally left out of this recommendation or this basic research has not been done. In either case, this gap in the information provided needs to remedied before any recommendation about the benefits and risks can be made.
Our comments specifically by recommendation section and number:
While the rationale is provided for using relative-risk reduction percentages for the benefits of circumcision, and absolute risk for harm due to circumcision, this does not resolve the fact that the average person, even one with some knowledge of statistics, will hear the benefits as far greater than the risks due to the large difference in the percentage numbers. A benefit of 50% sounds huge compared to a risk of 2-4% and does not provide the patient with easily understandable and comparable numbers with which to make an informed decision.
It is unethical for a medical practitioner to promote or perform a surgical procedure on a minor that does not treat an immediate medical condition. All other preventative procedures on children do not remove healthy tissue (vaccinations, teeth cleanings, general hygiene). Irrespective of purported health benefits, we do not allow female children to be circumcised on the basis of religion, societal norms and social customs, hygiene, or aesthetic preference, therefore these considerations surrounding male circumcision should be removed from Recommendation #1 and should not be taken into account when counseling patients or their parents and guardians. It is illegal to circumcise female children and it should be illegal to circumcise male children as well.
Sexually active males should be counseled with non-invasive risk reduction strategies rather than recommending circumcision which is an invasive and permanent operation.
This section focuses only on the risks of the foreskin with no mention of the benefits or functions of the foreskin. Nowhere is the risk of losing unique and irreplaceable sexual tissue mentioned. Statistics should be used so that parents and guardians are given accurate information about the very small risk of some of the listed conditions such as penile cancer.
This item should be removed, since medically and ethically, neonatal, pediatric, or adolescent male circumcision should not be performed except in the case of an immediate, diagnosable, medical condition.
Comments on Box 1:
The studies referenced have not been replicated in the United States or any similar Western country and therefore should be considered preliminary at best and should not be used by the CDC to justify circumcision as an HIV and STI prevention strategy.
Our organization has been contacted by numerous adult males who were circumcised as adults who have had significant loss of sexual satisfaction and/or function. The experiences of these men need to be investigated to determine the true long term risks of circumcision. The occurrence of adverse effects and risks may be underestimated. Men who have been circumcised as adults may not report adverse events due to shame or embarrassment, and doctors who performed the circumcision may be reluctant to report or investigate adverse events and patient complaints due to concerns of malpractice suits or due to their own denial of the possibility of such adverse events related to circumcision.
For all of the above reasons we do not support the use of circumcision as a preventative health strategy and recommend that the CDC focus on existing, effective strategies and treatments for the diseases and conditions mentioned in the recommendations.